RU2148959C1 - Method for preventing dumping syndrome after gastrectomy - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves forming constrictor-to-valve esophagojejunostomy. End-to-side jejunojejunal anastomosis is built 24-26 cm distal to it. Reservoir for accumulating food from the abducting loop of small intestine is formed. Seromuscular coat is dissected 6-8 cm proximal relative to the jejunojejunal anastomosis with three incisions: the middle one, the circular one and elliptic one drawn along the boundary to the omental edge. Interrupted sutures are put-in over the utmost superior and inferior edges of the seromuscular coat. A valve is formed. The intestinal reservoir is shifted from the median to the right by 30 deg towards the duodenum. The reservoir is sutured with separated sutures to the parietal peritoneum of the anterior abdominal wall. EFFECT: reduced risk of complications. 6 dwg

Description

 The invention relates to medicine, surgery, specifically to methods for preventing dumping syndrome after gastrectomy.

 Closest to the proposed is the method proposed by M.A. Polyakov (1984) [1], in which the initial loop of the jejunum is taken, is passed through a window into the mesocolon, an isoantiperistaltic reservoir is formed by continuous peritoneal sero-muscular enteroplication of two loops of intestines for 18–25 cm. From the “double-barreled” dome into the esophagus a reservoir anastomosis creates an areflux coupling according to Gilyarovich [2]. Then, a reservoir is formed by electrosurgical dissection of two stitched intestines over 18–25 cm (36–50 cm of jejunum and duodenum are used). The front walls of the dissected intestines are sutured all over with a continuous serous-muscular 2-row suture. The disadvantages of the above method are the lack of effectiveness in terms of preventing dumping syndrome, inadequate containment, the rapid entry of a food lump into the jejunum.

A new technical result, a reduction in the number of complications, is achieved by the use of a new method for the prevention of dumping syndrome after gastrectomy, including upper median laparotomy, gastrectomy, the application of esophagus and jujunoanastomoses and the formation of a reservoir for the accumulation of food from the jejunum, and they form pulp and valve oesophagea retreating 24-26 cm distal to it, impose end-to-side jejuno-anastomosis, moreover, the reservoir for accumulating food is formed from the outlet loop of the small intestine, for which 6–8 cm maximal maximal neuroanastomosis, the serous-muscular membrane of the intestine is cut into three sections in the middle, circularly, along the edges ellipsoid to the mesenteric edge, nodal sutures are applied to the uppermost and lower edges of the serous-muscular membrane, forming a valve, then the jejunum section, including the resulting reservoir, stack, offset from the midline by 30 ^o to the right towards the duodenum, and hemmed with separate sutures to the parietal peritoneum of the posterior abdominal wall.

 The method is as follows: from the upper median access perform gastrectomy. In the abdominal section of the esophagus by exfoliating the serous-muscular membrane from the submucosal base and hemming it in the form of a cuff, leaving an excess of the mucous-submucous membrane to form muscle pulp. Below the Treitz ligament, the jejunum is mobilized by 20-25 cm, the oral end is sutured tightly. On the anti-mesenteric side of the oral end, backing off 15-20 mm on a rectangular area measuring 25x30 mm, the serous-muscular membrane is removed (Fig. 1). An end-to-side valve esophageoyunoanastomosis is formed. The back row of serous-muscular sutures passes through the lower edge of the formed muscle pulp of the esophagus and the upper edge of the serous-muscular membrane of the mucous-submucosal area of the jejunum. Then the corners of the mucous-submucosal base are sutured with stitches attached by catgut thread 00. A submucosal suture is applied with one thread of the latter from the left corner. Next, the anterior sero-muscular nodal sutures passing through the lower edge of the muscular pulp of the esophagus and the lower edge of the serous-muscular membrane of the formed mucous-submucosal area complete the formation of esophagoejunoanastomosis (Fig. 2, 3).

24-26 cm distal from the esophageal-intestinal anastomosis, the small intestinal anastomosis is laid end to side along the Ru, proximal to which the jejunum is mobilized parietal intestine 6–8 cm further for 3-4 cm. The serous-muscular membrane is dissected in the mobilized area in three sections: circular in the middle , along the edges at a distance of 1.5 cm - ellipsoid to the mesenteric edge (Fig. 4). Nodal sutures are placed on the uppermost and lowermost edges of the serous-muscular membrane, when tying them, the mobilized section of the intestine is immersed with a dissector, invaginated, and a valve is formed (Fig. 5). The resulting reservoir is laid in the direction repeating the outline of the lesser curvature of the stomach, for which the discharge loop of the intestine is displaced from the midline by 30 ^° to the right towards the duodenum and fixed with separate sutures to the parietal peritoneum of the posterior abdominal wall (Fig. 6). The operation is completed by conducting a microprobe into the jejunum below the zone of jujunoanastomosis and the probe into the formed decompression tank.

 Enteral nutrition through a microprobe up to 5-6 days after surgery is a feature of the early postoperative period.

Pulp and valve esophagoejunoanastomosis is formed to prevent reflux esophagitis. A distance of 24-26 cm from esophageojejunoanastomosis to ejunojunoanastomosis for the formation of the reservoir is chosen in order to obtain a reservoir of optimal size for the accumulation of food. End-to-side jejuno-anastomosis is performed in order to reduce the time of surgery and prevent the failure of anastomotic sutures. Making cuts of this configuration in the form of an ellipse allows you to form a valve that does not narrow the lumen of the jejunum and sufficiently prevents the accelerated evacuation of food. The offset of the abducting intestine by 30 ^o to the right of the midline contributes to a more physiological passage of food through the formed reservoir.

 According to the developed technique, 9 patients with stage III stomach cancer aged 42 to 70 years were operated on. Combined gastrectomy was performed in 7 patients (77.7%).

 In the early and late postoperative period, a comprehensive examination of patients was carried out. During endoscopic examination, an anastomosis of the esophagus with a jejunum oval in the type of "end to side" freely pass. The length of the jejunum is 14-16 cm, the folds are not changed. The invagination valve in the form of a section of the intestine with increased tone freely pass. Changes in the mucous membrane in the area of the invagination valve were not detected. Below the valve zone was determined actively peristaltic small intestine, the mucosa of its usual color, in the lumen of bile. When x-ray examination: the esophagus is freely passable. Esophagogoyunoanastomosis opens up to 1.5 cm, rhythmic motility, reflux of a contrast agent into the esophagus is not observed. Small intestinal transplant up to 16 cm, in the expanded proximal part of the gas bubble. A valve is determined 10-12 cm proximal to the esophageal-intestinal anastomosis, the intestinal lumen in this place is from 1.5 to 2.0 cm, the contrast mass was delivered to the underlying sections after 40-60 seconds in small portions. After 60-90 minutes there are traces of barium in the transplant.

 Patients ate 4-6 times a day, added 5 patients in weight by 4-8 kg, in 2 - body weight remained unchanged, 1 patient lost 6 kg. Mild dumping syndrome was detected in 1 patient, who was stopped by the use of a diet and did not require drug correction, severe manifestations of the disease were not detected. Patients' stool was regular, decorated 1-2 times a day. Coprological examination determines muscle fibers without striation.

 Clinical example: (extract from the medical history).

 Patient S., 49 years old, was in the surgical department 2.04.99 to 05/05/99 with a diagnosis of Adenocarcinoma of the cardiac section of the stomach (total lesion) stage III.

Received as planned with complaints of weight loss, dysphagia. 04/13/99 in a planned manner under general anesthesia operation - combined gastrectomy, splenectomy, hemipancreatectomy. Extended lymphadenectomy P ₃ . Sagittal diaphragmotomy. Esophagogoyunoanastomosis according to Ru in the modification of the clinic. Abdominal drainage.

 In the postoperative period, probe enteral nutrition was performed for 5 days, infusion therapy, antibacterial and anti-inflammatory therapy, and administration of a single-group plasma.

 EFGDS from 05/05/99: The esophagus is not changed, 38 cm from the incisors there is an anastomosis end to the side with the jejunum. The anastomosis is round, freely passes the tube of the apparatus 11 mm, the mucous membrane in the anastomosis is moderately hyperemic. The blind section of the jejunum is without features. A loop of jejunum was examined up to 20 cm. There is a valve 16-17 cm distal to the esophageojunoanastomosis, the latter is closed, the tube of the apparatus passes freely, the mucosa in the valve area is without features.

 When x-ray examination: the esophagus is freely passable. Esophagogoyunoanastomosis opens up to 1.5 cm, rhythmic motility, reflux of a contrast agent into the esophagus is not observed. Small intestinal transplant up to 16 cm, in the expanded proximal part of the gas bubble. A valve is determined 10-12 cm proximal to the esophageal-intestinal anastomosis, the intestinal lumen in this place is from 1.5 to 2.0 cm, the contrast mass was delivered to the underlying sections after 40-60 seconds in small portions. After 60-90 minutes there are traces of barium in the graft.

 Thus, the proposed method reduces the number of postoperative complications after gastrectomy, prevents the development of dumping syndrome, especially in patients with severe cancer, when the primary eunogastroplasty is not indicated due to the patient’s serious condition and when the tumor spread to the duodenum.

Sources of information used in compiling the description
1, Polyakov M. A. On combined gastrectomy with the formation of an artificial stomach according to a new technique // Tomsk State University Journal. chir. -1984. -t. 132.-N3.- p. 33-36.

 2. Shalimov A. A., Saenko V. F. Digestive tract surgery. K .: 3dorov'ya.-1987.-568 p.

Claims (1)

A method for the prevention of dumping syndrome after gastrectomy, including upper middle laparotomy, gastrectomy, the application of esophagus and jujunoanastomoses and the formation of a reservoir for the accumulation of food from the jejunum, characterized in that pulsed-valve esophagoejunoanastomosis is formed, and distally 24 end-to-side jejuno-anastomosis, wherein the food storage reservoir is formed from the discharge loop of the small intestine, for which a serous-muscular obole is dissected proximally by 6-8 cm ku intestine three slits middle circularly around the edges ellipsoobrano to mesenteric edge, the uppermost and lowermost edges sero-muscular coat applied nodal joints, forming a valve, then the portion of the jejunum, including the resulting reservoir is placed by shifting from the midline 30 ^o to the right towards the duodenum and hem with separate sutures to the parietal peritoneum of the posterior abdominal wall.

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