RU2149588C1 - Method for doing ureteroileosigmostomy - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making urinary reservoir from an isolated terminal segment of the ileum. Anastomosis between the reservoir and the sigmoid colon is built. Invagination valve is created in the terminal segment of the ileum. The ileum is transected proximal to the valve and anastomosed to the side of the rectosigmoid segment of the colon. The ileum is stopped up distal to the valve. An area is formed from mucosubmucous layer of the ileum, a rectangle from the seromuscular layer being removed. The mobilized ureters are attached to the area. The ureter ends are anastomosed with single rowed interrupted sutures in the center of the area. Ileum continuity is restored by means of end-to-end anastomosis. EFFECT: reduced number of postoperative complications. 16 dwg

Description

 The invention relates to medicine, specifically to surgery, and relates to methods of ureteroileosigmostomy.

 There are various methods of ureteroileosigmostomy [1, 2], which consist in the formation of various types of urinary reservoirs from the ileum segment and its anastomosis into the colon, but not one of them is able to completely prevent the reflux of feces and colon gases into the ureters. Moreover, reflux fecal pyelonephritis and, as a result of secondary infection of the upper urinary tract, chronic renal failure, have a significant impact on the completeness of the social, labor and medical rehabilitation of the operated population, and in some patients they are even the cause of death [2].

 The closest prototype is the method of ureteroileosigmostomy proposed by Higgi [1]. Technique of operation. After a laparotomy, a urinary reservoir is formed: retreating 15 cm from the cecum, a 20 cm long segment of the intestine is isolated in the terminal ileal loop. In this case, the ileum is restored by anastomosis end to end. The proximal end of the isolated segment is sutured, and the distal one is freed from the mesentery by 6-7 cm. Clamp the mucous membrane, turn it outward at a distance of 5 cm and hem it to the serous membrane, forming a nipple. The formed urinary reservoir is anastomosed into the sigmoid colon: on the sigmoid colon, slightly above the cape of the sacrum, an incision is made and the inverted nipple is sutured into the lumen of the sigmoid colon. Ureteroileoanastomosis is applied: the ends of the ureters anastomose into the side of the isolated segment of the ileum (Fig. 1).

 This method has several disadvantages.

 A 20 cm long urinary reservoir has a sufficiently large suction surface, which increases the risk of complications associated with urine reabsorption of the ileo-graft mucosa. Isolation of the ureters and segment of the ileum from fecal reflux is not possible due to the weakness of the areflux mechanism in the form of a nipple. Even Higgi himself emphasizes that “the formation of the nipple in the ureteroileosigmostomy technique only helps to some extent prevent gross reflux of feces and gases into the isolated segment of the intestine and ureters of the nipple” (cited in [1]). Inevitably, with such an ureteroileoanastomosis (free communication of the ureters with the lumen of the reservoir), the peristaltic wave of the urinary reservoir itself, leading to an increase in intra-intestinal pressure, will be a provoking factor in the development of intestinal-ureteral reflux. The absence of a restraining mechanism in the formed urinary reservoir (segment of the ileum) contributes to the constant flow of urine into the colon, thinning stools, more frequent stools and the appearance of tenesmus in the intervals between bowel movements.

 The problem solved by the proposed invention is to reduce the number of complications after ureteroileosigmostomy due to the formation of an antiperistaltic urinary reservoir from the ileum segment with an invagination areflux valve in its lower third and invagination ureteroileoanastomosis.

 The task is achieved by the method of ureteroileosigmostomy, including the creation of a urinary reservoir from an isolated segment of the terminal ileum loop and anastomosis of the reservoir into the sigmoid colon: at a distance of 25-30 cm from the cecum, an invagination valve is formed in the terminal ileum loop in the antiperistaltic direction, 2-3 proximal to the valve see the oral loop of the intestine cross and anastomose in the side of the rectosigmoid colon, distal to the valve by 8-9 cm anastomosed pet th gut choke; restoration of continuity of the terminal loop of the ileum with an anastomosis end-to-end, by application of an invagination ureteroileoanastomosis: in the proximal part of the anti-mesenteric edge of the muffled reservoir loop, a site is formed from the submucosal-mucous layer of the intestine by separating and removing the serous-muscular layer in the form of a serous-muscle layer in the form of a rectangle with vertices at the top holders located along the length of the intestine with a size of 1-1.5 by 2.5-3 cm, mobilized ureters are fixed with single interrupted sutures to the prok to the imperial edge of the site at a distance of 1.2-1.5 cm from their free end, the ends of the ureters are anastomosed with single-row interrupted sutures in the center of the site on the ureter catheters through the ureteroileosigmoanastomosis into the anus, invagination sutures are placed on the distal and proximal edges of the submucosa, which tighten while immersing the intestinal wall with the dissector in the abduction direction.

 New in the invention is that at a distance of 25-30 cm from the cecum in the terminal ileal loop, an invagination valve is formed in the antiperistaltic direction, the intestinal loop of the intestine is intersected and anastomosed 2-3 cm proximal to the rectosigmoid colon, distal to the valve 8–9 cm of the anastomosed loop of the intestine is plugged, in the proximal part of the anti-mesenteric edge of the plugged loop of the reservoir, invagination ureteroileoanastomosis is applied, for this, a platform of submucous membranes is formed hundred-mucous layer of the intestine by separating and removing the serous-muscular layer in the form of a rectangle with peaks in the area of previously superimposed filament-holders located along the length of the intestine with a size of 1-1.5 by 2.5-3 cm, mobilized ureters are fixed with single nodular sutures to the proximal edge of the site at a distance of 1.2-1.5 cm from their free end, the ends of the ureters are anastomosed with single-row interrupted sutures in the center of the site on the ureter catheters through the ureteroileosigmoanastomosis into the anus, to the distal and proxima ny edge submucosa superimposed platforms invaginated seams which are tightened simultaneously immersing dissector intestine wall in offtake direction.

 The method is as follows. Under endotracheal anesthesia at a distance of 25-30 cm from the cecum in the terminal loop of the ileum, an invagination valve is formed in the antiperistaltic direction (Fig. 2) according to the following procedure (3): 3-4 mesenteric vessels are parietally ligated. In the middle of the mobilized section of the intestine, the serous-muscular membrane is circularly dissected. Above and below this incision, another 15 incisions of the serous-muscular membrane of the intestine are made by 15-20 mm. In this case, the incision, starting from the mesenteric edge, expanding, goes to the anti-mesenteric edge, i.e. this section describes an ellipse-like figure. Nodal sutures are applied to the upper and lower edges of the serous-muscular membrane. Alternately tying sutures and additional immersion of the intestinal wall form a valve. Proximal to the valve by 2-3 cm, the oral loop of the intestine is crossed and anastomosed into the side of the rectosigmoid part of the colon in the antiperistaltic way (oral end) (Fig. 3). Distant to the valve by 8-9 cm, the anastomosed loop of the intestine is drowned out (Fig. 4). The continuity of the terminal loop of the ileum restore anastomosis end to end. The pelvic part of the ureters is mobilized over 3-4 cm from the place where they flow into the bladder, where they are crossed and intubated with ureteral catheters to the pelvis (Fig. 4). In the proximal part of the anti-mesenteric margin of the reservoir, invagination ureteroileoanastomosis is applied. To do this, a platform is formed from the submucosal-mucous layer of the intestine by separating (Fig. 4) and removing (Fig. 5) the serous-muscular layer in the form of a rectangle with vertices in the region of previously superimposed filaments-holders (Fig. 4) located along the length of the intestine with a size of 1-1.5 by 2.5-3 cm. The ureters are fixed with single interrupted sutures to the proximal edge of the site at a distance of 1.2-1.5 cm from their free end (Fig. 6). The ends of the ureters are anastomosed with single-row interrupted sutures in the center of the site (Fig. 6) on the ureteric catheters carried through the ureteroileosigmoanastomosis into the anus. Invagination sutures are placed on the distal and proximal edges of the submucosal area (Fig. 7), which tighten, while immersing the intestinal wall with a dissector in the outlet direction, forming a valve ureteroileoanastomosis (Fig. 8, 9).

 The formation of the urinary reservoir from the terminal segment of the ileum, which is less sensitive to concentrated hyperosmolar solutions, 10-12 cm long and anastomosing it into the rectosigmoid section allows to “reduce” the contact surface of the mucosa with urine as much as possible. Taking into account the reduced risk of urine reabsorption due to destruction of the villous structure of the mucosa and the appearance of a protective layer of mucus [4], the antiperistaltic nature of the graft and the restraining function of the valve potentiate the reservoir function of the “urinal”, decreasing the rate of urine entry into the rectum, and thereby limiting the number of bowel movements . Invagination ureteroileoanastomosis excludes intestinal-ureteral reflux, both with an increase in cavity pressure in the isolated segment due to the accumulation of urine, and with antiperistaltic waves of reservoir contraction. The width of the mesenteric edge of the intestine determines the transverse dimensions (1.0-1.5 cm) of the submucosal area for the formation of invagination ureteroileoanastomosis. The necessary height (1.2-1.5 cm) of the formed invagination anastomosis determines its reliable areflux function and depends on the length of the submucosal area (2.5-3 cm). The shape and size of the formed valve gives the reservoir a reliable areflux function, preventing the possibility of an ascending infection of a reflux nature from the first minute of the postoperative period.

 If necessary, this operation can be performed in two stages. In the first stage, it is advisable to form an isolated segment of the intestine with an invagination valve and anastomose it into the rectosigmoid section, and in the second stage, a cystectomy with the creation of an invagination ureteroileoanastomosis. The effectiveness of the two-stage method is due to the fact that by the time the postoperative intestinal paresis disappears, which is dangerous due to the development of ascending pyelonephritis, the leading loop of the valve turned off from the passage becomes freed from the contents prepared for ureteroileoanastomosis.

 The ureteroileosigmostomy method was developed in an experiment on 10 outbred dogs.

 Example. On November 27, 1996, a ureteroileosigmostomy method was performed on a mongrel dog weighing 12.7 kg.

 Under endotracheal anesthesia after laparotomy at a distance of 25 cm from the cecum in the terminal loop of the ileum, an invagination valve was formed in the antiperistaltic direction according to the following procedure: 3 mesenteric vessels are parietally ligated. In the middle of the mobilized section of the intestine, the serous-muscular membrane is circularly dissected. Above and below this incision, 16 more two incisions are made of the serous-muscular membrane of the intestine. In this case, the incision, starting from the mesenteric edge, expanding, goes to the anti-mesenteric edge, i.e., this incision describes an ellipse-like figure. Nodal sutures are applied to the upper and lower edges of the serous-muscular membrane. By alternately tying sutures and additional immersion of the intestinal wall, a valve is formed. Proximal to the valve by 3 cm, the oral loop of the intestine was stitched with the UKL-40 apparatus and crossed. Then it was anastomosed into the side of the rectosigmoid part of the colon by the antiperistaltic method (oral end) using the continuous submucosal-mucous suture technique on the inner row of sutures and nodal joints on the outer one. The anastomosed ileal loop was flashed with the UKL-40 apparatus and drowned 8–9 cm distally from the valve. The terminal loop was continuous with anastomosis end-to-end. The pelvic part of the ureters was mobilized over 4 cm from the place where they flow into the bladder, where they were crossed and intubated with ureteral catheters to the pelvis. In the proximal part of the anti-mesenteric margin of the reservoir, invagination ureteroileoanastomosis was applied. To do this, a platform was formed from the submucosal-mucous layer of the intestine by separating and removing the serous-muscular layer in the form of a rectangle with vertices in the area of previously superimposed filament-holders located along the length of the intestine with a size of 1.5 by 3 cm. The ureters were fixed with single nodal sutures to the proximal edge of the site at a distance of 1.5 cm from their free end. The ends of the ureters were anastomosed with single-row interrupted sutures in the center of the site on the ureteral catheters through the ureteroileosigmoanastomosis into the anus. On the distal and proximal edges of the submucosal area, invagination sutures were applied, which were tightened, while immersing the intestinal wall with a dissector in the outlet direction, forming an invagination ureteroileoanastomosis. The abdominal cavity was sutured tightly.

 In the early postoperative period, clinical tests of blood and urine were performed, and urine was collected separately from the right and left ureteral catheters. Catheters were removed by subsidence of the general inflammatory response 12 days after surgery. In the short term after the operation, we studied the change in blood biochemical parameters (creatinine, urea, residual nitrogen). Irrigography was performed to study the areflux properties of the invagination valve, and fibrocolonoscopy was performed to study the changes in the nature of the transplant mucosa.

 SURVEY RESULTS.

Blood chemistry:
When studying the dynamics of changes in urea and residual nitrogen in the blood, a tendency toward an increase in the urea in the early stages after the operation was determined, which is probably associated with protein hypercatabolism due to postoperative trauma and transplant reabsorption of urine. However, in the near future, the latter approached normal values and stabilized. Creatinine concentration throughout the study remained within normal limits.

Irrigoscopy from 12.25.96:
The method of contrast enema was used to study the colon, which quickly filled with barium suspension. At the level of the rectosigmoid region, barium was distributed within the valve apex, contrasting its outlet loop. Phenomena of barium reflux into the reservoir (into the leading loop of the valve), and even more so into the ureters, were not (Fig. 10).

Excretory urography from 4.01.97:
When performing excretory urography, the contrast of the reservoir occurred from the 7th minute, while the contrast arrived in the colon only at 35-40 minutes of the study (Fig. 11).

 The latter fact confirms the good reservoir function of the transplant, which can reduce the frequency of bowel movements up to 4-5 times a day.

Fibrocolonoscopy dated January 12, 1997:
A colonoscope was drawn 30 cm from the anus. The external and internal sphincters are closed, the rectal mucosa is ordinary. At a distance of 12 cm there is a lateral anastomosis in the form of a fold of the mucosa. 2 cm more distant than the anastomosis, the invagination valve peristals, releasing a small amount of yellow, clear urine. When air is insufflated, the valve closes, ceasing to peristaltize, but the colonoscope tube freely overcomes the valve clearance. The leading loop up to 8 cm in size with the usual pink mucosa, plentifully lined with mucus. In place of the muffled loop of the reservoir, an invagination anastomosis with transparent urine dripping from its apex.

 On the 55th day of the experiment (01/21/97) under thiopental anesthesia, the dog was withdrawn from the experiment by intracardiac injection of ether for anesthesia.

 In addition to studying the areflux function of the invagination valve of the urinary reservoir, colon hydro-compression was performed on a macrodrug (Fig. 12). Under an overpressure of 80 mmHg filled the colon with water. In this case, the liquid spread to the areflux valve, and the latter did not get beyond its limits (into the valve leading loop), nor did water flow out of the ureters, which testified to the reliable areflux function of the formed valve.

 The study of a macrodrug (Fig. 13) of the urinary system of the animal began with the kidneys. Outside, the latter were smooth, the capsule freely separated from the parenchyma. On the longitudinal section of the kidneys, there was a clear boundary between the cortical and medulla. The pyelocaliceal system does not differ from the control. The right and left ureters were tubes up to 15 cm long and up to 2-3 mm in diameter with the usual longitudinal folding of the mucosa. The latter are anastomosed into the ileograft, the invagination anastomosis is freely passable (Fig. 14, 15). The graft is fused to surrounding tissues in some places. The surface of the mucous membrane of the reservoir is smooth, covered with a layer of mucus, in its lower third an invagination valve 2.5 cm in size without signs of inflammation (Fig. 16). Anastomosis with rectosigmoid colon in the form of a fold of the mucosa is located 2 cm more distal than the valve (Fig. 16). The rectum is made of feces, the mucosa is a normal, perianal region without signs of inflammation and maceration.

 Thus, the creation of an invagination valve in the lower third of the urinary reservoir eliminates the risk of developing an ascending infection due to its reliable areflux function. The antiperistaltic nature of the graft in combination with the restraining function of the valve limits the number of bowel movements in patients with normal obstructive function of the rectum, and the invagination ureteroileoanastomosis prevents ureteral reflux in conditions of reservoir dysmotility.

List of references
1. Chukhrienko D.P., Lyulko A.V., Romanenko N.T. Atlas of urogynecological operations. - Kiev: Vishcha school, Head publishing house, 1981, p. 112 and 121.

 2. Shirokorad V.I., Kolesnikov G.P., Kopyltsov E.I. Evaluation of urinary diversion methods after extirpation of the bladder in cancer. Collection of scientific works of the Omsk garrison hospitals "220 years in the service of health" Omsk, 1997, p. 165 and 166.

 3. Copyright certificate of the USSR N 1701294, 12.30.91.

 4. Vasiliev V.V. Materials for the assessment of morphofunctional changes in the transplant under conditions of ileocystoplasty. Abstract. for a job. student step. Cand. honey. sciences. L., 1967, 16 p.

Claims (1)

 Method of ureteroileosigmostomy, including the creation of a urinary reservoir from an isolated segment of the terminal loop of the ileum with restoration of its continuity by anastomosis end to end, anastomosis of the reservoir into the sigmoid colon with the application of ureteroileoanastomosis, characterized in that at a distance of 25-30 cm from the caecum loop in the terminal the invagination valve in the antiperistaltic direction, 2 to 3 cm more oral than the valve, the oral intestine is crossed and anastomosed to the side of the rectosigmoid about the colon, distal to the valve by 8 - 9 cm, the anastomosed loop of the intestine is plugged, in the proximal part of the anti-mesenteric edge of the plugged loop of the reservoir, invagination ureteroileonastomosis is applied, for this, a platform is formed from the submucosal-mucous layer of the intestine by separating and removing the serous-muscular-muscular layer located along the length of the intestine with a size of (1 - 1.5) • (2.5 - 3) cm, mobilized ureters are fixed with single interrupted sutures to the proximal edge of the site at a distance of 1.2 - 1.5 m from their free end, ends of the single row ureters anastomosed with interrupted sutures in the center area on ureteral catheters ureteroileosigmoanastomoz drawn through the anus, and the proximal to the distal edge of submucosa superimposed platforms invaginated seams which are tightened simultaneously immersing dissector intestine wall in offtake direction.

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