RU2208401C2 - Method for developing esophagealintestinal anastomosis - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: the method deals with treating gastric cancer. One should apply the first row of posterior sutures between esophagus and small intestine at 20-25 mm against distal esophageal end. Then one should suture lateral esophageal surfaces and those of mesenteric-free part of small intestine at the distance of 20-25 mm up to the end of esophagus and small intestine. The second row of sutures is applied between esophagus and small intestine. Excessive part of anterior intestinal wall is dissected with oval incision. The first row of sutures of anterior wall is applied. Then esophageal stump is put into small intestine due to the second row of sutures of anterior wall. The present innovation enables to increase reliability of anastomosis and develop anti-reflux mechanism. EFFECT: higher efficiency. 5 dwg, 1 ex

Description

 The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of stomach cancer.

 To date, the most serious and most frequent complication after gastroectomy and proximal resection of the stomach remains the failure of the sutures of the esophageal-intestinal anastomosis, leading to death in 50-70% of cases.

 In order to improve the healing conditions of the anastomosis, many methods have been proposed for performing the esophageal-intestinal anastomosis, aimed at creating optimal conditions for its healing and preventing suture failure.

 A known method of forming an esophageal-intestinal anastomosis, including the formation of a two-row / posterior and anterior / expansion suture, holding a thick probe under the control of the fingers, followed by tightening the back, then the front rows of expansion sutures (Surgery, 1986, 4, p. 69-71, " Formation of the esophageal-gastric / intestinal / anastomosis using N. I. Blokhin's expanding suture. "

 The disadvantage of this method is the difficulty in execution, the uneven immersion of the esophagus in the intestine, which leads to the failure of its sutures.

 The closest to the achieved result / prototype / is a method of forming an esophageal-intestinal anastomosis, including the creation of invagination of the anastomosis with the help of holders held in the lumen of the intestine 150 mm from its edge with a puncture outward, when pulling the holders, the esophagus is invaginated into the intestine 20-25 mm (K.N. Tsatsanidi. "Modification of invagination of the esophageal-intestinal and esophageal-gastric anastomoses after gastrectomy and cardia resection. - Dis. Cand. Sc. Medical Sciences, Moscow, 1965).

 The disadvantage of this method is the difficulty in execution, the uneven immersion of the esophagus into the intestine due to the uneven tension of the holding threads.

 A positive result of the proposed method is to simplify the method and increase the reliability of the anastomosis by eliminating the inconsistency of the sutures, creating an antireflux mechanism and forming an artificial stomach that excludes dumping syndrome.

 A positive result is achieved by the fact that ribs are formed proximally from the edge of the mesentery of the intestine over 20-25 mm, which eliminates the uneven immersion of the inner and middle cylinders, strengthens the anastomosis.

 The method is as follows.

 The patient is placed on the operating table, a roller is placed under the back at the level of the xiphoid process. The operating field is treated according to Grossikh, an upper midline laparotomy is performed with a belly button around the left and down by 30-40 mm. The wound is expanded with Seagal expanders, the stomach with a large and small omentum is mobilized. The duodenum 12 is flashed with the UO-40 apparatus with the intersection and ligation of the vessels of the stomach and glands, cut off from the stomach. The stump is immersed in two half-kits and 3-shaped seams. A clamp is applied to the esophagus, the stomach is cut off from the esophagus and removed.

 To form the esophageal-intestinal anastomosis, the initial section of the jejunum is mobilized at a distance of 100 mm from the tracheal ligament with the intersection of 1-2 radial vessels and the dissection of the abdominal mesentery. Throughout 40 mm the wall of the jejunum is separated from the mesentery, the UO-40 apparatus is proximally placed, leaving 30 mm of the skeletonized jejunum. Sew two times with the UO-40 device and cross between the seams. A distal stump of 30 mm without a mesentery with intramural blood circulation is obtained, two filaments of holders are applied to it. The intestine thus prepared is passed through a window made in the mesentery of the transverse colon and is positioned so that the mesentery of the small intestine is on the right. Using the clamp on the esophagus and thread-holders on the small intestine, the posterior surfaces of the anastomosed organs are brought together. At a distance of 20.50-30 mm from the clamp on the esophagus and at the place where the stump of the mesentery of the small intestine begins (Fig. 1), the posterior row of serous-muscular sutures is formed. Two sutures fix the edges of the esophagus and intestines and two more sutures between them at the same distance strengthen the back wall of the anastomosis. After that, on the edges of the wall of the esophagus and intestine impose three sero-muscular sutures (Fig.2) over a length of 20-25 mm in the proximal direction. The ribs of the anastomosis are formed, thereby eliminating the uneven immersion of the inner and middle cylinders, strengthening the anastomosis and unloading the inner and outer seams. Edge threads take on the clamps. open the lumen of the esophagus below the clamp and at the same level open the back wall of the small intestine / length from the opened lumen of the small intestine to the stump of the mesentery of the small intestine is 20-25 mm, which corresponds to the length of the stump of the esophagus /. Rare interrupted sutures are applied through all layers of the anastomosis of the posterior wall. The anterior wall of the intestine has an excess, which is excised with an oval incision above the posterior wall by 15 mm (Fig. 3). Form the first row of the front wall (figure 4) with rare interrupted sutures through all layers. The second row of the anterior wall invaginates the stump of the esophagus into the intestine, creating an invagination anastomosis. It starts from the left edge: the needle is injected at the level of the stump of the mesentery of the small intestine in the transverse direction with the capture of the serous-muscular layer, the second injection is 20 mm from the esophageal stump in the transverse direction with the capture of the serous-muscular layer. When tying the knot, the outer edge of the anastomosis is screwed into the lumen of the small intestine. The line formed on the front wall of the small intestine shows where to inject the needle into the intestine. A needle is injected along this line, a second injection on the esophagus is similar to the previous one. Such sutures are imposed 5-6. An excess of the anterior wall of the small intestine allows the esophagus to be immersed in the intestine to a depth of 20-25 mm without tensioning the external joints. An invagination anastomosis is created, its patency is checked by holding a thick gastric tube through it. At its completion, it is seen (Fig. 5) that the outlet part of the small intestine does not go vertically down to the anastomosis along the Ru, but is located to the left at a distance of 100 mm, then goes down and to the right to the place of the formation of the anastomosis along the Ru due to the mesentery of the small intestine. Figure 6 illustrates the final stage of the operation - a view of the incision formed esophageojejunostomy.

Clinical example
Patient P., 40 years old, was admitted with complaints of poor appetite and weight loss of up to 6 kg. With esophagogastroscopy "the esophagus is freely passable, in the body of the stomach the mucous membrane is infiltrated, bumpy, dense. Histological diagnosis: Cricoid-cell carcinoma.

 An operation was performed from laparotomic access with a navel bypass left and down. During the audit: the tumor affects the body of the stomach, dense, bumpy. Regional lymph nodes are not enlarged. Gastrectomy performed. Formed invagination esophagoyunoanastomosis according to the proposed method.

 Discharged from the hospital on the 12th day after the operation in satisfactory condition. Examined after 6 months. Complaints of dysphagia, burning behind the sternum, no pain. When FGC found that the mucous membrane of the esophagus throughout the pink, there are no signs of esophagitis. Esophagogoejunoanastomosis well pass. When fluoroscopy: barium suspension passes freely and portionwise enters the discharge intestine from an artificial stomach formed 100 mm from the anastomosis. Abduction gut b / o. In the Tendeleburg position, there is no leakage of contrast mass into the esophagus.

 A control examination of patient P. was performed after 12 months, 24 months from the time of the operation. With FGDS, X-ray examination of data for dumping syndrome, reflux esophagitis is not.

 Thus, the formation of ribs (stitching the edges of the small intestine of the esophagus at a distance of 20-25 ml) eliminates the uneven immersion of the inner and middle cylinders, thereby strengthening the anastomosis and unloading the inner and outer sutures. The imposition of rare sutures does not cause a violation of the blood supply to the tissues in the anastomosis. The outer row of sutures, applied at the level of the stump of the mesentery of the small intestine, where there is good blood supply to the walls of the small intestine due to the direct vessels of the mesentery, causes its rapid adhesion and healing, preventing its failure. The "non-spill" ink design creates an antireflux mechanism. The resulting bend to the left for 200 m forms an artificial stomach that excludes dumping syndrome.

Claims (1)

 A method of forming an esophageal-intestinal anastomosis, including the creation of invaginate in the intestine by 20-25 mm, characterized in that the first row of posterior sutures is placed between the esophagus and small intestine at a distance of 20-25 mm from the distal end of the esophagus and at the level of the mesentery of the small intestine, then the lateral surfaces of the esophagus and mesenteric portion of the small intestine are sutured for 20-25 mm to the end of the esophagus and small intestine, after which a second row of back sutures is placed between the esophagus and small intestine, an excess of the anterior wall is excised with an oval cut ishki and superposed first row of stitches of the front wall, immersing esophageal stump into the small intestine via the second series of seams of the front wall.

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