RU2228149C1 - Surgical method for treating the cases of intestinal fistulas - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves exposing intestine ends from abdominal wall tissues. They are mobilized from commissures without penetrating into free abdominal cavity with partitioned space being formed. Anastomosis is built by means of single-row suture and immersed into the formed space. Drainage is set. Suture line is irrigated via micro irrigator with fibrinolysis inhibitors 3 times a day during 3 days. EFFECT: enhanced effectiveness in prevented suture inconsistency. 1 tbl

Description

The invention relates to medicine, namely to abdominal surgery, and can be used in the treatment of double-barreled loop, double-barreled separate and parietal fistulas of the small and large intestine.

When performing surgery on the colon, when it is impossible to impose a primary anastomosis or to protect it, the operation is completed by the formation of an artificial intestinal fistula (stoma) [1]. The modern surgical classification according to the anatomical structure divides them into marginal (parietal), double-barreled loop, double-barreled separate and single-barreled; according to localization - ileostomy and colostomy [2].

The number of patients with intestinal fistula increases annually [3].

In this regard, operations that are accompanied by the formation of an intestinal fistula, further provide for the restoration of the natural continuity of the digestive tract [4]. In this matter, various surgical schools have different points of view on the implementation of surgical operations in terms and methods. In addition, some offer extraperitoneal recovery methods, while others prefer intraperitoneal. Each of the surgical schools provides a reasoned justification for the implementation of its technology [5].

Meanwhile, recovery operations are accompanied by a large number of complications. The most formidable, life-threatening complication is the failure of the anastomosis formed during the recovery operation, leading to a severe purulent-septic condition (diffuse peritonitis, sepsis, etc.), fatal cases [1, 6].

Thus, the development of a more advanced technology for recovery operations is relevant, and finding additional methods and techniques to prevent the failure of the joints of the anastomosis and spilled peritonitis is of great practical importance.

A known method of extraperitoneal plasty of intestinal fistula according to Vitsin [5]. The methods are as follows: make two bordering incision, penetrating to the intestinal wall. The intestinal wall is separated and pulled into the wound. A ligature is placed on the base of the fistulous passage, and if this cannot be done, the edges of the fistula are brought together with a cruciform suture. Around the fistula so closed, one purse string suture is applied, then another. The intestinal wall is covered with muscles from above and sutured to the skin. A rubber graduate is placed in the subcutaneous tissue for 2 days.

However, externalization of the intestine beyond the abdominal cavity is unphysiological. Unable to fix spur. It is impossible to eliminate interintestinal kinks and adhesions, which leads to acute or chronic intestinal obstruction. The intestinal loop with the formed anastomosis is placed in the tissues of the abdominal wall, which disrupts the motility of the intestine. The conditions for relapse of the fistula are created.

A known method of intraperitoneal closure of the fistula with circular resection of the intestinal loop carrying the fistula, according to Billroth [5]. The method is as follows: two semi-oval cuts around the fistula cut through the skin and provisional sutures applied to the skin, close the fistula to prevent infection of tissues and the abdominal cavity. Aponeurosis, muscles and peritoneum are dissected from the same incision. After opening the abdominal cavity under the control of a finger inserted into the abdominal cavity, carefully dissect the tissue around the intestinal loop carrying the fistula. An intestinal loop carrying a fistula is brought out of the wound and a resection is made within a healthy unchanged intestine. Patency restore anastomosis end to end. The abdominal cavity is sutured tightly.

In the event of inconsistency of intestinal sutures, spilled peritonitis will occur, which requires repeated surgical treatment with the formation of a new intestinal fistula. There is no possibility of drug exposure to the suture line in order to prevent anastomosis insolvency. The intestinal loop with the formed anastomosis under the influence of peristalsis can migrate to other parts of the abdominal cavity, since its fixation is not provided, which does not exclude the formation of acute intestinal obstruction by the type of strangulation.

There is a method that is transitional between intraperitoneal and extraperitoneal methods of closing intestinal fistulas, proposed by Brown [6]. The method is as follows: after dissection of the tissues around the fistula, the soldered intestinal loop is separated, if possible without opening the abdominal cavity. When the leading and outlet knees are sufficiently separated, they are sutured together by serous-serous sutures. Then, starting from the fistula and slightly departing from the superimposed row of sutures, parallel incisions are made in both knees of the intestine through all layers of the intestinal wall and the posterior, second row of sutures is applied. Suturing of the wide anastomosis obtained in this way is completed by applying the front row of sutures to two floors. The stitched intestinal loop sinks into the wound and the abdominal wall is sutured tightly.

This technology of closing the fistula in most cases is accompanied by the opening of the abdominal cavity. It does not exclude relapse to the abdominal wall or into the abdominal cavity. A wide anastomosis reduces the likelihood of obstruction in the obstructive type, but the side-to-side anastomosis, and even the antiperistaltic type, is unphysiological and increases the likelihood of developing anastomosis suture failure several times. There is no possibility of affecting the seam line to prevent its failure.

A known method of surgery for lip-shaped fistulas of the small intestine in the modification of Gakker-Janelidze [7]. The method is as follows: first, a laparotomy is performed away from the fistula, from this access the small intestine is crossed, an anastomosis is formed, and then a fistula is excised, stitching the wound in layers.

However, two laparotomic wounds are located on the abdominal wall, and the risk of suppuration increases by 2 times. The operation is difficult to perform. Additional viscerolysis causes extensive trauma and contributes to the development of postoperative intestinal paresis. When anastomotic suture inconsistency occurs, diffuse peritonitis develops, requiring repeated surgery.

There is a method of surgical treatment of double-barreled intestinal fistulas [8]: magnetic plates in the selicon membrane are introduced into the formed intestinal stoma, into the leading and outlet loops, and fixed on the common wall of the intestinal stoma. As a result of magnetic compression, a lateral magnetic compression anastomosis is created for 4-6 days, which allows the disabled section of the intestine to begin to function. Then, after 3-4 weeks, surgery is carried out aimed at closing the double intestinal stoma and anastomosing the adducting and diverting intestinal loops. Two bordering incisions excise the external opening of the double intestinal stoma, the skin edges above them are sutured. The stoma is gradually phased out from the tissues of the anterior abdominal wall, and the abdominal cavity is opened. After determining the exact localization of the lateral magnetic compression anastomosis with a Scalpel-1 laser beam, the distal stoma is resected together with a part of the magnetic compression anastomosis. Then, an atraumatic needle imposes a first row of continuous catgut suture and a second row of individual nodular silk sutures on the terminal anastomosis. The patency and tightness of the formed end-lateral inter-intestinal anastomosis are controlled.

The formation of a lateral magnetic compression anastomosis begins at the end of 2 weeks, against the background of ongoing inflammatory reactions in the intestinal wall and tissues of the abdominal wall, which can lead to its failure. In the event of inconsistency of intestinal sutures, diffuse peritonitis occurs. There is no possibility of affecting the seam line to prevent its failure.

The closest analogue taken as a prototype is the method of reconstructive surgery for double-barreled intestinal fistula [6]: the operation begins with careful closure of the colostomy with interrupted silk sutures. An oval skin incision is made around the sutured colostomy. The inner edges of the skin wound are sutured over the colostomy. A gauze strip moistened with a disinfectant solution is tied to these seams. Muscles and aponeurosis are cut around the colostomy. After additional coating of the layers of the anterior abdominal wall with gauze napkins, the peritoneum is opened in the most free place and dissected around the colostomy. Dissections around the intestine are dissected in order to free it for a future anastomosis. Sipping on the holders, the leading and abducting sections of the colostomy are mobilized for 5-6 cm in both directions. If the posterior wall of the colostomy was preserved, then after excision of its edges, the intestine is sutured together with a skin flap with the formation of anastomosis 3/4 according to Melnikov. More often, the back wall of the colostomy after Mikulich’s operation is so scarred that it cannot be saved and you have to make a circular resection of the intestine along with the colostomy within the same intestinal wall. An anastomosis is formed according to the type of end to end double-row sutures. The wound is restored in layers tightly.

The creation of a double-row end-to-end anastomosis makes the anastomosis less wide, which increases the intestinal pressure and increases the likelihood of insolvency. In the case of inconsistency of intestinal sutures, the possibility of the development of diffuse peritonitis is not excluded, which will require repeated surgical treatment with the formation of a new intestinal stoma. The absence of wound drainage does not allow for the prevention and early diagnosis of purulent postoperative complications. There is no possibility of drug exposure to the suture line in order to prevent anastomosis insolvency.

To reduce the likelihood of developing anastomotic insolvency, and in case of its occurrence, preventing the development of spilled fecal peritonitis, after isolating the ends of the intestine from the tissues of the abdominal wall, they are freed from adhesions, with the formation of a delimited space that does not communicate with the free abdominal cavity, an intestinal resection is performed, impose anastomosis end to end using a single-row continuous serous-muscular-submucosal suture, immerse the intestine in the formed space, establish drainage and micro an orrigator for the introduction of fibrinolysis inhibitors; the wound is sutured in layers.

The method is as follows: after treatment of the skin, the abducting and adducing parts of the intestine with an antiseptic solution, the two ends bordering the semi-oval incisions secrete the ends of the fistula until aponeurosis. Then the inner edges of the skin wound are sutured over the fistula with nodal nylon sutures and a gauze strip with an antiseptic is tied with the same sutures. After that, the fistula is continued to the peritoneum, preserving the unchanged tissues of the anterior abdominal wall as much as possible. They cover the abdominal wall layers with napkins and dissect the peritoneum under visual control as close to the fistula as possible.

The adducting and abducting intestines are isolated from adhesions minimally enough to form an anastomosis without penetrating into the free abdominal cavity and thus forming a delimited space around the future anastomosis that is not communicating with the free abdominal cavity. When such a message occurs, it is sutured.

An economical marginal resection of the intestine is performed, and with a pronounced cicatricial process of the intestinal wall, an economical circular resection is performed.

Anastomosis is imposed by a single-row continuous serous-muscular-submucosal suture and immersed in the created space. Drainage and microirrigator are brought to the seam line.

The abdominal wall is sutured in layers. Apply an aseptic dressing.

In the postoperative period, to prevent anastomotic insolvency, the suture line is irrigated through a microirrigator with a 5% solution of epsilon-aminocaproic acid at a dose of 3.0 ml, three times a day, for 3 days, after which the microirrigator is removed. At the same time, they constantly monitor the discharge through the drainage, which is removed no earlier than 8 days.

When signs of insolvency appear (drainage causes discharge of intestinal admixture), 2-3 sutures are removed from the skin and the wound is dilated, providing drainage of the discharge. Wound sanitation is performed with antiseptic solutions and water-soluble ointments (Levomikol, Levosin) until the wound is completely healed.

The method compared with the prototype and analogues has the following advantages:

- the formation of a delimited space around the anastomosis allows you to:

- perform reconstructive surgery intraperitoneally, which is more physiological than extraperitoneal abandonment of the intestine, however, it allows to delimit the applied anastomosis from other parts of the abdominal cavity, which in case of failure of the sutures of the anastomosis protects against the development of diffuse peritonitis;

- allows you to topically administer drugs with the aim of local drug exposure on the suture line.

- Anastomosis impose a single-row continuous serous-muscular-submucosal suture:

- a single-row anastomosis is wider, which improves the patency of intestinal contents through it, improves decompression of the anastomosis;

- performed technically uncomplicated, more quickly superimposed;

- less biologically permeable, provides the most rapid healing, which reduces the likelihood of suppurative complications in the postoperative period.

- Prevent anastomotic suture inconsistency due to

- medication in the postoperative period directly on the suture line with fibrinolysis inhibitors;

- the imposition of a wider and more physiological single-row anastomosis;

- due to the economical regional resection of the intestine, the size of the bowel defect is reduced and, as a result, the length of the seam is reduced.

- Due to the presence of drainage, early diagnosis of complications (failure of anastomotic sutures) is provided.

The proposed method for the period 2001-2002 31 patients aged 18 to 83 years were treated. The results of treatment in comparison with the literature [1, 6] are presented in the table.

Case Studies

1. Patient K., 32 years old, IS No. 9528, was admitted to the proctology department of the OKB with DS on 03.06.02: a double-barreled separate sigmostoma. From the anamnesis: 02/08/01, for sigmoid colon cancer T4NOMO complicated by chronic obstructive colonic obstruction in the stage of subcompensation, a resection of the sigmoid colon was performed with a double-barreled separate sigmoid.

After the examination, there is no evidence of cancer recurrence; the adductor and abductor are in satisfactory condition.

06/11/02, a reconstructive operation was performed: after treatment of the skin, the abducting and adducing parts of the intestine with an antiseptic solution, the ends of the intestine were separated by two bordering semi-oval sections before aponeurosis. Then, the inner edges of the skin wound were sutured over the fistula by nodal nylon sutures, and a gauze strip with an antiseptic was tied with the same sutures. After this, a fistula was isolated to the peritoneum and after additional covering with layers of abdominal wall tissues, the peritoneum was dissected under visual control. The adducting and abducting intestine was mobilized from adhesions by 3 cm without penetrating into the free abdominal cavity, forming a delimited space that did not communicate with the remaining parts of the abdominal cavity. An economical circular edge resection was performed with the anastomosis superimposed by a single-row continuous serous-muscular-submucosal suture with an atraumatic thread PHA No. 4-0. Anastomosis was loaded into the created delimited cavity. A drainage and microirrigator will be installed to the seam line. The wound was sutured in layers.

Within 3 days, a 5% solution of epsilon-aminocaproic acid in a dose of 3.0 ml was injected into the microirrigator, after which the microirrigator was removed. Drainage was removed on day 8. Sutures were removed on the 10th day. The postoperative period without complications. The patient was discharged in satisfactory condition on the 11th day after the operation.

2. Patient T., 73 years old, IS No. 18757, was hospitalized 12.11.01 in the proctology department of the OKB with DS: double-barreled separate ileotransversostoma. From the anamnesis: 05/31/01, for cecum cancer T3N0M0, complicated by chronic anemia of complex genesis, severe severity and chronic obstructive colonic obstruction in the stage of compensation, a right-sided hemicolectomy with a double-barreled or transversal stoma was performed.

After the examination, there is no evidence of cancer recurrence; the adductor and abductor are in satisfactory condition.

11/30/01 performed the operation according to the method described above.

On the 7th day, the patient had an admixture of intestinal discharge from the wound. The patient's condition is satisfactory. There are no signs of peritonitis.

2 seams were removed from the skin. The wound is divorced. Every 3 hours, the wound was sanitized with a solution of furatsilina and ointment “Levomikol” was administered. Against the background of treatment, the wound healed by secondary intention for 21 days after surgery.

Sources of information

1. Agavelyan A.M., Shakhnazaryan K.L. Plastic reconstructive surgery in coloproctology // Abstracts of the 5th All-Russian conference with international participation “Actual problems of coloproctology”. - Rostov-on-Don, 2001 .-- p.5-6.

2. Vorobiev G.I., Tsar'kov P.V. The basics of intestinal stoma surgery. -M.: Stolny Grad Publishing House CJSC, 2002. - 160 p.

3. Glubeva M.Yu., Alexandrov VB Problems of rehabilitation of ostomy patients // Abstracts of the 5th All-Russian conference with international participation “Actual problems of coloproctology”. - Rostov-on-Don, 2001. - p.20

4. Grigoriev EG, Nesterov IV, Pak V.E. Surgery colostomy patient. - Novosibirsk: Nauka, 2001 .-- 119 p.

5. Vitsin B.A., Blagitko E.M. Formed and unformed external intestinal fistulas. - Novosibirsk: Nauka, 1983 .-- 142 p.

6. Clinical Operative Coloproctology: A Guide for Physicians / Ed. Fedorova V.D., Vorobyova G.I., Rivkina V.L. - M .: SSCK proctology, 1994 .-- 432 p.

7. Bogdanov A.V. Digestive tract fistula in the practice of a general surgeon. - M.: Mokeev, 2001 .-- 160 p.

8. Patent 2018266 RU, IPC A 61 B 17/00. The method of surgical treatment of double-barreled intestinal fistula / Tsap N.A., Odinak V.M .; Sverdlovsk Medical Institute. - No. 4667035/14. Stated March 27, 89. Publ. 08/30/94. Bull. No. 16. - 4 p.

Claims (1)

A method of surgical treatment of intestinal fistulas, including the isolation of the ends of the intestine from the tissues of the abdominal wall, their mobilization from adhesions, anastomosis, drainage, layered wound closure, characterized in that the mobilization is performed without penetrating into the free abdominal cavity, with the formation of a delimited space, the anastomosis is applied using a single-row suture and immersed in the formed space, establish a micro-irrigator and irrigate the suture line with fibrinolysis inhibitors 3 times a day for 3 days.