RU2236181C2 - Method for surgical treatment of esophageal achalasia - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should mobilize abdominal, intrahiatus departments of esophagus, cardia, lesser curvature and bottom of the stomach by keeping stems and the main branches of vagus nerves. One should descend esophagus into abdominal cavity, perform gastrotomy along the greater curvature, introduce suturing apparatus with dissecting blade into an opening, branches of apparatus should be separated, one branch should be applied into esophagus, another one should be left at gastric bottom. One should perform incision with this apparatus at simultaneous suturing along the both edges of incision, moreover, the line of tissue dissection is located in frontal plane, and the line of suturing - in sagittal plane. The method enables to decrease destruction of smooth musculature and improve functional results of operation conducted.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to methods of operations, and can be used in surgical gastroenterology in the treatment of achalasia of the esophagus.

Esophageal achalasia is a chronic neuromuscular disease of the entire smooth muscles of the esophagus, caused by a number of reasons. It is customary to distinguish between a staged recurrent course, manifested by the absence of reflex opening of the cardia during swallowing, as well as the expansion, change in the shape of the upper sections of the esophagus, a violation of its tone and peristaltic activity, and the development of periesophagitis.

There is a significant variety of surgical and therapeutic methods for treating esophageal achalasia. Surgical treatment is carried out either by thoracotomy or laparotomy access and is divided into three groups - various types of cardiomyotomy, esophagogastrostomy above the site of stenosis and various methods of resection of the cardia. Recently, almost all methods have been supplemented with various antireflux constructs.

The effectiveness of all surgical interventions, despite the many proposed modifications (about 50), remains insufficiently high in terms of the development of complications in the postoperative period (reflux esophagitis, peptic ulcers of the esophagus, stricture), as well as relapse of the disease. All these complications grossly violate the quality of life of the operated patients, lead to disability, frequent disability, and require repeated complex operations. Thus, the development and widespread introduction of new methods of surgical treatment of achalasia of the esophagus is an urgent problem of modern gastooenterology.

A known method of surgical treatment of achalasia of the esophagus, in which Heller B (1913) (Mitt. Grenzgeb. Med. Chir. Magazine, 1913, 27, p. 141), first produced an extra-mucosal esophagocardiomyotomy. The essence of the operation is that abdominal access mobilizes the narrowed section of the esophagus and reduces it into the abdominal cavity. After that, the muscle membrane in the narrowed segment of the esophagus is longitudinally dissected along the front and rear walls to the mucous membrane.

The Dutch surgeon De Bruin-Groeneveldt (1918), slightly modifying Heller’s operation, suggested dissecting only the anterior wall of the esophagus and cardia. In this form, it began to be used by surgeons from various countries, not only by abdominal access, but also by transthoracic. Geller’s operation involves the divergence of the edges of the dissected muscles of the esophagus, the prolapse of the mucous membrane and the expansion of the narrowed lumen of the esophagus. For effectiveness, a complete intersection of all circular muscle fibers is necessary. The operation efficiency is quite high - good and excellent results are achieved in 79-91%. Mortality, according to summary data, is 0.7-1.5%. Many relapses (36-50%) and the lack of effect in 9-14%, a variety of complications in the near and distant period after Heller's operation are associated with incomplete dissection of the cardia muscles because of the danger of damaging the mucous membrane of the esophagus. Relapse occurs due to the development of a scar between the edges of the crossed muscles with the restoration of their tone.

Often after surgery, cardia failure occurs, followed by the development of reflux esophagitis and peptic esophageal strictures. Some authors consider reflux esophagitis a frequent and severe complication of Heller's surgery and find it in 14-37% of patients. Other complications also occur - peritonitis due to viewing damage to the mucous membrane of the esophagus, the formation of diverticula, bleeding from peptic ulcers of the esophagus and its cicatricial stenosis.

With the development of endovideoscopic technologies, cardiomyotomy (Heller's surgery) is preferred by a thoracoscopic or laparoscopic method with fundoplication. In the presence of a disease of 1-3 degrees, this technology has a clear advantage due to the minimum invasiveness of the intervention, but with achalasia of the 4th degree, laparoscopic execution of fundoesophageanastomosis or resection of the cardia is extremely problematic.

Known operation proposed Chernousov A. F. et al. (Surgery, 1986, N 12, p.14-19), which is an antireflux cardioplasty operation: cardiomyotomy in combination with selective proximal vagotomy (SPV) and cardia correction. At the same time, layer-by-layer skeletonization of the lesser curvature of the stomach is performed, starting slightly proximal to the place of entry into the antrum of the last branch of the anterior nerve of Laterger. After taking the esophagus onto the holder, its abdominal and intra hiatus segments are mobilized. Then mobilize the cardia and the bottom of the stomach to the spleen. In this case, the vagus nerves are carefully separated from the esophagus. In some cases, to create greater mobility of the bottom of the stomach, 1-2 short arteries are bandaged. After SPV and cardiomyotomy, the muscular defect of the esophagus is covered over the entire length with the front wall of the bottom of the stomach, imposing separate nodal sutures. Peritonize the lesser curvature of the stomach. Then, by applying 2-3 sutures between the anterior and posterior walls of the stomach with the capture of the muscular membrane of the esophagus, a fundoplication cuff is formed over 2 cm (no more) of the abdominal esophagus. The back wall of the bottom of the stomach is additionally fixed with two interrupted sutures to the posterior wall of the esophagus so that the entire mobilized section of the esophagus is half wrapped around the walls of the bottom of the stomach diverging in a cone.

Based on this operation Onopriev V.I. He proposed a method for the surgical treatment of esophageal achalasia (RF patent No. 2128950, publ. 04/20/99), including the mobilization of the abdominal and intrachiatous sections of the esophagus, cardia, lesser curvature and fundus of the stomach while preserving trunks and major branches of the vagus nerves, forming an anatomically holistic cardia, performing longitudinal esophagocardiotomy and esophagocardioplasty with hemming to the right edge of the myotome incision of the posterior wall of the fundus of the stomach, and to the left of the anterior wall of the fundus of the stomach, and the defect in the muscle layer of the esophagus is covered zhnoy front wall of the fundus. This design contributes to the constant finding of dissected muscle edges in a state of diastasis due to the elastic traction of both walls of the bottom of the stomach, directed in opposite directions. This design prevents contact, fusion, and scarring of the edges of the myotomic incision. This method of surgical treatment of achalasia is taken as a prototype.

The disadvantages of the known operations, including the prototype: high invasiveness of surgical access; significant technical complexity of performing these operations using laparoscopic technology; complete transverse destruction of the smooth muscles of the “Helvetius loop” at the site of interweaving in the anterior wall of the stomach and cardia, i.e. complete destruction of the tonal retention mechanism of the angle of His; with achalasia of degree 4 and severe esophagitis, the scar process affects both the submucous and mucous membranes, which can be an obstacle to a sufficient expansion of the lumen of the esophagus after myotomy.

The objective of the invention is to develop a method for the surgical treatment of achalasia, in which it would be possible to preserve the natural and maximum restoration of impaired functions of the esophagus and cardia and improve the immediate and long-term functional results of surgical treatment of achalasia of the esophagus.

The problem is solved in that in the method of surgical treatment of achalasia of the esophagus, including the mobilization of the abdominal and intrachiatous sections of the esophagus, cardia, lesser curvature and the bottom of the stomach by preserving the main branches of the vagus nerves, lowering the esophagus into the abdominal cavity, forming an anatomically holistic cardia, performing longitudinal esophageophysiophages , esophagocardioplasty is performed with a laparoscopic instrument in the frontal plane from the lumen of the stomach after combining in percent Essence of lowering the wall of the esophagus and the wall of the bottom of the stomach with simultaneous suturing along both edges of the incision, the sutures being placed in the sagittal plane.

The essence of the method.

After high mobilization of the abdominal and intra hiatus segments of the esophagus, cardia, lesser curvature and the fundus of the stomach, while maintaining the trunks and the main branches of the vagus nerves, a stapler is inserted into the lumen of the stomach, followed by dissection and simultaneous stitching of the walls of the esophagus and fundus of the stomach in the frontal plane from the inside of the His. Then perform the front door-type fundoplication.

The implementation of the method in dynamics is shown in FIG. 1-5. Figure 6 shows radiographs of the esophagus before and after surgery. 7 shows esophagomanograms before and after surgery.

Claimed as an invention, the operation is as follows.

Perform the imposition of pneumoperitoneum. Next, 5 thoracoports are staged: paraumbilical 10 mm on the left by 3-4 cm, 10 mm laterally in the hypochondrium on the right for the retractor, two 5 mm in the epigastrium along the midclavicular lines, laterally in the hypochondrium on the left 12 mm for the Beccock clamp, and subsequently for the introduction of the stapler . The operation begins with dissection of the left triangular ligament of the liver, the left lobe of the liver is removed medially, which dramatically improves access to the abdominal esophagus and cardia. Then, the esophageal opening of the diaphragm and its both legs is carried out by crossing the esophageal-diaphragmatic 1, diaphragmatic-cardiac 2 and diaphragmatic-fundal 3 ligaments. The cardia and abdominal esophagus 4 are produced together with fiber, ligamentous apparatus, trunks of vagus nerves 5, 6 and their main branches. Then cross the proximal part of the gastro-splenic ligament with 1-2 short gastric vessels 7 (Fig. 1). The mobilized bottom of the stomach is turned anteriorly and downward, the posterior wall of the bottom of the stomach is opened, which gives wide access to the left leg of the diaphragm and the gastro-pancreatic ligament, which is gradually separated from the walls of the bottom of the stomach from the gates of the spleen to the cardia. From the rear, the walls of the esophagus, cardia and the proximal portion of the body of the stomach are mobilized with the intersection of the first posterior transverse vascular branch. Over the course of 5-6 cm, the abdominal and intra hiatus segments of the esophagus are mobilized. At the same time, connective tissue jumpers are cut, located between the vagus nerves and the esophagus, which gives the nerves the greatest mobility. Skeletonize the proximal portion of the lesser curvature of the body of the stomach with the intersection of 1-2 transverse vessels 8 (Fig. 1).

The esophagus is maximally reduced to the abdominal cavity.

The next step is to conduct a turnstile thread around the esophagus, with traction down, check the mobility of the bottom of the stomach and the possibility of comparing the bottom and esophagus above the narrowing to perform the main stage of the operation (figure 2).

The next main step is shown in figure 3:

With a kauter hook, a gastrotomy is performed along a large curvature of up to 1 cm 9. An endoscopic linear stapler with a dissecting blade (manufactured by Auto Suture or ETHICON) is inserted into the gastrotomy opening, preferably with a 60 mm cassette, or flashing twice with 35 mm cassettes 10.

The jaws of the apparatus are diluted in the frontal plane, then, when traction for the thread-holder 11, a thin metal jaw is carried into the esophagus 12, the plastic jaw 13 remains in the bottom of the stomach. Thus, between the jaws 11 and 13 there is the wall of the esophagus at the narrowing and the wall of the bottom of the stomach 14. When applying a hardware suture, the apparatus is held so that the plane of the suture is sagittal, and the dissection line of the tissues is frontal.

In Fig. 4, the dashed line shows the cut line 15 inside the lumen of the stomach, and the stomach and esophagus 12 are also stitched together. Next, the gastrotomy opening 16 is sutured. The next step is to perform anterior fundoplication of the Door type with separate sutures.

The final view of fundocardioesophagoplasty is shown in Fig.5.

The method was tested in 3 patients with cardiac achalasia of the 4th degree in the clinical setting of GU DKB, art. Novosibirsk

Patient T, 45 years old, N medical history 218.

Date of receipt 10.12.01

Diagnosis: Achalasia of the esophagus of the 4th degree.

Complaints: the inability to swallow solid and even liquid food into the stomach, pain and a feeling of fullness behind the sternum, palpitations, weight loss of 17 kg over the past year, general weakness, constant belching and vomiting of recently eaten food.

Anamnesis morbid: Sick for about 10 years when, after suffering nervous stress, he first felt difficulty swallowing. He was repeatedly treated in the surgical department at the place of residence; courses of bougieurage and cardiodilation with insignificant improvement periods were conducted. Recently, I felt a sharp violation of the passage of even liquid food into the stomach, severe chest pains, general weakness appeared. Directed to the State Directorate for Children's Clinical Hospital for surgical treatment.

Anamnesis vitae: Tuberculosis, Botkin’s disease, venous disease denied. An allergic history is not burdened.

Status praesaents: Satisfactory condition. Patient with proper physique, reduced nutrition. The skin is clean, peripheral lymph nodes are not enlarged, painless. In the lungs, vesicular breathing, no wheezing. Heart sounds are clear rhythmic. Pulse 80 beats per minute, A / D 120/80 mm Hg The tongue is moist, the abdomen is soft, painless in all departments. The liver and spleen are not enlarged. Shchetkin's symptom is negative. Physiological administration is normal.

Instrumental research results:

FGDS - the contents of the esophagus on an empty stomach: mucus and liquid mixed with food in large quantities. The lumen of the esophagus is significantly widened, diameter up to 4-5 cm. Mucosal edema, there are isolated erosions. The cardia is not exposed to air, it is difficult to pass for the endoscope, it is located at a distance of 45 cm from the incisors, at the level of the diaphragm. Mucous membrane of the stomach with superficial inflammation on the background of focal atrophy.

Conclusion: Achalasia of the esophagus. Erosive esophagitis. Focal atrophic gastritis.

X-ray of the esophagus: the esophagus is S-shaped. The diameter is 6-7 cm, the contours are fuzzy, uneven, with filling defects, there is no peristalsis. The shape of the narrowing of the distal in the form of a mouse tail. The diameter of the cardia is 0.3-0.4 cm, the length of the constriction is up to 3 cm, during the act of swallowing the cardia is not revealed. Barium suspension passes into the stomach with a thin path under its own weight, emptying by 1/3 occurs 10 minutes when the esophagus is filled before entering. The supraphrenic ampoule and gas bubble of the stomach are absent, the water-siphon test is negative (Fig. 6, x-ray 1).

Conclusion: Achalasia of the esophagus of the 4th degree.

Laboratory results showed no changes.

A multi-channel manometric study revealed the complete absence of a peristaltic wave with a “dry” and “wet” pharynx; it is not possible to enter the achalasia zone (Fig. 5, manogram 1).

12/26/01 an operation was performed - laparoscopic esophagocardiofundoplasty according to the described technique.

The postoperative period without complications, the patient's enteral nutrition was restored by the end of the first day, was discharged in satisfactory condition 04.01.02.

Examination completed after 3 months.

The patient's condition is satisfactory. No complaints at the time of inspection. The passage of liquid and solid food through the esophagus into the stomach is free. There are no chest pains. He gained 9.5 kg in weight.

With FGDS: the esophagus on an empty stomach does not contain residues of liquid and food. The mucous is pink, there is no congestive esophagitis. There are no signs of gastroesophageal reflux.

X-ray of the esophagus: the diameter is significantly reduced (3 cm), the relief of the folds is not changed, there is a pronounced primary impulsive peristalsis of the esophagus. The cardia is revealed during the act of swallowing, while its diameter is 1.2 cm. Barium suspension passes portionwise into the stomach, its complete evacuation takes place in 0.5 min. There is no gastroesophageal reflux when the Trendelenburg position and muscle tension of the anterior abdominal wall. His angle is formed, there is a gas bubble of the stomach (Fig.6, x-ray 2).

With multichannel esophagomanometry, restoration of the peristalsis of the esophagus body, also normalization of pressure in the anterior fundoplication zone, restoration of the peristaltic wave along the esophagus body with a sip of water (Fig. 7, manogram 2).

This method of treatment of esophageal achalasia can be used in the late stages of the disease, allows you to save the trunks and the main branches of the vagus nerves, does not violate the secretory and motor-evacuation functions of the stomach, prevents the occurrence of acid reflux of gastric contents into the esophagus and related complications, prevents the development of relapse of the disease , reduces the rehabilitation time and significantly improves the quality of life of the operated patients.

Claims (1)

A method for surgical treatment of achalasia of the esophagus, including mobilization of the abdominal, intrachiatous sections of the esophagus, cardia, lesser curvature and the fundus of the stomach while preserving the trunks and main branches of the vagus nerves, lowering the esophagus into the abdominal cavity, forming an anatomically holistic cardia, performing longitudinal esophagocardiophardioptomy, and that a gastrotomy is performed along a large curvature, a stapler with a dissecting blade is inserted into the hole, the branches of the apparatus, one branch are bred carried out into the esophagus, the other is left in the bottom of the stomach, an incision is made with the apparatus with simultaneous suturing along both edges of the incision, while the tissue dissection line is located in the frontal plane, and the suturing line is in the sagittal plane.

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