RU2248758C2 - Method for operative treatment of colonic diseases - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: on should perform resection by crossing colonic wall being about 1-2 mm against the level of mobilization. Then on should form anastomosis by successively connecting wound edges of submucous foundations and seromuscular sheathes being butted. The method enables to create conditions to heal anastomosis and prevent complications.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, in particular to clinical surgery, and can be used in the treatment of diseases of the colon.

Colon resection is one of the common treatment methods used in diseases of the colon. Until now, the problem of preventing such complications as the failure of intestinal sutures with the development of purulent intra-abdominal complications, reaching 30%, cannot be considered resolved (Aliev F.Sh. et al., 2000). Mortality in early postoperative complications is 4-25.5% (Gibert B.K. et al., 2000). For the prevention of the former, surgical treatment methods have been developed related to the division of operations into several stages (Hartmann's operation), with the application of unloading proximal fistulas, which significantly lengthens the treatment time and does not guarantee the absence of anastomotic suture inconsistency, adding the risk of complications from the created stoma (Gibert B .K. et al., 2000). With a favorable immediate result of resection of the colon with the restoration of its continuity in the long term, it is possible to develop stenosis of anastomoses in up to 14% of cases (Kuzmin-Krutetskiy M.I., Soldatov A.I., 1998).

In the studied literature, methods of colonic anastomoses imposed using elements of the microsurgical technique are described (Lebedev L.V. et al., 1985; Yurlov V.V., 1988). The methodology for the formation of anastomoses was generally accepted; a 2-row suture was used. At the same time, an accelerated healing time was noted compared with the general surgical method, but epithelization occurred in the period of 25-40 days with necrosis of the tissues of the anastomosis zone, i.e. secondary tension. Subsequently, the researchers noted the formation of a coarse and wide scar that deforms the anastomotic zone, which served as the basis for recognizing the need for nodal sutures.

In more detail, the microsurgical technique for the formation of colonic anastomosis is described by Onopriev V.I. et al., 1981, which is selected as a prototype.

The method is described by the authors as follows: “within 5 cm, the intestinal wall is cleansed of the adipose tissue of the mesentery with the preservation of visible pulsating vessels, the intestinal walls are straightened in the anastomosing zone with a tight clamp; special probes with a stylet probe, at the end of which an illuminator, an irrigator, an aspirator, and a probe probe with perforation openings, are transanally and through the cecostomy into anastomosed stumps. 8-10 cm from the edge of the stump, the stump section is separated by a turnstile for continuous irrigation of the lumen for 10 minutes, then transillumination is turned on and nodal sutures with 4/0 material are applied along the line of vessels entering the mesenteric part of the intestine. At a distance of 0.5-0.7 cm from the seam line, the serous-muscular layer is opened, the serous-muscular cuff is separated to a clamp. At this level, the serous-muscular layer of the anterior intestinal wall is dissected and the submucosal layer is straightened, 2-3 mm from the serous-muscular margin, and submucosal layers are sutured with 6/0 U-shaped sutures with the capture of visible vessels. All 4 mucous-submucous layers of the anastomosed ends are captured with a tight clamp, over which stumps of both ends are cut off. Above the clamp on the front wall impose nodular sero-muscular-submucosal sutures with material 6/0, spend two more nodal sutures under the clamp. The threads of all the seams are simultaneously pulled together and the clamp is removed without opening after crossing the tissues captured by him. Without loosening the tissue tension, in turn, starting from the corners of the anastomosis, the sutures are tightened, the free ends of the threads are cut off. A second row of nodal sutures is applied with a 4/0 material, fixing locks of an omentum, fat pendants, and couplings from a demucous intestinal wall on a vascular pedicle to the suture line ”.

The disadvantages of the method include:

1. The complexity of the technical implementation, the need for additional non-standard equipment.

2. Injury to the intestinal tissue associated with manipulations: preparing the stump for anastomosis, applying turnstiles, dissecting the intestinal wall, applying and removing clamps on the stump at the stage of applying the anastomosis.

3. The imposition of nodal sutures of the type of inverting, which leads to primary diastasis of the mucous membranes and the creation of conditions for the secondary healing of the anastomosis.

4. A high risk of infectious complications, even if one nodal suture is inconsistent (noted by the authors in one case).

5. The inability to control the aseptic nature of the imposition of submucosal sutures of the posterior lip of the anastomosis due to the insignificant thickness of the submucosal base and the closed anastomosis technique.

6. In connection with the last two circumstances - the need for additional sealing of the anastomosis zone, continuous postoperative decompression of the intestinal lumen, including through the application of proximal fistulas, transanal intubation, a combination of these methods.

7. With secondary healing of the anastomosis, anastomosis stenosis may develop. The authors have no data on this complication.

The novelty of the method lies in the fact that there is minimal trauma and ischemia of the anastomosed segments, creation of conditions for the initial healing of the anastomosis and the prevention of complications, and the refusal of additional decompression of the anastomosis zone.

Significant differences in the proposed method is that the resection is carried out, crossing the intestinal wall 1-2 mm from the mobilization level, and form an anastomosis, sequentially connecting the edges of the wounds of the submucosa and the serous-muscular cases butt.

The method is as follows. After a laparotomy, determination of the indications and the volume of the resection, the corresponding section of the colon is mobilized, 3 serous-muscular ligature-holders are applied in the tendency of both segments of the intestine 3-5 mm from the proposed resection line. A thorough delimitation of the work zone on the intestine by hygroscopic material is performed before opening the lumen. At 1-2 mm from the mobilization level, the intestine is crossed with a microsurgical blade. Anastomosis begin to form by stitching with a continuous suture monofilament material 6 / 0-7 / 0 serous-muscular case of the posterior lip and matching the edges of the wounds butt. The posterior lip is terminated with an internal continuous suture behind the submucosa, puncturing the needle at the border of the submucosa and the mucosa proper, passing to the front lip and closing the intestinal lumen. An external continuous suture of the anastomosis of the anterior lip is applied, matching the edges of the wound of the serous-muscular case. When continuous stitches are applied, the vessels of the intestinal wall are captured by stitches, thereby achieving reliable hemostasis.

The laparotomy wound is sutured tightly. Decompression of the lumen of the colon is not carried out.

The method was carried out in an experiment on 10 unfixed human corpses and 15 rabbits. On the corpses of people, resection of the colon was simulated, both segmental and hemicolonectomy on the left with the application of terminal colonic anastomoses. The mechanical strength of the created anastomoses was studied by the hydropressing technique, the data of which ranged from 130 to 190 mm Hg. Art. In chronic rabbit experiments, colon resection and colorectal anastomosis were applied end-to-end using optical magnification up to 20 times and suture material 7 / 0-10 / 0. The healing of anastomoses in the periods of 1-10, 11-15, 30 days and 4-6 months and the motor function of the colon were studied using clinical, radiological (colonography), morphological (pathomorphological, histological and histotopographic) methods. It was established that the healing of anastomoses proceeds as primary with epithelization not later than 5-7 days with the formation of a thin connective tissue scar that does not deform the intestinal wall and does not violate the intestinal motor and evacuation functions.

In the clinic, the method was carried out in 12 patients. In 5 cases, resection of the sigmoid colon with sigmosigmoid anastomosis was performed, in one - resection of the transverse colon and transverse transversoanastomosis, in 6 - hemicolonectomy on the left and transverse sigmostomy. The postoperative period was uneventful. Early restoration of motor function and passage through the intestines: peristalsis - from 3.5 to 28 hours, gas discharge - from 15 to 60 hours, stool - from 64 hours to 4 days without additional stimulation. With fibrocolonoscopy and irrigoscopy, by 6 days after surgery, the anastomoses are completely epithelized, without signs of anastomositis, narrowing, deformation, and functioning. In no case was the failure of the seams.

Examples of clinical use:

Patient G., 61 years old, medical history No. 592, was treated with a diagnosis of

DOS Highly differentiated adenocarcinoma of the descending colon T ₄ N ₁ M ₊ (left lobe of the liver).

Donkey Hypochromic anemia.

Background. Chronic colitis.

Sop. Coronary heart disease (I.B.S.) Stable angina pectoris, 2 f. class CH 0. Hypertension 2 tbsp. Chronic bronchitis, remission; pneumosclerosis, DN ₀ Chronic pancreatitis, remission.

01/15/01, under anesthesia, the operation of upper-midline laparotomy, revision of the abdominal cavity organs, left hemicolonectomy with transversosigmostomy according to the proposed method, atypical resection of the left liver lobe. The postoperative period is smooth. Passage through the intestines was restored on the 3rd day. Liquid food 67 hours after surgery. The wound healed first. Discharged in satisfactory condition.

Patient S. 87 years old, medical history No. 3461, was on treatment with a diagnosis of

DOS Highly differentiated sigmoid colon adenocarcinoma T ₄ N ₀ M ₀ .

Donkey Acute obstructive colonic obstruction, local purulent-fibrinous peritonitis. Hypochromic anemia.

Sop. I.B.S. Stable angina pectoris 2 f.c., supraventricular and single ventricular extrasystoles, atherosclerotic and postinfarction cardiosclerosis, stenosis of the aortic orifice, CH 2a art. Arterial hypertension of complex origin. Dyscirculatory encephalopathy 2 tbsp. Chronic pyelonephritis, latent course, chronic renal failure 1 tbsp. Gallstone disease, chronic calculous cholecystitis, remission. Cysts (3) of the liver.

Received on an emergency basis. 04/25/01, Operation Mikulich. A histological study of the drug is the germination of adenocarcinoma into the mesentery fiber along the line of resection.

05/14/01, the operation of resection of the sigmoid colon and sigmoid, sigmosigmostomy by the proposed method. The wound of the anterior abdominal wall is sutured tightly. The postoperative period is smooth. Peristalsis after 18 hours, discharge of gases after 29 hours, stool - 100 hours after surgery. Fibrocolonoscopy on the 9th day after the operation - the anastomosis is epithelized, it functions without signs of anastomositis, narrowing. The surgical wound healed initially. Discharged on May 25, 01 in satisfactory condition.

Thus, the proposed method can significantly improve the results of resection of the colon in connection with the creation of conditions for the rapid healing of anastomoses.

Bibliography

1. Aliev F.Sh., Chernov N.A., Kecherukov A.I. and others. The problem of surgical suture of the colon. // Scientific Bulletin of the Tyumen Medical Academy. - 2000. - No. 4. - S. 94.

2. Gibberg B.K., Tsarik S.L., Zaitsev E.Yu. et al. Analysis of complications of colostomies according to City Clinical Hospital No 1, Tyumen Regional Clinical Hospital, MSC Neftyanik CJSC for 1997-1999. // Scientific Bulletin of the Tyumen Medical Academy. - 2000. - No. 4. - S. 98.

3. Kuzmin-Krutetskiy M.I., Soldatov A.I. Endoscopic treatment of strictures of colonic anastomoses. // http://www.seaexpress.ru/endoscopy/Gurnal%/201 /Statya3.htm -2000.

4. Lebedev L.V., Levin A.O., Yurlov V.V. et al. The use of microsurgical techniques in abdominal surgery. // Vestn. surgery. - 1985 - No. 1. - S. 28-33.

5. Yurlov V.V. The use of microtechnology elements in colon surgery. // Abstract of diss ... cand. honey. Sciences - L., 1988. –11 p.

6. Onopriev V.I., Siyukhov K.T., Eloso V.P. et al. Aseptic method and microsurgical technique for the formation of colonic anastomoses. // Clinical surgery. - 1981. - No. 2. - S. 19-23.

Claims (1)

A method for surgical treatment of diseases of the colon, including resection of the colon with the application of a colonic anastomosis of the end-to-end type using microsurgical surgical technique, characterized in that the resection is performed by crossing the intestinal wall 1-2 mm from the mobilization level, and form an anastomosis, sequentially connecting the edges of the wounds of the submucosal foundations and serosmuscular cases end-to-end.