RU2250755C2 - Method for making plastic substitution of the rectum in the cases of inferoampullar carcinoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves creating C-shaped large intestine reservoir. Bed is prepared to descend smooth muscle cuff and the large intestine reservoir. Internal sphincter and deep portion of the external sphincter are removed and levator is transected. After having accomplished descending stage, levator stump is fixed at the level of the upper smooth muscle cuff edge. Colo-anal anastomosis is created.

EFFECT: enhanced effectiveness in creating conscious fecal continence.

Description

The invention relates to medicine, in particular to surgery and oncology.

The standard in the surgical treatment of patients with cancer of the lower ampulla of the rectum is abdominal-perineal extirpation of the organ with the formation of a permanent unnatural anus on the anterior abdominal wall. However, this type of intervention leads to severe maladaptation and social isolation of patients due to the lack of conscious control over bowel movements, body image changes, difficulties in providing care for the colostomy (Heald RJ, Chir M., Smedh RK. Abdominoperineal Excision of the Rectum - An Endangered Operation Diseases of the Colon and Rectum, vol. 40, No. 7, 1997, 747-751).

A known method of forming a controlled perineal colostomy from a serous-muscular flap of the reduced intestine with abdominal-perineal extirpation of the rectum.

The essence of the method is as follows. After crossing the main vessels, an intestinal transplant is prepared for releasing from the overlying sections of the colon. For this, after mobilization of the mesentery of the sigmoid colon for 15 cm, the wall of the reduced intestine is thoroughly freed from fatty suspensions. Typical rectal extirpation is performed. At the same time, front-side portions of the levator are distinguished from the perineum, they cross, the stumps are stitched with catgut, and the ends of the threads are not cut. The rectum with the closure apparatus is removed. Levator stumps are tied together and sutured to the posterior-lateral walls of the pelvis and the posterior wall of the reduced intestine, forming the pelvic floor. The prepared intestinal transplant is reduced to the perineal wound, where the perineal team makes a circular incision of the serous-muscular membrane of the intestinal wall. Next, the membrane is separated to the cutaneous edge of the perineal wound. Then, a spiral-shaped incision is made of the separated intestinal wall, forming a serous-muscle flap on the leg, which is wrapped around the distal part of the reduced intestine at the skin level, forming a smooth-muscle cuff, immersed in the pelvic cavity, and the distal part is sutured to the perianal skin. The excess mucosa is cut off (Method for the formation of a controlled perineal colostomy, Ed. St. 17807226 of 08/15/92).

The technique allows you to restore the natural location of the colon, to preserve the habitual image of the body in the patient’s mind to simulate the involuntary component of holding. However, the loss of the rectal ampoule is accompanied by the loss of cumulative function, which leads to a violation of the frequency and rhythm of defecation, adversely affecting the quality of life of patients (Fedorov V.D., Odaryuk T.S., Tsarkov P.V. Formation of a smooth muscle coupling around the perineal colostomy after extirpation of the rectum, Surgery, Moscow, Medicine No. 2, 1990, pp. 128-131).

A known method of forming a large intestinal reservoir with abdominal-perineal extirpation of the rectum, aimed at compensating for the lost cumulative evacuation function.

The essence of the method is as follows. A section of the colon over 15 cm is carefully freed from the adipose tissue of the mesentery and pendants. The sigmoid colon in the distal part of the cleared area is crossed by the NLCA apparatus. Retreating from the distal edge of the stump of the sigmoid colon of 5-6 cm, the intestine folds in the shape of the letter S, is fixed with holders in such a way that the length of the outlet segment is at least 5-6 cm. The wall of the conjugated segments of the intestine is dissected by free horseshoe cuts. The knees of the tank are sewn together with a single-row seam. Check for leaks. In the distal part of the outlet knee, the serous-muscular layer of the intestinal wall to the mucosa is dissected in a circular incision. Separate the layer in the oral direction. The separated layer is helically dissected. Thus, a serous-muscular flap is formed on the feeding leg. It is wrapped around the distal part of the tank so that each subsequent turn fits into the previous one. The turns are fixed among themselves with rare catgut sutures. Synchronously, two teams of surgeons (from the perineum with the intersection of the levator) mobilize the rectum in the fascial-fat case with the intersection and ligation of the medium-rectal vessels. The drug is removed. Further, the pelvic floor is formed from the perineum by stitching the legs of the levator with catgut sutures. The prepared intestinal transplant is lowered into the perineal wound, where the distal part of the smooth muscle cuff is sutured to the edge of the skin with an excess of 3-4 cm of mucous membrane remaining (Patent No. 2144790 for the invention "Method for the formation of a large intestinal reservoir with peritoneal perineal extirpation of the rectum").

The technique allows you to restore the natural location of the intestine, to recreate the involuntary component of holding, to compensate for the lost cumulative function. Despite the undeniable functional advantages of the method, the operation has a number of technical and functional disadvantages. For the formation of an S-shaped colonic reservoir, preparation of an extended intestinal transplant is required. Due to the significant length of the seam forming the large intestinal reservoir, the risk of developing insolvency increases. The main disadvantage of this method is a pronounced violation of the evacuation function of the reduced intestine, clinically manifested by a feeling of incomplete emptying and constipation.

The aim of the proposed method is the preservation of voluntary and recreation of involuntary components of holding, improving the cumulative-evacuation function of the reduced intestine.

This goal is achieved by the fact that when the rectum is removed, the superficial and subcutaneous portions of the external sphincter are preserved, plastic replacement of the ampoule of the rectum and internal sphincter is performed by forming a C-shaped colonic reservoir and smooth muscle cuff, lowering them into a small pelvis with fixation of the levator stump to the reduced intestine at the level of the upper edge of the smooth muscle cuff and the formation of coloanal anastomosis.

The method is as follows.

Under endotracheal anesthesia in the position of the patient on the back with legs spread apart to the sides on special supports, lower middle laparotomy is performed. The inferior mesenteric artery is ligated distal to the place of discharge of the left colon artery, the inferior mesenteric vein is in the region of the lower horizontal part of the duodenum. Then study the vascular pattern of the mesentery of the sigmoid colon, evaluating the adequacy of blood supply to the reduced transplant. For the formation of the reservoir and smooth muscle cuff and their subsequent reduction into the pelvis, the length of the large intestine transplant should be 13-16 cm longer than during a normal reduction operation.

The sigmoid colon is crossed at a distance of 15 cm above the upper pole of the tumor using staplers. Proceed to the plastic phase of the operation. The formation of the cuff is performed from the serous muscle layer of the colon wall. First, the distal section of the lower intestine is freed from fatty pendants and mesentery for 3-4 cm.Then the serous-muscular layer of the colon is circularly dissected to the submucosal layer and it is separated in the form of a cylinder from the mucous membrane throughout the entire freed segment to the intestine with the mesentery. A flap on a leg 1.5-2 cm wide and 6-8 cm long is cut out from the serous-muscular cylinder obtained by spiraling. After processing the obtained flap with an antiseptic solution, stretch it in length and width and spirally wrap around the reduced intestine, fixing rounds among themselves and the serous-muscular layer of the intestine with Polysorb 3/0 sutures, loosening the flap tension with each turn to avoid compression of the marginal vessel. In this way, a 3-4 cm cone-shaped cuff is obtained.

To recreate ampoules of the rectum, the technique of forming a C-shaped colonic reservoir is used. To do this, the intestine prepared for releasing immediately above the cuff is folded in the form of a C-shaped loop, 4-5 cm long, and a septal wall duplication is dissected through a colotomy hole at the top of the loop with its stitching. The colotomy opening is sutured, a leak test is performed.

The rectum is isolated from the side of the abdominal cavity to the place of fixation of the levator to the wall of the rectum in a single block with pararectal tissue within the fascial case with ligation and intersection of the middle rectal vessels directly at the walls of the pelvis.

Then, from the perineal side, the anal canal is treated with an antiseptic solution and a purse string suture is applied to the mucosa of the anal canal below the tumor in order to exclude implantation metastasis at the time of drug removal. Produce a circular dissection of tissues along the intersphincter sulcus. Then, following in the lateral direction, the distal part of the internal sphincter is released, penetrating into the layer between the surface and deep portions of the external sphincter. In a sharp way, a deep portion of the external sphincter with the intersection of the levator is circularly secured to connect to the abdominal team of surgeons. The drug is removed from the abdominal cavity in order to minimize trauma to the structures of the external sphincter. At the same time, the stored subcutaneous and superficial portions of the external sphincter form the muscle bed to reduce the intestinal transplant. The pelvic cavity is washed with solutions of antiseptics and antibiotic.

Before the reduction step from the perineum, the intersected portions of the levator in 6 and perianal skin - at 8 points — evenly around the circumference with polysorb 3/0 threads on the atraumatic needle suture without tying. The colon with a reservoir and smooth muscle cuff is lowered into the pelvis. The first row of sutures fix portions of the levator to the reduced intestine at the level of the upper edge of the smooth muscle cuff, while the second row forms a coloanal anastomosis.

In all cases, in order to turn off the passage of intestinal contents through the colon and create optimal conditions for reparative processes in the area of the sutures of the reservoir and coloperianal anastomosis, the operation is completed with a Thornball ileostomy. The closure of the ileostomy is carried out in a planned manner 4-6 weeks after the operation in the absence of radiological signs of insolvency of the sutures of the reservoir and coloanal anastomosis.

Example 1. Patient P. 66 years old, medical history No. 2926-2002, was in the center for colorectal cancer at a distance of 3 cm from the edge of the anus. 06/13/2002, the patient was routinely operated. The rectum, internal and deep portions of the external anal sphincter were removed with the creation of a C-shaped pelvic colonic reservoir and smooth muscle cuff, the formation of a coloanal anastomosis, and Thornball ileostomy. The postoperative period was uneventful. Ileostomy closed routinely 2 months after surgery. 1 month after the closure of the ileostomy, the patient holds the decorated stool. Marks the urge to defecate and the possibility of arbitrary retention of the stool for 5 minutes. Stool daily 2-3 times a day. Tenesmus, false desires, a feeling of incomplete emptying are absent. 8 months after surgery, there were no signs of recurrence and distant metastasis of the tumor.

Example 2. Patient E., 60 years old, was in the clinic with a diagnosis of cancer of the rectum 3 cm from the edge of the anus. Case history No. 3294-2002, 10.25.2002, the Patient was operated on as planned. The rectum, internal and deep portions of the external anal sphincter were removed with the creation of a C-shaped pelvic colonic reservoir and smooth muscle cuff, the formation of a coloanal anastomosis, and Thornball ileostomy. The postoperative period was uneventful. The ileostomy is closed after 6 weeks from the day of surgery. During the examination, 1 month after the closure of the ileostomy, the differentiated stool and gases differentiated, and the stool was retained. The delayed defecation time was 3 minutes. 4 months after surgery, there were no signs of recurrence and distant metastasis of the tumor.

Thus, the method has the following advantages: provides a conscious component of holding by preserving the superficial and subcutaneous portions of the external sphincter, fixing the levator to the reduced intestine; recreates the involuntary component of holding by creating a smooth muscle cuff; improves the accumulative function of the reduced intestine due to the formation of a pelvic colonic reservoir; preserves the patient’s body image by reconstructing the natural passage through the gastrointestinal tract.

Claims (1)

The method of plastic replacement of the rectum in cancer of the lower ampullar region, including the creation of a C-shaped colonic reservoir, characterized in that the bed is prepared from the perineum to lower the smooth muscle cuff and colonic reservoir, while the internal sphincter, a deep portion of the external sphincter are removed and the levator crosses, and after the reduction stage, the levator stump is fixed to the reduced intestine at the level of the upper edge of the smooth muscle cuff, and a colanal anastomosis is formed.