RU2262896C2 - Method for applying small intestine plastic repair after gastrectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves transecting the first jejunum loop. Enterojejunal anastomosis is built. The transected jejunum is anastomosed to efferent intestine bend side from esophagointestinal anastomosis is created. Efferent end of transected jejunum is anastomosed to duodenum. Esophagus stump is fixed in esophageal diaphragm orifice. Window is produced in mesenterium of the loop anastomosed with the duodenum. Esophagus stump is brought through the window. Intestine loop is attached to the diaphragm. Esophagus stump wall and adjacent intestine loop are sutured. Intestine- and esophagus walls adjacent to each other are sutured with seromusculosubmucous sutures. External edges of intestinal wound are sutured with single-layer seromusculosubmucous sutures. Efferent bend of jejunum loop is laid along the duodenum path and fixed. Intestine loop lumen is opened around the esophagus stump.

EFFECT: reduced frequency of esophagointestinal anastomosis inconsistency; reduced risk of post-gastrectomy syndrome complications.

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Description

The present invention relates to medicine, namely to surgery, and can be used mainly for the treatment of cancer of the stomach.

Gastric cancer is currently one of the most common cancers. The leading method of treatment remains surgery, while one of the main operations in the arsenal of surgical treatment of gastric cancer is gastrectomy, which accounts for up to 70% of all radical operations for these tumors. These operations relate to severe traumatic surgical interventions and are accompanied by high postoperative mortality, the main reason for which is the failure of the esophageal anastomoses. In the distant postoperative period after gastrectomy, the condition of patients is aggravated by the development of reflux esophagitis, dumping syndrome, agastral asthenia, homeostasis disorders leading to a significant decrease in the quality of life of the operated patients, and therefore, in addition to a high degree of reliability, the anastomosis must have high functional activity and provide a satisfactory quality of life. Given the fact that about 50 thousand cases of gastric cancer are detected in our country every year and about half of these patients undergo surgical treatment, studies aimed at improving the reliability and functionality of the esophageal-intestinal anastomosis, as well as developing the most physiologically sound scheme for the restoration of the digestive tract, remain its high relevance.

There is a method of esophageal-intestinal anastomosis according to Hilarovitz on a long loop of the small intestine with an intestinal anastomosis (A.A.Shalimov, V.F. Saenko. Surgery of the stomach and duodenum. - Kiev, Zdorovya. -1972) (figure 1) . With this technique, the leading and abducting knees of the small intestine are inserted into the upper floor of the abdominal cavity through an incision in the avascular part of the mesentery of the transverse colon. The esophagus is placed on a discharge loop and anastomosis is applied end to side with a two-row suture. The anastomosis is sheltered by the bringing knee and stitched with the discharge. An entero-enteroanastomosis is applied between the leading and outlet loops of the intestine, which is fixed with separate serous-serous sutures to the edges of the mesentery section of the transverse colon.

The method has significant disadvantages. With this method, there is a high incidence of esophageal-intestinal anastomosis failure, which is observed even at the present stage of surgery in 4-18% of cases (McCulloch, 1994; Bonenkamp et al, 1995), leading to high postoperative mortality. In a significant part of patients with this technique, reflux esophagitis occurs, which is associated with the absence of valve antireflux function of the anastomosis. At the junction of two functionally different organs, a fibrous ring appears, freely passing food masses in both directions. There is a retrograde intake of the contents of the small intestine as a result of antiperistalsis, spasm, changes in the position of the esophageal-intestinal anastomosis ("pulling" the anastomosis above the diaphragm into the mediastinum). Regurgitation is the main reason for the development of reflux esophagitis, which occurs in almost 80% of the operated patients and leads to a significant deterioration in the quality of life and disability of the operated patients. With this method of restoring the digestive tract, the duodenum is turned off from the food passage, which is one of the main reasons for the development of severe functional postgastrectomy syndromes.

A known method of small intestinal gastroplasty proposed by V.I. Onopriev (V.I. Onopriev. Conceptual anastomosis after gastrectomy and right-sided hemicolectomy. - Diss .... Doct. Medical sciences. - Stavropol, 1976. -423 pp. 84) and accepted by us for the prototype. The essence of the method is presented in figure 2. Gastrectomy is performed. The stump of the duodenum is sutured. An end-loop esophagoenteroanastomosis is formed. Using the lavsan ligature and several serous-muscular sutures covering it with a lavage lobe of the end-loop esophageal-intestinal anastomosis, a stub overlapping the intestinal lumen is created using the lavsan ligature and covering it. Below the "stub" impose an intestinal anastomosis.

Disadvantages: the design used by the author with the formation of a “plug” on the leading loop of the esophageal-intestinal anastomosis carries the risk of necrosis of the intestinal wall at the site of application of the lavsan ligature. Subsequent recanalization of the leading sections takes place, this leads to the development of the leading loop syndrome, and due to the constant presence of bile in the area of the esophageal-intestinal anastomosis, as the bile circulates in the formed “vicious circle”, reflux esophagitis develops. Turning off the duodenum from the food passage naturally leads to the development of functional postgastrectomy disorders, since it performs not only the digestive function, but also is the most complex receptor and hormonal department that regulates digestion.

The objectives of the proposed method are:

1. Improving the immediate results of gastrectomy for gastric cancer by reducing the incidence of failure of the esophageal-intestinal anastomosis.

2. Improving the quality of life of patients after gastrectomy by reducing the frequency and severity of post-gastrectomy pathological syndromes.

The essence of the proposed method lies in the fact that after gastrectomy, small intestinal gastroplasty is performed by forming an end-loop esophageal-intestinal anastomosis, mobilizing and intersecting the first loop of the jejunum, applying enteroduodenoanastomosis, including the duodenum anastomosis, forming an esophageal-intestinal anastomosis in the passage loop construction and the formation of eunojunoanastomosis end to side.

For clarity, the implementation of the method is illustrated in figure 3-11, the digital notation in the figures:

1. - stump of the esophagus;

2. - Widely exposed submucosal layer of the esophagus;

3. The left leg of the diaphragm;

4. The right leg of the diaphragm;

5. - vessels feeding the stump of the esophagus;

6. -the anterior semicircle of the esophageal opening of the diaphragm;

7. spleen;

8.-pancreas;

9. The initial section of the jejunum;

10. - a diverting loop of the jejunum;

11.-superior mesenteric artery;

12. The duodenum;

13. -hepatic choledoch;

14. - common hepatic artery;

15. Enteroduodenoanastomosis;

16. - loop of the jejunum, anastomosed with duodenum;

17. splenic artery;

18. - a window in the mesentery of the jejunum loop;

19. - a stump of the bandaged left gastric artery;

20.-celiac trunk;

21. -seams of the first row of the end-loop esophagoenteroanastomosis;

22. -seams of the second row, forming from the wall of the loop of the intestine muscle pulp on the cult of the esophagus;

23. - line of precision serous-muscular-submucosal sutures that adapt the submucosal layers of the esophagus and intestine;

24. - the internal edges of the intestinal wound after opening the lumen of the loop of the jejunum;

25. The detectable edges of the intestinal wound after opening the lumen of the loop of the jejunum;

26. -line serous-muscular-submucosal sutures of the anastomosis;

27.-serous-muscular-submucosal sutures of the anastomosis anterior wall;

28. -endo-lateral enteroenteroanastomosis;

I, II, III, IV -8-shaped dacron seams-ligaments.

The method is as follows.

An extended upper median laparotomy is performed with the intersection and dislocation of the left costal arch and the correction of the wound aperture with Sigal-Kabanov retractors. When an intraoperative study determines the volume of the operation. In the presence of appropriate indications, gastrectomy is performed according to general oncological principles. An extended lymphadenectomy is performed in a volume of D ₂ , and if there are indications (metastasis to the lymph nodes n ₁ and n ₂ ), the volume of lymphadenectomy is expanded to the degree of D ₃ .

The stump of the esophagus is fixed in the esophageal opening of the diaphragm with 4 dacron 8-shaped sutures (Fig. 3 - I, II, III, IV). The seams capture the edges of the esophageal opening of the diaphragm and the diaphragmatic legs for their connective tissue cases, the esophagus is taken into the suture not by the muscle layer, which is easily cut and torn, but by paraesophageal fiber and neurovascular bundles entering the wall of the esophagus. The first seam is placed at 3 o’clock of the imaginary dial, the second at 6 o’clock, the last stitching of both legs of the diaphragm, and when pulling it closer, the legs come closer, the third at 9 o’clock, and the fourth at 12 o’clock on the dial (Fig. 3 - 1, 2, 3, 4, 5). The ends of the threads are not cut, but taken on the clamps. Thus, around the stump of the esophagus, above the alleged anastomosis, muscle pulp is created from the legs of the diaphragm, which is the foundation of the esophageal-intestinal areflux anastomosis.

Farther than the duodenojejunal junction, at the site of greatest mobility of the mesentery of the jejunum, usually at the level of 2-3 mesenteric arteries, at a distance of 15-25 cm from the Treitz ligament, the small intestine is crossed with the mobilization of arcade vessels along the resection line. Angioarchitectonics is investigated using transillumination. To increase the mobility of the taken loop of the intestine, a second-order radial vessel is additionally crossed with piercing.

In the right half of the mesentery of the colon, at the intersection with the vertical branch of the duodenum, create a wide "window". A “window” in the mesentery of the transverse colon is made at its very attachment to the left at the level of the beginning of the jejunum. Then, the lower peritoneal sheet of the mesentery is transversely cut above the Tracheal ligament, and the upper is opened along the line of transition of the peritoneum from the pancreas. The mesentery root stupidly exfoliates along the dissection line of the peritoneum from the posterior abdominal wall in front of the pancreas. In the upper floor of the abdominal cavity spend the distal end of the crossed jejunum. The loop of the jejunum is placed antiperistaltically, while the mesentery is located on the medial side.

The end-end jejuno-duodenoanastomosis is formed with a monofilament single-row serous-muscular-submucosal suture (Figs. 4-6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16). The seam is superimposed with nodes outward, for the formation of an anastomosis, it is preferable to use an absorbable monofilament filament (PDS 4 / 0-5 / 0).

The next step is the formation of the esophageal-intestinal anastomosis of the end-loop structure. The loop of the jejunum, anastomosed with duodenum, is tried on to the esophagus stump in such a way as to form an end-loop esophagoenteroanastomosis freely, without tension. Between the straight vessels of the mesentery of the anastomosed with DIC loop, a “window” is made (18), the size of which corresponds to the diameter of the esophageal stump.

The ends of the suture threads fixing the walls of the esophagus to the diaphragm (I, II, III, IV) are drawn through the edges of the mesenteric "window" in the avascular zones (Fig. 5 - 17, 18, 19, 20). If the gap between the vessels is narrow and it is difficult to grasp the edge of the mesenteric window, then the sutures are drawn through adjacent intervascular gaps, but strictly in such a way that, when tightening these sutures, the vessels feeding the intestine do not squeeze. The stump of the esophagus is passed through the mesenteric window (18), the sutures (I, II, III, IV) are tightened (not tight, only until the tissue touches), as a result of which the intestinal loop is fixed by the mesentery to the diaphragm (Fig.6). The wall of the esophagus stump and the wall of the intestinal loop adjacent to it are sutured together with the first row of sutures (21) (Fig. 7), consisting of 4-6 nodal sutures involving the esophagus, intestine and mesentery of the intestine so that its peritoneum fits snugly against the walls of the esophagus . With several gray-serous sutures, exciting the mesentery peritoneum, both knees of the intestinal loop are sewn together. 1.5-2.0 cm above the first row of sutures impose a second row of nodal sutures (22), adapting the muscle layer of the esophagus stump and the serous layer of the intestinal loop (Fig. 8). Thus, above the anastomosis zone, muscle pulp is formed from a loop of the jejunum on the esophagus stump. Retreating 1 cm from the line of sutures of the second row, open the lumen of the loop of the jejunum arched around the stump of the esophagus (Fig.9 - 24, 25). Stitched together parallel to the knee of the intestinal loop open for no more than 1 cm. Closely adjacent to each other in a circle the walls of the intestine and esophagus adapt sero-muscular-submucous sutures (23) in an open way (Figs. 10 - 26, 27), preferably use absorbable monolithic suture material on atraumatic needles (PDS 4 / 0-5 / 0). The adjacent intestinal loop walls (below the junction of the three walls) are stitched together (for a maximum of 1 cm, i.e. without creating a large reservoir). The external edges of the intestinal wound are sutured with a single-row serous-muscular-submucosal suture (27) (Fig. 10).

The outlet knee of the jejunum loop (10) is laid along the lead knee (9), the vertical branch of DNA and its horizontal branch. Under the large intestinal mesentery, the outlet knee of the jejunum loop is laid horizontally to the Treitz ligament. Thus, the course of the abducting knee maximally repeats the course of the duodenum. The nodal sutures in the peri-mesenteric zone fix the abducting intestine (right) and the initial section of the crossed jejunum. An end-lateral jejuno-anastomosis (28) is formed with a single-row suture of absorbable monofilament (Fig. 11).

The method was tested on 57 patients.

Patient L-a G.M., 55 years old, was admitted to the department of gastric surgery of the RCCH on October 13, 2001 with complaints of recurrent pain in the epigastric region, general weakness, loss of appetite, weight loss of 5 kg for 2 months. These complaints appeared about 4 months before hospitalization. On examination in the clinic: endoscopic picture of an exophytic tumor in the middle third of the stomach body along the anterior wall with a transition to lesser curvature and posterior wall. Biopsy: PIP - a moderate degree of differentiation adenocarcinoma. Fluoroscopy and gastrography correspond to cancer of the body of the stomach. According to the results of chest x-ray and ultrasound of the abdominal cavity and retroperitoneal space, no data were obtained for dissemination of the tumor process. 10.17.01, the patient was routinely operated. Extended upper mid laparotomy with hardware correction of the wound aperture by Sigal-Kabanov retractors. Intraoperatively revealed a tumor in the middle third of the body of the stomach with localization along the lesser curvature and spreading to the front and back walls of the stomach, which grows to the serous membrane, without germinating on the surrounding organs. The lymph nodes of the regions of regional metastasis are not visually changed. Given the data of an intraoperative study, it was decided to perform a gastrectomy and expanded lymphadenectomy in a volume of D ₂ . Produced mobilization of the stomach along the greater and lesser curvature. Performed precision lymphodissection D ₂ . The drug is removed. Farther than the duodenojejunal junction, at the site of greatest mobility of the mesentery of the jejunum, at the level of the 2 mesenteric artery, at a distance of 15 cm from the Treytz ligament, the small intestine was crossed with the mobilization of arcade vessels along the resection line. In the right half of the mesentery of the colon, at the intersection with the vertical branch of the duodenum, a wide "window" is created. The distal end of the crossed jejunum was drawn to the upper floor of the abdominal cavity, the loop was laid antiperistaltically. An end-terminal jejuno-duodenoanastomosis was formed by a single-row serous-muscular-submucosal suture with absorbable monofilament PDS 5/0. The stump of the esophagus is fixed in the esophageal opening of the diaphragm with 4 lavsan 8-shaped sutures, an esophageal-intestinal anastomosis of the end-loop structure is formed.

The outlet knee of the jejunum loop is laid along the adductor knee, the vertical branch of the duodenum and its horizontal branch to the Treitz ligament, fixed with gray-serous sutures. Formed end-lateral jejuno-anastomosis single-row suture. Abdominal drainage, layer-by-layer suturing of the abdominal wall wound. The postoperative period was uneventful. Drains removed on the 6th day. On the 10th day, the probe was removed, liquid intake through the mouth was allowed, and from 12 days it was allowed to eat liquid food. Healing by first intention. Discharged in satisfactory condition on the 14th day after the operation. PIP of the removed drug - moderate adenocarcinoma of differentiation with invasion to the serous layer. No metastases in the lymph nodes were found. Diagnosis after surgery - Cancer of the body of the stomach, T ₃ N ₀ M ₀ G ₂ , stage III, after surgical treatment. Subsequently, the patient underwent a course of adjuvant polychemotherapy (5-fluorouracil 500 mg / m ² , leucovorin 20 mg / m, 4 cycles). Examined after 1 year. I didn’t make any complaints, I didn’t follow a special diet, I worked by profession, she estimates the result of the operation as good. There are no endoscopic signs of recurrence of the disease and reflux esophagitis. The esophageal-intestinal anastomosis closes, while freely passing. X-ray patency of the anastomosis is free, evacuation of a portioned nature through it, no regurgitation of the contrast suspension in the Trendelenburg position is noted. The patient was examined after another 7 months, the condition is satisfactory, no data were found for the progression and relapse of the tumor.

Using the method allows to improve the immediate and long-term functional results of the surgical treatment of patients with gastric cancer.

Claims (1)

The method of small bowel gastroplasty after gastrectomy, including the mobilization and intersection of the first loop of the jejunum, the application of enteroduodenoanastomosis, anastomosis of the crossed jejunum in the side of the knee, which is diverging from the esophagus and intestines, characterized in that the endotracheal and duodenum have in the esophageal opening of the diaphragm with four dacron 8-shaped sutures, make a "window" between the straight vessels of the mesentery anastomosed with the duodenal loop through which the esophagus stump is drawn, the ends of the threads fixing the esophagus are drawn through the edges of the mesenteric "window" and the loop of the intestine is fixed behind the mesentery to the diaphragm, the esophageal stump wall and the adjacent intestinal loop wall are sewn together, the bowel loops are arched around it esophageal stumps adjacent to each other in a circle of the intestinal wall and esophagus are sutured with serous-muscular-submucosal sutures in an open way, the outer edges of the intestinal wound are sutured with a single-row serous-muscular-submucosal suture, abduction the lingering knee of the jejunum loop is laid along the duodenum so that it repeats the course of the last and fixes it.

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