RU2266716C1 - Method for applying esophago-large intestinal anastomosis at esophagoplasty - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should dissect posterior wall of large intestine withdrawn onto the neck through retrosternal tunnel, in cross-sectional direction in vessel-free area at the distance being equal to the diameter of tracheal tube lumen. Then one should form anastomosis between the foramen obtained at posterior wall of large intestine and esophagus, form the lower lip of anastomosis with separate interrupted sutures with knots being inside the organs under suturing through all the layers, form the upper lip of anastomosis from the side of intestinal lumen of the end of large intestine after removing pre-applied uninterrupted suture. It is necessary to suture in intestinal end with a two-row suture at fixing it towards paraesophageal cicatricial tissues above anastomosis. The method enables to remove the chance for developing failed sutures of anastomosis and favors valuable local circulation in anastomosis' area.

EFFECT: higher efficiency of operation conducted.

5 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, and can be used when performing the cervical stage of large intestine plasty of the esophagus, which is performed with cicatricial narrowing or atresia of the esophagus.

With congenital or acquired obstruction of the esophagus, surgical interventions are performed aimed at restoring the patency of the esophagus. If it is impossible to perform restoration of patency of the esophagus, they resort to esophageal plastic. There are many methods of esophageal plasty, where the artificial esophagus is formed from the small, large intestine, the large curvature of the stomach. The most common is colonic esophagoplasty, the cervical stage of which consists in the formation of an anastomosis between the esophagus or pharynx and the oral end of the colon, used as a transplant. In the near and distant period, complications are often noted, such as failure of the esophageal-colonic anastomosis with the development of intestinal fistula anastomosis and stenosis of the anastomosis with the development of a clinic for partial or complete obstruction of the artificial esophagus. According to some authors, these complications reach up to 37-50% of operated patients.

There is a method of applying an esophageal-colonic anastomosis of the type "end to end" (Vantsyan E.N., Toshchakov R.A. Treatment of burns and cicatricial narrowing of the esophagus. M., 1971, p.163-166).

The disadvantage of this method is that the anastomosed ends differ in diameter, there is a lot of tension along the suture line, which often leads to anastomosis failure and fistula development.

There is a method of applying a L-shaped anastomosis of the type "side to side", which consists in the fact that the colon is sutured to the esophagus obliquely from bottom to top and from left to right throughout along its left lateral surface, fixing the anastomosis with the second row of sutures (Shalimov A.A. ., Saenko V.F., Shalimov S.A. Esophagus Surgery. M., 1975, p.184-186).

The disadvantage of this method is that this anastomosis is “side by side”, that is, there are blind pockets into which food masses fall and stagnate, subsequently the pockets expand and lead to various dysphagia and stenosis of the anastomosis.

There is a method of applying an esophageal-colonic anastomosis of the type "end to side", consisting in the fact that an anastomosis is formed between the oral end of the esophagus and the anterior wall of the colon (Petrov B.A., Sytnik A.P. Artificial esophagus from the small and large intestine M., 1972, pp. 98-99).

The disadvantage of this method is that when moving the head, the greatest mobility is observed in the anterior wall of the esophagus, which leads to constant tension of the "weak" lower lip of the anastomosis. When vomiting or burping, the air or contents of the stomach, falling into the anastomotic zone, exert more pressure on the front wall of the colon, that is, on the joints of the anastomosis, since the back wall rests on a dense vertebral column. All this contributes to the development of insolvency of the anastomosis and the appearance of fistulas in the near postoperative period.

By the prototype of the invention, we have chosen a method of forming an areflux cervical esophageal-colonic anastomosis of the end-to-side type, consisting in the fact that muscle pulp is formed at the distal end of the resected esophagus, sero-muscular sutures are inserted between the posterior semicircle of the muscle pulp and the mesenteric edge of the colon in two tiers, a linear section of the colon is made at the level of the lower edge of the pulp, the mucosal-submucosal part of the esophagus is invaded by the opening of the colon, mucus is superimposed then submucosal sutures between the esophagus and colon, then sero-muscular sutures are placed between the anterior semicircle of muscle pulp and the upper edge of the colon opening in two tiers, the end of the colon is sutured with serous-muscular sutures (RF patent No. 2207069, IPC A 61 V 17 / 11, 2003).

The disadvantage of this method is the imposition of a large number of sutures (about 30) in 3 tiers, which leads to impaired local blood circulation, partial necrosis and the development of anastomotic suture failure in the immediate postoperative period, fistula and stenosis in the long term after the operation. The absence of a suture through all layers of the wall of stitched organs contributes to this.

The aim of the invention is the formation of an esophageal-colonic anastomosis, in which the possibility of the development of anastomotic suture failure and the appearance of intestinal fistulas of the anastomosis is completely eliminated.

The goal is achieved by applying an esophageal-colonic anastomosis on the neck in an “end to side” type, in which a transverse section in the avascular zone is performed on the posterior wall of the colon led to the neck through the chest tunnel, equal to the diameter of the lumen of the esophageal tube, an anastomosis is formed between the obtained hole on the posterior wall of the colon and the esophagus, where the lower lip of the anastomosis is sutured externally with nodular sutures with nodules into the stitched organs through all layers, and the upper lip is s the intestines of the intestinal lumen are also nodular sutures with nodules inward after removing the suture from the end of the colon, then the end of the intestine is sutured with a two-row suture with its fixation to paraesophageal scar tissue over the anastomosis.

The implementation of the method is illustrated by illustrations, where

figure 1 shows the formation of the lower lip of the esophageal-colonic anastomosis and two holders at the fillet seams;

figure 2 shows the opening of the lumen of the colon in the region of its end, dissolving continuous previously applied catgut thread;

figure 3 shows the formation of the upper lip of the anastomosis through the intestinal lumen with nodular sutures with nodules into the stitched organs;

figure 4 shows suturing with a double-row suture of the end of the colon;

figure 5 shows the fixation of the colon over the anastomosis to cicatricial paraesophageal tissues.

The method is as follows. The patient is on his back with a roller under the shoulder blades and his head turned to the right. Through the cervical incision of the skin, the cervical segment of the esophagus is separated from the surrounding soft tissues in a blunt and sharp way. The oral end of the large intestine transplant is carried out from the abdominal cavity through the sternal tunnel to the neck. The posterior wall of the colon is dissected in the transverse direction in the avascular zone for a length equal to the diameter of the lumen of the esophagus tube at a distance of 1-2 cm from the oral end. Between the lower edge of the colon opening and the posterior edge of the esophagus, the lower lip of the anastomosis is formed by applying Vicryl 3/0 nodal sutures with nodules into the stitched organs (Fig. 1). Corner seams are not cut, but are used as holders. The lumen of the colon is opened in the region of its end, dissolving the continuous catgut thread superimposed earlier (figure 2). In the formed intestinal lumen, 2 uncut filaments at the corners of the anastomosis are removed. Between the upper edge of the opening of the colon and the front edge of the esophagus, the upper lip of the anastomosis is formed through the intestinal lumen, superimposing Vicryl 3/0 nodal sutures with nodules into the stitched organs (Fig. 3). The end of the colon is sutured with a double-row suture (Fig. 4). One of the last sero-muscular sutures is the colon located above the anastomosis to the cicatricial paraesophageal tissues (Fig. 5). Rare seams are applied to the edges of the skin.

The proposed method of surgical intervention was used to treat patients with cicatricial narrowing and atresia of the esophagus in the children's surgical clinic of the Rostov State Medical University on the basis of the city hospital No. 20. We give the following observation as an example.

Patient A., 1 year old (medical history No. 1879/483), was admitted to the pediatric surgery clinic on 02.03.04 with complaints from her parents about the inability to eat through the mouth. From the anamnesis it was found that on the 2nd day after birth, the child underwent surgery for atresia of the esophagus. Due to significant diastasis between the ends of the esophagus, an esophageal-respiratory fistula was ligated and crossed, a cervical esophagostoma and gastrostomy according to Kader were placed to feed the child. On March 4, 2004, the patient underwent total colonic retrosternal esophagoplasty with the cervical stage of the operation performed according to our method. Before removing the transplant on the neck, the esophagostoma was excised and the cervical segment of the esophagus was mobilized. Then, through the sternal tunnel, the oral end of the large intestine transplant is withdrawn to the neck and an anastomosis is placed between the end of the esophagus and the posterior wall of the intestine, using the formation of the lower lip of the anastomosis outside and the upper lip - from the side of the lumen of the intestinal tube. After this, the end of the intestine was sutured using a 2-row suture and fixed to paraesophageal tissues above the level of the anastomosis. Rare seams are applied to the edges of the skin. The postoperative period was uneventful. The surgical wound on the neck healed by primary intention. Through the gastrostomy, the girl began to be fed on the 4th day after the operation, she began to take food through her mouth on the 8th day of the postoperative period. The girl was discharged in satisfactory condition 03/20/04.

Compared with the prototype, the proposed method has the following advantages: a small number of sutures are applied across all layers of the wall of the esophagus and colon in one row, the upper lip of the anastomosis is sewn through the lumen of the colon, the esophageal-colonic anastomosis is formed between the oral end of the esophagus and the posterior wall of the large intestine transplant. All these advantages contribute to full local blood circulation, create favorable conditions for the healing of the anastomosis and reduce the risk of failure of the joints of the anastomosis with the appearance of intestinal fistulas to a minimum.

Claims (1)

The method of applying the esophageal-colonic anastomosis on the neck with esophagoplasty, including dissecting the posterior wall of the colon, brought to the neck through the chest tunnel, in the transverse direction in the avascular zone for a length equal to the diameter of the lumen of the esophagus tube, forming an anastomosis between the hole in the posterior wall of the colon and the esophagus, the formation of the lower lip of the anastomosis with separate nodal sutures by nodules into the stitched organs through all layers, the formation of the upper lip of the anastomosis from the side ishechnogo end colon lumen after removal of previously superimposed on it a continuous suture, suture end intestine seam double row latching it to the tissues over paraesophageal anastomosis.

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