RU2278619C1 - Large intestine gastroplasty method applicable after performing gastrectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out invaginating end-to-end esophagocoloanastomosis with large intestine graft on vascular pedicle. Isolated area is cut out from distal graft portion. It is cut along edge opposite to mesentery. Mucosubmucous layer is excised with blood-supplied seromuscular layer being retained due to mesenterial blood vessels. Region deprived of mucous membrane is sutured with corrugating sutures in tube-like manner. The tube is fixed around the distal graft portion. Coloduodenal end-to-end anastomosis is created between distal large intestine graft end and duodenum stump.

EFFECT: reduced frequency and severity degree of postgastrectomy syndromes.

12 dwg

Description

The present invention relates to medicine, namely to surgery, and can be used to treat cancer of the stomach. Gastrectomy is the most common operation for malignant diseases of the stomach [Zherlov G.K., Koshel A.P., Klokov S.S., 2002.]. For more than a century, the efforts of numerous surgical schools have significantly (from 60% to 2%) reduced mortality after gastrectomy. At the same time, despite hundreds of original technical proposals, to date, it has not been possible to get rid of typical postgastrectomy diseases: reflux esophagitis, dumping syndrome and hypoglycemic syndrome, peptic ulcer anastomosis, afferent loop syndrome, agastral asthenia, homeostasis disorders, which lead to a significant decrease in the quality of life of patients [Fukuhara K., Osugi H., Takada N., Takemura M., Higashino M., Kinoshita H. - 2002.].

A known method of colonic gastroplasty (Errigo J., "Retablissement de la continuite du tube digestiv apres G.E. T. au colon transvers". Giorn. Ital. Chir., 1950, 6, 262), (Figure 1). Gastrectomy is performed. A colonic transplant is cut out on the vascular pedicle, which is sutured on both sides tightly with a two-row suture. The graft is placed antiperistaltically and a double-row suture is applied to the lateral-lateral esophagocoloanastomosis and duodenocololoanastomosis. The continuity of the large intestine is restored by the formation of an anastomosis between the proximal and distal parts of the large intestine.

The method has significant disadvantages. The design used by the author predisposes to the formation of a blind bag and subsequently to stagnation of food. With this method, a high incidence of failure of the esophageal-intestinal anastomosis is also noted, 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 anastomoses, at the junction of two functionally different organs, a fibrous ring appears that freely passes food masses in both directions.

The closest in technical essence and the achieved result is a method of gastroplasty with a section of the colon after gastrectomy (figure 2) (Androsov PI "Substitution of the stomach with total gastrectomy with the colon". Surgery, 1955, 6, 94-95). With this technique, after a gastrectomy, a fragment from the transverse colon is cut out on the vascular pedicle. An end-to-end esophagocololoanastomosis isoperistaltically is applied with a double-row suture. Between the stumps of the duodenum and the distal section of the thal intestine transplant, an end-to-end coloduodenoanastomosis is formed with a double-row suture.

However, when using this method, there is a high incidence of failure of the esophageal-intestinal anastomosis, 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 anastomoses. At the junction of two functionally different organs, a fibrous ring appears, freely passing food masses in both directions. There is a retrograde flow of the contents of the colon 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.

The objectives of the proposed method

1. Creation of the design of the esophageal-colonic anastomosis, providing free passage of food through the esophageal-intestinal anastomosis and at the same time completely eliminating reflux into the esophagus.

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

3. Reducing the frequency of complications caused by insufficiency of sutures of the esophageal anastomosis.

The technical essence of the proposed method is the exclusion of reflux into the esophagus, reducing the severity of postgastrectomy pathological syndromes, ensuring the consistency of anastomotic sutures due to the fact that after removal of the stomach, invagination of the end-terminal esophagocoloanastomosis is performed, then a pseudo-pyloric is formed from the demotectic part of the large intestine, from the intestine, in the form of a tube and circularly fixed around the distal trans plantate.

The method is as follows.

A gastrectomy is performed, if necessary, with a resection of part of the abdominal esophagus. The esophageal aperture of the diaphragm is narrowed to the diameter of the esophagus due to the application of three 8-shaped sutured suture ligaments, the walls of the esophagus are fixed to the walls of the esophagus for the remnants of the esophageal-diaphragmatic membrane, paraesophageal fiber and neurovascular bundles entering the wall of the esophagus (Figure 3).

For clarity, the method is illustrated in FIGS. 3-12, in which: FIG. 3 - suturing ligaments and narrowing the esophageal opening of the diaphragm to the diameter of the esophagus; figure 4 - fixation of the III-m suture ligament for the mesenteric shade of the large intestine transplant to the legs of the diaphragm; figure 5 - the formation of a precision single-row esophagocoloanastomosis; 6 - flashing stitches-ligaments of the free and stuffing tennii colonic transplant; Fig.7 - invagination of esophagocoloanastomosis in the colon transplant by tightening the suture ligaments; Fig - excision of the mucous-submucosal layer in an isolated area of the colon; Fig.9 - corrugation of the muscle layer of an isolated area of the colon; figure 10 - formed serous-muscular tourniquet from an isolated area of the colon; 11 - circular fixation of the serous-muscular tourniquet at the distal end of the large intestine transplant; Fig - the formation of a precision single-row duodenocoloanastomosis.

Digital designations in the drawings:

1 - anterior semicircle of the esophageal opening of the diaphragm;

2 - widely exposed submucosal layer of the esophagus;

3 - the stump of the esophagus;

4 - the left leg of the diaphragm;

5 - splenic artery;

6 - a stump of the bandaged left gastric artery;

7 - common hepatic artery;

8 - celiac trunk;

9 - the right leg of the diaphragm;

10 - colonic transplant;

11 - free teniya;

12 - mesenteric tennia;

13 - omental tenia;

14 - precision serous-muscular-submucosal sutures that adapt the submucosal layers of the esophagus and colon;

15 - serous-muscular-submucosal sutures of the anastomosis anterior wall;

16 - invagination end-terminal esophago-coloanastomosis;

17 - removed mucous-submucous layer;

18 - serous-muscular cuff, blood supply to the mesentery of the colon;

19 - seams forming a serous-muscular "tourniquet";

20 - serous-muscular "tourniquet" for the formation of a pseudo-pyloric;

21 - a window in the mesentery of the large intestine transplant for conducting a serous-muscular "tourniquet".

22 - line of serous-muscular-submucosal sutures of duodeno-coloanastomosis;

23 - the right sections of the colon;

24 - line serous-muscular-submucosal sutures of a bell anastomosis;

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

Thus, around the stump of the esophagus, above the alleged anastomosis, muscle pulp is created from the legs of the diaphragm and prevent the esophagus from moving up.

Mobilization of the colon transplant is performed from the transverse colon. Mesocolon mesentery is dissected in the avascular part. The transverse colon is crossed at the branching level of the middle colon artery, due to which the graft is supplied with blood. Next, anastomosis is applied with a single-row precision serous-muscular-submucosal suture "end to end" between segments of the colon and the mesentery of the colon is sutured. A 20-25 cm long section of the colon thus selected on the vascular pedicle is antiperistaltically brought to the esophagus stump and fixed with the III stitch-ligament for the mesenteric shade to the legs of the diaphragm (Figure 4). Then impose precision serous-muscular-submucosal sutures between the wall of the intestine and the esophagus (Fig.5, 6). Using the free ends of the suture-ligaments that fix the legs of the diaphragm and the walls of the esophagus, an invagination esophageal-colonic anastomosis is formed by capturing each of the teni of the large intestine transplant 4 cm below the anastomosis (Figure 7). An isolated section of 8 cm in length is cut from the distal graft, which is dissected along the mesenteric edge. On this site, the mucosal submucosal layer is excised while maintaining a well-supplied sero-muscular layer on the mesentery (Fig. 8). The demucosized area is sutured in the form of a tube with corrugating catgut sutures, as a result of which a serous-muscular "tourniquet" is formed to form a pseudo-pylorus (Figs. 9, 10). In the mesentery of the large intestine transplant, a window is formed through which a serous-muscle tourniquet is passed, wrapping it around the intestine in the form of a muscle loop around the distal section of the large intestine transplant, and a pseudo-pylorus is formed. The muscle pseudo-pylorus is fixed with separate gray-serous sutures (Fig. 11). A distal end-to-end coloduodenoanastomosis is applied with absorbable PDS 5/0 filaments between the duodenal stump and the distal end of the large intestine transplant (Fig. 12).

The method was tested on 8 patients.

Patient M.M.M., 55 years old, was admitted to the department of gastric surgery of the RCCH for 06/18/2001 with complaints of severe bursting constant pain and heaviness in the epigastric region, general weakness, belching of air, nausea and dizziness after eating sweet and dairy foods. The patient had a history of surgery in 1997, suturing of a perforated duodenal ulcer, and in 1998, due to duodenal stenosis, a subtotal gastrectomy was performed according to Hoffmeister-Finster. In the postoperative period, the above complaints appeared and began to grow. On examination at the clinic: endoscopic picture of an exophytic tumor of a stump of the stomach state after a resection of the stomach, gastritis of the stump, anastomositis, biopsy: PGI adenocarcinoma of a moderate degree of differentiation. With an X-ray passage of barium through the gastrointestinal tract, there is a tuberous defect in the filling of the stomach stump, a pronounced accelerated rate of evacuation from the stomach stump and passage through the colon. 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. 07/02/01 the patient was operated on for cancer of the stump of the stomach and severe dumping syndrome. Enhanced upper-median laparotomy with hardware correction of the wound aperture by Sigal-Kabanov retractors. Intraoperatively: the stomach is resected according to the Hoffmeister-Finsterre scheme without Brownian anastomosis, the stump of the stomach is very small, resected very subtotally, only the part of the bottom of the stomach is preserved, in which the tumor is palpated, which does not extend to the esophagus and does not germinate the serous membrane. No distant metastases were found. Lymph nodes of regional metastasis zones are not visually changed. It was decided to perform the extirpation of the gastric stump with expanded lymphadenectomy in the volume of D2 and reconstructive surgery using colonic plastic from the transverse colon. The duodenal stump was isolated from the cicatricial commissure mantle, opened, the stump suture line was excised. Mobilized the vertical branch of the duodenum. Gastroenteroanastomosis isolated from cicatricial adhesions. A stump of the stomach was isolated and mobilized from adhesive layers. The esophageal opening of the diaphragm was mobilized, a sagittal diaphragmotomy was performed. The lower third of the esophagus has been mobilized. Both vaguses are crossed. Removal of gastroenteroanastomosis. A wedge-shaped resection of the jejunum region in the region of the former GEA was performed, restoration of the integrity of the jejunum wall by a single-row precision serous-muscular-submucosal suture. Extirpation of the stump of the stomach. The esophagus is crossed 5 cm above the palpable tumor. The esophageal opening of the diaphragm is narrowed to the diameter of the esophagus due to the imposition of three sutured 8-shaped suture ligaments on the legs of the diaphragm with fixation of the walls of the esophagus for the remains of the esophageal-diaphragmatic membrane, paraesophageal fiber and neurovascular bundles entering the wall of the esophagus. Mobilization of the colon transplant was performed from the transverse colon. Dissected mesentery mesentery in the avascular part. The transverse colon was crossed at the branching level of the middle colon artery, due to which the graft is supplied with blood. Next, an anastomosis was performed between segments of the colon with a single-row precision sero-muscular-submucosal end-to-end suture, and the mesentery of the colon was sutured. A 20–25 cm long section of the colon thus selected on the vascular pedicle is brought anti-peristally to the esophagus stump, fixed with the 3rd stitch-ligament for the mesenteric shade of the large intestine transplant to the legs of the diaphragm. Next, sero-muscular-submucosal sutures were made between the wall of the intestine and the esophagus. Using the free ends of the suture-ligaments that fix the legs of the diaphragm and the wall of the esophagus, an invagination esophageal-colonic anastomosis is formed by capturing each of the teni of the colonic transplant 4 cm below the esophageal-colonic anastomosis. An isolated section of 8 cm long was cut from the distal section of the graft, which was dissected along the mesenteric edge. On this site, the mucosal submucosal layer was excised with the preservation of a well-supplied sero-muscular layer due to vessels on the mesentery. The demucosed area is sutured in the form of a tube with corrugating catgut sutures, as a result of which a serous-muscular "tourniquet" is formed to form a pseudo-pyloric. A window is formed in the mesentery of the large intestine transplant through which a serous-muscle tourniquet is drawn and wrapped around the distal section of the large intestine graft in the form of a muscle loop, a pseudo-pylorus is formed. The muscular pseudo-pylorus is fixed with separate gray-serous sutures. Performed coloduodenoanastomosis "end to end" between the duodenal stump and the distal end of the large intestine transplant. Abdominal drainage. Layer-by-layer suturing of a laparotomy wound. An aseptic dressing.

The postoperative period was uneventful. Drains removed on the 6th day. From 3 days, the introduction of fluid through the nasogastric umbrella was started, from 6 days the probe was removed, fluid intake through the mouth was allowed, and food was allowed to feed with liquid food from 8 days. Healing by first intention. Discharged in satisfactory condition on the 11th day after the operation. PIP of the removed drug - moderate adenocarcinoma. No metastases in the lymph nodes were found. The diagnosis after surgery is gastric stump cancer, T2N0M0, stage 3 after surgical treatment, the disease of the operated stomach, severe dumping syndrome, the condition after resection of the stomach according to Hoffmeister-Finsterre (1998). The patient was examined after 1 year and 3 months. She did not make any complaints; she did not adhere to a special diet. The result of the operation is rated as good. There are no endoscopic signs of recurrence of the disease, duodenogastric reflux and reflux isophagitis. The valve esophageal-colonic anastomosis closes, while freely passing.

X-ray anastomosis patency is free, evacuation through the esophageal-colonic anastomosis and pseudo-pyloric anterior nature, regurgitation of contrasting suspension in the Trendelenburg position was not observed. No complications associated with the anastomosis were observed. In the study in the postoperative period in all cases, the use of this method made it possible to achieve good food evacuation through esophagocolo- and coloduodenoanastomosis, and prevent coloesophaginal and coloduodenoal reflux. 3 patients in the early long-term postoperative period from 6 months to 1.5 years were re-examined. The endoscopic picture of recurrence of the disease did not show. Patients feel good, no complaints.

The use of cologastroplasty with the formation of invasive esophagocololoanastomosis and pseudo-pyloric can improve the immediate and long-term functional results of surgical treatment of patients with gastric cancer, eliminate the development of post-gastrectomy syndromes (reflux esophagitis, dumping syndrome) and reduce the frequency of complications caused by failure of the esophageal anastomotic sutures.

Claims (1)

The method of colonic gastroplasty after gastrectomy, including providing passage through the duodenum, characterized in that after removal of the stomach an invagination end-terminal esophagocololoanastomosis is performed with a colonic graft on a vascular pedicle, an isolated area is cut out from the distal graft, dissected by an open mucous membrane and dissected by mucous membrane. - submucosal layer with preservation of the blood supply to the serous-muscular layer due to the vessels of the mesentery, demucosity sewn seams corrugating a tube, is carried out through a window in the colonic mesentery graft is wrapped and fixed around the distal graft division gray-serous sutures operate koloduodenoanastomoz "end-to-end" between the distal end of the graft and colonic stump duodenum.

Images