RU2283622C2 - Method for hiding circular skin defects of inferior vena cava with plastic operation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves creating arteriovenous fistula between femoral arteries and a 1.5 cm long vein with intravenous anesthesia being applied. Laparotomy is carried out, inferior vena cava injuries are diagnosed and its diameter is measured. Segment of required length and diameter is produced from anterior stomach surface adjacent to the greater curvature. It is washed in Furacilin solution 1:5000 during 5 min to remove the content and placed into 0.9% sodium chloride solution. Then tubular graft is produced turned with serous membrane turned into the blood vessel lumen and its diameter being equal to vena cava diameter with Longitudinal blanket suture. The tubular stomach graft is sutured into the circular vena defect after having excised inferior vena cava segment. The arteriovenous fistula is eliminated 3-4 months later.

EFFECT: high strength and reliability of coverage; reduced risk of postoperative complications.

Description

The invention relates to medicine, namely to vascular surgery, and can be used, in particular, for plastics of circular defects of the main venous vessels - the inferior vena cava.

A method is known in the practice of medicine (Ribbe EB, Aim P., Hallberg E., Norgren LE, Evaluation of peritoneal tube grafts in the inferior vena cava of the pig. Br. J. Surg. - 1988. - V.75. N 4 - P.357-360) transplants into the infrarenal section of the inferior vena cava of transplants 2.5 and 5 cm long, formed from the peritoneum of the anterior abdominal wall in 12 pigs. 2 weeks after surgery, out of 6 prostheses taken, 3 were passable, and 6 long grafts were thrombosed by that time. After 4 months, 2 short grafts recanalized. Thus, only 5 short grafts were passable.

The disadvantages of the method include a very high percentage of transplant thrombosis (6 long - 100% and 1 short of 6 - 16.6%), which may be due to the low quality of the plastic material, the method of preparing it for surgery, transplantation technique, and other reasons.

The closest and most widespread method compared to the proposed one is the method of plasty of the inferior vena cava defect with prostheses made of porous polytetrafluoroethylene (Soyer T., Lempinen M., Cooper P. et al. A new venous prothesus. Surgery. - 1972. V.72 - P .864-872). In the experiment, the suprarenal section of the inferior vena cava was made with PTFE prostheses for the first time and good results were obtained, and when replacing the infrarenal section, only every third turned out to be passable. As you can see, the prototype method has the following significant disadvantages:

- synthetic prostheses can be infected in the patient's body with the formation of aneurysms of the anastomoses and subsequent aortocaval, aortoduodenal fistula and bleeding;

- in the patient's body, prostheses are a foreign body;

- the internal lining of the prosthesis does not epithelize for a long time, this can lead to thrombosis, especially in conditions of low blood flow velocity;

- thrombectomy from prostheses is difficult (except for the North prostheses) due to the peculiarities of their structure;

- Artificial vascular substitutes due to the high cost may not always be available to replace the vena cava defect.

The aim of the invention is to increase the reliability, strength of plastic material, reduce postoperative complications (thrombosis, bleeding, infection), ensure the long-term function of the reconstructed vessel.

The goal in the invention is achieved in that a segment of the required length and diameter is obtained from the front surface of the stomach closer to the greater curvature. This section of the stomach, and not its posterior surface, is more accessible, well supplied with blood, the wounds of this area heal better, the wall is of sufficient thickness (3 times thicker than the wall of the inferior vena cava), plastic material can be obtained from this region of the stomach without disturbing the evacuation motor organ functions.

The obtained sections of the stomach are washed from the contents in a solution of furatsillin 1: 5000 for 5 minutes, because this chemical antiseptic is widespread and affordable, of low cost, used in any surgical hospital, is still quite effective. Then the segments of the stomach are placed in 0.9% sodium chloride, it does not violate the structure of the obtained autotissue and protects the material from drying out and physical trauma during the formation of tubular grafts from the segments of the stomach, turned into the lumen of the vessel by the serous membrane (peritoneum). The latter is close in anatomical structure to the intima of the vessel - smooth, smooth, shiny - and provides laminar blood flow in the vessel, in contrast to the uneven, tuberous, secreting hydrochloric acid and enzymes of the gastric mucosa. The circulation of the latter into the lumen of the vessel leads not only to turbulent blood flow, but also to the fusion of parietal thrombi along the suture line with the edges of the reconstructed vessel, followed by bleeding.

Tubular transplants were formed with a diameter equal to the diameter of the inferior vena cava, since with different diameters of the graft and the vessel into which the transplant is carried out, blood flow turbulence may occur and the likelihood of thrombosis may increase. Precision stitching of the edges of the tubular graft with a longitudinal curling seam ensures uniform lumen along the entire length of the graft. The formed tubular grafts from the stomach wall were sutured into the newly formed circular defects of the inferior vena cava by excision of its segment. Arteriovenous fistulas were eliminated 3-4 months after plastic surgery. Cardiovascular function did not suffer.

To study the possibility of using stomach tissue for plasty of defects of the inferior vena cava, experiments were performed on 20 outbred dogs of both sexes weighing from 7 to 20 kg on the basis of the Alexander Mariinsky Regional Clinical Hospital No. 1 and the Astrakhan State Medical Academy during 1999-2003.

Figa). Obtaining from the wall of the stomach a full-layer segment and the formation of a tubular transplant from it with the peritoneum into the lumen.

Fig.1b). A tubular transplant of the stomach is transplanted into a circular defect of the inferior vena cava.

Figure 2. Experience 31. A macrodrug of the inferior vena cava and gastric transplant after 2 weeks of the experiment. There is a complete connection of the vein and graft at the sites of anastomoses. The graft is pink, intima is smooth, smooth, shiny.

Figure 3. Experience 35. Phlebogram of the inferior vena cava 6 months after surgery. Complete patency of the contrast medium in the projection of the gastric transplant is noted (marked by arrows).

Figure 4. Experience 32. A macrodrug of the inferior vena cava and transplant from the wall of the stomach 6 months after transplantation. Patency is preserved, intima is shiny, elastic tissue, graft boundaries are visible at the seams of prolene.

Figure 5. Experience 34. Phlebogram of the inferior vena cava 1 year after surgery. Complete patency of the gastric transplant transplanted into a vein defect is noted.

6. Experience 34. Fresh macrodrug of the inferior vena cava and transplant from the wall of the stomach 12 months after transplantation. Patency is preserved, intima is shiny, elastic tissue, graft boundaries are visible at the seams of prolene. Stenosis and deformation in the lumen of the transplant is not observed.

7. Experience 31. Two weeks of the experiment. The preserved structure of the mucous membrane, muscle plate and submucosal layer of the stomach flap. Hematoxylin-eosin stain. × 200.

Fig.8. Experience 34. 12 months of the experiment. The zone of a smooth transition of the mesothelial lining of the gastric flap into the endothelium of the inferior vena cava. Van Gieson stain. × 100.

Fig.9. Experience 27. Two years after plastic surgery of the defect of the NPS with a flap of the stomach. Anastomosis of the IVC and the flap of the stomach: a slit-like space with muscle and collagen fibers oriented along them and a large number of vessels. Hematoxylin-eosin stain. × 200.

The proposed method was carried out as follows: under anesthesia (a solution of hexenal 2% - 20 ml intravenously), an arteriovenous fistula (AVF) was applied between the femoral artery and vein 1.5 cm long. Then, a median laparotomy was performed. The vena cava was exposed below the level of the renal vessels, its diameter was measured, three pairs of lumbar veins were ligated and crossed. Then the stomach was exposed, a free full-layer flap was obtained from its front wall, and it was treated in a 1: 5000 solution of furatsillin for 5 minutes. Then, a tubular transplant was formed on the plastic mandrel with the peritoneum into the lumen, and the mucous membrane outward. The inner diameter of the graft corresponded to that of the inferior vena cava (figa). In preparation, the graft was placed in a vessel with a solution of 0.9% sodium chloride to prevent mesothelium from drying out and mechanical injury. Then clamps were applied to the inferior vena cava, between which the vessel was dissected and, thus, circular defects were formed, into which the formed tubular grafts were sutured (Fig. 1, b). The longitudinal seam of the grafts was located on the ventral side for its better control and ease of application of the anastomosis in this position with the LEL wall, since there are certain technical difficulties that require the precision technique of placement because of the different thickness of the wall of the graft of the stomach and vena cava (as 3 :one).

The size of the excision of the vena cava for plasty by the wall of the stomach was as follows: 2.5 cm in 1 dog, 3 cm in 2 dogs, 3.5 cm in 1 dog, 5 cm in 16 dogs.

The length of the gastric transplants to replace the circular NPS defects was as follows: 4.5 cm - 1 dog, 5 cm - 1 dog, 6 cm - 9 dogs, 6.5 cm - 9 dogs.

The animals were monitored, intravital and posthumous phlebograms were performed, preparations were evaluated macroscopically, histological studies of the area of anastomoses and graft walls were carried out. All 20 dogs survived and were observed for periods ranging from 7 days to 2 years.

In one dog (experiment No. 67), transplant thrombosis occurred 7 days after plastic surgery (this was manifested by small edema of the hind limbs, some uncertainty in walking and was confirmed on intravital phlebograms). Arteriovenous fistulas were eliminated 3-4 months after transplantation.

As an example, we cite the following experiments.

Experience 31, the dog is a male weighing 15 kg, age 3 years. The protocol of the operation of 01/01/1999.

Under intravenous anesthesia, AVF was applied between the femoral vessels on the right. After laparotomy, the inferior vena cava is exposed, its diameter is 8 mm. Bandaged 3 pairs of its lateral branches. Vienna mobilized. The front surface of the stomach is exposed. From its front wall, according to the accepted technique, a 6 × 3 cm full-layer section was obtained. A tubular graft on a plastic mandrel was formed from a stomach flap (after processing it in a solution of furatsillin and a 0.9% solution of sodium chloride). Clamps are applied to the selected section of the vena cava, between which the vein is excised for 5 cm. A defect of 6 cm is formed, into which the prepared gastric transplant is transplanted. After the start of blood flow, the transplant straightened and began to function. The dog was observed for two weeks. Her condition remained good. The wound on the stomach healed by primary intention. Then, in connection with the end of the experiment, the animal is withdrawn from the experiment. Produced relaparotomy. There are no adhesions in the abdominal cavity. The graft of the stomach in the defect of the inferior vena cava is pink, it functions. The animal is slaughtered. A macro product was taken, including a vein adjacent to the anastomoses and a gastric transplant (Fig. 2), as well as a fragment of the transplant anastomosis and vena cava for morphological examination.

Experience 35. The dog is a female weighing 8 kg, age 4 years. 11.11.1999, an operation was performed - plastic surgery of a circular defect of the inferior vena cava with a full-layer gastric transplant with the application of AVF. After median laparotomy, an IVC with a diameter of 9 mm is exposed. A vein is isolated during ligation of 3 pairs of lumbar veins. A 6 × 2 cm full-layer graft was obtained from the anterior wall of the stomach, and a tube was formed from it. The thickness of the graft wall is 1.5 mm, the vena cava in the plastic section is 0.4 mm. The vena cava was excised for 5 cm, a gastric transplant was transplanted into the resulting defect with direct anastomoses superimposed with 6/0 prolene sutures. The postoperative period in the animal proceeded smoothly. 02/11/2000, under intravenous analgesia eliminated AVF. 05/11/2000, - 6 months after plastic surgery of the NPS - in connection with the end of the observation period, the animal is withdrawn from the experiment. Cavography was performed under intravenous anesthesia, which demonstrates the patency of the graft from the stomach (Fig. 3). At autopsy, there are no adhesions after opening the abdominal cavity. At the site of graft removal from the stomach wall there is a longitudinally located scar that does not cause deformation. In the projection of the inferior vena cava, the peritoneum is mobile. After opening, a gastric transplant was sewn, 6 months ago, sewn into a circular defect of the vena cava. There are no fluids, there are no cavities around the transplant; it is soldered to the surrounding tissue. A preparation was excised, including a graft with sections of the vena cava (Fig. 4). Similar results were obtained in experiments 66, 68, 105, 108.

Experience 34. The dog is a female weighing 3 kg, age 4 years. 11/03/1999, an operation was performed - plastic surgery of a circular defect of the NPS with a full-layer gastric transplant. Under intravenous anesthesia, AVF was applied between the right femoral vessels. A median laparotomy was performed, the LEL was exposed, 10 mm in diameter. A 6 × 3 cm flap was obtained from the anterior wall of the stomach, from which a tubular graft was formed. After applying clamps to the IVC, it is excised for 5 cm; a prepared transplant is sewn into the defect formed by direct anastomoses. Its wall thickness is 3 mm, the vein wall thickness is 1 mm. After removing the clamps, blood flow in the vena cava was restored. The graft straightened and began to function. The postoperative period was uneventful. The animal was observed for 12 months. 11/03/2000, produced in vivo phlebography (figure 5). At autopsy, there are no adhesions after opening the abdominal cavity. A preparation was obtained, including a graft from the stomach and adjacent sections of the inferior vena cava intimately fused with it. The transplant patency is preserved, the intima is smooth, shiny (Fig.6). Anastomosis site was taken for histological examination. Similar results were obtained in experiments 69, 70, 104, 107 and after 2 years in experiments 103, 106.

Thus, the data of a macroscopic study of gastric autografts in LEL defects during the observation period from 7 days to 24 months after plastic surgery showed that the gastric transplant and the vena cava wall intimately fused together. The thickness of the graft exceeded the thickness of the vein wall by 3 times. The segments from the wall of the stomach placed in the rupture of the vena cava adapted to the conditions of venous blood flow. This was facilitated by the imposition of arteriovenous fistula, which provided accelerated blood flow and increased pressure in the IVC. In no experience, when the wall of the vena cava was replaced by a gastric transplant, there was no formation of cavities, fluid accumulation around the transplanted tissue, although the mucous membrane of the gastric transplant turned outward.

Histological examination (experiment 31) of the anastomosis of the inferior vena cava and gastric transplant after 2 weeks of the experiment revealed the following. The gastric mucosa is preserved (Fig. 7), but with pronounced dystrophic phenomena in the integumentary mucosa of the cylindrical epithelium, especially in the apical part. The muscle wall of the graft consists of three layers of muscle fibers. The intramural plexuses are preserved, the structure is represented by ganglion cells. Between the muscle bundles, a moderate amount of thin, convoluted collagen fibers is noted. The serous membrane is represented by a line of mesotheliocytes. The anastomotic line between the gastric autograft and the vein is easily traced. The wall of the vein has a typical three-layer structure.

When histological examination (experiment 35) after 6 months of the experiment - surgery of the plasty of the defect of the inferior vena cava with a gastric transplant. A fragment of the anastomosis is represented by a section of the gastric flap and the wall of the inferior vena cava, which are fairly tightly attached to each other. The wall of the stomach flap is structurally altered, the mucous membrane is absent in it, the muscle layer contains collagen fibers and blood vessels with thickened walls. Vein wall with the presence of vasa vasorum. The line of transition of the endothelial lining of the vein into the mesothelial layer of the stomach flap is determined

Experience 34. - 12 months of the experiment. The drug is represented by a fragment of the anastomosis of the inferior vena cava and a graft of the stomach. In this case, the autograft is tightly connected to the wall of the inferior vena cava. On the flap side, sections of the mucosa are noted, which underwent pronounced structural changes, manifested by the disappearance of the typical structure, collagenization of their own plate. In the muscle layer - an increased amount of collagen fibers, vessels with thickened walls. The serous membrane is represented by the endothelial lining and at the border of the anastomosis passes into the mesothelium of the stomach (Fig. 8).

Experience 27. - 24 months of the experiment. Anastomosis of the inferior vena cava and gastric transplant. The connection between them has the form of a slit-like space with muscle and collagen fibers oriented along it, among which a large number of small blood vessels that extend parallel to the described structures are determined (Fig. 9). There is no mucous layer in the stomach transplant; the muscular membrane has a three-layer structure with the presence of collagen fibers spreading between the muscle elements. Intima of the inferior vena cava passes into the mesothelial lining of the gastric transplant.

The effective healing and strength of the lines of the anastomosis between the transplant of the stomach and the inferior vena cava may be due to the histological similarity of the inferior vena cava and the flap of the stomach due to the predominance of the muscle component of their walls. In the later stages of the experiment, the blood supply of the flaps is quite effective and is provided by a large number of newly formed vessels from the side of the vein wall. In this case, a smooth transition of the vein endothelium into the mesothelial lining of the graft is observed with the restoration of a single internal wall of the formed flap and vein. Thus, the results of a histological study of gastric autografts used to close circular defects of the inferior vena cava indicate sufficient justification for such operations.

The proposed method achieves the following positive effect: increases the reliability and strength of the plastic material (the thickness of the wall of the stomach is 3 times greater than the wall of the inferior vena cava). The number of postoperative complications is reduced - transplant thrombosis from the stomach wall occurred after 7 days in only one animal from 20 experiments. In no experience was there any bleeding in the area of plastics, infection of transplants, and no formation of cavities around the transplants or accumulation of fluid was noted. In addition, in the long follow-up periods (up to 2 years), the tested transplants fully ensured the function of the reconstructed vessel - the lower vein fields.

Based on the studies it is concluded that the proposed method can be successfully used on patients. He is ready for implementation in clinical practice.

Claims (1)

The method of plastic sheathing of circular defects of the inferior vena cava, consisting in applying an arteriovenous fistula between the femoral arteries and a vein 1.5 cm long under intravenous anesthesia, laparotomy, diagnosing damage to the vena cava, determining the diameter, which is closer to the greater curvature from the front surface of the stomach get a segment of the required length and diameter, wash it from the contents in a furatsillin solution 1: 5000 for 5 minutes, place it in a 0.9% sodium chloride solution, and then tubules are formed from it graft rotated serosa in vessel lumen diameter equal to the diameter of the vena cava, twining round a longitudinal seam, then, after excision of the inferior vena cava segment gastric tubular graft sewn into a circular defect of the veins, arteriovenous fistula and eliminate 3-4 months after the plastics.

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