RU2290103C1 - Method for developing esophago-small-intestinal and esophago-gastric anastomosis - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: the present innovation deals with forming a coupling-shaped esophago-small-intestinal or esophago-gastric anastomosis. It is necessary to form a coupling with serous-muscular sutures from the bottom upwards, moreover, all the sutures that capture esophageal wall should be under the upper edge of the coupling. The innovation enables to decrease the risk of anastomosis' failure.

EFFECT: higher efficiency.

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Description

The invention relates to medicine, specifically to thoracic and abdominal surgery. The aim of this invention is the prevention of insolvency of the anastomosis of the esophagus with the intestine or esophagus with the stomach.

State of the art

Currently, when performing gastrectomy, proximal resection of the stomach and resection of the esophagus to restore the continuity of the digestive tract, various modifications of the esophageal-gastric and esophageal-enteric anastomoses have been proposed. The most commonly used types of anastomoses: manual invagination [Tsatsanidi K.N., Bogdanov A.V. Esophageal-intestinal and esophageal-gastric anastomoses. - M .: Medicine, 1969; Miroshnikov B.I., Ananyev N.V., Udova E.A., Trushnikova N.A. Intrathoracic esophagogastroanastomosis - a problem and its solutions. // Bulletin of surgeons. - 2004. - No. 5. - S.39-44], manual clutch-like [Sigal MZ, Akhmetzyanov F.Sh. Gastrectomy and gastrectomy for cancer. - Kazan, 1991; Chernyavsky AA., Lavrov N.A., Palagin S.E., Volodin A.N., Mironov A.V. Comparative evaluation of some methods of the formation of esophageal-intestinal anastomoses and reconstruction of the digestive tract after peritoneal gastrectomy. // Annals of the surgeons. - 2002. - No. 5. - S.29-35], manual submersible [Davydov M.I. Principles of surgical treatment of malignant tumors in a thoracoabdominal clinic. // Questions of oncology. - 2002. - No. 4-5. - S.468-479] and mechanical [De Giacomo T., Francioni F., Venuta F., Trentino P. et al. Complete mechanical cervical anastomosis using a narrow gastric tube after esophagectomy for cancer. // Eur. J. Cardiothorac. Surg. - 2004 .-- Vol.26. - P. 881-884]. Nevertheless, the problem of reliability of the anastomoses with the esophagus remains relevant to date, since the failure of the anastomosis is one of the main causes of fatal outcomes of operations [Urchel J.D. Esophagogastrectomy anastomic leaks complicating esophagectomy: a review // Am. J.Surg. - 1995 .-- Vol. 169. - P.634-640].

In the development of insolvency of the esophageal-intestinal and esophageal-gastric anastomoses, the design of the latter plays a large role. It is well known that the wall of the esophagus, devoid of serous cover, is the weakest anatomical structure of the formed anastomosis. Any sutures placed on the mechanically unstable muscle wall of the esophagus are prone to eruption, which often leads to the formation of perforation. However, almost all of the proposed anastomoses with the esophagus involve the imposition of load-bearing fixing sutures between the muscle layer of the esophagus and the serous-muscle layer of the stomach or small intestine.

SUMMARY OF THE INVENTION

We propose a method for forming the esophageal-intestinal and esophageal-gastric anastomoses without imposing load bearing fixing sutures on the wall of the esophagus. The method of forming the esophageal-enteric anastomosis is as follows:

1) The esophagus intersects in an oblique direction, after which we conditionally select the posterior rib (Fig. 2-A), the front rib (Fig. 2-B), the posterior angle (Fig. 2-C) and the rake angle (Fig. 2-D). A stitched loop of the small intestine is brought to the line of resection of the esophagus (Fig. 1a). In the case of an anastomosis with a Ru segment, a “racket" is formed at the end of the latter (Fig. 1b). The length of the stitched section of the intestine is 12-15 cm.

2) For the posterior edge of the esophagus, directly above the posterior angle, between the esophagus and the leading loop of the intestine, 1-1.5 cm below the upper interloop suture, a provisional suture is applied (Fig. 2-D). At a distance of 1 cm from the previous superimposed second seam (Fig.2-E). After stitching both seams, they are tied. We do not consider these sutures as bearing ones; they serve exclusively the purpose of drawing together the anastomosed organs and are not obligatory.

3) From the level of the posterior angle of the cut of the esophagus, parallel to the line of the inter-intestinal suture, gaps of the outlet and lead loops are opened over 7-8 cm. The medial edges of the intestinal incisions are sutured, as a result, the posterior lip of the anastomosis is formed (Fig. 3-A). Stapling is done from the bottom up. The upper adaptive suture of the posterior lip is superimposed with a through grasp of the posterior angle of the esophagus (Fig. 3-B).

4) The esophagus is sutured into the formed section of the intestine. Sewing is done from the upper adaptive seam. End-to-end adaptive anastomosis sutures between the walls of the intestine and the esophagus are alternately superimposed on the right and left semicircles of the anastomosis (figure 4). The last lower adaptive suture is carried out through the lateral edges of the incision of the leading and outlet intestinal loops with a through grasp of the anterior angle of the esophagus (Fig. 5a). The front lip of the anastomosis ends with suturing between the edges of the intestinal wound (Fig.5b).

5) Next, an intestinal clutch is formed, circularly covering the line of the first row of the adaptive sutures of the anastomosis and 2 retaining sutures. A thick gastric tube with a diameter of up to 15-18 mm is passed through the anastomosis. During the formation of the coupling, only the leading and removing knees of the intestine are sutured with serous-muscular sutures. There are no more sutures behind the wall of the esophagus. The formation of the coupling is made from the bottom up. With his left hand, the surgeon feeds the posterior wall of the anastomotic loop of the intestine up the length of the esophagus, as a result of which the upper edge of the intestinal loop moves in the oral direction. On figa this movement is shown by a dashed line with two arrows. The first suture that closes the intestinal clutch is superimposed at the level of the point P of the convergence of the three adaptive sutures of the first row (figa). The suture is applied far enough away from point P in such a way that when it is tied, the intestinal clutch covers the esophagus with virtually no tension. This is verified by simply folding the threads before tying. When tying this suture, the gut mufto closes above the esophagus, and the upper edge of the sleeve rises somewhat along the axis of the esophagus. Above the first seam, sequentially from the bottom up, another 3-5 seams closing the clutch are superimposed and immediately tied. When each subsequent suture is tied, the upper edge of the sleeve (Fig.6b-U) rises and the degree of tension of the intestine around the esophagus increases. The intestinal clutch creeps up from the esophagus from the bottom up and all the sutures made through the wall of the esophagus, which are the most dangerous from the point of view of eruption, sink deeper into the clutch and are further from the upper edge of the clutch. Below the first suture (Fig.6b-I), the intestinal loops are sutured according to the general rules for applying the second row of serous-muscular intestinal sutures, after which the anastomosis acquires its finished appearance (Fig.7).

The anastomosis of the esophagus and stomach is fundamentally no different from the anastomosis of the esophagus and small intestine, with the only difference being that the leading and diverting intestinal loops before stitching the anastomosis are stitched together, and the stomach, being a wide organ, is directly ready for the anastomosis. For this, retreating from the apical part of the gastric transplant (Fig. 8-A) 2-3 cm down, the front wall of the stomach is cut lengthwise for 4-5 cm (Fig. 8-B). The first adaptive suture is applied between the posterior angle of the esophagus and the upper angle of the incision of the stomach (Fig.9-A), after which the esophagus is sutured into the incision of the stomach. Stitching is done from the upper adaptive seam. The through seams between the walls of the stomach and the esophagus are alternately superimposed on the right and left semicircles of the anastomosis (figure 10). The last lower adaptive suture is carried out through the right and left semicircles of the incision of the stomach with a through capture of the anterior angle of the esophagus (Fig. 11). The front lip of the anastomosis ends with suturing between the edges of the wounds of the stomach (Fig). Similarly, an intestinal clutch is formed from the wall of the stomach. In Fig.13 shows the first closing clutch seam, and Fig.14 shows the final view of the clutch of the anastomosis.

Thus, the problem that the proposed invention solves is to create an esophageal-intestinal or esophageal-gastric anastomosis, the construction of which excludes the weakest link in most anastomoses with the esophagus - bearing fixing sutures held through the muscular wall of the esophagus.

The essential features of this invention are:

1) the absence of bearing fixing sutures conducted through the muscular wall of the esophagus;

2) the location of the sutures that adapt the anastomosis, inside the small intestine or gastric sleeve, below its upper edge, which eliminates the formation of perforation in case of suture eruption;

3) the dependence of the tightness and reliability of the anastomosis only on the joints closing the sleeve, which are carried out through a mechanically strong, serous-muscular layer of the small intestine or stomach;

4) the formation of small intestinal or gastric couplings by successively applying and tying sutures from the bottom up with the crawl of the clutch on the esophagus.

The combination of these features provides a technical result in all cases. The technical result of this invention is to prevent perforation of the anastomosis during the eruption of sutures imposed on the wall of the esophagus. This is achieved due to the fact that the small intestine or gastric sleeve tightly covers the anastomosis and the distal esophagus. Since all adaptive sutures that are dangerous from the point of view of eruption are located inside the hermetic sleeve at a considerable distance from its upper edge, the perforation that occurs when they erupt opens with a fistula inside the airtight, tight sleeve and the esophageal and intestinal contents do not leak outside the anastomosis.

Information confirming the possibility of using the invention

The proposed method for the formation of the esophageal-intestinal and esophageal-gastric anastomosis is used in the work of the surgical thoracic department of the Penza Regional Oncology Center from January 2000 to the present. Twenty-six patients underwent thoracic esophagogastroanastomosis during Lewis type surgery (resection of the esophagus with simultaneous gastric plastic surgery of the esophagus in the right pleural cavity). Nine patients underwent proximal gastrectomy with resection of the distal esophagus and simultaneous intrapleural esophagoplasty with the stomach. In 9 patients, gastrectomy with resection of the lower thoracic esophagus with simultaneous intrapleural esophagoplasty of the small intestine was performed according to S.S.Yudin. In 6 patients, this type of anastomosis was used after gastrectomy. All 50 patients were operated on for malignant tumors of the corresponding locations. None of the patients recorded anastomotic failure.

Example No. 1. Patient U., born in 1946, medical history No. 5406, was admitted to the thoracic surgical department of the Penza Regional Oncology Center on October 10, 2000. Clinical diagnosis: cancer of the middle third of the retrocardial segment of the esophagus pT3N0M0G3, adenocarcinoma. On October 24, 2000, a Lewis operation was performed. An esophagogastroanastomosis in the dome of the right pleural cavity was laid according to the proposed method. The postoperative period without complications. Discharged on November 5, 2000. Last control on January 19, 2005, alive without signs of tumor progression.

Example No. 2. Patient T., born in 1950, case history No. 5681, was admitted to the surgical thoracic department of the Penza Regional Oncology Center on September 8, 2004. Clinical diagnosis: gastric body cancer with ingrowth into the liver and pancreas pT4N1M1G4, adenogenic cancer. On September 17, 2004, gastrosplenectomy, pancreatoduodenectomy, and marginal resection of the left lobe of the liver were performed. Looped esophagogastroanastomosis is applied according to the proposed method. On the 5th day, the postoperative period was complicated by the development of acute perforated ulcer of the rectosigmoid colon, spilled with fecal peritonitis. September 22, 2004 performed relaparotomy, Hartmann's surgery, rehabilitation and drainage of the abdominal cavity, nasointestinal intubation of the small intestine. Peritonitis is stopped, the subsequent postoperative period without complications. Despite an early purulent-inflammatory complication in the abdominal cavity, there was no esophagogastroanastomosis failure. Discharged on October 20, 2004 in satisfactory condition with a functioning colostomy.

Claims (1)

A method of forming a sleeve-like esophageal-enteric or esophageal-gastric anastomosis, characterized in that the sleeve is formed by serous-muscular sutures from bottom to top, while all sutures that capture the wall of the esophagus are located below the upper edge of the sleeve.

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