RU2302827C1 - Method for creating large intestine reservoir after low anterior rectum resection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves longitudinally cutting descended intestine wall with the wall being sutured next to it. Seromuscular tunic segment is dissected 20-30 cm above the future colorectal anastomosis place along anti-mesenterial edge. The segment is 70 mm long and 15-18 mm wide. Intestine lumen is not opened. The created segment is sutured in transverse direction with interrupted sutures without intestine lumen being opened.

EFFECT: reduced risk of postoperative complications.

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Description

The invention relates to medicine, surgery, and specifically to methods of forming colonic reservoirs after rectal resection.

The formation of a direct colorectal anastomosis after a low anterior resection of the rectum is associated with a partial removal of the rectal ampoule, which primarily causes a violation of its evacuation and reservoir functions and is clinically manifested in frequent bowel movements, multi-stage, prolonged and incomplete emptying, imperative urges, incontinence I-II degrees combined in “syndrome of low anterior resection of the rectum” [1, 2]. The proposed methods for the formation of an artificial rectal ampoule after its resection are generally not always effective and are fraught with complications specific to each, in particular the development of purulent-inflammatory processes due to failure of sutures [4, 5].

Closest to the proposed is a method of forming a large intestinal reservoir by conducting transverse coloplasty, which consists in creating a reservoir by longitudinal dissection of the wall of the reduced intestine with its subsequent cross-linking [3].

This method has several significant disadvantages.

The known method is not effective enough in connection with the opening of the lumen of the intestine, which increases the risk of postoperative complications. Serious and fairly common complications associated with the formation of the reservoir are: necrosis of the reduced intestine, failure of the sutures of the intestinal anastomosis and purulent changes in the pelvic cavity, which, according to various authors, comprise from 6.5% to 56% of all postoperative complications.

The problem solved by the proposed invention is to reduce the number of postoperative complications.

The problem is solved in a new way of forming a large intestinal reservoir after low anterior resection, which consists in creating a reservoir by longitudinal dissection of the wall of the reduced intestine with its subsequent cross-stitching, and retreating by 20-30 mm along the mesenteric edge, excising a section of the serous-muscular membrane 70 mm long , a width of 15-18 mm without opening the lumen of the intestine, the formed area devoid of the serous-muscular membrane is sutured in the transverse direction with interrupted sutures without opening the lumen, forming a okishechny tank.

In the literature analyzed by the authors, this combination of distinctive features was not found, and this combination does not follow explicitly for a specialist from the prior art. This technical solution was used in clinical practice at the Institute of Gastroenterology, Siberian State Medical University. Thus, this method meets the criteria of the invention of "novelty", "inventive step", "industrially applicable".

This method is as follows.

After performing the main stages of the operation - laparotomy, revision of the abdominal organs, mobilization and low anterior resection of the rectum, a large intestinal reservoir is formed as follows. Above the site of future formation of colorectal anastomosis by 20-30 mm along the mesenteric edge, a serous-muscular membrane of 70 mm long and 15-18 mm wide is excised without opening the intestinal lumen (Figs. 2, 3). The formed site, devoid of the serous-muscular membrane, is sewn in the transverse direction with interrupted sutures (Fig. 4; 5). The formed structure is lowered into the pelvic cavity. In the region of the posterior semicircle of the sigmoid and rectum, nodular sero-muscular sutures are applied so that the suture lines on the sigmoid colon are located at an angle to its mesenteric edge along the dissected serous-muscular membrane. Muscle-free submucosal bases of both intestines are restored with a continuous submucosal catgut suture. The anterior semicircle of the colorectal anastomosis is peritonized with nodular sero-muscular sutures. The pelvic peritoneum is restored over the area of the formed colonic reservoir (Fig.6).

The parameters used - making an incision at a distance of 20-30 mm from the anastomosis line, excising a portion of the serous-muscular membrane with a length of 70 mm and a width of 15-18 mm - are necessary and sufficient for the formation of an intestinal reservoir with a volume comparable to the volume of an ampoule of the rectum of a healthy person and providing a portioned emptying of the colon without a long delay in contents.

The effectiveness of the proposed method demonstrates the following clinical example:

Example No. 1: patient A., 57 years old, was admitted to the clinic on December 13, 2004 from the clinic with complaints of discomfort, pain of a dull, aching nature in the rectum, blood and mucus secretion during the bowel movement, weight loss over the past six months by 5 kg, loss of appetite. Considers himself ill during the last 6 months when the above complaints appeared. I didn’t go to doctors, I wasn’t treated by anything. The intensity of complaints began to increase over time. In November 2004, he went to an appointment with a therapist. It is directed to the FCC - 10 cm from the anus revealed a tuberous formation 4 cm long, tuberous, contact bleeding. Biopsy taken. Further, it was not possible to examine the intestine; feces were present in the lumen. The result of histology No. 21473 is a low-grade adenocarcinoma. Ultrasound - no focal pathology. With a chest radiograph - there is no evidence for distant metastasis.

Survey conducted:

An extensive blood test dated December 2, 2004. Hemoglobin - 141 g / l, red blood cells - 4.8 × 10 ¹² / l, CP - 0.88, platelets - 271 × 10 ⁹ / l, white blood cells - 9.6 × 10 ⁹ / l, stab - 5%, segmented - 60%, eosinophils - 3%, basophils - 1%, lymphocytes - 25%, monocytes - 6%, ESR - 26 mm \ h, bleeding time 30 "according to Duke, coagulation time - 5 'according to Moravica, Ht - 41% er.mass.

B / chem. blood test dated 12/14/2004. Total protein - 66 g / l, creatinine - 93 mmol / l, total bilirubin - 6.6 mmol / l, cholesterol - 4.3 iron - 14.7 glucose - 4.6 mmol / l, AlAT - 17 U / l, Asat - 27 U / l.

Coagulogram dated December 2, 2004. The prothrombin ratio is 0.85, fibrinogen is 5.0 APTV - 36, RFMC - 16.0.

RW (December 2, 2004), At to HCV (December 7, 2004) - negative. Blood group A (II) is negative.

HBs-Ag was detected on December 7, 2004.

No antibodies to HIV were detected on December 7, 2004.

Urinalysis dated 12/02/2004. Yellow, slightly turbid, relative density - 1025, pH-6.0, protein - negative, glucose - negative.

ECG dated 12/13/2004. Sinus rhythm. Heart rate 71 per minute. Conclusion: Signs of a violation of the process of myocardial repolarization of the lower lateral LV.

Fluorogram No. 315 of November 15, 2004. Focal and infiltrative changes in the lungs were not detected.

Ultrasound of the abdominal cavity from 12/2/2004: free fluid in the abdominal cavity is not determined. The liver is not enlarged, the structure is homogeneous, without foci. The biliary system is not expanded. Gall bladder 65 × 18 mm, wall 3 mm. The contour of the pancreas is even, clear, dimensions 24 × 19 × 23 mm, structure of medium echogenicity. Wirsung duct is not expanded. Spleen of homogeneous structure, 100 × 40 mm. With an overview copy of the pelvic organs, a symptom of a lesion of the hollow organ in the projection of the rectum is determined (outer diameter up to 53 mm, wall thickness up to 15 mm). Retroperitoneally enlarged lymph nodes were not detected. The bladder with a flat wall, the prostate 55 × 38 × 38 mm in the capsule, the structure is heterogeneous, with calcifications.

Conclusion: Tumor lesion of the rectum.

FCC from 12/15/2004. The colon was examined to the level of the dome of the cecum. The preparation is good. 10 cm from the anus there is a tumor, the tissue is tuberous, dense, bleeds in contact. The lumen is narrowed by _^1/2. The length of the tumor is up to 8 cm. The Bauginieva valve is lip-shaped, peristalsis. Intestine tone saved.

Conclusion: Tumor of the rectum. Biopsy taken earlier.

Irrigoscopy from 12/17/2004. Using the contrast enema method, all sections of the colon are freely filled. The large intestine is developed and located usually. At 9 cm from the anus, the deformation of the relief of the predominantly rectal anterior wall and the irregularity of the contours with a slight narrowing of the lumen up to 8 cm are determined, the displacement in the accessible palpations of the sections is preserved, the emptying is almost complete. Conclusion: Cancer of the mid-ampullar rectum.

On the basis of complaints, anamnesis, the results of laboratory and instrumental examination, the diagnosis was made: Basic: cancer of the middle ampulla of the rectum T3NxM0.

Concomitant: Concomitant: CHD: atherosclerotic cardiosclerosis. Hk0. Chronic non-calculous cholecystitis, remission. Hepatitis B virus carrier

After preoperative preparation on December 20, 2004, under a general anesthesia with a long epidural block, the patient underwent lower middle laparotomy. When revising the abdominal cavity and retroperitoneal space, distant metastases were not detected. During revision of the small pelvis, the upper edge of the tumor is located above the pelvic peritoneum, spreading down into the cavity of the small pelvis. Visually, tumor invasion through the serous membrane is noted. A lyre-shaped incision of the parietal peritoneum was made along the left lateral with the transition to the pelvic peritoneum and mesosigma. The inferior mesenteric artery was ligated at the level of the superior rectal. Enlarged l / nodes along the aorta, iliac vessels is not determined. The tumor occupied the upper and partially middle ampullar sections of the rectum. After dissection of the fascia and traction of the rectum, the posterior semicircle of the intestine was mobilized with its surrounding tissue and lymph nodes to a depth of 3 cm distal to the lower edge of the tumor. Middle rectal arteries crossed at the base.

The sigmoid colon was sealed with a mechanical suture, parietally mobilized from the mesentery and pendants for about 15-17 mm and cut off. Next, we proceeded to the formation of a large intestinal reservoir according to the proposed method, for which, having retreated 5 mm from the line of the mechanical suture, we made a circular dissection of the serous-muscular layer of the reduced intestine at an angle to the mesenteric edge to increase the clearance of the anastomosis (Fig. 1). Above the circular dissection of the serous-muscular membrane (the place of formation of the colorectal anastomosis) by 20-30 mm along the mesenteric edge, a serous-muscle membrane was excised with a length of about 70 mm and a width of 15-18 mm without opening the intestinal lumen (Fig. 2, 3). The formed site, devoid of the serous-muscular membrane, was sutured in the transverse direction with interrupted sutures (Figs. 4, 5). The formed structure was lowered into the pelvic cavity. In the region of the posterior semicircle of the sigmoid and rectum, nodular sero-muscular sutures are applied so that the suture lines on the sigmoid colon are located at an angle to its mesenteric edge along the dissected serous-muscular membrane. Muscle-free submucosal bases of both intestines are restored with a continuous submucosal catgut suture on an atraumatic needle. The anterior semicircle of the colorectal anastomosis is peritonized with nodular sero-muscular sutures (Fig.6)

The created colorectal anastomosis and the formed colonic reservoir located in the pelvic cavity were peritonized by the pelvic peritoneum. The retroperitoneal space and abdominal cavity were drained through separate incisions in the right and left iliac regions with two silicone tubes. The abdominal cavity was sutured in layers. At the end of the operation, anus devulsion was performed.

Macrodrug: rectum with surrounding fiber and lymph nodes; at a distance of 5 cm from the distal border exophytic tumor resection shape occupies _^3/4 the circumference of the intestine, a length of 8 cm. Histological conclusion № 22883 of 23.12.04, the poorly differentiated adenocarcinoma with invasion of all layers of the bowel wall. Resection within healthy tissues. No lymph node metastases were detected.

Diagnosis: cancer of the mid-upper ampulla of the rectum T3N0M0.

The postoperative period was relatively satisfactory. On the 2nd day after the operation, the patient began to exhaust gases, on the 3rd day there was a stool. The frequency of bowel movements during the first week was 3-4 times a day of a mushy consistency with a tendency to decrease and take a formal form. Drainage from the abdominal cavity was removed on the 4th day, and from the retroperitoneal space on the 5th day after surgery. There were no signs of urodynamic disturbances in this patient. Sutures were removed on the 10th day. The patient was discharged on the 12th day after the operation in satisfactory condition under the supervision of an oncologist, a surgeon of the clinic with recommendations on the regimen and diet.

Subsequently, the patient underwent 4 courses of adjuvant chemotherapy for an additional purpose.

During the control examination 4 months after the operation.

The patient does not show complaints, he is satisfied with the results of the operation, considers himself socially rehabilitated. When interviewing the patient it was found that the continent of feces and intestinal gases is satisfactory, the chair is regular at the same time (rarely in 2 doses in 15-20 minutes), 1-2 times a day. He added 4.5 kg in body weight. Diet does not comply.

Survey Results:

General blood test dated April 26, 2005. Hemoglobin - 133 g / l, erythrocytes - 4.8 × 1012 / l, CP - 0.83, white blood cells - 6.4 × 109 / l, stab - 1, segmented - 47% , eosinophils - 6%, basophils - 1%, lymphocytes - 43%, monocytes - 2%, ESR - 3 mm \ h.

B / chem. blood test from 26.04. 2005 General protein - 72 g / l, albumin - 36, creatinine - 105 bilirubin total - 5.5; glucose - 4.7; AlAT - 21; AsAt - 21; total amylase - 76.

Coagulogram dated 04/26/2005. The prothrombin ratio is 1.1 fibrinogen is 3.18, the ethanol test is negative.

Urine analysis dated April 26, 2005. Light yellow, transparent, 1010, reaction - alkaline, protein - negative, glucose - negative, flat epithelium - single in the field of view, white blood cells - single in the field of view.

Chest x-ray No. 1862 of 04/27/2005. No focal and infiltrative changes in the lungs were detected.

Ultrasound of the abdominal cavity from 04/27/05: Conclusion: there is no pathology in the abdominal cavity.

Colonoscopy from 04/28/2005: a colonoscope was taken before the hepatic bend of the colon. Mucous in the examined areas with signs of atrophy. At 5 cm from the anus, the colorectal end-to-end anastomosis is in the form of a fold of the mucous membrane about 2-3 mm high, the mucosa in the region of the anastomosis is of normal color, there are no mucosal defects. Clearance of the intestine in the anastomosis zone is freely passable. Behind the anastomosis line for up to 6 cm with air insufflation, an ampoule-like expansion of the adducting gut is determined.

Conclusion: Condition after low anterior resection of the rectum with the formation of a colorectal anastomosis and reservoir.

Proctography No. 1901 of April 29, 2005. With the help of a contrast enema, the left half of the colon is freely filled with barium. Colorecal anastomosis 4.5 cm from the anus in the form of a circular fold, immediately after it the intestine smoothly passes into the reservoir, resembling a natural rectal ampoule, 5.0 × 5.5 cm in size. Complete bowel movement.

During the examination (ultrasound of the abdominal cavity, chest x-ray), data for the generalization of the main process were not found. The patient was discharged in satisfactory condition under the supervision of a polyclinic oncologist with recommendations for colonoscopy once every 6 months.

Thus, the simplicity of the proposed method of colonic reservoir formation by coloplasty consists in excising the serous-muscular area of the reduced intestine without opening its lumen, while simultaneously reducing the risk of purulent complications and achieving good functional results after low anterior rectal resection. The formation of the ampoule allows you to get a new, functionally "full" section of the colon, fully compensating for the lost part of the rectum.

Bibliography:

1. Vasiliev S.V., Nechay I.A., Chania Z.D., Klimenko A.N., Popov D.E., Vasiliev A.S., Ruseikin I.M. The experience of low anterior resections with the formation of a large intestinal reservoir // Actual problems of coloproctology / IV All-Russian Conference with international participation. - Irkutsk, 1999 .-- S.198-199.

2. Odaryuk TS, Eropkin P.V., Shelygin Yu.A., Tsarkov P.V., Dzhaneev Yu.A., Trigolosov A.V. Does the formation of a pelvic colonic reservoir improve the functional results of abdominal-anal resection of the rectum. // Russian Journal: Gastroenterology, Hepatology and Coloproctology, No. 1, T.6., 1996, p. 86.

3. Neal W.B. Jr. Abdominoperineal resection of the rectum by the two-team technic / W.B. Jr. Neal [et al.] // Ann Surg. - 1953. - Vol.137, No. 3. - P.325-328.

4. Abelevich A.I., Ovchinnikov V.A., Seropyan G.A. The choice of the method of surgery for colorectal cancer. // Surgery. Magazine them. N.I. Pirogova, No. 4, 2004, p.30-33.

5. Yaitsky N.A. Quality of life for patients after surgery for colorectal cancer. Sphincter-preserving operations / N.A. Yaitsky [et al.] // S. Tyulyandin Practical Oncology: Selected Lectures. Edited by S.A. Tyulyandin and V.M. Moiseenko. - St. Petersburg: TOMM Center, 2004. - S.196-206.

Claims (1)

A method of forming a large bowel reservoir after a low anterior resection of the rectum, including creating a reservoir by longitudinally dissecting the wall of the reduced intestine and then stitching it, characterized in that on the reduced intestine, retreating 20-30 mm above the site of the future formation of colorectal anastomosis, the incision is excised along the mesenteric edge a section of the serous-muscular membrane 70 mm long, 15-18 mm wide without opening the intestinal lumen, after which, the formed area devoid of the serous-muscular membrane is sewn into interrupted sutures-screw direction without opening the lumen, forming an intestinal reservoir.

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