RU2316271C1 - Method for carrying out the first stage in treating patients with combined strictures of esophagus and antral gastric department - Google Patents

Abstract

FIELD: medicine, thoracic surgery.

SUBSTANCE: it is necessary to fulfill superior-median laparotomy, close jejunum V-shapely due to forming enteroenteroanastomosis by "end-to-side" type and withdraw it as a nourishing stoma, form gastroenteroanastomosis. Moreover, at the site of enteroenteroanastomosis formation one should fulfill V-shaped incision at distal part of the intersected small intestine, its sharp angle being towards aboral direction. At incision angles one should apply three sutures-holders through all intestinal layers. The fourth holder should be applied seroso-muscularly in the center between the ends of the incision at the bottom of the valve. The n one should form a double-row anastomosis. The first row of sutures fixes external edge of V-shaped incision and the intersected proximal end of small intestine through all the layers. In area of the fourth holder one should suture the closed jejunum with seroso-muscular sutures by forming enteroenteroanastomosis by "side-in-side" type with posterior gastric wall at the border with the stricture of output department. Moreover, V-shaped incision should be made on the stomach. It is important to for similarly an antireflux valvular gastroenteroanastomosis with anterior gastric wall in fundal area. Below this anastomosis one should apply two transverse sutures through the lumen of small intestine and seroso-muscular gastric layer by providing the obliteration of intestinal lumen. Terminal end of the closed small intestine should be withdrawn as a stoma. The innovation enables to considerably decrease surgical wound, keep physiological passage along digestive tract in area of both narrowing parts and, also, keep the chance for both esophageal bougienage and coloesophagoplasty at the second stage.

EFFECT: higher efficiency of therapy.

1 dwg, 1 ex

Description

The invention relates to medicine, namely to thoracic surgery. It can be used in the first stages of treatment of combined strictures of the esophagus and antrum.

A surgical method is known for treating patients with combined strictures of the esophagus and antrum of the stomach, consisting in the fact that the patient at the first stage of treatment is performed with a mid-median laparotomy and form a distal terminal gastrostomy without distal gastric resection and anterior excision gastroenterostomy according to Ru. Next, retrograde gastric esophagus is performed (Rakhmetov N.R., Zhetimkarinov D.S., Khrebtov V.A., Aimagambetov M.Zh., Bulegenov T.A. Surgical treatment of combined burn strictures of the esophagus and stomach. // Surgery. - 2003 . - No. 11 - p.17-19).

The disadvantage of this method is the presence of terminal gastrostomy, which reduces the capacity of the stomach and, as a result, subsequent nutritional disorders occur; gastric juice leaks around the terminal stoma, which leads to maceration of the skin around; the formation of anterior colonic gastroenteroanastomosis complicates subsequent coloesophagoplasty and the passage of food from the stomach worsens.

The closest is the method of carrying out the first stage of treatment of combined stenosis of the esophagus and exit from the stomach (AS USSR No. 1681846, IPC АВВ 17/00, publ. 1991), including upper median laparotomy, gastric mobilization with further resection of its pathological area, gastroenteroanastomosis, stoma formation. A jejunum of the jejunum is carried out and its output in the form of a stoma, gastroenteroanastomosis is formed - "end to side".

The disadvantages of this method are the large volume of gastric resection, the difficulty of forming an anastomosis in the second stage of treatment due to the remaining small surface of the anterior wall of the stomach, the partial shutdown of the stomach from digestion due to passage of food through the intestine, bypassing the stomach, the difficulty of retrograde gastric esophageal gastrointestinal tract.

The objective of the invention is the elimination of these disadvantages, reducing the duration of treatment of patients by reducing the morbidity of surgical treatment, preserving the physiological passage through the digestive tract in the area of both narrowings and maintaining the possibility of conducting both the esophageal bougienage and coloesophagoplasty in the second stage.

To this end, in the method of carrying out the first stage of treatment of patients with combined strictures of the esophagus and antrum, including upper median laparotomy, Y-shaped disconnection of the jejunum by forming end-to-side enteroenteroanastomosis, removing it as a nutritional stoma, formation of gastroenteroanastomosis, it is proposed to cross the thin the intestine at an angle of not less than 30 degrees with respect to the mesentery at a distance of 10 cm from the Treitz. At the site of the formation of enteroenteroanastomosis, a V-shaped incision is made in the distal section of the crossed small intestine, an angle in the aboral direction. The base of the valve is 2 cm. At the corners of the incision, three holder sutures are applied through all layers of the intestine. At the base of the valve impose a serous-muscular suture. Enteroenteroanastomosis is formed above the valve, fixing the outer edge of the V-shaped incision and the crossed proximal end of the small intestine. A gastroenteroanastomosis of the side-to-side type is formed with the posterior wall of the stomach at the border with the stricture of the output department of the side-to-side type on the disconnected loop, and a V-shaped incision is made on the stomach. A large curvature is skeletonized with a length equal to the diameter of the intestine, and a loop of the small intestine anastamosed with the stomach is carried out, which spreads on the wall of the large curvature of the stomach. Another antireflux valvular gastroenteroanastomosis is formed with the front wall of the stomach in the bottom and the terminal end of the disconnected small intestine is excreted as a stoma in the left hypochondrium through a separate pararectal incision by fixing the intestinal mucosa to the skin. Two sutures are inserted through the lumen of the intestine and capture the serous-muscular layer on the stomach. Sutures are transverse to the length of the intestine. Then both seams are covered with gray-serous seams.

The fact that mobilization and resection of the cicatricial section of the stomach is not performed significantly reduces surgical trauma and the duration of the operation, helps to reduce bed days, earlier rehabilitation of patients and reduce the number of complications associated with the failure of anastomoses and duodenal stumps. The formation of a wide oblique antireflux valvular inter-intestinal anastomosis provides adequate evacuation and prevents the duodenal contents from being thrown into the stomach. The fact that the intestine is passed through the mesentery of the transverse colon creates favorable conditions for the subsequent execution, if necessary, of the esophagoplasty with the colon. The formation of the first gastroenteroanastomosis on the posterior wall of the stomach closer to the pylorus is carried out to ensure the best evacuation of food masses, at the same time, due to the presence of a valve mechanism in this anastomosis, the intestinal contents are thrown into the stomach. Skeletonization of the greater curvature of the stomach over 4 cm is necessary for holding the intestine along the wall of the stomach. The intestine is flattened, and also stitched with two interrupted sutures through the intestinal lumen and fixation with gray-serous sutures to the stomach ensures obliteration of the intestinal lumen to prevent intestinal masses from entering the intestine besides the stomach. The seams are covered with gray-serous sutures to create a seal in the event of their eruption. The formation of a second gastroenteroanastomosis on the front wall of the stomach in the bottom creates favorable conditions for the possibility of esophageal bougienage at the next stage, and also contributes to the full participation of the stomach in digestion. The valve mechanism of the anterior gastroenteroanastomosis prevents the throwing and leakage of gastric contents onto the skin. The food masses through the juvenile stem enter the intestine, and then through the anterior gastroenteroanastamosis to the stomach, and then through the gastroenteroanastamosis on the posterior wall are evacuated into the discharge intestine. The fact that the stoma is excreted through a separate pararectal incision helps prevent suppuration of the postoperative wound. Fixation of the intestinal mucosa to the skin provides the formation of a lip-shaped fistula that does not heal even when the gastrostomy tube is removed for nutrition. What makes it unessential to wear it constantly and contributes to the most rapid adaptation of the patient in society. The fact that the distance between the injections on the intestine is three times greater than on the skin, helps to reduce the diameter of the stoma, a more tight coverage of the gastrostomy tube and prevents leakage of gastric contents.

The drawing shows a diagram of the proposed operation.

The method is as follows.

In a patient with combined stricture of the esophagus and antrum, under general anesthesia, an upper median laparotomy and an abdominal cavity are performed. 10 cm distal to the ligament of the Treitz, taking into account the nature of blood supply, the small intestine obliquely intersects at an angle of 30 degrees to the mesentery of the intestine. A Y-shaped disconnected small intestine 1 is formed by forming a V-shaped 2 valve antireflux enteroenteroanastomosis of the type "end to side" (proximal end of the crossed intestine to the side of the distal segment). At a distance of 30 cm from the intersection of the intestine, a V-shaped incision is made at the abdominal edge of the intestinal mesentery with an acute angle in the aboral direction. The length of each of the sections is equal to the diameter of the oblique section of the proximal end of the crossed intestine. At the corners of the V-shaped incision, three holder sutures are applied through all layers of the intestine. The fourth holder is superimposed sero-muscular in the center between the ends of the incisions in the region of the opposite corner of the future anastomosis. An enteroenteroanastomosis is formed by interrupted sutures, while the outer edge of the V-shaped incision and the crossed proximal end of the small intestine through all layers using the suture of the holders are fixed first by the first row. And only in the area of the fourth holder the disconnected intestine is stitched with serous-muscular sutures, which contributes to the formation of a free flap valve that performs the antireflux function. In the mesentery of the transverse colon, an opening is formed to the left of the middle colonic artery, into which the disconnected small intestine is held. Then, an obstructive antireflux valvular gastroenteroanastomosis with a posterior wall of the stomach in the antrum of the side-to-side type 3 is formed according to the procedure described above, with a V-section being made on the stomach. The vessels are ligated and intersect at great curvature to the width of the disconnected small intestine. There is a loop of the small intestine, which spreads on the stomach. At 2 cm from the alleged anterior gastroenteroanastomosis, two transverse sutures are inserted through the lumen of the small intestine and the serous-muscular layer of the stomach. Each of the seams captures half the diameter of the intestine. Then these sutures are covered with gray-serous longitudinal sutures on the intestine. An anterior gastroenteroanastomosis 4 is formed in the area of the fundus of the stomach, while a V-shaped incision is performed on the stomach. Anastomosis is formed according to the method described previously. The terminal end of the intestine disconnected according to Ru is discharged through a separate pararectal incision in the left hypochondrium, where it is formed by jeunostoma 5 by suturing the intestinal mucosa to the skin, while the distance between the injections on the intestine is three times greater than on the skin, which leads to a decrease in the stoma diameter by three times. Perform drainage of the abdominal cavity. Layer wound closure.

Example.

Patient V., 47 years old, (and / b 11285, 2004), was admitted to the hospital with complaints of dysphagia a month after the burn. An X-ray examination of the patient revealed an extended lesion of the esophagus and severe cicatricial deformity of the output section of the stomach with a pronounced violation of evacuation.

The operation was performed - under general anesthesia, the upper middle laparotomy and revision of the abdominal cavity were performed. It was revealed that there is a significant cicatricial deformity of the stomach in the pylorus, antrum and lower third of the body of the stomach. The remaining part of the stomach is significantly reduced in volume. 10 cm distal to the ligament of the Treitz, taking into account the nature of blood supply, the small intestine obliquely intersects at an angle of 30 degrees to the mesentery of the intestine. A disconnected small intestine is formed by forming a V-shaped valve antireflux anastomosis of the “end to side” type (the proximal end of the crossed intestine to the side of the distal segment). At a distance of 30 cm from the intersection of the intestine, a V-shaped incision is made at the abdominal edge of the intestinal mesentery with an acute angle in the aboral direction. The length of each of the sections is equal to the diameter of the oblique section of the proximal end of the crossed intestine. At the corners of the V-shaped incision, three holder sutures are applied through all layers of the intestine. The fourth holder is superimposed sero-muscular in the center between the ends of the incisions in the region of the opposite corner of the future anastomosis. A double-row anastomosis is formed by interrupted sutures, while the first row fixes the outer edge of the V-shaped incision and the crossed proximal end of the small intestine through all layers using stitches of the holders. And only in the area of the fourth holder the disconnected intestine is stitched with serous-muscle sutures. In the mesentery of the transverse colon, an opening is formed to the left of the middle colonic artery, into which the disconnected small intestine is held. Then, an obstructive antireflux valvular gastroenteroanastomosis with a posterior wall of the stomach in the antrum is formed along the side-to-side type according to the method described above, with a V-section being made on the stomach. The vessels are ligated and intersect at a large curvature for 4 cm. A loop of the small intestine, which spreads on the stomach, is also carried out there. At 2 cm from the alleged anterior gastroenteroanastomosis, two transverse sutures are inserted through the lumen of the small intestine and the serous-muscular layer of the stomach. Each of the seams captures half the diameter of the intestine. Then these sutures are covered with gray-serous longitudinal sutures on the intestine. An anterior gastroenteroanastomosis is formed in the bottom of the stomach, with a V-shaped incision being made on the stomach. Anastomosis is formed according to the method described previously. The terminal end of the intestine disconnected according to Ru is excreted through a separate pararectal incision in the left hypochondrium, where a jejunostoma is formed by suturing the intestinal mucosa to the skin, while the distance between the injections on the intestine is three times greater than on the skin. Abdominal drainage. Layer wound closure.

According to the proposed method, 5 patients were operated on, the following positive aspects were revealed: the absence of leakage of gastric contents through the jujunoma, a large reservoir capacity of the stomach is preserved and gastric digestion is preserved, evacuation from the stomach is not impaired and duodenogastric reflux is not present, conditions for retrograde bougienage and subsequent esophagocoloplasty are preserved.

The proposed method allows to reduce the duration of treatment of patients by reducing surgical trauma and the absence of possible complications, to maintain a physiological passage along the digestive tract in the area of both narrowings, to improve the quality of life of the patient and accelerate his rehabilitation.

Claims (1)

A method of carrying out the first stage of treatment of patients with combined strictures of the esophagus and antrum, including upper median laparotomy, Y-shaped disconnection of the jejunum by forming end-to-side enteroenteroanastomosis, excretion of it in the form of a nutritional stoma, formation of gastroenteroanastomosis, characterized in that it first crosses the thin the intestine, at a distance from the intersection edge at the distal end of the intestine, a V-shaped incision is made with an acute angle in the aboral direction, at the corners of the V-shaped incision there are three suture-holders through all layers of the intestine, the fourth holder is imposed sero-muscularly in the center between the ends of the incision at the base of the valve, then a two-row anastomosis is formed, the first row of sutures fixes the outer edge of the V-shaped incision and the crossed proximal end of the small intestine through all layers, while in the area of the fourth holder, the disconnected intestine is sutured with serous-muscle sutures, forming an enteroenteroanastomosis above the valve; then the disconnected intestine is passed through an opening in the mesentery of the transverse colon and, similarly, valve gastroenteroanastomosis is formed with the posterior wall of the stomach at the border with the stricture of the outlet section of the stomach according to the “side to side” type, with the V-shaped incision being made on the stomach, then vessels are ligated and the vessels cross. on the large curvature of the stomach to the width of the disconnected small intestine, where the latter is carried out and spread on the stomach, then form the anterior valvular gastroenteroanastomosis of the type "side to side" in a similar way in about Asti fundus below which two superposed transverse seam through the lumen of the small intestine and sero-muscular layer of the stomach, grasping each half gut suture diameter, providing gut luminal obliteration further output terminal disconnected end intestine, forming the stoma.