RU2338468C1 - Method of surgical treatment of immature admixed incomplete fistulas of gastroenteric tract with split muscular flap on vascular pedicle - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: form a muscle flap on a vascular pedicle of an abdominal rectus muscle. Closing of fistulas is carried out in two stages. At the first stage close a fistula with the muscle flap, the most distant from the flap basis. After healing of this fistula, at the second stage close the second fistula located away from the muscle flap. Thus partially cross and split the muscle flap. Move an again formed affiliated muscle flap on the fistula.

EFFECT: method allows reliable closing of plural gastroenteric fistulas.

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Description

The invention relates to medicine, namely to surgery. The aim of the invention is to improve the results of surgical treatment of unformed mixed incomplete fistulas by stage muscle plasty with parts of a flap formed from the rectus abdominis muscle.

Unformed gastrointestinal fistulas are a complex and unresolved problem of abdominal surgery. They arise due to insolvency of the gastric and intestinal suture and perforation of the wall of the hollow organ, do not have a channel and open into the abdominal cavity or wound of the abdomen wall. The appearance of an unformed fistula causes the appearance of life-threatening complications: severe disorders of homeostasis, local and widespread peritonitis, erosion bleeding, multiple new fistulas and sepsis (Kanshin N.N., 1998; Grigoryev E.G., Kogan A.S., 2000) . In the area of the gastric, duodenal and jejunum unformed fistulas, alteration processes predominate, and normal tissue regeneration is absent. Spontaneous healing of such fistulas is rare, and conservative treatment requires ingenuity, patience, lasts a long time and does not guarantee success (Kanevich M.D., Dolgiy R.N., 2003; Kanshin N.N., 2004; Saenko V.F. and et al., 2004). Long-term inpatient treatment, a significant need for expensive drugs and infusion-transfusion environments lead to high financial costs.

Recommendations for the treatment of unformed fistulas, especially the duodenum, the failure of the sutures of the esophageal and intestinal and gastrointestinal anastomoses are contradictory. Kanshin N.N. (1999, 2004) prefers the drainage method with aspiration in the “air stream” through TMMK two-channel silicone tubes and the formation of a compression suspension unitostomy according to the author’s technique. The use of an obturator with an incomplete small intestinal fistula on an eventual intestinal loop can lead to the formation of a complete fistula and the urgent need to turn off the intestinal loop carrying the fistula through surgical access outside the purulent wound (Makarenko T.P., Bogdanov A.V., 1986; Kanshin N .N., 2004). Mortality in surgical treatment of unformed intestinal fistulas reaches 44-50% (Ruzin E.P. et al., 1991; Maksimov A.M., Pakin V.P., 2004).

At the XXV All-Union Congress of Surgeons (Moscow, 1.-8.10.1946), dedicated to the surgical treatment of gunshot wounds during the Great Patriotic War, N. Vazin cited data on muscle plastic fistula of the colon. The author eliminated colonic parietal fistulas by suturing, followed by covering the suture line with a muscle flap from the external oblique muscle of the abdomen. Muscular plasty with a non-free gluteus maximus flap was used in the treatment of fistula type anus sacralis. According to N.A. Vazin, muscle plasty allows eliminating the morphological defect and the “dead” space near the intestine carrying the fistula, eliminates the location of surgical sutures in one plane.

Petrov V.P. et al. (2003) reported 3 observations of the successful closure of an extensive gunshot rectal defect by the gluteus maximus muscle in 2 and the femoral tender muscle in 1 patient.

We have developed a method of staged closure of mixed fistulas of the gastrointestinal tract with one split flap formed from the rectus abdominis muscle. As an analogue, we used the method of plastic duodenal fistula with a flap from the rectus abdominis muscle described by M. Grinev. (1992). The author performs muscle plasty in the following way. A single defect in the wall of the duodenum is sutured with a purse string suture. A mobilized and crossed rectus abdominis muscle on the feeding upper epigastric artery is moved from its vagina to the abdominal cavity and sutured to the duodenum along the circumference of the previously applied purse string suture with a continuous catgut suture. Grinev M.V. (1992) cited 5 clinical observations of the application of the described technique.

Unlike the analogue, we sequentially, in two stages, close several unformed fistulas of the gastrointestinal tract with one flap, formed from the rectus abdominis muscle, by partial intersection and splitting (stratification) with the transfer of the newly formed daughter muscle flap to the intestinal fistula located in side of the axis of the main flap.

Description of the technique for developing the plastic method developed by us. At the first stage, according to well-known rules, a flap is formed from the rectus abdominis muscle. After a longitudinal dissection of the anterior wall of the fascial vagina of the rectus abdominis muscle, the muscle is secreted in a sharp and blunt way for a length sufficient to cover the most distant unformed fistula. The rectus muscle after mobilization crosses laterally, and the formed muscle flap is excreted outside the fascial vagina. The fascial vagina is drained with a silicone tube and sutured. Muscle flap primarily cover the most distant fistula and fix it to the wall of the organ around the fistula (Figure 1).

The second stage of the operation is performed no earlier than 16 days after the first stage. By this time, the fistula, covered by a muscle flap, is healing, and blood vessels are formed between the distal part of the muscle flap and surrounding tissues. When performing the second stage, the muscle flap is bluntly partly separated from the underlying tissues, cut into half the width, and delaminated along the fibers towards the base. The vasculature provides blood supply to both halves of the flap. The newly formed daughter flap is moved to the second fistula (Figure 2). The interval between the first and second stages of the operation is necessary to maintain the viability of the distal part of the main flap after splitting due to new additional sources of blood supply from neighboring tissues and organs.

We give a clinical observation.

Sh., 33 years old, medical history 8291. Hospitalized in the city hospital on 10/23/1999 due to profuse bleeding from multiple acute and chronic gastric ulcers. Over a month and a half, he underwent 9 operations for the underlying disease and numerous postoperative complications: 24.10. and 26.10. - emergency laparotomy and relaparotomy-1, gastrotomy, stitching of bleeding vessels in ulcers of the body and cardiac section; 10/29. - relaparotomy-2, subtotal resection of the stomach at the height of another heavy bleeding, drainage of the left-sided subphrenic abscess; 2.11. - relaparotomy-3, gastrotomy, stitching of bleeding vessels of the stomach stump, sanitation and drainage of the abdominal cavity due to diffuse purulent peritonitis; 3.11. - relaparotomy-4, extirpation of the stomach stump at the height of the next gastric bleeding in conditions of diffuse purulent peritonitis. Pathological examination of the drug 5611-5620: multiple chronic and acute ulcers with fibrinoid necrosis of the tissues of the edges and the bottom, arrosion of blood vessels; 8.11., 12.11. and 18.11. programmed relaparotomies 5, 6 and 7 were carried out regarding the continued diffuse peritonitis with the formation of inter-intestinal, subhepatic and pelvic abscesses; 11/29. - relaparotomy-8, suturing of a defect in the esophageal-jejunal anastomosis, conducting an intestinal probe for nutrition. After 5 days, the failure of the anastomosis recurred. In addition, in the purulent median wound, 2 unformed fistulas were formed on the eventual transverse colon. Left-sided lower lobar pneumonia was complicated by pleural empyema. Sepsis and multiple organ failure developed. The patient's condition is extremely serious. A purulent wound with dull granulations of the anterolateral abdominal wall had a size of 23 × 15 cm. Two fistulas of the transverse colon with a diameter of 2 and 0.8 cm were located at a distance of 6 cm from each other. At the bottom of the slit-like space under the left lobe of the liver and the diaphragm with a depth of 14 cm, a defect of the esophageal-jejunal anastomosis was detected by palpation, occupying a third of its circumference. A “bare” nasointestinal probe located in the discharge loop of the jejunum was palpated. Bile, saliva, mucus, and the nutrient mixture introduced through the probe flowed through the fistula. The loss of body weight at this point was 26 kg (30% of the initial value). It is impossible to examine the defect of the anastomosis and suture from the side of the wound of the abdominal wall. The 10th operation is completed. A flap 18 cm long, formed from the right rectus abdominis muscle and supplied with blood by the superior epigastric artery, was submerged to the bottom of the subphrenic slit-like space to an unsuccessful esophageal-jejunal anastomosis (Figure 1). Muscle flap plugged holes of the esophageal and jejunal fistula. A gauze swab soaked in Levosin ointment is tightly inserted into the subphrenic space near the muscle flap. The left pleural cavity is drained by a silicone tube. After the operation, intensive multicomponent therapy was continued in the intensive care unit of the city hospital. The patient's condition gradually improved. Isolation of the contents of the oral section of the digestive tract into the subphrenic space ceased after a week, the drainage was removed. 12/23. the 2nd stage of fistula plastic surgery was performed: the muscle flap was cleaved according to the described procedure and the formed “daughter” flap 7 × 3 cm closed a large fistula of the transverse colon, the fistula healed under the muscle flap (Figure 2). The second colon fistula with a diameter of 0.8 cm healed independently as a result of active reparative processes in the wound. An X-ray examination of 12/27/1999 revealed the free passage of the esophagus and esophageal-intestinal anastomosis, the absence of sagging of the contrast mass beyond the anastomosis. No defects of the mucous membrane and narrowing in the anastomotic zone during esophagoscopy were detected; moderate edema and hyperemia of the mucous membrane occurred. The intestinal probe was removed, and the patient began to be fed through the mouth. During inpatient treatment lasting 76 days, the patient received 11.5 L of erythrocyte mass, 37 L of freshly frozen plasma, 14 L of aminoplasmal.

The patient was examined in the clinic after 2 years. The condition is satisfactory. There is no dysphagia and intestinal fistula. Body mass deficit is 10%. He works as a waiter. A hernia repair was performed for a postoperative ventral hernia. The postoperative period was uneventful. The patient is demonstrated at a meeting of the Arkhangelsk Regional Scientific Society of Surgeons named after N.I. Pirogova 02/29/2002

Brief Description of the Drawings

Figure 1 schematically shows the first stage of surgical treatment of unformed mixed fistulas with a muscle flap on the feeding upper epigastric artery. The number 1 indicates the esophageal-jejunal fistula that occurred after gastrectomy, the number 2 - the flap from the right rectus abdominis muscle, moved from its fascial vagina to the esophageal-jejunal fistula, the number 3 - the functioning unformed fistula of the transverse colon and the figure 4 - the tubular drainage into the fascial vagina of the right rectus abdominis muscle.

Figure 2 schematically shows the second stage of surgical treatment of unformed mixed fistulas with a muscle flap on a vascular pedicle. Numeral 1 denotes a healed esophageal-jejunal fistula, numeral 2 - a split flap from the right rectus abdominis muscle, numeral 3 - an unformed fistula of the transverse colon, covered with a newly formed muscle flap. Tubular drainage from the fascial vagina of the right rectus abdominis muscle was removed.

Claims (1)

A method for surgical treatment of unformed mixed incomplete fistulas of the gastrointestinal tract, comprising the formation of a muscle flap on a vascular pedicle from the rectus abdominis muscle, in which fistula closure is carried out in two stages, and at the first stage, the fistula closest to the base of the flap is closed with a muscle flap; after the healing of this fistula, in the second stage, close the second fistula, located away from the muscle flap, by partial intersection and splitting of the latter, as well as moving to the fistula the newly formed daughter muscle flap.

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