RU2344769C1 - Method of rear colonic-gastric anastomosis application during esophagoplastics - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: anastomosis is made between distal end of colonic transplant and stomach. After transplant cutting from transverse colon, proximal transplant part is put through lesser omentum fenestra. Further the transplant passes over cervix in retrosternal compartment. Distal transplant part remains behind stomach. At the border of cardiac compartment and unaltered rear stomach wall body anastomosis is applied between distal end of colonic transplant and rear stomach wall. To prevent sacking transplant is fixated by serous-muscular sutures to the rear stomach wall. Method ensures prevention of inflammation alterations in anastomosis area and reflux colitis of colonic transplant by positioning colonic-gastric anastomosis at unaltered rear stomach wall where stomach mucosa has almost no acid-producing cells.

EFFECT: prevented twist of vascular transplant pedicle, compression of distal transplant half between stomach and front abdominal wall in lesser omentum fenestra.

2 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, and can be used when performing the abdominal stage of large intestine plasty of the esophagus, which is performed with cicatricial narrowing or atresia of the esophagus.

Currently, colonic esophagoplasty is most prevalent when a transplant (artificial esophagus) is cut out from the transverse colon on the feeding leg, including the left colonic artery and vein. The graft is carried out behind the stomach through the “window” in the small omentum and placed in front of the stomach, leaving the feeding leg behind it. Next, the large intestine of the artificial esophagus is carried out behind the sternum and its proximal end is brought to the neck, where it is connected to the cervical segment of the patient's esophagus. The distal end of the graft is connected to the stomach by a gastrointestinal anastomosis. This anastomosis is always applied to the anterior gastric wall slightly below the gastrostomy, previously applied in patients for nutrition. When a gastrostomy is applied, a significant part of the anterior gastric wall is often used and, taking into account the development of a significantly pronounced adhesive process around the surgical area, the distal part of the body of the stomach and its antrum, in the best case, remain intact. those parts of the stomach, the mucous membrane of which has the highest acid-producing and enzymatic activity. The imposition of anastomosis between the colon of the transplant and these parts of the stomach always carries the risk of developing anastomositis, erosive and ulcerative inflammation in the colon, because aggressive gastric contents as a result of the reflux mechanism are constantly thrown into the colon of the transplant.

Various plastic surgeries have been proposed for the formation of valves in the area of anastomoses that impede such a reflux mechanism (A.G. Lymar, 1992). In connection with the foregoing, the aspirations of surgeons are aimed at raising the colonic-gastric anastomosis as high as possible, closer to the cardiac section of the stomach, where there is a relatively calm acid-enzymatic region of the mucosa. This, as a rule, can never be done. There are 3 options for applying the anastomosis: 1) apply it below the gastrostomy with the creation of an antireflux valve, 2) remove the gastrostomy and use the gastrostomy hole for the anastomosis (in these cases, sutures are applied to the scarred tissues of the gastric wall), 3) apply the anastomosis with the jejunum, completely turning off the stomach from the act of digestion.

In the literature available to us, we have not seen cases of using the posterior wall of the stomach for applying a colonic-gastric anastomosis in esophagoplasty.

The prototype of the invention selected a method of applying the anterior colonic-gastric anastomosis to the anterior wall of the stomach below the gastro (esophago) stoma with the formation of an antireflux shutter (A.Yu. Razumovsky, 1987).

In the prototype, after the transplant is removed through the “window” in the small omentum in front of the stomach, a platform is allocated on its front wall immediately down from the gastrostomy and after dissection of the sero-muscular layer, the distal end of the graft is carried out in the muscle layer of the stomach for 2-3 cm, which is then anastomosed with gastric wall. The disadvantages of the method are: 1) limited ability to find a free area on the anterior gastric wall for antireflux surgery; 2) the gastrointestinal anastomosis is applied in the aggressive (in the acid-enzymatic relation) zone of the stomach; 3) when creating a channel in the muscle layer of the gastric wall, the formation of hematomas is often possible, which subsequently scar, squeezing the intestine passing in this layer; 4) the time of surgical intervention is lengthened due to the formation of an antireflux shutter.

The objective of the invention is to provide a method for applying the posterior colonic gastric anastomosis with the elimination of reflux colitis of the colonic transplant by placing the gastrointestinal anastomosis on the unchanged posterior gastric wall.

The task is achieved primarily by leaving a part of the graft in the stomach space and removing through the “window” in the small omentum only that part of the graft, which will subsequently be placed in the chest tunnel; overlapping of the gastrointestinal anastomosis at the border of the cardiac section and the body of the posterior wall of the stomach closer to the greater curvature with transverse dissection of the gastric wall in proportion to the diameter of the anastomosed colon, the formation of anastomosis using a two-row suture using modern atraumatic suture materials (Vicryl 4/0, Biosyn 4 / 0, Prolen 4/0) with fixation of the transplant to the posterior gastric wall to eliminate sagging intestines.

The implementation of the method is illustrated by illustrations, where

figure 1 shows the relative position of the abdominal organs used in esophagoplasty, with the imposition of the posterior colonic-gastric anastomosis, front view: 1 - stomach, 2 -abdominal esophagostoma, 3 - gastrointestinal anastomosis, 4 - transplant, 5 - post-gastric transplant, 6 - vascular leg of the transplant, 7 - interintestinal anastomosis, 8 - “window” in the small omentum;

figure 2 shows the relative position of the abdominal organs used in esophagoplasty, with the imposition of the posterior colonic-gastric anastomosis, rear view (same designations).

The method is as follows. After the graft has been cut out from the transverse colon on the feeding leg, including the left colonic artery and vein, the proximal end of the transplant intestine is passed through a “window” in the small omentum and then in the created chest tunnel to the neck for anastomosis with the cervical segment of the esophagus. The distal part of the graft below the "window" of the small omentum is placed behind the stomach. On the unchanged posterior wall of the latter, at the border of the cardia and body, a colonic-gastric anastomosis is applied with a transverse section of the stomach wall and a double-row continuous suture (Biosyn 4/0, Prolen 4/0). The intestine is fixed with two sero-muscular sutures to the posterior gastric wall to eliminate sagging graft.

The proposed method of surgical intervention was used to treat patients with atresia and cicatricial narrowing of the esophagus in the children's surgical clinic of the Rostov State Medical University on the basis of the city hospital №20. We give the following observation as an example.

Patient Anastasia Ts-va, 10 months (history. Bol. No. 671/158), at 2 days of age she underwent double esophagostomy surgery according to G.A.Bairov regarding esophageal atresia.

01/31/07, performed total colonic retrosternal esophagoplasty. After median laparotomy, a marked adhesion process was found in the upper floor of the abdominal cavity: the abdominal segment of the esophagus used for esophagostomy is walled up in adhesions; the left lobe of the liver is soldered to the stomach, the entire front wall of the stomach is involved in a rough adhesion process.

After the graft has been cut out from the transverse colon on the vascular pedicle, consisting of the left colonic artery and vein, its proximal end is drawn through the “window” in the small omentum and then through the formed sternal tunnel to the neck, and the distal one is placed behind the stomach and the colonic gastric anastomosis on the posterior wall of the stomach at the border of the cardiac section and the body closer to the greater curvature. A section of the stomach with a length of 3 cm was made in the transverse direction parallel to the branching of the intra-wall vessels. A continuous 2-row suture was used: internal - Biosyn 4/0 on an atraumatic needle, external - continuous prolene thread (Prolen 4/0). In order to eliminate sagging graft, the latter is hemmed with two sero-muscular sutures to the posterior gastric wall. Colon patency restored by end-to-end anastomosis after removing the “window” into the mesocolon. The anterior abdominal wall is sutured in layers tightly. On the neck, the esophagus is connected end to end with the proximal end of the transplant colon. The intestine below the anastomosis is hemmed to the sternum tenderloin. Skin sutures were placed over the anastomosis. A teflon tube was introduced into the stomach through an abdominal esophagostoma for decompression and subsequent nutrition of the patient.

The postoperative period was difficult: on the first night there was a convulsive syndrome, stopped medically. Feeding through abdominal esophagostoma on the 7th day after surgery has begun. The girl began to eat through the mouth on the 9th day of the postoperative period; sutures were removed on the 9th day, discharged in satisfactory condition on the 18th day. When x-ray examination after 2 months. after surgery, the patency of the artificial esophagus is good throughout.

Compared with the prototype, the proposed method has the following advantages: the application of a colonic-gastric anastomosis is performed on a completely unchanged posterior gastric wall, which, of course, matters in the reparative tissue regeneration; this anastomosis is imposed on a site where acid-producing cells in the gastric mucosa are almost completely absent; the inflection of the vessels of the graft feeding leg in the “window” of the small omentum is eliminated; the distal part of the graft is not squeezed between the stomach and the anterior abdominal wall; elimination of sagging of the intestine of the transplant does not allow the contents to accumulate in it; no need to create an antireflux shutter.

Claims (1)

A method for applying a colonic-gastric anastomosis in esophagoplasty, including the creation of an anastomosis between the distal end of the colonic transplant and the stomach, characterized in that after the graft has been cut from the transverse colon, the proximal part of the graft is carried out through a window in the small omentum and further into the chest area, the distal part the graft is left behind the stomach, then at the border of the cardiac section and the body of the unchanged posterior wall of the stomach an anastomosis is applied between the distal ntsom colonic graft and posterior gastric wall.

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