RU2357682C1 - Method of surgical prevention of sutures failure of cervical esophageal-intestinal anastomosis in total esophagoplasty with colonic antiperistaltic transplant - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention pertains to medicine, namely, to surgery. Colonic transplant in antiperistaltic position is placed in anterior mediastenium up to the corner of the low jaw. Oral end of the transplant is pulled to the neck; a drainage tube is installed into the opening of the transplant. Tube is pulled down below the level of gastric-colonic anastomosis. Thereat a "tunnel" above the tube is formed with 8-10 interrupted stitches in the apical part of the colonic transplant. The tube is plunged into the opening of the transplant by the low edge of the formed above it "tunnel". Incised bowel lumen with the tube is tightened with purse-string suture. The second row of seromuscular sutures is applied above the formed "tunnel". External end of the tube with the transplant apical end are pulled through the incision in the left half of the neck. Intra-intestinal tube is removed after healing of the gastric anastomosis.

EFFECT: method ensures creating of intra-lumen decompression of the transplant and of the zone of cervical esophageal anastomosis; absence of gastric-intestinal discharge, independent healing of the fistulous channel in the neck by secondary adhesion, increases safety of the esophageal-colonic anastomosis, antireflux effect.

4 dwg, 1 tbl, 1 ex

Description

The present invention relates to medicine, in particular to surgery, gastroenterology and is a surgical method for the prevention of insolvency of sutures of the esophageal-intestinal anastomoses on the neck with total antiperistaltic esophagocolonoplasty.

Currently, the following methods are used in surgery aimed at preventing the inconsistency of sutures of the cervical esophageal anastomosis in case of total esophagoplasty with an antiperistaltic colonic transplant.

A known method of prevention by establishing a nasogastric tube in the lumen of an artificial esophagus for intraorgan decompression ("Surgery of the esophagus" AF Chernousov, PM Bogopolsky, FS Kurbanov M .: Medicine. - 2000. - P.137, p. 179). This method allows to reduce the pressure on the joints of the anastomosis, due to the accumulation of intestinal and gastric contents as a result of the inevitable postoperative paresis of the gastrointestinal tract, and subsequently the anti-peristaltic wave of the artificial esophagus. The main disadvantage of this type of prevention of anastomotic insufficiency in the neck is the need for a long-term finding of the nasogastric tube, which causes concern for the patient, and in this connection forced or independent (by the patient) removing it from the lumen of the artificial esophagus. However, the duration of the antiperistaltic function of the graft, significantly exceeding the healing time of the anastomosis, significantly increases the risk of failure of the joints of the created anastomosis, the development of respiratory failure.

There is also a method of applying an esophageal-intestinal anastomosis on the neck, similar in its surgical methods to Maidl’s surgery (“Atlas of operations on the esophagus, stomach and duodenum” Shalimov AA, Polupan VN M: Medicine. - 1975. - S.13-14). In this case, the decompression of the transplant and the esophageal-intestinal anastomosis consists in the fact that the oral part of the large intestine transplant in the form of a stoma is placed on the neck, in the lumen of which a polyvinyl chloride gastric tube is installed. Below the apical part of the graft, 3.0-4.0 cm, esophagocolonoanastomosis is formed by double-row interrupted sutures "end to side". This method is taken as a prototype.

Significant disadvantages of this method are: infection of the cervical surgical wound; flow rate of the intestinal contents into the oral fistula of the graft, reaching 55% -60% with natural food intake; the formation of a persistent, nonhealing intestinal fistula on the neck, often requiring repeated surgical intervention to eliminate it.

EFFECT: creation of intraluminal decompression, absence of gastrointestinal flow rate, independent healing of the fistulous canal on the neck by secondary tension, antireflux effect.

The proposed method is as follows. In the anterior mediastinum, to the angle of the lower jaw, the created large intestine transplant is placed in the antiperistaltic position, the skin and soft tissues are dissected in front of the left sternocleidomastoid muscle, the oral portion of the graft is removed into the wound, and the end-to-side esophageal-colonic anastomosis is formed. In the apical section of the graft above the polyvinyl chloride tube form a "tunnel" of 8-10 interrupted sutures (figure 1). Then the tube is immersed in the transplant lumen at the lower edge of the “tunnel” formed above it and lowered by the gastrointestinal anastomosis. After this, the intestinal lumen with the tube is tightened with a purse string suture, a second row of sero-muscular sutures is placed over the formed “tunnel”, the outer end of the tube with the apical end of the graft is removed through a separate incision in the left half of the neck (Fig. 2). After healing of the esophageal anastomosis (1.5-2 weeks after surgery), the intestinal tube is removed, and the fistulous canal on the neck heals independently by secondary tension.

The presence of the tube in the antiperistaltic colonic transplant provides intraluminal decompression, reducing the likelihood of failure of the sutures of the esophageal-intestinal anastomosis on the neck (Fig. 3). Due to the created tight tubular colonic fistula, the gastrointestinal flow through the oral end of the graft is absent on the neck, and after healing of the esophageal anastomosis (1.5-2 weeks after the operation) and removal of the intraintestinal tube, the fistulous canal on the neck heals independently by secondary tension due to compression its gases formed a "tunnel" on the front wall of the graft (figure 4).

The proposed method is illustrated by the following drawings: Fig. 1 shows an antiperistaltic version of esophagoplasty of the left half of the colon with intraorgan drainage of the artificial esophagus by a polyvinyl chloride tube, in the apical section of the graft above the drainage - a formed "tunnel" on the front wall of the colon; figure 2 - the steps of immersion of the tube into the lumen of the graft after the formation of a "tunnel" above it; figure 3 - esophageal-colonic anastomosis with the formed "tunnel" on the front wall of the graft; figure 4 - gas pressure in the area of the formed "tunnel" and the compression of its channel by gases after removal of the tube.

Clinical example. Patient G., 50 years old, (medical history No. 109530), was admitted to the hospital with complaints of mechanical dysphagia. Previously, the patient underwent a resection of the stomach according to Billroth II for gastric ulcer complicated by bleeding. According to x-ray of the esophagus and stomach, fibroesophagogastroscopy, the patient revealed decompensated cicatricial peptic stenosis of the lower third of the esophagus. Surgical intervention performed. Under general anesthesia, the “old” median post-laparotomic scar was excised. Laparotomy The upper floor of the abdominal cavity is inflated. Viscerolysis was performed. The left half of the colon was mobilized from the rectosigmoid region to the middle of the transverse colon. A test clamping of the left colonic artery and branch of the sigmoid artery was performed. The isolated fragment of the colon to create an “artificial esophagus” was recognized as transplantable - the color of the organ is normal with a pronounced pulsation of the parallel vessel, about 45 cm long. The colon was intersected in the rectosigmoid region and at the mid-transverse colon level. The anatomical integrity of the intestinal tube is restored by an inter-intestinal end-to-end anastomosis with double-row interrupted sutures. An anastomosis is formed between the large intestine transplant and the anterior wall of the end-to-side stump of the stomach with double-row interrupted sutures. A tunnel has been created in the anterior mediastinum to the angle of the lower jaw, into which the large intestine transplant has been moved in the antiperistaltic position. In front of the left sternocleidomastoid skin and soft tissues are dissected. The oral section of the graft was removed to the wound, the esophageal-colonic anastomosis was formed with double-row interrupted nodal nylon sutures “end to side”. In the apical section of the graft, a “tunnel” is formed over the polyvinyl chloride tube with 8 interconnected nylon seams. The lumen of the large intestine transplant was opened at the border of its middle third and the oral part (at the lower edge of the “tunnel” formed above the tube). A drainage tube is immersed in the lumen of the graft, which is reduced for the gastrointestinal anastomosis. An opened intestinal lumen with a tube is tightened with a purse string suture. The second row of serous-muscular sutures is imposed. Anterior colic stoma is formed in front of the left sternocleidomastoid muscle. Control for hemostasis and foreign bodies. Tubular drainages are installed in the anterior mediastinum and abdominal cavity. Layered seams on the wound. Aseptic dressing.

In the postoperative period, failure of the esophageal anastomosis on the neck was not detected. According to x-ray of the esophagus - patency of the esophageal-intestinal anastomosis on the neck is satisfactory, the passage of contrast along the artificial esophagus is not impaired. The tube was removed 12 days after surgery.

Discharged in satisfactory condition. Healing of the fistula on the neck by secondary intention.

The proposed method was applied in a clinic in 14 patients with cicatricial stenosis of the esophagus and previously operated stomach. Complications associated with the use of the method are not registered. Evaluation of treatment results up to 2 years after surgery was carried out according to clinical and instrumental (contrast radiography of the artificial esophagus and stomach, fibroesophagogastroduodenoscopy) examination in comparison with 79 patients (67 in group I, and 12 in group II), after antiperistaltic colonic esophagoplasty with the prevention of cervical esophageal insufficiency anastomoses according to traditional methods.

As can be seen from table 1, in groups I and II, failure of sutures of the esophageal-colonic anastomosis occurs in 16 and 2 cases, respectively. In group III, insolvency was not noted, which clearly proves the advantages of the proposed method for the surgical prevention of esophageal cervical anastomosis insolvency with this type of esophagoplastic. In all cases, in the III group, the healing of the intestinal fistula on the neck occurred by secondary intention, in the II group in 3 cases it was required to be eliminated by surgical intervention.

Thus, the results of clinical studies show that the proposed surgical method allows to achieve adequate intraluminal decompression of the transplant and the cervical esophageal anastomosis zone and increases the reliability of the esophageal-colonic anastomoses on the neck with total antiperistaltic colonic esophagoplasty, does not require surgical elimination of the intestinal cyst.

Table 1
The frequency of insufficiency of esophageal anastomoses with antiperistaltic esophagoplasty of the colon Method for the prevention of insufficient esophageal-intestinal anastomosis Frequency (cases) Group I (the establishment of a non-gastric probe). 16 Group II (stoma on the neck as Maidle). 2 Group III (the proposed method) -

Claims (1)

A method for surgical prevention of suture failure of the cervical esophageal-intestinal anastomosis in case of total esophagoplasty with an antiperistaltic large intestine transplant, including placement in the anterior mediastinum to the angle of the lower jaw of the large intestine transplant in the antiperistaltic position, the removal of the oral end of the graft to the neck, the drainage of which is lower than the lower tube, the drainage is lower than the tube gastrointestinal anastomosis, characterized in that in the apical part of the colonic of the transplant form a “tunnel” above the tube with 8-10 interrupted sutures, after which the tube is immersed in the lumen of the graft at the lower edge of the “tunnel” formed above it, the opened lumen of the intestine with the tube is tightened with a purse string suture, a second row of serous-muscular sutures are placed over the formed tunnel ”, the outer end of the tube with the apical end of the graft is removed through an incision in the left half of the neck, after healing of the esophageal anastomosis, the intestinal tube is removed.

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