RU2367360C1 - Surgery technique for ulcero-necrotic enterocolitis in subtotal colonic involvement in newborns - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to operative coloproctology, can be used in surgical treatment of ulcero-necrotic enterocolitis in subtotal colonic involvement in newborns. Extensive resection of large intestine is performed to form a right lateral segment within proximal ascending colon and a left lateral segment within distal sigmoid intestine. The segments are connected by anastomosis. Thus at first, the right lateral segment is separated. It is ensured by mobilising a blindgut and ascending colon after dissection of peritoneal transitory fold in lateral canal. An artery and vein that feed the right lateral intestinal segment, iliac artery and vein are separated from retroperitoneal space. Ascending colon and blindgut is unfolded 180° in sagittal plane. Then proximal end of the right intestinal segment is end-connected to distal end of the left lateral segment at the level of inferior lumbar vertebras.

EFFECT: offered method allows effective treatment in tissue deficiency of colocolonic plasty.

1 ex

Description

The invention relates to medicine, in particular to surgical coloproctology, and can be used in the surgical treatment of ulcerative necrotic enterocolitis with subtotal rectal lesion in newborns.

A known method of surgical treatment of ulcerative necrotic enterocolitis in newborns, including extensive resection of the colon with the formation of the left and right lateral sections of the intestine and connecting them using anastomosis. (T.V. Krasovskaya, N.V. Beloborodova "Surgical infection in newborns", M .: Medicine, 1993, p.125-133).

In this method, depending on the volume of intestinal lesions, colon resection can be as small as a few centimeters. Moreover, the connection of two lateral segments of the rectum is carried out using an end-to-end anastomosis. In the case of a subtotal lesion, in which the terminal ileum, the cecum and the ascending transverse colon (80%), the splenic angle (12%) and the rectosigmoid part (8%) are affected most, the rectum is extensive, the authors indicate in this case, only the lesion volume, but not the resection volume and the nature of the operation, but with enterocolitis often the lesion volume is larger than the resection volume. In addition, with perinatal hypoxia, the volume of the lesion increases. In this case, a stoma is placed on the remaining segment of the colon, which subsequently requires closure. Moreover, the deficit of tissue does not allow to close it with the help of colonic plastic. Therefore, to close it, an insert from the small intestine is used. In this case, the small intestine falls into conditions that do not correspond to its biocenosis, which can cause a chronic inflammatory process in a segment of this intestine, which in turn significantly reduces the effectiveness of treatment.

In accordance with this, the task was set to expand the functionality of the method due to its use in conditions of tissue deficiency with extensive resection of the colon, as well as increasing the effectiveness of treatment by eliminating possible postoperative complications.

To solve this problem, in a method of surgical treatment of ulcerative necrotic enterocolitis in newborns, including extensive resection of the colon with the formation of two segments: the right, consisting of the lower third of the ascending and cecum, and the left - from the pelvic segment of the sigmoid colon and connecting them using an anastomosis , it was previously proposed that the right segment of the colon, along with the vessels supplying it, should be isolated from the retroperitoneal space, rotated 180 ° in the sagittal plane on the iliac vessels (iliaka), inter schat inwards, and then the proximal end of the right side of the segment joining to the distal end of the segment at the left lower lumbar vertebrae.

The implementation of the method is illustrated by a specific example.

The baby Maria K. was born on December 30, 87. Received in DRL MONIKA 02.01.88. and was operated on the same day for ulcerative necrotic enterocolitis with multiple perforations of the colon, peritonitis, sepsis.

An extensive resection of the colon was made, as a result of which two segments remained: the left, consisting of the pelvic segment of the sigmoid colon, and the right, consisting of the lower third of the ascending and cecum.

An end colostomy is imposed. The postoperative period was difficult. Peritonitis, sepsis, and toxicosis were treated. Was in the hospital 26 k / days. After discharge during the observation process, she was hospitalized at MONIKI for rehabilitation and treatment of anemia.

For reconstructive surgery was received 05/11/89. at the age of 11 months with a weight of 3800. Height 54 cm. General condition of the child is satisfactory. The skin is clean, pale. Stool 3-4 times a day. The anemia was expressed in the child, for which she received appropriate therapy and 100 ml of transfused blood.

Vesicular breathing. Heart sounds are sonorous, rhythmic, pulse - 112 per minute. The liver and spleen are not enlarged. The abdomen is slightly sunken, painless. On the skin are postoperative scars that deform the abdomen. In the mesogastric colostomy with a roller from the colon.

In the blood, Нb - 120 g / l, l - 5.4 · 10 ⁶ , n - 2, s - 40, e - 1, l - 48, m - 9, protein - 68 g / l, Al-67%, K - a / g - 1.5, in the urine - reaction. alkaline, protein - 0.06 g / l, white blood cells up to 30, er. - 3-5 p / sp. Bilir. - 5 g / mm / l, thymol, sample - 1.8, sugar - 4.5 mm / l, ALT - 53 nm / s.L., AST - 62 nm / s. L., Fibrinogen - 4.2 g / l, prothrom. - 106% °.

After appropriate preparation 05/18/89. operation: under endotracheal anesthesia, median laparotomy with excision of the old scar. The abdominal cavity is obliterated by scars and commissures after transferred peritonitis. Mobilized bowel loops. A short segment of the sigmoid colon ended at the level of the lower lumbar vertebrae and was mobilized by the parietal peritoneum. It turned out that the stoma was placed on the middle third of the ascending colon. After removal of the ascendostomy and minimal excision of the altered ends of this intestine, the initial section of the ascending intestine was very short, the diastasis between this intestine and the sigmoid region was significant. The question arose of inserting from a segment of the small intestine between the ends of the ascending and sigmoid colon.

An attempt was made to reduce this distance by mobilizing the cecum and ascending colon, which were mobilized after dissection of the transitional folds of the peritoneum in the lateral canal, but this was not enough. Therefore, from the retroperitoneal space, the ileo-colonic vessels (iliaka) passing in the retroperitoneal tissue (iliac artery and vein) were isolated, after which the mobilized intestine became mobile. An attempt to move them in the medial direction led to an excess of blood vessels. Therefore, the ascending and cecum were rotated 180 ° in the sagittal plane so that the cecum was located proximal to the ascending one. This movement did not lead to vascular twisting and significantly reduced the distance between segments of the intestines.

Between the right segment of the ascending intestine and the left sigmoid stump, due to the difference in the diameter of the intestines, a “oblique” colonic anastomosis (end-to-end type) was applied at the very beginning of the “blind” end (without bowel resection), which allowed a small area and so reduced in size of the sigmoid colon.

Appendectomy performed. The wound is sutured in layers to drainage. A probe into the rectum is inserted behind the anastomosis.

As a result of this operation, an additional passage was included in the intestinal passage: the distal sigmoid and rectum.

After the operation, the child was monitored in the intensive care unit. The condition corresponded to the operation. The main indicators of blood circulation and respiration were within normal limits, there was a slight paresis of the gastrointestinal tract, for which stimulation with proserin, iv hypertensive p-p, HBO, infusion therapy, antibiotics was prescribed. After 2 days, gases began to flow, an independent chair for 4 days. The diet was gradually expanding. Sutures were removed on day 10. The wound healed by primary intention. After surgery, anti-adhesion therapy was performed. Discharged 06.06.89.

The first days there was a mushy stool 2-4 times a day. At home, the chair returned to normal 2 times a day, and after a long time after surgery, the child’s stool 1-2 times a day.

The use of this invention will allow for effective treatment in conditions of tissue deficiency for colorectal plasty.

Claims (1)

A method of surgical treatment of ulcerative necrotic enterocolitis with subtotal lesion of the colon in newborns, including extensive resection of the colon with the formation of the right lateral segment in the proximal part of the ascending colon and the left side segment in the distal part of the sigmoid colon and connecting them using an anastomosis, characterized in that the right lateral segment is preliminarily isolated, for which the blind and ascending colon are mobilized after dissection of the transitional fold of the peritoneum in lat ral channel, secrete an artery and vein from the retroperitoneal space that feed the right lateral section of the intestine, the ileal artery and vein, unfold the ascending colon and cecum 180 ° in the sagittal plane, then the proximal end of the right segment of the intestine is connected to the side with the distal end of the left lateral segment at the level of the lower lumbar vertebrae.