RU2408304C1 - Method of esophageal-gastric anastomosis formation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for formation of esophageal-gastric anastomosis. Transplant in form of stem from greater curvature of stomach is formed. On the apex of stem seromuscular layer is dissected on esophagus diametre length. Seromuscular wall of stoimach is separated from mucosa. Seromuscular layer is turned out with formation of duplication. Anastomosis between end of transected esophagus and end of gastric transplant is formed with matching of muscular layer of esophagus with internal surface of duplication of stomach cuff in area of fistula. Interrupted suture is applied between duplication of posterior wall of seromuscular stomach coat with posterior wall of muscular coat of esophagus. Interrupted sutures are applied between mucous membrane of stomach and mucous membrane of esophagus on posterior and anterior wall. Interrupted sutures are applied between anterior wall of esophagus and through all layers of duplication of seromuscular layer of gastric transplant.

EFFECT: method allows to reduce risk of anastomosis inconsistency.

1 ex

Description

The invention relates to medicine, namely to thoracic surgery. It can be used for plasty of the esophagus due to post-burn strictures of the esophagus and for the surgical treatment of cancer of the esophagus.

A known method of forming an esophageal-gastric anastomosis (Zherlov G.K., Gibadulin N.V., Alipov V.V., 1999, RF patent No. 2143849). A gastric transplant is formed from the greater curvature of the stomach. Mobilize the esophagus. The esophagus is resected. In the distal section of the esophagus stump, muscle pulp is formed, while the muscle membrane is separated with a width of 10-12 mm. Wrap the shell up. The gastric transplant is brought to the esophagus. Position the suture line along the lesser graft curvature in the middle of the anastomosis anterior semicircle. The valve is formed by invagination of excess mucosal submucosal layers of the esophagus and gastric transplant stump into the transplant lumen. Two rows of sutures are placed between the stump of the esophagus and the gastric transplant.

The disadvantage of this method is the shortening of the gastric transplant (due to circular excision of the serous-muscular layer 20 mm distal to the resection line) and the esophagus (due to unscrewing and stitching up the free edge of the muscle membrane), which does not allow using this method in conditions of deficiency of plastic material. High risk of necrosis of the invagination valve. Anastomosis is not covered by the serous-muscular layer, as a result of which the likelihood of developing anastomosis failure increases.

The closest is the method of forming an esophageal-gastric anastomosis according to Morton and Foyer, in which, after the formation of a gastric transplant, a serous-muscular layer is dissected at the top of it. Separate the mucous membrane and bandage the vessels of the submucosal layer. A strip of mucous membrane of the stomach with a height of 1-2 cm is excised. Anastomosis is placed between the esophagus and the gastric mucosa. The sero-muscular cuff is set and sewn to the esophagus. Thus, the anastomosis is covered with a high serous-muscular cuff from the wall of the stump of the stomach (A.A. Shalimov, V.F. Saenko, S.A. Shalimov. Surgery of the esophagus. M .: Medicine. 1975. S. 258-259) . The disadvantage of this method is that it is necessary to excise the site of the serous-muscular layer and, as a result, the transplant is shortened. The height of the serous-muscular cuff is small and is only 1-2 cm and does not allow creating sufficient strength of the formed esophagogastroanastomosis. The formation of a cavity between the serous-muscular cuff of the stomach and the wall of the esophagus contributes to the development of anastomositis and an increased risk of anastomotic insolvency.

The objective of the invention is the elimination of these disadvantages, reducing the duration of treatment of patients by reducing the number of complications in the postoperative period, maintaining the physiological passage through the digestive tract, reducing the incidence of anastomotic strictures in the late postoperative period.

To do this, in the method of forming an esophageal-gastric anastomosis, including the formation of a gastric transplant, dissection of the serous-muscular layer, separation of the mucous membrane with the formation of the serous-muscular cuff, turning it outward, imposing anastomosis between the esophagus and the stomach, covering the anastomosis with the serous-muscular cuff, dissection of the serous-muscular layer should be carried out along the line of transplant formation, starting from its top, along the length of the diameter of the esophagus. When applying anastomosis between the esophagus and the stomach, it is first recommended to stitch their mucous membranes, then combine the muscular layer of the esophagus with the inner surface of the duplicate of the stomach cuff in the anastomosis, stitch them through all layers of the duplicate.

The fact that the dissection of the serous-muscular layer is carried out along the line of the formation of the graft, starting from its top, as well as economical excision of the mucosa until a lumen equal to the lumen of the esophagus appears, does not lead to a shortening of the gastric stem, which contributes to the formation of esophagogastroanastomosis without tissue tension and prevents its failure. This contributes to a significant reduction in bed days, earlier rehabilitation of patients and a decrease in the number of complications associated with the failure of anastomoses.

The fact that when the anastomosis is applied between the esophagus and the stomach, their mucous membranes are first sutured, then the muscular layer of the esophagus is combined with the inner surface of the gastric cuff duplicate, significantly strengthens the anastomosis line, prevents the formation of cavities around the suture line and, as a result, reduces the likelihood of anastomositis and anastomosis failure.

The fact that esophagogastroanastomosis is covered by a high serous-muscular cuff helps to further strengthen the anastomosis. The formation of an oblique serous-muscular cuff promotes a more thorough shelter of the lateral wall of the anastomosis.

The method is as follows.

Under general anesthesia, an upper median laparotomy is performed. The stomach is mobilized along the greater and lesser curvature, a large omentum is resected while preserving the right gastro-omental gland. The duodenum is mobilized according to Kocher. With the help of linear suture devices, by resection of the cardia and lesser curvature, a gastric transplant of at least 3 cm wide is formed from large curvature (iso- or anti-peristaltic). The line of the mechanical suture is covered with nodular gray-serous sutures, while the distal section of the gastric transplant is left uncovered with a length of equal to the diameter of the esophagus, usually 3-4 cm. Perform a sagittal diaphragmotomy according to the Savins. The right leg of the diaphragm is stitched, bandaged, and crossed. Through the esophageal opening of the diaphragm, the thoracic esophagus is mobilized as high as possible. The abdominal stage of the operation is completed by drainage of the abdominal cavity, layer-by-layer suturing of the surgical wound.

Perform anterolateral thoracotomy in the 5th intercostal space on the right. Dissect the mediastinal pleura above the esophagus from the diaphragm to the dome of hemithorax. The arc of an unpaired vein is resected. In a dull and acute way, the thoracic esophagus is isolated and traversed as proximal as possible. The formed gastric stalk is moved to the posterior mediastinum in the bed of the resected esophagus. The thoracic stage of the operation is completed by drainage of the pleural cavity and layer-by-layer suturing of the thoracotomy wound.

Perform a colotomy on the front edge of the left sternocleidomast from the angle of the lower jaw to the jugular notch of the sternum. The superficial fascia and m.platysma are dissected, the short muscles of the neck cross parallel to the inner edge of the sternocleidomus, while the thyroid gland and the neurovascular bundle of the neck are exposed. The fascia of the neurovascular bundle is dissected in parallel and medially from the external carotid artery, the upper thyroid vessels are ligated. The neurovascular bundle is diverted to the side, while the trachea and esophagus are visualized. Additional mobilization of the upper thoracic esophagus is performed in a blunt way. A L-shaped clamp is applied to the oral end of the esophagus, the caudal end of the esophagus is stitched using a linear suture apparatus. The esophagus crosses between the clamp and the apparatus. The gastric transplant is removed to the wound on the neck. At the top of the stem, the serous-muscular layer is dissected along the length of the diameter of the esophagus along the line of formation of the stem, then the serous-muscular wall of the stomach is separated from the mucosa for at least 15-25 mm. The sero-muscular layer of the stomach is inverted, thereby duplication is formed. Subsequently, the mucous membrane is dissected until a lumen appears in it with a diameter approximately equal to the inner diameter of the esophagus. An anastomosis is formed between the distal end of the crossed esophagus and the proximal end of the gastric transplant according to the “end to end” type. First, nodal sutures are applied between the duplicate of the posterior wall of the serous-muscular membrane of the stomach with the posterior wall of the muscular membrane of the esophagus. Subsequently, a second row of esophagogastroanastomosis is formed by nodal sutures between the mucous membrane of the stomach and the mucous membrane of the esophagus along the posterior and anterior walls. Then, nodal sutures are applied between the anterior walls of the esophagus and through all layers of the duplicate of the serous-muscular layer of the stomach. The serous-muscular membrane of the duplicate is adjusted, and then fixed with interrupted sutures above the anastomosis line.

Example 1

Patient T., born in 1960, and / b No. 3185, was admitted to the thoracic surgical department of MONICA with a diagnosis of Post-burn extended cicatricial stricture of the esophagus on February 26, 2006. On January 15, 2006, Krot fluid was mistakenly drunk. After preoperative preparation, March 26, 2006, the upper middle laparotomy was performed. When auditing in the upper abdominal cavity, the adhesive process. The cardiac section of the stomach is determined at the level of the esophageal opening of the diaphragm. The abdominal segment of the esophagus was isolated and taken in a dull and sharp way. Performed a sagittal diaphragmotomy according to the Savinykh. The right leg of the diaphragm is stitched, bandaged, crossed. Through the esophageal opening of the diaphragm, the lower thoracic esophagus is mobilized. The stomach is mobilized along the greater and lesser curvature with preservation of the right gastro-omental vessels and the right gastric vessels. The left vessels of the stomach are crossed. Next, the operation is performed according to the method described above.

Smooth postoperative period. She began to eat independently on the 7th day after the operation. The patient was discharged in satisfactory condition on the 14th day after surgery.

According to the proposed method, 5 patients were operated on, the following positive aspects were revealed: the absence of anastomotic insufficiency, in connection with which there was a reduction in the bed day, faster rehabilitation of patients, the absence of anastomotic stenosis in the long term.

The proposed method allows to reduce the duration of treatment of patients by reducing surgical trauma and the absence of possible complications, preserve the physiological passage along the digestive tract, improve the patient's quality of life and accelerate his rehabilitation.

Claims (1)

A method for the formation of an esophageal-gastric anastomosis, including the formation of a gastric transplant, dissection of the serous-muscular layer, separation of the mucous membrane with the formation of the serous-muscular cuff, turning it outside, imposing an anastomosis between the esophagus and the stomach, covering the anastomosis with a serous-muscular cuff, characterized in that form a graft in the form of a stalk from the greater curvature of the stomach, on the top of the stalk, the serous-muscular layer is cut to the length of the diameter of the esophagus, and the serous-muscular c henna of the stomach from the mucosa, the serous-muscular layer is turned out, forming a duplicate, an anastomosis is formed between the end of the crossed esophagus and the end of the gastric transplant with the combination of the muscular layer of the esophagus with the inner surface of the duplicate of the cuff of the stomach in the anastomosis, at the same time, the nodular posterior suture walls are inserted between the duplicate the muscular membrane of the stomach with the back wall of the muscular membrane of the esophagus, impose nodal sutures between the mucous membrane of the stomach and the mucous membrane of the esophagus her and the front walls, impose nodal sutures between the front wall of the esophagus and through all layers of the duplicate serous-muscular layer of the gastric transplant.