RU2448659C2 - Method of treating patients with total necrosis of small intestine - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to surgery and may be applied for treating total necrosis of small intestine. The whole necrotised small intestine is removed completely. A duodenum is mobilised; a Treitz's ligament is dissected, and a duodenal stump on a border of viable tissues, and a distal stump is formed at a level of a blind intestine or a middle one-third of a transverse colon. A probe is introduced in a stomach to evacuate the gastrointestinal content continuously that is combined with intensive parenteral nutrition. Sanation re-laparotomy in 24-36 hours involves restoration of gastrointestinal continuity by creating delayed side-to-side duodenotransversoanastomosis.

EFFECT: method reduces a risk of the anastomosis inconsistency.

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Description

The invention relates to medicine, namely to surgery, and can be used to restore the natural passage through the gastrointestinal tract after total removal of the small intestine, and sometimes the right parts of the colon due to their necrosis.

One of the most important and not completely resolved problems of clinical medicine is the restoration of continuity of the gastrointestinal tract and nutrition with total necrosis of the small intestine arising from mesenteric thrombosis, strangulated intestinal obstruction, thrombophilia, when only the duodenum (duodenum) remains to maintain passage and colon.

A known method of treating patients with small bowel necrosis by resection of the latter with the application of endo-intestinal enteroenteroanastomoses according to the type “end to end”, “side to side” or “end to side” with the unloading enterostomy (Surgery and topographic anatomy edited by academician RAMS B. V. Kovanova. - M .: Medicine. -2001. - P.351-355; Features of the formation of enteroanastomosis in conditions of peritonitis / V.F. Zubritsky, I.S. Osipov, E.V. Shadrivova, M.V. Zabelin , V.A. Zhilenkov // Surgery. - 2009. - No. 12. - P.25-29.

However, the known method has several disadvantages, namely: the absence of proximal and distal loops during total necrosis of the small intestine for the implementation of inter-intestinal anastomosis, the inability to bring the duodenum to the anterior abdominal wall in the form of duodenostomy, large water-electrolyte and protein losses during external drainage of the duodenum rapid development of enzymatic dermatitis of the anterior abdominal wall with an unformed duodenal fistula.

The closest technical result achieved (prototype) is a method for resection of the necrotic small intestine with subsequent restoration of intestinal continuity by applying delayed inter-intestinal anastomoses (Grigoryev E.G., Kogan A.S. Surgery of postoperative peritonitis. - Irkutsk. - 1996. - 216 s. .; Savelyev BC, Filimonov MI, Eryukhin IA, Podachin PV, Efimenko NA, Shlyapnikov SA Surgical treatment of peritonitis. - Infections in surgery. - Volume 05. - No. 2 . - 2007. - S.7-10).

The authors conclude the proposed technique with the imposition of entero-enteroanastomosis. This method has the disadvantage of total necrosis of the small intestine, which extends to the ligament of the treitz. In the postoperative period, suture failure may occur due to progression of the necrosis zone of the upper intestine, as well as due to the tension of the ends of the intestine after resection. The fact is that the blood supply to the small intestine comes from the superior mesenteric artery, and the duodenum - from the celiac artery basin, so the inter-intestinal anastomosis with it is more reliable, and with the transverse colon - the closest in distance and can be applied without tension. In contrast to the proposed technique, we use rehabilitation relaparotomy, in which additional resection of the small intestine can be made with the progression of its necrosis.

The technical result of the proposed method is to increase the effectiveness of treatment of patients with total necrosis of the small intestine by restoring the passage through the gastrointestinal tract with complete loss of the small intestine, and sometimes the right part of the colon due to their necrosis.

The technical result is achieved by the fact that after resection and removal of the necrotic small intestine, both ends are sutured tightly with the formation of a proximal stump at the level of the duodenum, distal stump at the level of the cecum or the middle third of the transverse colon; a probe is inserted into the stomach and constant evacuation of the gastrointestinal contents is carried out with intensive parenteral nutrition; during rehabilitation relaparotomy, after 24-36 hours, the continuity of the gastrointestinal tract is restored by applying the lateral side-by-side duodenotransversoanastomosis, and after 2-3 months, an application is made to the Institute of Transplantology for small intestine transplantation.

The authors propose an effective way to treat patients with total necrosis of the small intestine by resecting it and restoring the passage through the gastrointestinal tract by applying a delayed anastomosis between the duodenum and the transverse colon, which will restore intestinal motility, provide minimal enteral nutrition and find time for the possibility of transplantation of the small intestine in the near future.

To illustrate the method presented figures.

Figure 1a, 1b after resection of the necrotic small intestine shows the formation of a duodenal stump by immersing it in purse string sutures, and figure 1a shows the formation of a distal stump of the colon at the cecum, and figure 1b shows the formation of a distal stump of the colon at the mid-level third of the transverse colon in cases of a combination of necrosis of the small and right half of the colon. Insertion of the probe into the stomach to decompress the aspiration of the contents.

Figure 2a, 2b during a programmed relaparotomy shows the mobilization of the upper part of the duodenum according to Kocher and the mobilization of the transverse colon, and figure 2a shows the mobilization of the hepatic angle of the colon to the duodenum, and figure 2b shows the mobilization of the transverse colon stump up necrosis of the right colon.

Figures 3a, 3b show a side-by-side overlay of duodenotransversoanastomosis with a two-row suture, and in figure 3a, duodenotransversoanastomosis is superimposed with the hepatic angle of the transverse colon, and figure 3b shows the overlap of duodenotransveolar and non-intestinal neoplastic cases necrosis of the right half of the colon. Conducting a probe beyond the anastomosis zone into the colon.

The positions noted in figures 1a, 1b, 2a, 2b, 3a, 3b indicate: 1 - the stump of the duodenum; 2 - stump of the cecum; 3 - a stump of the middle third of the transverse colon with necrosis of the right half of the colon; 4 - insertion of the probe into the stomach; 5 - KDP mobilization according to Kocher; 6 - mobilization of the hepatic angle of the colon; 7 - upward mobilization of the stump of the transverse colon with necrosis of the right half of the colon; 8 - duodenotransversoanastomosis with a hepatic angle of the colon, 9 - duodenotransversoanastomosis with a stump of the transverse colon.

The method is as follows:

Under endotracheal anesthesia, relaparotomy and a resection of the necrotic small intestine are performed (Figure 1a, b). Dissect the ligament of the treitz and carry out the mobilization of the distal segment of the duodenum. At the border of viable tissues, the duodenum stump 1 is flashed with UO-60 with immersion of a stitch seam in 2 purse string sutures. In case of necrosis of only the small intestine, the distal stump of the colon is formed at the level of the cecum 2 by flashing it with the UO-60 apparatus with immersion of the stitch seam in 2 purse string sutures. With a combination of necrosis of the small intestine and necrosis of the right half of the colon after resection of the small intestine and right-sided hemicolectomy, a distal stump of the colon is formed at the level of the middle third of the transverse colon 3 also by immersion of staples in purse string. Primary anastomosis with the colon at this stage of the operation ^; do not impose due to the possible progression of necrosis in the duodenal stump. A probe 4 is inserted into the stomach and duodenum for decompression and drainage.

After 24-36 hours, programmed relaparotomy is performed and the abdominal organs are revised (Figure 2a, b). In the absence of necrosis of the distal duodenal stump, mobilization of its upper part according to Kocher 5 and mobilization of the hepatic angle of the colon 6 to the duodenum, or mobilization of the stump of the transverse colon 7 to duodenum. With necrosis of the duodenal stump, an additional resection is performed and the stump is re-formed.

The upper part of the duodenum and the hepatic angle of the colon are brought together (Figure 3a, b) and a delayed duodenotransversoanastomosis 8 is applied “side to side” with a two-row suture. The first row is twisted, continuous, using atraumatic suture material. The second row of interrupted sutures. The diameter of the anastomosis is 3 cm. The operation is completed by transnasal intubation with a shortened probe through the anastomosis to the splenic corner of the colon. With the combination of total necrosis of the small intestine by necrosis of the right half of the colon, delayed duodenotransversoanastomosis 9 is applied after mobilization of the stump of the colon-colon 7. In some cases, taking into account the presence of biliary hypertension in the duodenum, cholecystostoma is applied for unloading.

Clinical examples

1. Patient V., 24 years old, was urgently admitted to the purulent surgery department of the regional hospital on September 24, 2005 with complaints of moderate pain in the abdomen and in the area of the postoperative wound, fever up to 38 ° C, severe weakness, shortness of breath at rest. From the anamnesis it was found out that on September 21, 2005, against the background of pregnancy, 27 weeks was operated on in the NRB x / o due to acute strangulation of small bowel obstruction. In the operation, necrosis of the small intestine was detected.

The cecostomy was imposed and the small intestine was intubated through the cecostoma, supravaginal amputation of the uterus without appendages (intrauterine fetal death). On September 22, 2006, a surgeon called a consultant at the Regional Center for Disaster Medicine was called to the Central Hospital. 09/22/06 was operated repeatedly in the Central Hospital. Performed relaparotomy, resection of the small intestine and the right half of the colon, ileostomy, debridement and drainage of the abdominal cavity. Diagnosis: Acute strangulation small bowel obstruction. Necrosis of the small and right half of the colon. Postoperative widespread peritonitis. Severe abdominal sepsis. Multiple organ failure.

Taken to the purulent surgery department of the regional hospital. Operation September 24, 2006. Relaparotomy, resection of the entire small intestine / total necrosis /, rehabilitation and drainage of the abdominal cavity. At this stage, it was decided to abstain from the primary anastomosis with the colon and confine oneself to introducing the probe into the duodenum for drainage. The postoperative period is difficult with signs of severe sepsis, multiple organ failure. After 2 days (September 26, 2005), he was re-operated. During the audit, in the cult of the duodenum there are signs of focal necrosis up to 5 mm in diameter and along the mesenteric edge up to 7 mm and 6 mm. Sutures on the colon are wealthy. Resection of the duodenal stump was performed with the remaining part immersed in purse string sutures. Mobilized duodenum according to Kocher, mobilized stump of the transverse colon up. Superimposed duodenotransversoanastomosis "side to side". Patency of the anastomosis is up to 3 cm. Transnasal intubation through the anastomosis into the splenic corner of the colon was performed. Given the presence of biliary hypertension, a cholecystostomy is imposed with an unloading purpose. The subsequent period was very difficult. The treatment of abdominal sepsis, correction of water-electrolyte, protein balance. Gradually, signs of peritonitis and sepsis began to stop. However, 02.11.05, the patient appeared recurrent profuse gastric bleeding. Conservative measures using endoscopic hemostasis are ineffective. Emergency operation 02.11.05, at 9-00. Under endotracheal anesthesia, relaparotomy, gastrotomy, stitching of a bleeding acute ulcer of the stomach, sanitation and drainage of the abdominal cavity. 2 hours after surgery, the patient again relapsed bleeding. Again taken to the operating room. November 2, 2005 (11-00) - relaparotomy, skeletonization and ligation of the branches of the left gastric artery, rehabilitation and drainage of the abdominal cavity. In the future, taking into account the need for long-term parenteral nutrition, on 11.11.05, an intravenous port was implanted in the left subclavian vein. The patient was administered combined enteral and parenteral nutrition. Gradually, the patient's condition returned to normal. Upon discharge, the condition is satisfactory. No abdominal pain. The temperature is normal. Active, walks. Nausea, no vomiting. The abdomen is soft, painless. The chair is independent, up to 4 times a day, liquid. Diuresis is sufficient. Analysis at discharge: HB - 116 g / l l - 8.3 e - 2 p - 3 s - 75 l - 12 m - 8 ROE - 13 mm / h, creatinine - 63 mmol / l, ALT - 0.11 mmol / l ACT - 0.14 mmol / L; K - 4.2 mmol / L. Na - 136 mmol / L. Lipid metabolism - normocholesterolemia, moderate hypertriglyceridemia. Total protein - 65.2 g / l.

The patient was examined after 3 months. The condition is satisfactory. Weight 61 kg. No abdominal pain. The temperature is normal. Active The chair is independent, up to 4-5 times a day, mushy. Diuresis is sufficient. Nausea, no vomiting. The abdomen is soft and painless. A well-formed postoperative scar. Parenteral nutrition is given twice a week to the implanted port.

After 4 months, the patient was sent to the Institute of Transplantology / Moscow /, where she underwent small bowel transplantation.

2. Patient B., 25 years old, was admitted as an emergency to the purulent surgery department of the regional hospital on 09/30/08 with complaints of moderate abdominal pain, bloating, nausea, and vomiting. On September 28, 2008 she was operated on at the Central Clinical Hospital for a perforated ulcer of the anterior duodenal wall. Perforation suturing completed. Subsequently, she was taken to the purulent surgery department of the regional hospital. 10/01/08, operated repeatedly. Performed relaparotomy. Total necrosis of the small intestine was detected against the background of mesenteric thrombosis. A total obstructive resection of the small intestine was performed. The proximal segment is muffled at the level of the duodenojejunal junction (Treitz ligament) by flashing with the UO-60 device with immersion of the stitch seam in the purse string, the distal segment is muffled at the level of the ileocecal angle. A probe is installed in the stomach. 10/03/08, relaparotomy was performed. Scanty serous effusion in the abdominal cavity. Stitches on the stomach are wealthy. There are no signs of failure on the duodenal stump and ileum stump in the ileocecal angle. There are no signs of ischemia and necrosis of the colon. The phenomena of serous-fibrinous peritonitis are stopped. Mobilized DIC by Kocher and the hepatic angle of the colon. A duodenotransversoanastomosis “side to side” with a two-row suture was applied (the first row is continuous, with atraumatic thread “Caprofil”). Patency of the anastomosis up to 3 cm. A nasogastric tube for the anastomosis zone was established. The integrity of the peritoneum of the right lateral canal was restored. During the audit, the gallbladder is enlarged, size 14 × 5 cm, tense. With an unloading purpose, a cholecystostomy is imposed. 10.28.08 - implantation of an intravenous port for parenteral nutrition. In the postoperative period, parenteral nutrition was performed: Nutriflex lipid 40 / 150-1750 ml × 1 time per week with the addition of 10 ml addamel, vitalitid 10 ml, solvit 10 ml. The infusion was carried out for 5-6 hours. Enteral: Berlamin - modular 150-200 g / day in small portions, strong broths (jellied meat), mashed potatoes 500/600 g / day. Slow recovery.

Inspected in December 2008. Condition is satisfactory. No abdominal pain. The temperature is normal. The chair is frequent, liquid (up to 10 times). The abdomen is soft, painless, there is no compaction of infiltrates. Liver + 3-4 cm. HB - 98 g / l L - 4.4 e - 1 p - 2 s - 44 L - 40 m - 13 ROE - 27 mm / h. K - 3.4 mmol / L, sodium - 139 mmol / L, creatinine - 63.5 mmol / L, total. protein - 65.2 g / l. ALT - 88.6 U / L, ACT - 57.9 U / L, en. urine - without features. An application has been submitted to the regional health department to resolve the issue of referral to the Institute of Transplantology.

Thus, the effectiveness of the proposed method lies in the fact that in a hopeless situation when the entire small intestine is absent, it is not possible to impose an intestinal enteroenteroanastomosis or remove an enterostomy, transplant a lost organ, there is a chance to save patients through the use of delayed duodenotransversal anastomosis, which ensures restoration gastrointestinal tract; internal drainage of gastric, pancreatic juice, bile into the colon; partial enteral nutrition with full parenteral support and subsequently gaining time for transplantation of the small intestine.

Claims (1)

A method of treating total necrosis of the small intestine by applying a delayed duodenotransversoanastomosis, characterized in that after resection and removal of the entire necrotic small intestine, the duodenum is mobilized with a dissection of the Trenta ligament and a duodenal stump is formed at the border of the viable tissues, and also form the distal or middle third of the transverse colon; a probe is inserted into the stomach and constant evacuation of the gastrointestinal contents is carried out with intensive parenteral nutrition; during reorganization relaparotomy after 24-36 hours, the continuity of the gastrointestinal tract is restored by imposing a lateral side-by-side duodenotransversoanastomosis.

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