RU2452400C1 - Method of treating obturative obstruction of large intestine - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and can be applied for treatment of obturative obstruction of large intestine. Intra-operation decompression and washing of adducting parts through one- or two-orifice probe for washing through cecostoma, last sero-serous interrupted suture on the wall of cecum above probe is applied S-shaped, ends of whose threads are passed between cuff, installed at the skin level, and probe and fixed in tightened position. Ozonised crystalloid solution is introduced through probe and colon is washed several times with 3 minutes exposure. Proximal end is sutured and fixed to peritoneum. Laparotomic wound is sutured. In post-operation period adducting part of colon is washed through probe periodically during 7-10 days. When intestinal passage is recovered and inflammatory process subsides, anastomosis is applied.

EFFECT: method makes it possible to improve quality of intestine purification, reduce risk of anastomosis failure.

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Description

The invention relates to medicine, in particular to abdominal surgery and coloproctology, and can be used in the treatment of patients with obstructive colonic obstruction.

There is a method of treating obstructive colonic obstruction, including ligation and intersection of blood vessels supplying the affected area of the vessels and mobilization of the affected area of the intestine in accordance with the principles of oncological radicality proximal to the tumor, then fix the collection bag, which is a completely isolated contour from the external environment. The transport system is installed in the cecum. The cannula is fixed with a purse string suture. Then, intestinal lavage begins with saline. During the procedure, the gut is gently massaged so that the large feces are eroded and can pass into the collection bag. The time required for successful irrigation depends on the consistency and quantity of the contents of the intestine, as well as on the anatomical features of the colon (high and acute hepatic and splenic bends), and varies from 20 to 50 minutes. The volume of washing liquid in this case is from 3 to 11 liters (an average of 4.5 liters). After washing the colon, a mobilized section of the intestine with a tumor is resected, the adequacy of blood supply to the anastomosed sections of the intestine is assessed, and anastomosis is formed (D.E. Popov, A.V. Semenov, V.V. Grigoryan, A.V. Lisichkin, S.V. Vasiliev, Surgical treatment of intestinal obstruction in patients with obstructive cancer of the left colon. // Bulletin of St. Petersburg University, ser. 11, issue 2, 2009).

The disadvantage of this method is that it is not always possible to impose an anastomosis, a high risk of anastomotic suture failure. Due to the short cannula on the cecum, it is difficult to perform a complete cleaning of the adducting colon and the duration of irrigation. The high technical complexity of the process of intraoperative irrigation of the colon.

A known method according to Schlofer, including a three-stage resection of the left half of the colon. At the 1st stage of the operation, if bowel resection with restoration of intestinal patency is further envisaged, an unnatural anus according to Maidl is placed on the transverse colon (or blind). At stage 2, after 2 weeks, when the inflammatory and congestion at the site of the pathological focus in the colon is eliminated without removing the unnatural anus, the left half of the colon is resected, with the restoration of patency of the anastomosis. At stage 3, after 3-4 weeks, the unnatural anus is closed, simultaneously eliminating the spur (Shalimov A.A., Saenko V.F. Intestinal surgery, Kiev, Health, p. 65, 1977).

The disadvantage of this operation is that after the first stage of the operation, a growing tumor remains in the abdominal cavity, which is also a source of new complications, intoxication, bleeding, and suppression of the immune defense reactions. A cecostomy without complete intubation of the adducting segment of the colon does not always quickly and fully provides decompression and bowel movement, especially from the distal colon.

A known method of surgical treatment of obstructive colonic obstruction by the Hartman method (Yaitsky N.A., Sedov V.M., Intestinal tumors, ed. ANT-M, p. 195, 1995). It occupies an intermediate position between simultaneous and two-stage interventions with external abduction of intestinal contents. The advantage is that the resection of the area of the intestine affected by the tumor is performed in accordance with the oncological principles. The operation ends with suturing the tightly distal portion and exposing the proximal portion as a colostomy. Restoring intestinal continuity may not be performed at all, or is performed after a certain time, when the patient's condition improves and there is confidence in the absence of recurrence or tumor metastases.

The disadvantage of this operation is a decrease in the quality of life and possible complications due to the existence of a colostomy for a long time. Restoring intestinal continuity requires repeated laparotomy and, often, is associated with certain technical difficulties in mobilizing segments of the intestine for anastomosis and its imposition.

A known method of minimally invasive surgical intervention in the treatment of obstructive colonic obstruction (Pugaev A.V., Achkasov E.E., Obstructive tumor colonic obstruction, Moscow, Profile, 2005, pp. 141-142). At the same time, at the first stage, the colon is decompressed from the mini-access, usually 5-7 cm on the anterior abdominal wall in the projection zone of the adduction of the colon, with the formation of a lip-shaped complete external colon intestine through this incision. After 1.5-3 months, a reconstructive operation is performed.

The disadvantages of this method are:

1) certain difficulties in removing from the abdominal cavity of the swollen colon due to mini-access and the threat of perforation;

2) difficulties in determining the exact projection of the adducting colon on the anterior abdominal wall before surgery;

3) not the radicalism of the first stage;

4) inadequate decompression of the adducting department;

5) the threat of intoxication and complications due to the tumor remaining in the abdominal cavity;

6) long periods of treatment.

A known method for the treatment of OTCN, including primary delayed anastomosis with a temporary proximal colostomy for an obstructing tumor of the left half of the colon (Sugrobov S.I. Tactics for completing resection of the left half of the colon for cancer complicated by intestinal obstruction: Dis. Cand. Sc. ., 1986). With this technique, after resection of the tumor, the oral and aboral ends of the intestine are ligated and immersed in purse string sutures, after which the same ends of the intestine are sutured along the perimeter with nodular serous-muscular sutures of the end-to-end type. Above impose double-barreled colostomy according to Maidl. 3-4 weeks after surgery, transintestinal restoration of intestinal continuity is performed by endoscopic recanalization of the intestinal septum. The final stage is closed colostomy extraperitoneal method.

The disadvantages of the method:

1. when ligation of the proximal section and suturing of the distal to the proximal section, there is a high probability of developing stenosis of the intestinal suture area after autorecanalization;

2. a delay in the restoration of continuity of the colon is possible, which entails the need for forced recanalization;

3. the application of one row of seams when performing the method in question does not provide adequate physical strength of the anastomosis.

A known method of treatment of obstructive colonic obstruction (OTC) (RF patent No. 2111705, 1998), we have chosen as a prototype. After mobilization of the intestine, the removed part of the intestine with the tumor is carefully moved to a special sleeve made of a transparent polymer film and the clamps are used to fix the sleeve to the sheet, which borders the surgical field. Through the wide opening of the sleeve and inside it, under visual control, the intestinal lumen is opened proximal to the pathological process, emptying it. A thick probe is inserted into the intestinal lumen and a suspension of adsorbing substances is introduced through it. After 10-15 minutes, intestinal contents are removed with the sorbent and this procedure is repeated two to three times. After completion of the procedure, the probe is removed, the purified leading part of the intestine is used to form a colostomy or anastomosis.

The disadvantages of this method are the impossibility of a complete cleansing of the adducting colon, the difficulty of performing intraoperative cleaning and a high risk of imposing a primary anastomosis.

The objective of the invention is to increase the efficiency of cleaning the adducting department of the colon, which leads to the effectiveness of surgical treatment of obstructive colonic obstruction.

The solution to this problem is achieved by performing a tumor resection, suturing of the distal stump, passive removal of the contents of the colon through the proximal end, placed in a special sleeve. Intraoperative decompression and washing of the leading sections are performed through a single or double lumen probe for washing through the cecostoma, with the last gray-serous nodular suture on the wall of the cecum above the probe imposed S-shaped, the ends of the threads of which are carried out between the cuff installed at the skin level and the probe and fixed in a tense position, an ozonated crystalloid solution is introduced through a probe and the colon is washed several times with an exposure of 3 minutes, the proximal end is sutured, and it is fixed to the peritoneum. Then, the laparotomic wound is sutured, in the postoperative period, the leading section of the colon is washed through the probe periodically for 7-10 days, when the intestinal passage is restored and the inflammatory process subsides, an anastomosis is applied.

The invention is illustrated by drawings, where:

Figure 1 - the imposition of cecostomy, with the installation of the probe in the cecum;

Figure 2 - the formation of an S-shaped seam on the wall of the cecum;

Figure 3 - complete intubation of the adducting department of the colon.

The method of surgical treatment of OTC is as follows.

After mobilization of the intestine, the intestine is resected in accordance with the principles of oncological radicalism. The distal stump is sutured with a two-row suture, and fixed to the parietal peritoneum. The proximal end is placed in a special sleeve made of a transparent polymer film and with the help of clamps the sleeve is fixed to the sheet, which borders the surgical field. The clamp is removed and the contents of the colon are passively removed. During the procedure, the gut is carefully massaged so that large feces can pass into a special sleeve.

Next impose on the front wall of the cecum 1 purse string suture. After opening its lumen in the distal direction, a one- or two-lumen probe 2 is inserted with a diameter of 15-17 mm, a length of 90-120 cm, with multiple side openings, for complete intubation of the leading part of the colon (Figure 1). The purse string suture is tied and several nodular gray-serous sutures 3 are applied over the probe. In this case, the S-shaped suture 4 (Figure 2) is last applied as follows. Sew the upper semicircle of the purse string suture from right to left with a thread so that the last stitch is 4-5 mm closer to the center than the first. Then the needle is thrown to the beginning of the seam of the upper semicircle and, sticking it at the first stitch of the upper semicircle, a few inwards from it, also sew the lower semicircle of the pouch from right to left, ending the seam somewhat outwards from the last stitch of the upper semicircle. For the formation of an S-shaped seam, a thread of vicryl is used. The wall of the intestine around is hemmed to the parietal peritoneum with several interrupted sutures. A cuff 5 made of rubber is put on the proximal part of the probe at the skin level, the ends of the threads 6 are drawn between the cuff and the probe and fixed in a taut position. An ozonated crystalloid solution is introduced through the cecostoma into the colon and washed several times with an exposure of 3 minutes. The contents of the intestine are discharged into a special sleeve, which, if necessary, is removed through the wide opening of the sleeve or a specially made hole. After washing the colon, its proximal end is sutured, fixed to the peritoneum, then the laparotomic wound is sutured.

In the postoperative period, periodically washed through the cecostoma, the leading section of the colon for 7-10 days. When restoring the intestinal passage and subsiding of the inflammatory process in the intestinal wall, an anastomosis is applied. The probe is removed, the ends of the removed ligature are tied on a gauze turund, which leads to the closure of the cecostomy.

The proposed method allows for complete intubation of the adducting department of the colon through the imposed cecostomy. Intra- and postoperative irrigation with an ozonized cristaloid solution promotes early application of anastomosis by 7-10 days and reduces the treatment time. The imposition of a cecostomy according to the new technique leads to its independent closure, and does not require repeated operations. The method was investigated in the clinical setting of Clinical Hospital No. 7 of Kazan in patients with acute colonic obstructive obstruction, and showed its effectiveness.

Examples of specific performance.

Patient K., 64 years old, medical history No. 659/89, was admitted to a surgical clinic with a diagnosis of cancer of the sigmoid colon complicated by obstructive colonic obstruction. After preoperative preparation, the patient was operated on. Resection of the sigmoid colon was performed by applying a cecostomy with complete intubation of the adducting colon, with intraoperative decompression by an ozonized crystalloid solution according to the proposed method. In the postoperative period, 2 times a day, the leading section of the colon was irrigated with an ozonized crystalloid solution with an ozone concentration of 6 mg / L. There is a rapid improvement in the patient's condition. On the second day, intestinal motility appeared. The dynamics of the wall thickness of the colon was monitored by ultrasound. On the 8th day anastomosis was applied end-to-end. The postoperative period was uneventful, the wound healed by primary intention. The probe on the cecum was removed on the 7th day after the second operation, the cecostomy closed independently. Held 24 days.

Patient I., 67 years old, medical history No. 1798/245, was admitted to the hospital in serious condition with a diagnosis of cancer of the descending colon, complicated by obstructive colonic obstruction. After preoperative preparation, the patient was operated on. A left-sided hemicolectomy was performed by applying a cecostomy with complete intubation of the adducting colon, with intraoperative decompression by an ozonized crystalloid solution according to the proposed method. Also in the postoperative period, 2-3 times a day was carried out irrigation of the leading part of the colon through cecostomy. A rapid improvement in the patient's condition was noted. On the third day, intestinal motility appeared. The wall thickness of the colon was monitored by ultrasound. On day 10 superimposed transversosigmoid anastomosis end to end. The postoperative period was uneventful, the wound healed by primary intention. The probe on the cecum was removed on the 9th day after the second operation, the cecostomy closed independently. Held 27 days.

Claims (1)

A method of treating obstructive colonic obstruction, including resection of the tumor, suturing of the distal stump, passive removal of the contents of the colon through the proximal end placed in the sleeve, intraoperative decompression and washing of the leading parts of the intestine, forming a colostomy and applying anastomosis, characterized in that intraoperative decompression and washing of leading of departments is carried out through a single or double-lumen probe for washing through the cecostoma, with the last gray-serous nodal suture on the cecum wall above the probe is superimposed S-shaped, the ends of the filaments of which are drawn between the cuff mounted at the skin level and the probe and fixed in a stretched position, an ozonated crystalloid solution is introduced through the probe and the colon is washed several times with an exposure of 3 minutes, the proximal the end, fix it to the peritoneum, then the laparotomic wound is sutured, in the postoperative period the leading section of the colon is washed through the probe periodically for 7-10 days, with the restoration of the intestinal passage and stan and the inflammatory process is applied anastomosis.

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