RU2452408C1 - Method of treating failure of intrapleural esophagogastroanastomosis sutures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to oncology, and can be applied in case of development of failure of intrapleural esophagogastric anastomosis sutures in early post-operation period after surgery of cancer of cardial part of stomach with spread on esophagus, cancer of thoracic part of esophagus. Essence of method lies in installation of self-extending esophageal stent with antireflux valve in the place of defect under endoscopic control. In case of failure of intrapleural esophagogastric anastomosis, suspended enterostoma is additionally applied. Stent is installed on the length, exceeding zone of esophagogastric anastomosis failure on 6-8 cm.

EFFECT: application of claimed invention makes it possible to improve treatment results in early post-operation period in patients with cancer of esophagus and cancer of cardial part of stomach with spread onto esophagus.

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Description

The invention relates to medicine, namely to oncology, and can be applied in case of failure of sutures of the intrapleural esophageal-gastric anastomosis in the early postoperative period after surgical treatment of cancer of the cardiac section of the stomach with passage to the esophagus, cancer of the thoracic esophagus.

Surgery for cancer of the esophagus and cardia of the stomach are serious and difficult. Despite the successes in this section of oncological surgery, there is a high risk of serious and sometimes fatal complications, one of which is the development of inconsistency of the sutures of the esophageal-gastric anastomosis, which occurs in 0.5-33% of cases [1, 2, 4], and in intrapleural the imposition of anastomosis - empyema of the pleura, leading to the death of 25-71% of patients [4, 5, 6].

Intrathoracic anastomosis failure is the most serious postoperative complication. The causes of the pathology may be in regional or more extensive necrosis of the esophagus or gastric transplant stump with esophagogastroplasty due to circulatory disorders or due to poor tissue repair. We should not forget about the role of technical errors: mismatch of mucous membranes, very frequent seams and excessive tight knotting, needle piercing of mucous membranes during the formation of the second row of sutures, tension of stitched organs, etc. [1, 2, 4].

There are two fundamental ways to treat the failure of the sutures of the esophageal-gastric anastomosis. The first is conservative. Patients undergo a nasogastric tube much distal to the anastomosis, prescribe antiseptic solutions, antibiotics, and vegetable oils per os.

The second method is active surgical tactics. A short intensive infusion preoperative preparation is carried out with repeated surgical intervention - separation of the anastomosis, to eliminate the source of pleural empyema - inconsistency of anastomotic sutures, with cervical esophagostoma and abdominal gastrostomy [1, 2, 4] or resection of a failed anastomosis with a new one [3]. Mortality in this type of operation, even in specialized clinics with extensive experience in esophageal surgery, reaches 15-60% [3].

The disadvantage of the first method is the duration and inefficiency in the occurrence of pleural empyema, since in the early postoperative period there is a predominance of catabolism and negative nitrogen balance, on the one hand, and the constant maintenance of purulent inflammation of the pleura with secretion and microflora of the gastrointestinal tract.

The disadvantage of the second method is the high lethality of the repeated surgical intervention and the inability to impose a repeated anastomosis in the conditions of inflamed tissues. As a result, even with successful operations, a low level of quality of life of treated patients.

The closest analogue of the claimed "Method for the treatment of insolvency of sutures of intrathoracic esophagogastroanastomosis" (KOROLEV M. et al. Endoscopic stenting of esophageal strictures. Endoscopic section of the Surgical Society of Pirogov. Master class June 19-20, 2008), known from the prior art, staging a self-expanding esophageal stent with an antireflux valve, in which the stent is delivered to the defect site with a delivery device, 2-3 cm from the edge of the defect. The technique described in the analogue does not provide a solution to a number of fundamental, in our opinion, issues, which include: 1) ensuring the tightness of the insolvency zone with the separation of the esophageal-pleural fistula and creating adequate conditions to prevent the contents of the esophagus from entering the pleural cavity; 2) the normalization of the patient’s nutritional status, and, accordingly, the patient’s metabolism, which are necessary for the further successful healing of the anastomotic defect and the treatment of developed fatal purulent complications (pleural empyema, mediastinitis).

Technical result achieved:

1) the elimination of the inconsistency zone of the sutures of the intrapleural esophagogastroanastomosis due to the creation of a reliable hermetic closure of the defect of the anastomosis by placing the esophageal stent. The upper and lower edges of the stent during installation should be 6-8 cm above and below the borders of the anastomotic insolvency, since, firstly, in the anastomotic insolvency zone, tissues are inflamed and are in a state of ischemia, necrobiosis with possible occurrence of extensive necrosis on one side secondly, during expansion, the stent is shortened and can migrate. Fulfillment of the above conditions ensures the tightness of the zone of insolvency with the separation of the esophageal-pleural fistula, in contrast to the above analogue.

2) Normalization of the patient’s nutritional status and metabolism and exclusion of food from the passage through the insolvency zone for further healing of the insolvency zone and treatment of developed fatal purulent complications (pleural empyema, mediastinitis) due to the application of a suspended enterostomy for nutrition, which was not revealed in the given analogue.

The main manifestation of the failure of sutures of the intrapleural esophageal-gastric anastomosis after surgical treatment of patients with cancer of the esophagus and cancer of the cardiac section of the stomach with transition to the esophagus in the early postoperative period is the presence of the esophageal-pleural / mediastinal fistula with the development of pleural empyema or mediastinitis. A technical result is achieved due to the gentle elimination of the arisen esophageal-pleural fistula which is acceptable in weakened oncological patients by staging the esophageal stent with the application of a suspended nutritive enterostomy.

For this, we used Hanarostent self-expanding esophageal coated stents with an anti-reflux valve, diameter 18-22 mm, length 90-160 mm, M.I. Tech, S. Korea.

Before installing the stent, an X-ray examination of barium sulfate, an endoscopic examination with visualization and localization of the insolvency zone were performed.

Stenting was performed under the control of an endoscope monitor, in the patient’s position on the left side, using Pentax endoscopes (Japan). It is necessary to take into account the fact that the stent is shortened during its expansion and the possibility of migration of the latter, therefore, the length of the endoprosthesis during installation should be 6-8 cm longer than the length of the defect. The stent is supplied by the manufacturer, complete with a delivery device for its introduction. This device with a compressed metal mesh stent was inserted inside the insolvency zone along the guide string. After that, gradually, very slowly pulled the sheath that holds the stent in the assembled state, controlling the position of the stent and the degree of its disclosure. The hand holding the delivery device must be firmly pressed to the body, that is, its position must be fixed, otherwise, when the outer shell is pulled together, the stent can be displaced. Correction of the position of the stent along with the delivery device by pulling is allowed, however, the partially opened stent can not be moved forward due to the risk of damage. After the stent was fully opened, the outer sheath, the delivery device with the olive at the distal end, and the string were removed. Then, the position of the upper edge of the endoprosthesis was endoscopically monitored. Full opening of the prosthesis occurs after 24-72 hours, which was determined by control esophagoscopy and panoramic fluoroscopy. In the stent itself there are 3 radiopaque tags, which greatly facilitates the control of the position of the endoprosthesis. Defect closure was evaluated by radiography with a water-soluble contrast agent.

To ensure adequate enteral nutrition, the patient is given a suspended enterostomy on a disconnected loop with an intestinal anastomosis, which is eliminated after the healing of the insolvency zone.

Clinical example

Patient E., b. 1941 / 69 years old, turned to the outpatient department of the Ryazan Regional Clinical Oncology Center (ROCOD) on 05/05/2010 with complaints of difficulty in passing solid food through the esophagus, weakness, weight loss.

After a comprehensive examination with esophagogastroduodenoscopy with a biopsy, x-ray of the esophagus and stomach with barium sulfate, adenogenic cancer of the cardiac section of the stomach was diagnosed with a transition to the esophagus.

After preoperative preparation on June 3, 2010, the patient was operated on.

Under endotracheal anesthesia, a median laparotomy was performed. A revision of the abdominal organs in the cardia revealed a circular saucer-like tumor, infiltration of the posterior wall of the stomach occupies the upper third, closer to the lesser curvature with the transition to the abdominal and diaphragmatic segments of the esophagus. Diaphragmotomy according to the Savinykh, with a revision of the mediastinum, a paraaortic lymph node with a diameter of 2 cm was revealed, squeezing the supraphrenic segment of the esophagus along the back wall. It was decided to perform D2-subtotal proximal gastric resection with transthoracic resection of the middle thoracic esophagus and 2S-mediastinal lymphatic dissection. The stomach is mobilized with D2 lymphadenectomy and moved to the mediastinum. The abdominal cavity is drained in both hypochondria and sutured in layers. Anterolateral thoracotomy in the VI intercostal space on the right. An unpaired vein is crossed. The esophagus is mobilized to the level of an unpaired vein with thoracic paraaortic lymphadenectomy to Karina. Subtotal proximal resection of the stomach with resection of the esophagus in the thoracic region was performed. A narrow gastric stalk is formed. An invagination esophagogastroanastomosis of the Berezkin-Tsatsanidi type was imposed at the level of intersection of the unpaired vein. Control of aero- and hemostasis. The pleural cavity is drained in the VII and IX intercostal spaces. Thoracotomy wound sutured in layers.

A histological examination (No. 14751-69 of 06/08/2010) picture of a low-grade stomach adenocarcinoma with a transition to the esophagus. The tumor germinates all layers of the wall of the stomach with dissemination in the tissue of lesser curvature. Metastases in 4 lymph nodes of lesser curvature with exit beyond the capsule. Hyperplasia and anthracosis of mediastinal lymph nodes.

The immediate postoperative period was uneventful. The nasoenteric probe was removed on the 6th day, it is allowed to drink, and on the 8th day the pleural drains were removed. On day 11, the patient complained of back pain in the thoracic spine, a feeling of lack of air, an increase in body temperature to 38 ° C. In the general blood test (06/14/2010), leukocytosis is up to 16.9 * 10 ⁹ , the stab shift of the leukocyte blood count is up to 9%, ESR is 51 mm / h. When fluoroscopy of the organs of the chest and abdominal cavities (06/14/2010): the right pulmonary field is darkened to the 1st rib. Through blackout visible lung tissue. The mediastinum is shifted to the left. When taking urographin per os, the contrast enters the free right pleural cavity. Conclusion: the failure of the sutures of the esophageal-gastric anastomosis, pleural empyema.

With ultrasound of the right pleural cavity, a fluid with a dense suspension is determined. The pleura sheets are thickened, the pleural gap is up to 30-40 mm. Marked the boundaries of the empyema cavity and places of thoracocentesis. Thoracocentesis in the II intercostal space on the right along the midclavicular line and in the VII intercostal space on the right along the mid-scapular line with the placement of vinyl vinyl drains, 1600 ml of purulent effusion was obtained. A system of active aspiration and washing of the right pleural cavity has been established.

Nutrition through the mouth is stopped, feeding only to the nasogastric tube.

06/18/2010 with FEGDS esophagus pass. 30 cm from the anterior incisors esophagogastroanastomosis. In the area of the anastomosis, a wide hole of insolvency (1/2 semicircle), freely passing the apparatus.

06/19/2010 under anesthesia, a suspended enterostomy was placed on a disconnected loop with an intestinal anastomosis to ensure adequate enteral nutrition of the patient.

For 2 weeks, the right pleural cavity was washed with antiseptic solutions, antibiotic therapy with a slight positive dynamics. Fractional nutrition up to 6-8 times a day through enterostomy. With X-ray endoscopic monitoring, there is no tendency to close insolvency. A decision was made to place the esophageal stent.

06/30/2010 with FEGDS, a Hanarostent nitinol self-expanding esophageal stent with an anti-reflux valve and an anti-migration mechanism with a diameter of 18 mm and a length of 120 mm was installed.

The lower edge of the stent stands in the cult of the stomach. The upper edge in the esophagus at the level of 25 cm from the incisors. The insolvency hole is covered by a stent.

Subsequently, the right pleural cavity was washed with the formation of a thoracostomy, feeding through an enterostomy. The abscess cavity has decreased. Body temperature returned to normal. 07/26/2010 pleural drainage removed.

07/30/2010 the patient was discharged in a relatively satisfactory condition for outpatient monitoring with nutrition recommendations via enterostomy 6-8 times a day.

During the follow-up examination on August 31, 2010, a fluoroscopy of the organs of the chest cavity, esophagus and stomach was performed. On the right, pronounced pleural overlays. Easy straightened. Fluid in the pleural cavities is not determined. When taking per os, the water-soluble contrast drug Omnipac in the study of standing and lying streaks in the anastomosis is not determined. Evacuation from the stump of the stomach through the pylorus is timely.

09/13/2010 after FEGDS, on which the esophagus is freely passable, it is well expanded with air, no stent migration has been detected - the proximal edge of the latter is 24-25 cm from the incisors, the stent is freely passable. Allowed food through the mouth, enterostomy closed.

The patient was examined in December 2010. He feels satisfactory, eats through the mouth. Ultrasound of the abdominal organs, fluoroscopy of the esophagus and stomach showed no signs of disease recurrence.

Thus, by staging the esophageal stent with the application of an enterostomy, we achieved an effective, less traumatic for patients closure of the esophageal-pleural fistula, elimination of the failure zone of the intrapleural anastomosis and successful treatment of fatal purulent complications (pleural empyema, mediastinitis).

List of sources of information

1. Ganul V.L., Kirkilevsky S.I. Esophageal carcinoma. Guide for oncologists and surgeons. Kiev, 2003, 199 pp., P. 181-184.

2. Wagner EA, Brooks VA, Artyomov OT, Kasatov AV, Altyntsev MV Postoperative complications of proximal resection of the stomach. Surgery, 1998, p. 62-64.

3. Davydov M.I., Stilidi I.S. Esophageal carcinoma. M .: Practical medicine, 2007, 392 p., P. 277.

4. Zubarev NN, Sinechenko GI, Kovan M.E., Lytkin S.I. Surgical treatment of cancer of the esophagus and cardia. Complications and dangers. Herald of Surgery, 1998, pp. 100-104.

5. Chernousov A.F., Bogopolsky P.M., Kurbanov F.S. Esophagus surgery. - M.: Medicine, 2000 .-- 350 p.

6. Chernyavsky A.A., Lavrov N.A. Surgery for gastric cancer and esophageal transition. Nizhny Novgorod, 2008, 360 p.

Claims (1)

A method for treating esophagogastroanastomosis suture inconsistency, including installation under endoscopic control at the site of a defect in a self-expanding esophageal stent with an antireflux valve, characterized in that if intrapleural esophagogastroanastomosis is inconsistent, additionally suspend enterostomosis of the stent is necessary for 6 years.