RU2466688C1 - Method of treating postoperative abdominal anastomoses complicated by cicatrical stricture formation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: endoscopic injections of a combined biomaterial Alloplant consisting of a connective tissue repair activator 35-45 wt %, a phagocytosis activator 35-45 wt % and a nervous structure repair activator 10-30 wt % in cicatrical tissues in the form of 4-5 courses every 4-5 days consisting of 5-15 injections. It is followed by therapeutic-diagnostic laparoscopy of the abdominal organs underwent a surgical intervention with creating 1-3 anastomoses, every 7 days which involves instrumental palpation of the anastomosis for its elasticity, degree of puffiness and manifestation of surrounding cicatrical periprocess, incision of early postoperative adhesions, expansion of the anastomosis from the cicatrical constrictions and curves. The combined biomaterial Alloplant is introduced by a Vim-Silvermann needle of the diameter G22-24 through a separate puncture of an abdominal wall by 1-5 injections, 2-3 ml of the biomaterial in each injection in seromuscular tissues surrounding the anastomosis.

EFFECT: method enables reducing a risk of developing rough stricture formation of the anastomosis, reducing a risk of recurrent operation.

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Description

The invention relates to medicine, to surgical methods of treating organs of the abdominal cavity (stomach, small and large intestine, rectum), in particular to the treatment of postoperative anastomoses complicated by cicatricial stenosis.

The annual growth of oncopathology of the abdominal organs, the increase in the number of traffic accidents and related injuries of these organs require reconstructive, plastic surgery on the hollow organs of the abdominal cavity with the creation of anastomoses.

A surgical method is known for treating a duodenal ulcer complicated by stenosis, in which a longitudinally scar-shaped wall is cut from two sides from the ulcer to the changed tissues and circularly excised, after which pyloroduodenoanastamosis is formed (RF patent No. 220051, IPC АВВ 17/00, publ. November 20, 2004).

Since the anastomosis is created by suturing the edges of the hollow organ with foreign threads, and the edges of the anastomoses are injured with tools (intestinal pulp, holders, etc.), this causes the development of reactive processes in the organs - inflammation, perivisceritis, the formation of adhesions, which can lead to rough scarring stenosis of the anastomosis and require unwanted reoperation.

It is known to use conservative methods for treating postoperative anastomoses complicated by cicatricial stenosis, such as electrophoresis with lidase, radiation therapy (www.abdominalnye_posleoperacionnoe_oslozhnenija).

However, the known methods are ineffective in such cases and, as a rule, do not eliminate the need for repeated surgery.

The objective of the invention is to develop a method for the treatment of postoperative cicatricial stenosis in the area of anastomoses on the organs of the abdominal cavity.

The result of the invention is to increase the effectiveness of the treatment of postoperative scar stenosis.

The problem is solved by the method of treatment of postoperative anastomoses on the abdominal organs complicated by cicatricial stenosis, including endoscopic injections into cicatricial tissues on the inside of the anastomosis with Alloplant biomaterial combined, consisting of a connective tissue regeneration stimulator 35-45 wt.%, A phagocytosis stimulator 35-45 wt. % and stimulator of regeneration of nerve structures of 10-30 wt.%, which are carried out in 4-5 courses with a break between them 4-5 days, 5-15 injections per course, after which medical diagnostic laparoscopy of the abdominal organs subjected to surgical intervention with the creation of anastomoses in an amount of 1-3 with an interval of 7 days is performed, during which an anastomosis is instrumental palpated to determine its elasticity, degree of swelling and severity of adhesions around it, dissection of early postoperative adhesions, spreading of the anastomosis from cicatricial constrictions, cicatricial bends, after which the combined Alloplant biomaterial is injected with a Wim needle -Silverman's diameter G22-24 through a separate puncture of the abdominal wall through 1-5 injections of 2-3 ml of biomaterial for each injection into the serous-muscle tissue around the anastomosis.

The specified technical result is achieved due to the following.

It is known that the hollow organs of the abdominal cavity are formed: outside - 1) the serous membrane, 2) the own muscle plate, represented by a layer of smooth muscles located in the organs longitudinally, circularly, in the oblique direction, 3) the submucosal layer with vessels and nerve fibers passing through it (submucous arteries, veins, lymphatic vessels and plexuses, nerve ganglia of the sympathetic and parasympathetic nervous systems), with various options for the thickness of the wall of the hollow organ, the development of the smooth muscle layer, the intensity of the vascular Uslan, branching smooth muscle and nerve tissue in different organs ( "Atlas of Human Anatomy," by. Ed. V.D.Sinelnikova, Volume 2, pp. 50-81).

It is known that the use of multicomponent Alloplant biomaterial provides a complex effect on the reparative regeneration of scar-modified mucous membranes, blood vessels, nerve fibers, tubular, hollow organs of the abdominal cavity (RF patent №2325919, IPC A61K 35/12, publ. 06/10/2008; a positive decision on the application for the invention 2010125516/14 "Method for the treatment of decompensated pyloroduodenal stenosis") and improves the effectiveness of the treatment of scar-degenerative lesions of the mucous tissues of these organs.

In the proposed method, with the aim of deeper layer-by-layer penetration of the combined Alloplant biomaterial into the scar tissue of the anastomosis, an additional diagnostic and diagnostic laparoscopy of the abdominal organs is performed. As a result, the effect on all layers is significantly increased, which contributes to the resorption of cicatricial stenosis. According to the invention, the treatment takes place three-dimensionally, three-dimensionally, through all layers of the anastomosis, with the elimination of the early postoperative adhesive process.

The method is as follows. After fibrogastroscopy (FGS) or fibrocolonoscopy (FCC) and determining the degree of cicatricial damage to the postoperative anastomosis, endoscopic injections are made into the scar tissue on the inside of the anastomosis with the Alloplant biomaterial combined, consisting of a connective tissue regeneration stimulator 35-45 wt.%, A phagocytosis stimulator 35-45 wt.% wt.% and stimulator of the regeneration of nerve structures of 10-30 wt.%. For injection, the dispersed combined biomaterial (mixture) is diluted in a 2% lidocaine solution in a ratio of 10-15 g of biomaterial per 30 ml of solution. Injections are carried out in courses in an amount of 4-5 with a break between them of 4-5 days, 5-15 injections per course, 1-2 ml in each injection, depending on the degree of cicatricial damage to the anastomosis. After that, medical and diagnostic laparoscopy of the abdominal organs, subjected to surgery with the creation of anastomoses, is carried out in an amount of 1-3 with an interval of 7 days, during which an anastomosis is instrumentally palpated to determine its elasticity, the degree of swelling and the severity of adhesions around it, is carried out dissection of early postoperative adhesions, expansion of the anastomosis from cicatricial constrictions, cicatricial bends. After that, a combined Alloplant biomaterial is used through a separate puncture of the abdominal wall with a Wim-Silverman needle with a diameter of G22-24, used for the above endoscopic chipping of scar tissues by 1-5 injections of 2-3 ml each in serous-mucous tissues around the anastomosis. Such an introduction to anastomosis tissue previously prepared during laparoscopy provides a deeper, layer-by-layer penetration of the combined Alloplant biomaterial into them and increases the therapeutic effect. The number of laparoscopies depends on the patient's tolerance of this procedure and the effectiveness of eliminating cicatricial stenosis during the proposed complex treatment.

Practical examples.

Example 1. Patient V. Yu., 38 years old, with a diagnosis of peptic ulcer of the duodenum, complicated by ongoing bleeding, according to Forrest classification: F-P-A, an emergency resection of the stomach according to B-1 with termo-lateral anastomosis was performed. The postoperative period is smooth. On the 5th day, signs of dysphagia appeared - regurgitation, vomiting. Beginning gastric lavage, parenteral nutrition. Radiation therapy with the RUM-20 apparatus was performed 2 times to the anastomosis area in the oncology dispensary. The condition is the same. On the 9th day, FGS was performed, the picture of cicatricial stenosis is determined. The treatment was carried out according to the proposed method - endoscopic chipping with Alloplant combined biomaterial in 3 courses, with an interval of 5 days, 10 injections per course. In the final stage, diagnostic and treatment laparoscopy with intravenous anesthesia was performed. For this, carbon dioxide was introduced into the abdominal cavity with a pressure of 12-14 mm Hg. pillar. A laparoscope was inserted through a 10-mm proakar, an anastomosis area was examined, an adhesion-cicatricial periprocess was introduced, then a scissor tool was inserted through a 5-mm proakar, scissors connected to the electrosurgical unit of the Gimmi video stand, adhesions, scar tissue elements were dissected. A Wim-Silverman needle was inserted through a separate puncture of the abdominal wall and the sero-muscular tissues of the anastomosis were chipped together with Alloplant combined biomaterial in 10 points of 2 ml each. As a result, the patient's condition improved, he began to take liquid food.

Example 2. Patient N., 56 years old, with a diagnosis of obstructing cancer of the sigmoid colon, the tumor was resected in a planned manner within healthy tissues with the creation of a lateral side-to-side lateral anastomosis. The postoperative course is normal, on the 6th day there were signs of dysphagia, a clinic of partial intestinal obstruction - bloating, vomiting. Siphon enemas, intestinal stimulation were performed. The condition is the same. On the 8th day, FCC was performed - a picture of the development of cicatricial stenosis in the area of intestinal anastomosis. The patient was treated according to the proposed method: endoscopic injections with Alloplant combined biomaterial into the anastomosis region in 5 courses with an interval of 4 days, 10 injections per course. Then, diagnostic and treatment laparoscopy was performed 2 times with dissection of the scar-commissural periprocess of the anastomosis region, followed by the introduction of Alloplant combined biomaterial into this region through 6-7 points, respectively. The patient's condition began to improve, the gases went away, began to take liquid food, and loose stools appeared.

Example 3. A 37-year-old patient with a diagnosis of adhesive disease of the peritoneum, complicated by signs of partial intestinal obstruction, developed after removal of destructive appendicitis. A 4-fold surgical manual was carried out in various clinics, in the last 2 operations - with the application of inter-intestinal anastomoses. After preoperative preparation and further examination - a survey radiography of the abdominal cavity, X-ray contrast studies with barium sulfate, Napalkov's test - the surgeons decided to perform left-side hemicectomy with removal of the intestinal anastomoses and the application of lateral ileo-transversoanastomosis according to the “side to side” type . Postoperative course was usually. Intestinal probe removed on 4-5 days. On the 7-8th day, the patient worsened - there were signs of ChKN, bloating, dysphagia, pain. Siphon enemas, parenteral nutrition, and intestinal stimulation were performed. The patient's condition remained the same. On the 9th day, FCC was performed - the ileo-transversoanastomosis region is deformed, swollen, and scarred. The patient was treated - endoscopic chipping of the anastomosis area with Alloplant biomaterial combined 4 times, with an interval of 5 days and once (due to technical difficulties - the severity of the adhesions and the difficulty of introducing the instruments into the abdominal cavity), the treatment and diagnostic laparoscopy was performed, as a result of which the expressed adhesive process. A delicate dissection of planar adhesions was carried out, through the Wim-Silverman needle, the area of ileo-transversoanastomosis was chipped off with Alloplant combined biomaterial in 5 points of 2-3 ml each. The patient's condition began to normalize - gases began to flow, the stomach fell, he began to take liquid food on his own.

Thus, the proposed invention improves the treatment of postoperative cicatricial stenosis in the field of anastamoses.

Claims (1)

A method for the treatment of postoperative abdominal cavity anastomoses complicated by cicatricial stenosis, comprising endoscopic injections into cicatricial tissues on the inside of the anastomosis with Alloplant biomaterial, consisting of a connective tissue regeneration stimulator 35-45 wt.%, A phagocytosis stimulator 35-45 wt.% And a stimulator regeneration of nerve structures of 10-30 wt.%, which is carried out by courses in an amount of 4-5 with a break between them of 4-5 days, 5-15 injections per course, after which a diagnostic paroscopy of the abdominal organs subjected to surgical intervention with the creation of anastomoses, in an amount of 1-3 with an interval of 7 days, during which an anastomosis is instrumentally palpated to determine its elasticity, the degree of swelling and the severity of adhesions around it, dissection of early postoperative adhesions, straightening of the anastomosis from cicatricial constrictions, cicatricial bends, after which the combined Alloplant biomaterial is introduced with a Wim-Silverman needle with a diameter of G22-24 separate puncture the abdominal wall by 1-5 injections of 3.2 ml per injection biomaterial in sero-muscular tissue around the anastomosis.