RU2524301C2 - Method of combined surgical treatment of morbid obesity with prevention of bypass-enteritis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for treatment of morbid obesity. Gastroplasty, and jejunoileo bypass surgery are performed with the distal part of the defunctioned small intestine and the gall bladder, and cholejejunoanastomosis is applied.

EFFECT: method makes it possible to reduce a risk of bypass-enteritis development.

5 dwg, 2 tbl

Description

The invention relates to medicine, in particular to surgery, and can be used to prevent bypass enteritis after a combined surgical method for the treatment of morbid obesity.

The epidemic of overweight and obesity is currently one of the most acute public health problems worldwide.

There are methods for the combined treatment of morbid obesity, which in the postoperative period effectively reduce body weight.

One of these surgical interventions is a method of combined surgical treatment of obesity (patent No. 2138201), which consists in a combination of gastroplasty and ejunoejoint bypass surgery. Eunoeyl bypass surgery is performed while maintaining a functioning segment of the small intestine with a length of 80-100 cm. The scheme of the combined operation of the prototype is presented in figure 1.

The disadvantage of the prototype is a complication, which in the postoperative period is referred to as bypass enteritis.

The cause of bypass enteritis is reflux into the intestine of the enteric contents, the development of an excess of non-clostridial anaerobic microflora and the production of hepatotoxins by it, which ultimately leads to the development of liver failure, and its most severe forms pose a threat to life (Nikolaev EV, 1997 "The combined method of surgical treatment of exogenously constitutional obesity." The dissertation for the doctor of medical sciences Khabarovsk, 1997; Siedletsky Yu.I. "Modern methods of le obesity "Monograph, St. Petersburg, ELBI SPb. 2007, pp. 315-316, 328-329; Т Brannon Hubbard, Petersburg, ELBI SPb. 2007, pp. 315-316, 328-329; Т Brannon Hubbard, JR ., MD PH.D. The Prevention of Bypass Enteritis After Jejunoileal Bypass for Morbid Obesity).

The clinical picture of bypass enteritis is diverse, but it mainly manifests itself in the form of prolonged persistent diarrhea, dyspeptic disorders, intestinal pneumatosis, bloating, discharge of fetid gas, and finally, bypass enteritis can lead to cirrhosis of the liver and the development of liver failure. In laboratory indicators, moderate leukocytosis, with a shift to the left, hypoalbuminemia, moderate hyperbilirubinemia due to non-direct fraction, and an increase in the level of serum enzymes are noted. An ultrasound of the abdominal organs reveals an enlarged liver, intestinal hyperpneumosis, and a hyperpneumatosis of a disconnected portion of the small intestine also reveals on a panoramic radiography of the abdominal organs. According to a histological study, in micropreparations, a picture characteristic of enteritis is noted.

The objective is to propose a method for the combined surgical treatment of morbid obesity in order to reduce body weight and prevent bypass enteritis.

The technical result is the ability to avoid bypass enteritis by applying the present invention. The illustrations show:

Figure 1. The operation scheme of the prototype.

Figure 2. The operation scheme for the proposed method.

Figure 3. The histological picture of the small intestine mucosa characteristic of bypass enteritis.

Figure 4. The histological picture of the normal wall of the small intestine mucosa after surgery according to the proposed method.

Figure 5. The histological picture characteristic of the normal wall of the small intestine mucosa after surgery according to the proposed method.

Table 1. The dynamics of weight loss after surgery by the proposed method.

Table 2. Indicators of protein and bilirubin in patients operated on by the prototype and the proposed method.

The technical result is achieved by the fact that the first stage of surgical treatment is gastroplasty, which is carried out by intussusception of large curvature after mobilization into the lumen of the stomach by corrugating seams. The second stage - they perform heroejoint bypass surgery: they retreat 60 cm from the tracheal ligament, cross the jejunum, the distal segment of which is sutured tightly with three floors of sutures. With a proximal segment of the jejunum, departing 20 cm from the ileocecal angle, they create end-to-side jejunoanastomosis. Thus, a functioning section of the small intestine with a length of 80 cm is formed, which is quite enough to maintain adequate life. The third stage of the operation is the application of cholecystoyunoanastomosis (XEA): with the distal segment of the jejunum turned off, an anastomosis with the gall bladder is applied.

The scheme of the proposed method of combined surgical treatment is presented in figure 2.

The proposed method of combined surgery used for morbid obesity, not only effectively reduces body weight, but also is the prevention of bypass enteritis, which consists in the fact that in the disconnected section of the small intestine there is a constant flow of bile, which has the following qualities: bile, irrigating the mucous membrane activates the motility of the small intestine and intestinal villi, stimulates the proliferation of enterocytes, having a bacteriostatic and bactericidal property, inhibits the development of intestinal microflora and edotvraschaet putrefaction in the OFF segment of the small intestine, thereby preventing bypass-enteritis (Korotko GF "Physiology of the digestive system" Krasnodar, 2009. - 608 p.).

The treatment results were studied in 112 patients. The control group consisted of 88 patients suffering from morbid obesity who underwent surgery according to the prototype. The second group is the main, which included 24 patients with morbid obesity who underwent surgery according to the proposed method.

It is reliably established that the proposed method of combined surgical treatment of morbid obesity effectively reduces body weight. The dynamics of weight loss are shown in table 1.

Of 88 patients operated on the prototype, in 12 patients in the long-term period, a bypass enteritis clinic was identified, which was accompanied by signs of liver failure. In one of these patients, developed liver failure caused a fatal outcome.

We conducted a study of the main indicators of the functional state of the liver in 24 patients who underwent surgical treatment according to the proposed method in terms of 3 or more years, and compared them with the previously operated patients for obesity according to the prototype.

The table shows the indicators of protein and bilirubin in patients operated on by the prototype and the proposed method. See table 2.

As can be seen from the table, in patients with morbid obesity of the III-1V degree, some differences were observed between the control and the main group. In the control group of patients with bypass enteritis, the amount of protein was reduced to 54.64 g / l, which is characteristic of this complication, and in the main group, the protein was within the normal range, which ranged from 63 to 83 g / l (Severin ES, Nikolaev A.Ya. “Biochemistry” GEOTL Moscow, 2002, 448 pp.; Severin ES “Biochemistry - a textbook for high schools”, published by GESTAR Moscow, 2003; Sidorov EP "Guidelines for the appointment and interpretation of biochemical blood tests" 2010).

A group of patients with bypass enteritis showed a significant increase in the content of total bilirubin, its concentration in the blood serum reached 28.8 mmol / L, which significantly exceeds normal values and indicates impaired liver function.

As for the concentration of total bilirubin in the blood, it should be noted that in the main group its content in the blood plasma in the early postoperative period was 16.1 mmol / l, and in the long-term period the total bilirubin in the same group of patients was 6, 7 mmol / l. It should be noted that these indicators did not go beyond the norm, which ranges from 3.4 to 17.2 mmol / l (Severin BC, Nikolaev A.Ya. “Biochemistry” GEOTL, Moscow, 2002, 448 pp. .; Severin ES “Biochemistry - a textbook for universities”, published by GESTAR, Moscow, 2003; Sidorov EP “Guidelines for the appointment and interpretation of biochemical blood tests” 2010).

In the operated patients according to the proposed method, no signs of liver failure were noted.

Thus, the data obtained allow us to conclude that the indicators of protein and bilirubin are relatively satisfactory in most patients operated on for morbid obesity by the proposed method.

Of great importance for the detection of metabolic disorders in patients after surgical treatment of morbid obesity is the study of biochemical blood parameters in the long term, i.e. in terms of 2 or more years after surgery. This is due to the onset of stabilization of body weight loss by the end of the second year after surgery, as well as the development of late metabolic insufficiency and liver failure in some patients after ejuno-shunting.

To assess the histological picture in a disconnected loop of the small intestine during repeated surgical interventions in previously operated patients with morbid obesity, a biopsy of the wall of the disconnected small intestine was performed.

In a study of a group of patients where bypass enteritis was observed, the histological picture was characteristic of irritable bowel syndrome, which was accompanied by mucosal hypertrophy, the prevalence of macrophages.

A histological examination of the small intestine mucosa after a combined operation with the application of cholecystoanastomosis revealed no pathology.

The advantages of the proposed method:

- gastroplasty in combination with ileo-shunting and supplemented with cholecystoyunoanastomosis, significantly reduces excess body weight in severe stages of obesity;

- the application of cholecystoyunoanastomosis is an effective way to prevent bypass enteritis, since bile constantly enters the disconnected section of the small intestine and, irrigating the mucosa, has the following quality: it activates the motility of the small intestine and intestinal villi, stimulates the proliferation of enterocytes, having bacteriostatic and bactericidal properties, inhibits the development of intestinal microflora, does not allow the development of excessive amounts of nonclodystrial anaerobic flora and prevents putrefactive processes in turn a small segment of the small intestine;

- the proposed invention, recommended for the treatment of morbid obesity, significantly improves the functional parameters of the liver compared with those in patients who underwent an operation according to the prototype.

Example 1. Patient X., 49 years old, was admitted 04/22/91 years with a diagnosis of Morbid obesity of 4 degrees. Symptomatic arterial hypertension.

From the anamnesis it was found that she was obese from childhood, but her body weight began to increase especially rapidly in recent years. It was treated by a therapist without a significant effect. With a height of 162 cm, the body weight is 117 kg.

After examination and preoperative preparation on 05.39.91, the operation was performed: gastroplasty and ejuno-shunting according to the prototype. The early postoperative period was complicated by paresis of the gastrointestinal tract, which was managed to stop with the help of conservative treatment. Sutures were removed on day 13. Primary healing. Diarrhea before discharge from the hospital ranged from 3 to 12 times a day. During her stay in the hospital she lost 10 kg. Upon discharge from the hospital under the supervision of a local surgeon, the patient is given the necessary recommendations.

4 months after the operation, the patient was hospitalized in a moderate condition with complaints of general weakness, malaise, excessive salivation, periodic vomiting. Despite the relatively rare stool, not exceeding, as a rule, 3-4 times a day, the patient had a significant decrease in body weight to 79 kg.

The examination revealed hypoproteinemia - the total protein was 54.5 g / l, hyperbilirubinemia - indirect bilirubin was 31.63 mmol / l.

Intensive conservative treatment was prescribed, as a result of which complaints decreased significantly on the 10th day, indicators of the functional state of the liver returned to normal, the patient gained 6 kg in weight. On the 18th day, at the request of the patient, she was discharged from the hospital in a satisfactory condition with mandatory monthly monitoring by the operated surgeon.

2-3 weeks after discharge from the hospital, the patient's condition worsened again: general weakness, vomiting appeared, body weight began to decrease, although the frequency of the stool did not exceed 4-5 times a day. Despite the deterioration, she did not seek medical help and only 11/11/91 in a serious condition was hospitalized.

Upon admission, the patient is in serious condition. There are swelling on the lower extremities. AD-90/60 mm Hg Pulse - 84 per minute. The tongue is dry, coated with a white coating. The abdomen is soft, painless in all departments, the liver is not palpable. Stool up to 6 times a day. Noteworthy is the significant exhaustion of the patient, whose body weight is 74 kg, i.e. body weight loss for 5.5 months after surgery was 41 kg.

During the examination, the total protein was 54.3 g / l, the total bilirubin was 20.6 μmol / l.

The patient was prescribed massive infusion therapy, hormonal drugs, antibiotics, hepatoprotectors, but nevertheless, protein and bilirubin indices worsened. Total blood protein decreased to 50 g / l, total bilirubin was 38.8 μmol / l.

Despite the treatment, the condition progressively worsened, and on 10.01.92 the patient died.

At an autopsy of the wall of the disconnected small intestine, the histological picture was characteristic of bypass enteritis, mucosal hypertrophy was observed, and macrophages predominated. See FIG 3.

Example 2. Patient M, 43 years old, medical history No. 141, was admitted to the surgical department of the Khabarovsk hospital of the Federal State Medical Center FMBA of Russia in a planned manner on January 21, 2007 with a diagnosis of Morbid obesity of the fourth degree.

From the anamnesis it was found that he was obese for about 20 years after childbirth, was repeatedly treated conservatively in various ways - without any particular effect. With a height of 167 cm, the body weight is 146 kg. The patient is recommended surgical treatment of obesity.

In a planned manner, on January 22, 2007, an operation was performed - laparotomy, gastroplasty and ejunoelomination, supplemented by the application of cholecystojejunoanastomosis according to the proposed method.

The early postoperative period was uneventful. Complaints of indomitable vomiting and diarrhea - did not show.

Drainages removed on the 3rd day. The sutures were removed on the 14th day, and the patient was discharged from the department in satisfactory condition under the supervision of a polyclinic doctor. During the stay in the clinic after the operation, she lost 12 kg. The patient was observed by the surgeon for 3 years. The last examination was carried out in March 2010. The weight of the patient was 79 kg, indicators of protein and bilirubin were within normal limits.

A histological examination after surgery indicates a normal wall of the mucosa of the small intestine. See FIG. 4.

In the remote period after surgery, evidence of bypass enteritis was not detected. 4 years after the operation she got married, she is satisfied with the quality of life.

Example 3. Patient S., 32 years old, was admitted to the surgical department as planned on March 24, 2008, with a diagnosis of morbid obesity of the fourth degree.

From the anamnesis it was found that he suffered from obesity since childhood, but especially rapidly, body weight began to increase over the past years. Treated conservatively with a therapist without significant effect. With a height of 169 cm, the body weight is 132 kg.

General analysis of blood, urine and biochemical parameters within normal limits.

As planned, on March 25, 2008, an operation was performed: gastroplasty, by invagination of a large curvature of the stomach into the lumen of the organ with 2.0 corrugating sutures on a round needle. Performed ejunoile bypass with the leaving of the functioning segment of the small intestine 80 cm (60 cm + 20 cm) and applied cholecystoyunoanastomosis according to the proposed method.

The early postoperative period was uneventful. Total protein and bilirubin in the early postoperative period are within normal limits. Drainages removed on the 3rd day. Sutures were removed on the 12th day after surgery: healing by first intention. During his stay in the clinic, the patient lost 11 kg. The patient was discharged on the 12th day after the operation in satisfactory condition under the supervision of a polyclinic surgeon.

Examined after two years. No complaints. Body weight was 82 kg. Indicators of total protein reached a level of 69.2 g / l and bilirubin - 12.6 μmol / l. Pathology from the mucosa of the small intestine was not detected. See FIG. 5.

The last observation was carried out after four years. The patient's weight was 80 kg, total protein - 72.7 g / l and total bilirubin - 6.8 μmol / l. No evidence of bypass enteritis was found. Celebrates a good quality of life.

Claims (1)

A method for the combined surgical treatment of morbid obesity with the prophylaxis of bypass enteritis, including gastroplasty, ejunoelusation, characterized in that cholecystojunoanastomosis is applied with a distal segment of the disconnected small intestine and gall bladder.

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