RU2621168C1 - Treatment method of ruptured diverticulum of sigmoid colon - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to the area of medicine, surgery. The stenting of the sigmoid colon and the diverticulum area is performed by a self-expanding stent. The laparoscopic lavage of the abdominal cavity is performed by an antiseptic solution. The diverticulum is isolated by the Tachocomb plate. The abdominal cavity is drained.

EFFECT: method of decreasing of the risk of postoperation complications providing the prevention of relapse of the ruptured diverticulum of the sigmoid colon.

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Description

The invention relates to medicine, namely to coloproctology, and for the treatment of perforated diverticulum of the sigmoid colon.

Diverticular disease (code according to ICD-10 K 57) is a disease characterized by the presence of single or multiple thinned protrusions of the mucous membrane (diverticula) beyond the intestinal wall [A manual for doctors “Diverticular disease of the colon: clinical forms, diagnosis and treatment." M., 2011].

Diverticular colon disease has so far remained an “underestimated nosological unit” (V. Cruis, 2005). Diverticulitis - an inflammation of the diverticulum - is the most common complication of diverticulosis, the progression of which can lead to formidable complications such as an abscess, para-intestinal infiltrate, and perforation. Considering the above, timely rehabilitation of diverticulums, especially diverticulums with a narrow mouth, is of considerable importance in the prevention of complications of diverticular disease.

Perforation of the diverticulum is the most severe complication of diverticular disease and is found, according to the literature, in 7-10% of patients with devirticular disease. The outcome of the disease is the formation of abdominal infiltrate or peritonitis. An increase in the symptoms of the disease - the clinic of peritonitis against the background of ongoing antibacterial and detoxification therapy, is an indication for surgical treatment, and in most cases the operation ends with the application of a temporary colostomy, which subsequently requires a heavy reconstructive operation after 2-4 months. This tactic is universally recognized and leads to temporary disability of patients, disability, causing serious psychological trauma to the patient. In the postoperative period after colostomy, due to perforation of the diverticulum, a high level of postoperative complications, such as the formation of intraperitoneal abscesses, paracolostomy inflammatory complications, and suppuration of postoperative wounds, is noted.

These problems require the development of new methods for treating this severe complication of diverticular disease.

A number of methods for treating diverticulum perforation are mentioned in the medical and patent literature.

In clinical practice, various techniques have been successfully applied to treat patients with diverticular colon disease through an endoscope, such as laser therapy, which has shown high efficiency of local treatment in the complex treatment of patients with complicated forms of colon diverticulosis [Khasanov, A.G. Endoscopic laser therapy in the treatment of complicated diverticulosis / A.G. Khasanov I.M. Urazbakhtin, D.I. Mehdiev // Diverticulosis of the colon: abstract. region. scientific and practical. conf. - Kuibyshev, 1990. - S. 44-46].

In addition to complex traditional treatment, endoscopic sanitation of diverticulums is described. To this end, an Endo-Flex catheter of at least 1.8 m in length with a cone-shaped end part, which avoids microtraumatization of diverticula, was carried out through the instrument channel. The tip of the catheter was inserted through the mouth into the cavity of the diverticulum. Initially, the state of the mucous membrane in the area of the mouth of the diverticulums, the contents of the diverticulums for the presence of fecal stones and pus were evaluated. A saline solution was carefully injected into the catheter with a syringe to rinse its cavity, a small amount of contents was aspirated back to collect the wash water and their bacteriological examination. The diverticulum was washed until complete release from fecal stones. Then the diverticula were irrigated with an antiseptic solution (a 0.3% solution of collargol was used, heated to a temperature of 37 ° C). For the rehabilitation of one diverticulum spent 10-15 ml of solution. Therapeutic fibrocolonoscopy was completed by introducing Levomekol ointment in a volume of 0.5-2 ml into a diverticulum cavity heated in a water bath to 37 ° C. Fibrocolonoscopy with debridement was performed to patients once every 4 days 3 times (N.M. Galimov, I.I. Khidiyatov, I.R. Ibragimova, PM Subkhangulov, O.T. Nugaev. Endoscopic sanitation of diverticulums in the complex treatment of complicated forms of diverticulosis colon).

The disadvantage of this method is that the technique used by the author is not applicable for complications of diverticulitis - perforation.

The technique of laparotomy is described, during which the following surgical interventions were performed for patients with acute diverticulitis: resection of the sigmoid colon with anastomosis, left-sided hemicolectomy with anastomosis, transversostomy. The intersection of the large intestine (TK) above and below the last diverticuli was determined on the basis of a comprehensive preoperative examination, which included irrigoscopy and double contrast irrigography, fibrocolonoscopy, ultrasound and CT. In some cases, intraoperative colonoscopy was used to detect intraluminal organic pathology of the colon. When applying end-to-end anastomoses, the localization of TC sphincters was taken into account. The average preoperative bed day was 5.9, the postoperative bed day was 13.9. There were no fatal outcomes. There was an anastomosis failure after left-sided hemicolectomy in 1 patient with a previously imposed transversalostomy, which required temporary removal of the ileostomy. To determine the volume of large intestine resection and its intersection, it is advisable to use data from a preoperative examination (double-contrast irrigoscopy, fibrocolonoscopy, ultrasound, CT). During surgical interventions, it is possible to use intraoperative fibrocolonoscopy, transillumination of an air-swollen colon (I.V. Gaponov. Features of the diagnosis and treatment of acute colon diverticulitis. // Surgery News. - Volume 22. - No. 6 - 2014. - P. 687- 691).

The disadvantage of this method is that when using this tactic and the used techniques in case of diverticulum perforation, in most cases it is necessary to apply colostomy for 2-4 months, which invalidates the patient, leads to long-term disability, increases the level of paracolostomy complications.

This technique is closest to the claimed invention and is accepted by us as a prototype.

The invention is known is a method of surgical treatment of diverticular disease of the colon (patent No. 2248756, 03/27/2005), including serosotomy, characterized in that the intestinal wall along the mesenteric edge of the intestine is exposed to radio-frequency electromagnetic waves with a frequency of 3 × ^{10 6} -3 × ^{10 10} Hz, power flow density of 20-30 kW / cm in cutting and coagulation mode.

A known method of performing an operation in the treatment of diverticular disease of the colon (patent No. 2127550, 03.20.1999) by penetrating into the abdominal cavity and performing serosomyotomy on the colon with preservation of the mucosa, characterized in that penetration into the cavity is made through punctures of the abdominal wall, into one of which are introduced with a laparoscope with a video camera, and in another - a scalpel with a given depth of dissection, and the operation is performed after filling the colon with air.

A known method of treating diverticular disease of the colon (RF patent No. 2228146, 05/10/2004), comprising serosomyotomy, characterized in that serosomyotomy is performed to reduce tissue pressure in the colon wall by 15% from the original.

Their disadvantages include the performance of a traumatic operation, associated with a high risk of purulent-septic complications, patient stomatization, prolonged disability and patient disability.

Thus, well-known methods of treating diverticulum perforation include performing a traumatic operation associated with a high risk of purulent-septic complications, patient stomatization, prolonged disability and patient disability.

The closest is the technique described in the source I.V. Gaponov // Features of the diagnosis and treatment of acute colon diverticulitis [Surgery News. - Volume 22. - No. 6 - 2014. - S. 687-691].

Our proposed method is devoid of the disadvantages of the prototype.

The objective of the invention is to develop a method of minimally invasive treatment of perforation of the diverticulum of the sigmoid colon with a complicated course, which allows to avoid laparotomy and colostomy.

The problem is solved by the fact that the claimed method of treatment of a perforated diverticulum of the sigmoid colon, which includes laparoscopic sanitation of the abdominal cavity with an antiseptic solution and intraoperative colonoscopy, while the diverticulum perforation zones and the length of the refocal inflammation are determined under double-column and laparoscopic control, depending on this the choice of the size of the self-expanding colorectal stent along the length and then through the colonoscope above the refocal zone inflammation above the site of perforation is carried out by a conductor of a self-expanding colorectal stent, and then a stent is installed on it so that its center is located in the area of inflammation with perforation, and also extends distal and proximal to this zone, the diverticulum perforation area is sealed with a Tachocomb adhesive plate laparoscopically, and an insurance cover is installed after surgery drainage to the site of perforation and into the pelvis.

The technical result is that thanks to the proposed method eliminates the need for emergency laparotomy, colon resection, colostomy, and a planned operation can be performed 8-12 weeks after the inflammation subsides in the area of the perforated diverticulum, which reduces the risk of postoperative and septic complications. Thus, the risk of temporary disability, disability and serious psychological trauma to the patient is reduced.

According to numerous definitions, diverticular disease is the various symptoms and syndromes associated with the presence of diverticula in a patient. However, as practice shows, the question of predictors of its complicated course has not been resolved. The principles of pathogenetic therapy and minimally invasive treatment of perforation of the diverticulum of the sigmoid colon with a complicated course, which avoids laparotomy and colostomy, have not been developed.

In our developed technique, intraoperative colonoscopy (during laparoscopy) allows us to determine with high accuracy the boundaries of refocal inflammation and the area of perforation of the diverticulum. Thus, under double colono- and laparoscopic control, the diverticulum perforation zones and the extent of refocal inflammation are determined, the size of the self-expanding colorectal stent is selected in length: if the inflammation zone is up to 30 mm, a stent of 60 mm is chosen, and if more than 30 mm, a stent of 80 mm is chosen . The use of a self-expanding colorectal nitinol stent of a certain length, as well as placing the stent above the zone of refocal inflammation above the perforation site so that its center is located in the inflammation zone with perforation, and also extends distal and proximal to this zone, in combination with the use of Tachocomb adhesive plate 4, 8 × 4.8 × 0.5 cm or 9.5 × 4.8 × 0.5 cm allows you to tightly cover the place of perforation of the diverticulum of the colon, which prevents the development of peritonitis, contributes to normalization and passage of intestinal contents through the large intestine and avoids the ingestion of intestinal contents into the abdominal cavity with the development of diffuse fecal peritonitis.

Installing insurance drainage at the perforation site and in the pelvis reduces the risk of postoperative and septic complications.

The development of local peritonitis and abdominal infiltrate resistant to antibacterial and detoxification therapy is an indication for emergency laparotomy, which in most cases ends with the application of a colostomy. The inventive method allows to avoid open surgery and patient stoma, to reduce the number of septic and postoperative complications.

A detailed description of the method and an example of its clinical use

A patient with a suspected perforation in the presence of a clinic of local peritonitis or an infiltrate with severe pain syndrome resistant to antibiotic therapy makes a decision on the need for surgical treatment. The presence of perforation or infiltrate should be confirmed by such studies as ultrasound of the abdominal organs, radiography of OBP or CT OBP, and laboratory tests.

The patient in the operating room under endotracheal anesthesia undergoes a review laparoscopy, sanitation of the abdominal cavity with an antiseptic solution (chloramine solution and saline solution up to 6 liters), then a colonoscopy is performed using an Olympus 150 series colonoscope, in which the place of perforation of the sigmoid colon diverticulum and zone refocal inflammation, determine the length of the self-expanding stent. Next, colonic stenting of the perforation site is performed using an Olympus 150 series colonoscope having an operating channel for a 10 Fr. stent delivery system.

Previously, under double colono- and laparoscopic control, the diverticulum perforation zones and the length of the refocal inflammation are determined, the size of the self-expanding colorectal stent is selected along the length: if the inflammation zone is up to 30 mm, a stent 60 mm long is chosen, and if more than 30 mm, a stent 80 is chosen or 90 mm. According to the endoscope, a special conductor of the stent delivery system is inserted through the surgical channel above the perforation site. The endoscope is removed. Then, under double colono- and laparoscopic control, a self-expanding nitinol-coated colorectal stent 60 mm or 80 mm long with a diameter of 22 mm is carried out along the conductor, depending on the prevalence of the area of perifocal inflammation. The stent is positioned and installed so that its center is on the area of inflammation with perforation, and also spreads more distally and proximal to this area. After stent deployment, the delivery device and conductor are removed.

After that, a laparoscopic shelter is made for the perforation site with the diverticulum insulated with a Tachocomb adhesive plate 4.8 × 4.8 × 0.5 cm in size (Manufacturer Nycomed Austria GmbH, Austria. St. Petershtrasse 25, A-4020, Linz, Austria).

Through a trocar in the iliac region on the left install insurance drainage to the site of perforation and into the small pelvis. Diagnostic laparoscopy and sanitation of the abdominal cavity is carried out in a standard way using a laparoscopic stand and a set of tools.

The performance of the proposed method is confirmed by the following clinical examples.

Example 1

Patient K., 61 years old, was admitted to the first surgical department with a preliminary diagnosis of an acute abdomen, presumably a perforation of a hollow organ. A history of the presence of sigmoid colon diverticula. The diagnosis was confirmed by clinical and instrumental examinations, including a clinical examination. The presence of soreness in the lower abdomen, severe soreness and positive peritoneal symptoms in the left iliac region, fever up to 38 ° C, 2-fold vomiting were noted. The duration of the disease is about 3 days. In laboratory analyzes, leukocytosis was observed up to 19⋅10 ⁹ , stab shift up to 11%, ESR acceleration up to 32 mm per hour. Computed tomography of the abdominal organs: signs of infiltrate, diverticulitis of the sigmoid colon, which confirmed the clinical diagnosis: diverticular disease of the colon. Diverticulitis of the sigmoid colon with perforation (ICD X - K57.2).

08/20/13 in the operating room under endotracheal anesthesia in the position of the patient on the back, a skin incision was made 1 cm long, 1 cm above the navel in the midline. Performed a trocar puncture of the anterior abdominal wall, superimposed carboxyperitoneum, introduced a laparoscope. With a review laparoscopy: loops of the small intestine are moderately inflated, up to 300 ml of turbid effusion is determined. The abdominal cavity, with a sanitation and detoxification purpose, is washed with 6 liters of antiseptics (0.5% solution of chloramine 3 liters, physiological solution 3 liters). Loops of the ileum, which were bluntly separated, were soldered to the inflammatory-altered area of the colon in the region of the rectosigmoid bend. An intraoperative colonoscopy was then performed using an Olympus 150 series colonoscope. With double laparo- and colonoscopic control, it was found that in the middle third of the sigmoid colon, up to 50 mm there is a pronounced perifocal inflammation. Colonic stenting of the perforation site was performed using an Olympus 150 series colonoscope with an operating channel for a 10 Fr. delivery system. To do this, a special conductor of the stent delivery system was passed through the operating channel above the perforation site, then a self-expanding nitinol coated Hanarostent colorectal stent 90 mm long, 22 mm in diameter with a delivery device diameter of 8 mm and a long delivery device of 700 mm was placed along the conductor, and it was installed under the visual colono- and laparoscopic control so that its center was on the area of inflammation with perforation, from which it spread distal and proximal to approximately equal distances. The colonoscope is removed. Laparoscopically, the area of the perforated diverticulum is isolated by a 4.8 × 4.8 × 0.5 cm Tachocomb plate and covered by a strand of a large omentum. An insurance drainage to the perforation site and to the small pelvis is installed through the trocar in the iliac region on the left. Diagnostic laparoscopy and sanitation of the abdominal cavity were carried out in a standard way using a laparoscopic stand and a set of instruments.

The postoperative period is smooth. Independent stool recovered 3 days after surgery on the probe table, the disappearance of intoxication symptoms and normalization of laboratory parameters were also noted. The patient was discharged from the hospital on the 6th day.

Example 2

Patient Zs A.V., 69 years old, was admitted to the first surgical department with a preliminary diagnosis of acute abdomen: presumably perforation of a hollow organ. A history of the presence of multiple sigmoid colon diverticula. The diagnosis was confirmed by clinical and instrumental examinations. On examination: the presence of soreness in the lower abdomen, severe soreness and positive peritoneal symptoms in the left iliac region, an increase in body temperature to 37.5 ° C, 1-time vomiting. Anamnesis of the disease for about 2 days. In laboratory analyzes, leukocytosis was observed up to 16⋅10 ⁹ , stab shift up to 12%, acceleration of ESR up to 34 mm per hour. When computed tomography of the abdominal organs - signs of infiltrate, sigmoid colon diverticulitis, which confirmed the clinical diagnosis: diverticular disease of the colon. Diverticulitis of the sigmoid colon with perforation (ICD X - K57.2).

07/03/14 in the operating room under endotracheal anesthesia in the position of the patient on the back, a skin incision was made 1 cm long, 1 cm above the navel in the midline. Performed a trocar puncture of the anterior abdominal wall, superimposed carboxyperitoneum, introduced a laparoscope. With a survey laparoscopy in the abdominal cavity, the loops of the small intestine are moderately inflated, up to 250 ml of turbid effusion is determined. The abdominal cavity with a sanitation and detoxification purpose is washed with 6 liters of antiseptics (0.5% solution of chloramine 3 liters, saline 3 liters). Loops of the ileum are soldered to the inflammatory-altered part of the colon, the infiltrate is bluntly divided. Performed intraoperative colonoscopy using an Olympus 150 series colonoscope. With double colono- and laparoscopic control, it was found that the extent of refocal inflammation in the middle third of the sigmoid colon is about 30 mm. Then, colonic stenting of the perforation site was performed using an Olympus 150 series colonoscope with an operating channel for a 10 Fr. delivery system. To do this, a special conductor of the stent delivery system was passed through the operating channel above the perforation site, a self-expanding nitinol coated Hanarostent colorectal stent 60 mm long, 22 mm in diameter with a delivery device with a diameter of 8 mm, length 700 mm, and installed under the visual colono- and laparoscopic control so that its center was on the area of inflammation with perforation, from which it spread distal and proximal to approximately equal distances. The colonoscope is removed. Laparocopically, the area of the perforated diverticulum is isolated by a 4.8 × 4.8 × 0.5 cm Tachocomb plate and covered by a strand of a large omentum. An insurance drainage to the perforation site and to the small pelvis is installed through the trocar in the iliac region on the left. Diagnostic laparoscopy and sanitation of the abdominal cavity were carried out in a standard way using a laparoscopic stand and a set of instruments.

The postoperative period is smooth. Independent stool recovered 3 days after surgery on the probe table, the disappearance of symptoms of intoxication and normalization of laboratory parameters were also noted. The patient was discharged from the hospital on the 6th day.

The study did not include patients with neoplasms, concomitant diseases in the stage of decompensation. The method was tested in 14 patients, no complications were observed. Nonparametric criteria were used to assess the significance of differences in average indicators: for interconnected samples, the Wilcoxon test (W), for unrelated samples, the Mann-Whitney test (U). To assess the relationships between the characters, a correlation analysis was carried out with the calculation of Spearman's rank correlation coefficients (ρ). In all statistical analysis procedures, the critical significance level p was taken to be 0.05. Statistical processing of the results was carried out using the software product STATISTICA 6.1 (StatSoftlnc) and Excel-2010.

The advantages of the claimed method:

- treatment can be carried out laparoscopically;

- severe postoperative complications are excluded;

- prevention of relapse of this disease.

The claimed method for the treatment of perforated diverticulum of the sigmoid colon has been successfully tested on sufficient clinical material, has shown its effectiveness and can be recommended for use in specialized surgical hospitals.

Claims (1)

A method for treating a perforated diverticulum of the sigmoid colon, which includes laparoscopic abdominal sanitation with an antiseptic solution and intraoperative colonoscopy, characterized in that the diverticulum perforation zone and the length of the refocal inflammation are determined under double colono- and laparoscopic control, and the size of the self-expanding colort is selected length: if the length of the zone of refocal inflammation is up to 30 mm, a stent of 60 mm is chosen, and if more its 30 mm - a stent of 80 mm is chosen, then a conductor of a self-expanding colorectal stent is passed above the perforation through a colonoscope above the perforation site and a stent is placed on it so that its center is located in the area of inflammation with perforation of the diverticulum, from which it extends distally and proximal at approximately equal distances, noting the coincidence of the x-ray marks of the conductor and the stent for colonic stenting, laparoscopically seal the diverticulum perforation zone with Vashti Tachocomb, postoperative drainage establish insurance to the place of perforation and pelvis.