RU2688002C1 - Method esophageal and intestinal anastomosis formation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for esophageal-intestinal anastomosis formation. In upper and lower angles of esophageal and leading and abducent elbows connection, upper and lower "stitching sutures" are applied without fastening. Between inner edge of the lead elbow incision and the left edge of the esophagus wall, a continuous through suture is made, adapting mucous membrane of the esophagus and small intestine from upper angle of incision clockwise to lower angle, and connected with lower by "stitching suture". Right esophagus wall is sutured together with an internal edge of the abducent elbow to an upper edge of the angle. Outer edges of the incisions of the small intestine elbows are connected by a single-row continuous through suture with the free end of the lower "stitching suture", fixed with 1-2 sutures with capturing an esophagus and upper parts of the elbows.

EFFECT: method enables simplifying the anastomosis application, preventing postoperative stenosis of the anastomosis.

1 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, in particular to surgical methods of surgical treatment of peptic ulcer and gastric cancer, and can be used to impose postoperative esophagojejunostomy (EEA) during gastroectomy.

Stomach cancer, as before, occupies one of the first places among the causes of death from malignant tumors.

Currently, gastric cancer in the morbidity structure of the population of the Russian Federation takes the 6th place and makes up 6.42% of the total number of malignant neoplasms.

About 37,000 new cases of gastric cancer are detected every year in the Russian Federation.

The total number of patients and the mortality from this disease remain high, and the possibility of early detection of the tumor is not fully realized. Therefore, the problem of improving the methods of diagnosis and treatment of this disease remains relevant.

Despite the success of modern medical science, the results of treatment of gastric cancer cannot be considered satisfactory. This is due to the high incidence of this disease, the increase in advanced and complicated forms of stomach cancer that are difficult to diagnose, and the presence of a large number of postoperative complications.

The main and only treatment for gastric cancer is gastrectomy, the results of which are still not fully satisfactory. Mortality after gastrectomy according to literature data is 4.4-21.6%. Mortality increases to 60-70% in case of insolvency of EEA.

Known anastomosis by Bondar GV, which choose a loop of the initial section of the small intestine and carry it through the hole in the avascular zone mesocolon, so that it reaches the esophagus without tension. At the top of the loop, 4-5 nodular sero-muscular sutures along the mesenteric edge, create two knees (bend) at a distance of 1.5-2 cm between them. Nodal sero-muscular suture from the side of the mesenteric edge of the intestine bring together the created knee, getting a wide dome, continuing to sew the interconnecting and leading loops for 5-6 cm between the interrupted sutures between them and get a T-shaped suture on the mesentery. Three sero-muscular sutures sew the tops of the "knees" and get a channel formed at the dome stitched loops. Through this canal, the esophagus is carried out, at the slice level of which (judging by the figure in the article), dissecting the adductor loops and dischargers over a length slightly exceeding the size of the esophagus slice, and above it, the front lip of the anastomosis is stitched, imposing two rows of nodal stitches on it. With the nodal sero-muscular sutures the esophagus entering the canal is stitched to the intestinal “muff”, covering the anastomotic sutures with it. Below, a two-row inter-intestinal anastomosis is imposed by 6-7 cm of the esophageal-intestinal anastomosis (Bondar GV Two-team operations in gastroesophageal cancer / A.Yu. Popovich, VP Zvezdin / Surgery Pirogov Magazine / 1987 P. 74 -77). According to the authors, the method allows you to securely cover the anastomosis line, however, its implementation is quite difficult and requires the imposition of a larger number of seams. The disadvantages of the method include such postoperative complications, as the syndrome of inter-anastomotic loop obstruction, postoperative pancreatitis. At the same time, although somewhat less frequently, in the postoperative period, the insolvency of the esophago-intestinal anastomosis develops.

The known method (RU No. 2371120, 10.27.2008), by which the formed esophageal-intestinal anastomosis (the end of the esophagus in the gut flank) is covered with an excess of the intestinal wall, for which four or five longitudinal stitches along the mesenteric edge are stitched through the intestine, forming its apex. Next, with stitches along the mesenteric edge, stitch the leading and discharging loop with the posterior wall of the esophagus into the seam. After insertion of the crossed esophagus into the incision of the small intestine, cover the anterior wall of the anastomosis with an excess of small intestine obtained by stitching, stitching the anastomosis line. The method allows to cover the line of the esophageal-intestinal anastomosis, but does not exclude the development of insolvency of the anastomotic sutures, as well as the development of reflux esophagitis and pancreatitis after surgery.

Despite the differences and features of these methods, each of them has its own advantages and disadvantages, but all of them are aimed at strengthening the front wall of the EEA as the weakest point of the operation.

As a prototype of the selected method of forming the esophageal-intestinal anastomosis, developed by M.Z. Segal (M.Z. Sigal, F.Sh. Akhmetzyanov, “Gastrectomy and resection of the stomach for cancer.” Kazan: Tat. Book. Publishing House 1991. P. 182-185). If the problems of EEA insolvency were practically solved using the method of M.Z. Segal, these methods did not solve the problem of postoperative EEA stenosis. The main disadvantage of this method is the imposition of multi-row suture, which can lead to mechanical narrowing of the anastomosis, especially when the “narrow” diameter of the small intestine. Also, the use of only non-adaptive sero-muscular sutures between the esophagus and the jejunum can lead to late anastomotic strictures. To eliminate these deficiencies in the postoperative period, endoscopic esophageal-intestinal anastomosis is used, and in later strictures, after repeated bougienage, electrosurgical correction has to be applied, which may be complicated by perforation of the esophagus and jejunum. These complications increase mortality in radically operated patients, which negatively affects the long-term results of surgical treatment.

To prevent these shortcomings, a simplified method of imposing anastomosis, which allows to reduce postoperative complications, is proposed.

The aim of the invention is to simplify the technique of imposing anastomosis and the reduction of postoperative complications.

This goal is achieved by the fact that in the proposed method of forming an esophageal-intestinal anastomosis, including the imposition of an anastomosis between the leading and the diverting knees of the small intestine and the esophagus, in the upper and lower corners of the connection of the esophagus and the leading and outlet knees impose, without tying the ends, the upper and lower " lock seams ", between the inner edge of the incision of the leading knee and the left edge of the esophagus wall, perform a continuous through seam that adapts the mucous membrane of the esophagus and small intestine from the upper angle of the incision in hours Asoc arrow to the lower corner and connect with the lower "lock seam", then sew the right wall of the esophagus with the inner edge of the discharge knee to the upper edge of the corner, the outer edges of the incisions of the knees of the small intestine are connected with a single continuous continuous seam, fixed with the free end of the lower "lock seam" Strengthen 1-2 sutures with the seizure of the esophagus and the upper parts of the knees.

The essence of the proposed invention is illustrated by drawings.

In fig. 1 shows the implementation of the anastomosis according to the claimed method.

In fig. 2 - the final overlay anastomosis.

In fig. 1 presents:

1 - the esophagus

2 - resulting knee of the small intestine;

3 - diverting knee of the small intestine;

4 - cuts on the adductor and distended knees of the small intestine;

5. - the inner edge of the incision of the small intestine leading the knee;

6 - the inner edge of the incision of the small intestine of the outlet knee;

7 - "lock seams"

The method in accordance with the proposed invention is as follows.

After mobilization of the stomach and abdominal segment of the esophagus 1 on the esophagus above the cardiac sphincter, the Seal M.Z. clamp is applied 2 cm. at an angle of 30-60 °. The esophagus is cut off at the clamp, the drug is removed.

1) Choose the most mobile initial loop of the small intestine, impose one sero-muscular suture at the apex. The esophagus with a clip Seagal is brought to the loop of the small intestine laid in the form of a double-barreled gun and consisting of 2 leading elbows 3 leading. 3-5 nodal sero-muscular suture is placed between the back edge of the esophagus and the small intestine.

2) Impose "lock" through seams in the upper and lower corners and temporarily they are not knotted. On the sides of the esophagus 1, longitudinal cuts 4 are made in the resulting 2 and discharging 3 bends of 3 cm in size (Fig. 1).

3) Remove Segal's clip from the esophagus. The edges of the esophagus are resected along the crush line with a Seagal clamp. First sew the wall of the esophagus with the inner edge of the leading knee 2, starting from the top corner in a clockwise direction through the continuous seam to the bottom corner. Tie the "lower locking" seam of the lower corner and a continuous seam. Then, using the same thread, clockwise sew the right wall of the esophagus and the inner edge of the discharge knee 3 with a continuous continuous seam to the top corner, fasten the “upper lock” seam and continuous seam (Fig. 1).

4) The outer edges of the dissected 2 small intestine leading to 3 and the abductor 3 of the knee are sutured with 1-2 rows of continuous through seam over the superimposed esophageal-intestinal anastomosis (Fig. 2).

5) The application of EEA is completed by imposing in the upper corner of the anastomosis 1-2 sero-muscular suture with the capture of the esophagus and the upper "domes" of both knees to strengthen the upper angle of the EEA.

The main disadvantage of this method is the imposition of multi-row suture, which can lead to mechanical narrowing of the anastomosis, especially when the “narrow” diameter of the small intestine. Also, the use of only non-adaptive sero-muscular sutures between the esophagus and the small intestine can lead to late anastomotic strictures.

CLINICAL EXAMPLES

Mr. 59 years old, medical history: he entered the Oncology Department No. 3 of the State Healthcare Institution Committee of the Ministry of Health of the Republic of Tajikistan on January 17, 2017 with a diagnosis of stomach cancer. Polyposis of the stomach T3 N0 M0, Art. 2. Conducted preoperative preparation. 01/19/2018 (2 days after admission) an operation was performed on which an infiltrative ulcer of the stomach was detected 5 × 4 cm along the lesser curvature, the lymph nodes were not visually altered. Produced - Laparotomy, gastroectomy, EEA, developed by prof. Sigalom MZ, with the adaptation of the mucous with inter-intestinal anastomosis according to Brown according to the proposed method. Initially, the posterior and lateral sero-muscular sutures between the esophagus and the knees of the small intestine were applied. Then along the sides of the esophageal opening some 4 mm from the line of the lateral seams, the knees of the small intestine were cut in the longitudinal direction over 3 cm. The upper and lower “locking” sero-muscular sutures between the knees of the small intestine and the esophagus, which are temporarily not tied, are superimposed. Starting from the upper corner clockwise, a continuous through seam is placed between the inner edge of the leading knee and the left wall of the esophagus with the adaptation of the mucous to the lower corner, where it is fixed by the lower "lock" seam. Then, a continuous, continuous mucosae adapting the mucosa between the inner edge of the retractable knee and the right esophagus wall is also applied to the upper corner, where it is fixed by the upper locking seam. After the outer edges of the incisions of the knees of the small intestine are connected by a continuous through seam.

Additionally, reinforcing sero-muscular sutures are imposed on the upper and lower corners of the wound. At a distance of 6 cm from this anastomosis, an inter-intestinal Brown anastomosis was imposed. The postoperative period without complications. Discharged 10 days after surgery for outpatient treatment.

This method of the esophago-intestinal anastomosis differs from the method according to Segal M.Z. simplicity of imposing, which is achieved by the imposition of a continuous suture, which facilitates and accelerates the implementation of the anastomosis.

The occurrence of an EEA stricture is eliminated due to the use of a single-row continuous through adaptive suture, instead of a multi-row one, the occurrence of an EEA stricture is excluded.

For the period from 2015 to the present, 18 patients were operated on this technique. Operated patients according to this method were observed every 3 months for 2 years, FGDS was performed, none of the patients had stenosis and stricture were observed. Postoperative complications were not.

Claims (1)

The method of forming the esophageal-intestinal anastomosis, including the imposition of an anastomosis between the leading and the withdrawing knees of the small intestine and esophagus, characterized in that in the upper and lower corners of the connection of the esophagus and the leading and discharging knees impose, without tying the ends, the upper and lower "lock seams", between the inner edge of the incision leading the knee and the left edge of the wall of the esophagus perform a continuous through seam, adapting the mucosa of the esophagus and small intestine from the upper angle of the incision clockwise to the lower angle, and unite with the lower "lock seam", then sew the right wall of the esophagus with the inner edge of the discharge knee to the upper edge of the angle, the outer edges of the incisions of the knees of the small intestine are connected with a single continuous continuous seam with the free end of the lower "lock seam", fixed with 1-2 seams with a grip esophagus and upper knees.

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