RU2712042C1 - Method for forming antireflux valve on interstitial segment of small intestine after gastrectomy - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to abdominal surgery. Small intestine segment 25–30 cm long is cut out and moved into the remote stomach bed. Thoracic intestinal integrity is restored by one-row end-to-end anastomosis. Double row jejunoduodenoanastomosis and a one-row esophagoenteroanastomosis are formed. Valve is formed on the interposed segment of the small intestine between the esophagus and duodenum by dissecting the seromuscular membrane to a mesenteric border in two places, followed by closing the seromuscular portion of the intestine with gray-serous separate interrupted sutures without a muscular layer. Separate nodular serous-serous sutures are applied on the upper and lower edges of the dissected seromuscular lining by immersing the intestinal wall with a dissector.EFFECT: method provides prevention of dumping syndrome and oesophagitis reflux.1 cl, 7 dwg, 2 ex

Description

FIELD OF THE INVENTION

The invention relates to medicine, namely to surgery, and can be used in the treatment of cancer of the stomach.

State of the art

The current stage in the development of gastric surgery is characterized by a critical assessment of the functional results of traditional operations, as evidenced by the large number of fundamental works on creating and searching for the most physiological reconstruction options after gastrectomy, remaining the only radical method of treating gastric cancer. Recently, there has been a tendency to move away from traditional modifications in favor of more complex, but beneficial for digestion methods. The proposed options are aimed at creating valve anastomoses, reservoirs on the loop according to Brown and Ru (Oleksenko V.V. et al., Functional results of the reconstruction of the digestive tract after gastrectomy (with commentary) Surgery. // Journal named after N. I. Pirogov // 2017. - No. 1. - S. 36-41)

However, these methods do not solve the main problem of loop reconstruction - “switching off” the duodenum from digestion as the main cause of pathological disorders after operations on the stomach. The creation of techniques that restore the natural passage of food with orthotopic replacement of the stomach, and today is an urgent area of operational gastroenterology.

Known methods of eunogastroplasty (EGP) include cutting a small intestinal segment up to 20–25 cm long with the formation of endoduodenal and esophageojejunoanastomoses of the “end to end” and “end to side” types. In some cases, they create invagination and valve anastomoses, leave a part of the pyloric pulp, “corrugate” the transplant according to the type of duplicates, forming reservoirs, arrange the segment antiperistaltically, which undoubtedly helps to slow the passage of food through the intestines and normalize digestion processes (Zakharov, E.I. Eyunogastroplastika with diseases of the operated stomach / EI Zakharov, AE Zakharov // - M .: Medicine. - 1970. - 232 p.).

The disadvantages of the above methods is, as a rule, very low efficiency in terms of prevention of dumping syndrome and reflux esophagitis.

Closest to the claimed solution is the method proposed by G.K. Zherlov [Zherlov G.K. Fundamentals of functional surgical gastroenterology, 2009, Tomsk, S. 274]. The publication describes the formation of a circular valve in the outlet loop according to Roux after gastrectomy and distal resection of the stomach, the intussusception valve in the small intestine after EGP, 7-8 cm below the Trent ligament. The method of creating an antireflux valve is similar in both cases. The jejunum is mobilized for 3 cm, in the mobilized area the serous-muscular membrane is dissected in three sections: in the middle is circular, and along the edges it is ellipsoid to the mesenteric edge of the intestine. Nodal sutures are imposed on the uppermost and lowermost edges of the serous-muscular membrane, when tied, the mobilized part of the intestine invaginates, forming a valve (Fig. 1). Due to ellipsoidal incisions, the invaginated area is extended by 1-1.5 cm, avoiding the possible narrowing of the intestinal lumen in the valve region [see also patent for invention No. 1701294. The method of forming the valve of the small intestine].

However, the known method has the following disadvantages. Forming the valve after gastrectomy and resection of the stomach with reconstruction according to Roux, the author “turns off” the duodenum from digestion, which is the main cause of diseases of the operated stomach (GOD); forming an invagination valve after EGP 7-8 cm below the Trentz ligament in the small intestine, the intestinal lumen is narrowed significantly, creating hypertension in the upper parts of the digestive tract, which can be a danger of insolvency of duodenoanastomosis; dissection of the serous-muscular membrane of the small intestine in three places with a length of 3 cm, and subsequent invagination of the mobilized area into the intestinal lumen is dangerous by the occurrence and development of obstructive intestinal obstruction.

A technical problem is the possibility of the formation of an antireflux valve on the interposed segment of the jejunum after gastrectomy, devoid of the above disadvantages.

Disclosure of the invention

The technical result to which the claimed invention is directed is the prevention of dumping syndrome and reflux esophagitis due to the formation of valves on the interposed segment of the small intestine between the esophagus and duodenum.

The claimed invention allows to prevent the development of postoperative reflux esophagitis and to provide portioned evacuation of food from the transplant to the duodenum, which in turn leads to a slower passage of food throughout the intestine preventing the development of dumping syndrome.

The claimed invention allows to reduce the risk of developing pathological functional disorders of the operated stomach after gastrectomy, by maintaining food passage through the duodenum; create conditions for portioned evacuation of food from the interponed segment in the duodenum, and an obstacle to the reverse reflux of bile to the upper graft and esophagus. The invention is also directed to the possible prevention of postoperative necrosis and atony of the transplant, preventing the circular mobilization of the intestinal segment, while maintaining its blood supply and innervation throughout.

The technical result is achieved due to the following set of essential features:

carry out the replacement of the stomach with the small intestine segment in the isoperistaltic position with the formation of the antireflux valve,

- cut out the small intestinal segment and move it to the bed of the removed stomach,

- restore the integrity of the small intestine with a single-row end-to-end anastomosis, after which a two-row jeunoduodenoanastomosis and a single-row esophageoejunoanastomosis are formed,

- in the lower third of the small intestinal segment, a valve is formed by dissecting the serous-muscular membrane to the mesenteric edge in two places, followed by suturing of the serous-muscular part of the intestine with gray-serous separate nodal sutures without muscle layer,

- Further, separate nodular gray-serous sutures are placed on the upper and lower edge of the dissected serous-muscular membrane, immersing the intestinal wall with a dissector.

In special cases, the implementation of the method:

- the valve is formed on the interposed segment of the small intestine between the esophagus and duodenum (duodenum).

- the valve is formed while maintaining the mesenteric edge of the intestine without circular mobilization of the segment.

Brief Description of the Drawings

The invention is illustrated by drawings, where:

in FIG. 1 schematically shows a method of forming an invagination

valve according to G.K. Zherlov,

in FIG. 2 - a diagram of the execution of eunogastroplasty with the formation of an antireflux valve is presented: a) the stage of dissection of the serous-muscular membrane; b) valve formation; c) valve invagination into the intestinal lumen;

in FIG. 3 - intraoperative photograph of the EGP type with the formed antireflux valve;

in FIG. 4 presents the results of a control x-ray examination of the patient according to example 1 on the 8th day after valve EGP (the arrow indicates the valve): a) contrasting of the intestinal insert; b) portioned evacuation of contrast below the valve;

in FIG. 5 - the results of an endoscopic examination of EGP with an antireflux valve of the patient according to example 1 a month after the operation;

in FIG. 6 presents the results of an X-ray examination one year after the valve EGP of the patient according to example 2: a) after oral administration of contrast; b) after 5 minutes, a second sip of contrasting cock; c) control after 30 minutes;

in FIG. 7 - the results of the endoscopic examination of the patient according to example 2 one year after valve EGP.

The implementation of the invention

The method is as follows.

During the resection phase, the duodenal bulb is mobilized, it is optimal for 1.5-2.0 cm, and it is crossed immediately below the pylorus with a hardware suture. The stump is freed from surrounding tissues for the unobstructed formation of the terminal double-row jeunoduodenostomy. After removal of the stomach, the esophagus stump is left on the L-shaped clamp. A segment of the jejunum is selected and transferred to the upper floor of the abdominal cavity. In the process of selecting a segment of the jejunum, the architectonics of its vessels is evaluated and the main vessel is selected to power the future transplant, which is performed in transmitted light from an operating lamp using the so-called transillumination. To create an intestinal transplant, use the initial part of the jejunum (optimal 30-40 cm from the Treitz ligament). This is usually a segment of the intestine that feeds on the 3rd intestinal artery. Vascular architectonics in this zone, as a rule, is represented by a single or double arch and is located distal along the superior mesenteric artery. But its remoteness is compensated by the largest diameter and length among all jejunal arteries. The mesentery of this section of the intestine is located in the middle part of the abdominal cavity, is mobile and has a sufficient length so that the proximal end of the mobilized segment can be anastomosed without tension with a stump even with a high resection of the esophagus. An important tactical moment for creating a reservoir is the length of the segment used - the recommended length is 25-30 cm. This choice of length is explained by the ability to anastomose the interposed segment with the esophagus and the duodenal stump without tension, choosing a longer segment can cause it to bend and cause patency . When assessing blood circulation, they are guided by macroscopic criteria for transplant viability - color, turgor, peristaltic activity and pulsation of the marginal arteries. Even local venous stasis is regarded as a sign of doubtful vitality. A segment of the jejunum suitable for plasty is moved to the upper abdominal cavity through a window into the mesocolon, avoiding the torsion of the vascular pedicle along the axis. The integrity of the small intestine is restored with a single-row suture "end to end".

Of fundamental importance is the alternating sequence of superposition of digestive anastomoses: double-row eunoduodeno- and single-row esophageojejunoanastomosis. This sequence allows you to get extra time to assess the viability of the already displaced intestinal segment, notice terminal necrosis or hematoma. During this phase, a final assessment of transplant viability is performed. After, on the interposed segment, in two places, the serous-muscular membrane is dissected circularly to the mesenteric edge of the intestine, the first 5 cm above the juvenoduodenostomy, the second 1.5 cm proximal (Fig. 2a). Then, the upper and lower edges of the serous-muscular plate are sutured with separate gray-serous sutures without grasping the muscle layer, thereby forming a “circular leaflet” of the valve (Fig. 2b). Valve invagination is carried out by suturing the upper and lower serous-muscular layer with separate interrupted sutures, immersing the intestinal wall into its lumen with a dissector (Fig. 2c). The final view of the reconstruction is shown in FIG. 3.

According to the proposed methodology, 30 patients were operated on. The average age was 56 years old, men were 18 (60.0%), women 12 (40.0%). All patients in the early postoperative period underwent a set of examinations, under the supervision in the long-term period, 19 (63.3%) patients remained.

Clinical examples:

Example No. 1. Patient B., aged 77, was admitted with complaints of weakness, shortness of breath, weight loss of 15 kg for 6 months, periodically black feces. Examination at the Central District Hospital at the place of residence was diagnosed with stomach cancer.

On examination: MSCT of the chest organs 03/20/17: focal and infiltrative changes in the lungs were not detected. Signs of emphysema and diffuse pneumosclerosis. MSCT of the abdominal cavity 03/30/17: revealed a total lesion of the stomach tumor without signs of generalization of the process. Endoscopy 04.04.2017: picture of gastric cancer with infiltrative growth in the cardiac section and the body of the stomach. The histological conclusion is low-grade adenocarcinoma of the stomach.

The patient was hospitalized on April 17, 2017 at the Scientific Research and Medical Center for Surgery where gastrectomy, lymphadenectomy D2, and heronastroplasty with the formation of the antireflux valve were performed according to the method described above. The postoperative period was satisfactory, the patient was discharged on the 8th day after the operation.

The histological conclusion: low-grade gastric adenocarcinoma, with the germination of the muscle layer of the stomach wall and invasion of the tissue along the lesser curvature, without metastases in 26 regional lymph nodes and without tumor elements at the edges of the resection. pT3 pN0 (0/26) cM0; M 8480/3; Grade 3; Pn0, L0, V0, R0.

During the control x-ray examination at discharge from 04/28/17: The esophagus passes, is not deformed. Esophagogoyunoanastomosis consistent evacuation is not broken. At the first throat, there is a uniform contrast of the intestinal insert above the valve, after 3-5 minutes the contrast is evacuated through the valve, with a “thread-like trickle” followed by contrast of the duodenum and lower lying sections of the gastrointestinal tract (GIT) (Fig. 4a).

1 year after the operation, he feels well, he observes the diet and diet. He has a good appetite, gained 5 kg in weight since the operation, received 7 courses of chemotherapy. According to the MSCT of the abdominal organs from 05/07/2018 data for relapse, disease progression is not. With FGDS, a month after the operation of 05/29/2017, there were no changes in the esophagus, its mucosa was not changed, the anastomosis was closed, it was free to pass, when it was inflated, it opens up to 15 mm. The type of transplant mucosa is characteristic of a small intestine of normal color with transverse folds. When insufflated with air, the valve opens in the form of a rectangular rhombus, with a narrowing of the intestinal lumen, along the edge there are dense folds in the form of a “half-ring”, almost circular to the circumference of the segment (Fig. 5).

Example No. 2. Patient S., 43 years old, was admitted to the NIICH on 10.25.2016 with complaints of weakness. From the anamnesis in March 2016, total stomach cancer with spread to the bulb of the duodenum, subcompensated stenosis of the output section of the stomach, ascites, dissemination along the peritoneum was revealed. The patient underwent stenting of the stenosis zone, 8 courses of chemotherapy. Against the background of treatment, drug regression, by the decision of the oncological consultation of the patient, surgery is indicated. 10/28/2016 combined gastrectomy with resection of the duodenal bulb, cholecystectomy, left-sided tubovariectomy, eunogastroplasty according to the method described above.

The histological conclusion of 10.29.2016: Low-differentiated adenocarcinoma of the body and the pyloric stomach, sprouting all layers of the organ wall, spreading to subserous connective tissue without signs of invasion of the visceral peritoneum, in the proximal edge of the resection, with the presence of tumor growth with tumor metastases in 12 of the 15 examined lymph nodes by lesser curvature, with metastases in 9 of the 16 examined lymph nodes of the tissue, by greater curvature, with metastasis to the ovary. pT3 pN3b (21/31) pM1 [OTH]; Grade 3, M 8140/3; R1; L1; V1; Pn 0.

The postoperative period was satisfactory, the patient was discharged on the 10th day after the operation. 1 year after surgery, the patient complains of weakness not related to food intake. After surgery, she receives PCT, has gained 4 kg in weight, does not follow a diet, and feels good. During the control X-ray examination, the contrast mass freely passes through the esophagus, the intestinal insert is somewhat enlarged with clear Kerkring folds, although the graft is slightly smoothed in the proximal part where the expansion is traced to the valve, a gas bubble is also noted, which characterizes the valve closure function (Fig. 6a )

After performing contrast insertion after 3-4 minutes, the contrast is evacuated to the duodenum and the initial sections of the small intestine. At the second sip of contrast mass, the picture is similar, contrast fills the insert to the valve and deposits in it (Fig. 6b). After half an hour, the 2/3 graft is filled with contrast (Fig. 6c), and after an hour and a half, only traces of barium in the intestinal segment are noted. Filling of the small intestine occurs evenly, without areas of accumulation, and deposition, which indicates a portioned emptying of the upper gastrointestinal tract.

In the control FGDS, a year after the operation, smoothness of the valve cusps is noted, the mucosa in this area differs little from the mucosa of the intestinal segment, and a persistent narrowing of the transplant lumen (Fig. 7a), which is also preserved during insufflation with air (Fig. 7b), freely passable for apparatus. There is no bile in the esophagus and proximal part of the interposed segment.

All patients remaining under observation in the long-term period showed a delay in the initial evacuation from the proximal interposed intestinal segment up to 3-4 minutes followed by portioned evacuation; during X-ray examination, there were no signs of postoperative reflux esophagitis. When FGDS in the separated period in 2 patients revealed bile in the proximal part of the graft without endoscopic picture of postoperative reflux esophagitis.

Thus, the proposed method of ejunastroplasty with the formation of a valve on the interposed segment of the jejunum prevents the development of postoperative reflux esophagitis and provides portioned evacuation of food from the transplant to the duodenum, which in turn leads to a slowdown in food passage throughout the intestine preventing the development of dumping syndrome.

Claims (1)

The method of jejunastroplasty, including the replacement of the stomach with the small intestinal segment in the isoperistaltic position with the formation of an antireflux valve, characterized in that the small intestinal segment is cut out 25-30 cm long and moved to the bed of the removed stomach, the integrity of the small intestine is restored with a single row anastomosis end to end, after which they form two rows of anastomoses and single-row esophageoyunanastomosis, a valve is formed on the interposed segment of the small intestine between the esophagus and duodenum by dissecting the serous-muscular membrane to the mesenteric edge in two places, followed by suturing of the serous-muscle section of the intestine with gray-serous separate nodal sutures without the muscle layer, then separate nodular gray-serous sutures are placed on the upper and lower edge of the dissected serous-muscular membrane, immersing the intestinal wall with a dissector.

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