RU2718496C1 - Method for surgical management of iii-iv cardiac achalasia, complicated by s-, l-shaped oesophageal deformation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to abdominal surgery. Wall-to-wall mobilization and lower thoracic oesophagus lowering is performed to its moderate tension state. Seromuscular membrane of the anterior and posterior walls of the stomach is incised at 3.5 cm from the cardia. From the edge of the incision, the seromuscular lining of the stomach and the lowered oesophagus are removed in the form of a "stocking" for 16 cm. Demuscularization area of the mucous-submucosal layer is invaginated into the gastric lumen by means of 6 interrupted sutures applied along a line of osseous membrane and stomach contact. On the anterior wall of stomach at 14 mm below the sutures a seromuscular flap with length of 45 mm, width of 20 mm with axial circulation in the region of the stomach bottom is cut out. Submucosal area after the flap cutting is closed. Seromuscular flap is passed between the left wall of the oesophagus and the stomach bottom to the posterior wall with fixation of the flap on the anterior wall of the stomach below its base in a phase of moderate tension.

EFFECT: method enables improving the clinical results of severe cardiac achalasia, eliminating oesophageal enlargement and deformity, restoring its shape and tone, as well as the closing and reflux functions of the oesophageal-gastric junction.

1 cl, 1 ex, 6 dwg

Description

The invention relates to medicine, namely to surgery and can be used in the surgical treatment of achalasia of cardia of the III-IV stage with S-, L-shaped deformation of the esophagus.

There are many methods for the surgical treatment of severe forms of achalasia of the cardia with decompensation of the motor-evacuation function and a change in the anatomy of the esophagus, ranging from minimally invasive interventions, for example, Heller surgery, to extremely radical ones - demucosis or extirpation of the esophagus. Experience shows that Geller’s surgery is ineffective due to frequent relapses of the disease. Extirpation and demucosis of the esophagus, despite their radical nature, are associated with dangerous purulent complications, which can often cause the patient's death in the early postoperative period.

Closest to the technical solution to the claimed method is a method for the surgical treatment of achalasia of the cardia of the III-IV stage (patent No. 224217 of 02.25.2003 "Method for the surgical treatment of achalasia of the cardia of the III-IV stage"; authors: Koshel A.P., Zherlov G.K. ., Zykov D.V., Raish D.V., Ryzhov A.I., Artemenko M.V.), including the mobilization and demuscularization of the narrowed cardia and 1.5 cm proximal and distal to the narrowing point on the esophagus and stomach, and also intussusception by nodal sutures of the demusculated submucosal-mucous region in the form of a valve.

This method has several significant disadvantages. When performing the operation, the lower thoracic esophagus is not reduced, which does not affect the expansion and deviation of the esophagus. Demuscularization of a narrowed cardia, as well as one and a half centimeters adjacent to it on the esophagus and stomach, is insufficient for severe forms of cardiac achalasia associated with severe muscular hypertrophy and decompensation of motor-evacuation function. When creating the valve, the formation of the His angle does not occur and the natural course of the muscle fibers of the cardiac sphincter is not restored. In addition, the formed valve narrows the lumen by stitching over it the hypertrophied muscle layer of the esophagus with the serous-muscular membrane of the stomach 1.5 cm from the cardia, where the lumen of the stomach is not wide enough. Thus, this method cannot be applicable for the surgical treatment of severe forms of achalasia of the cardia with decompensation of motor-evacuation function due to the high probability of relapse of the disease.

The problem solved by the proposed invention is the development of a radical method for the treatment of achalasia of cardia of the III-IV stage, complicated by S-, L-shaped deformation of the esophagus by eliminating the expansion and curvature of the esophagus, restoration of its shape and tone, as well as the closure and areflux function of the esophageal-gastric transition.

A new technical result is achieved by the method of surgical treatment of achalasia of the cardia of the III-IV stage, complicated by S-, L-shaped deformation of the esophagus consisting in mobilization and demuscularization of the esophagus-gastric transition around the narrowing zone, the formation of an invagination valve by immersing the demusculated mucous-submucous layer with nodular sutures, characterized the fact that by traction for the turnstile, parietal mobilization and lowering of the lower thoracic esophagus to a state of moderate tension are performed; circularly dissecting the serous-muscular membrane of the anterior and posterior walls of the stomach 3.5 cm from the cardia; from the edge of the incision, the serous-muscular membrane of the stomach and the reduced esophagus are removed in the form of a “stocking” for 16 cm; the demuscularized section of the mucous-submucosal layer is invaginated into the lumen of the stomach with the help of 6 nodal sutures imposed along the contact line of the muscular membranes of the esophagus and stomach; on the front wall of the stomach 14 mm below the sutures, a non-free serous-muscular flap is cut out 45 mm long, 20 mm wide with an axial type of blood circulation in the bottom of the stomach; the submucosal pad after suturing the flap is sutured; a serous-muscle flap is carried out between the left wall of the esophagus and the bottom of the stomach on the back wall with the fixation of the flap on the front wall of the stomach below its base in the phase of moderate tension.

New in the invention is that by traction for the turnstile, parietal mobilization and reduction of the lower thoracic esophagus to a state of moderate tension are performed; circularly dissecting the serous-muscular membrane of the anterior and posterior walls of the stomach 3.5 cm from the cardia; from the edge of the incision, the serous-muscular membrane of the stomach and the reduced esophagus are removed in the form of a “stocking” for 16 cm; the demuscularized section of the mucous-submucosal layer is invaginated into the lumen of the stomach with the help of 6 nodal sutures imposed along the contact line of the muscular membranes of the esophagus and stomach; on the front wall of the stomach 14 mm below the sutures, a non-free serous-muscular flap is cut out 45 mm long, 20 mm wide with an axial type of blood circulation in the bottom of the stomach; the submucosal pad after suturing the flap is sutured; a serous-muscle flap is carried out between the left wall of the esophagus and the bottom of the stomach on the back wall with the fixation of the flap on the front wall of the stomach below its base in the phase of moderate tension.

The developed method allows you to restore the anatomical shape and tone of the esophagus by eliminating the bag-like expansion and loop formation of the intrathoracic part of the esophagus. Due to demuscularization and contraction of the serous-muscular layer, an extended section of the exposed submucosa is created along the edge of the resection: 10 cm on the esophagus and 6 cm on the stomach. The mechanisms of restoration of the tone of the atonic esophagus are associated with tension and straightening of the intrathoracic part of the esophagus during its reduction and invagination of the demusculated submucosal-mucous layer throughout its entire length (at least 16 cm) into the lumen of the stomach. A positive effect and prevention of relapse is achieved by extensive demuscularization of the reduced segment of the esophagus and the upper third of the stomach, as well as by the wide anastomosis of the muscular membranes of the esophagus and the upper third of the stomach. In fact, the hypertrophied muscular membrane of the esophagus is stretched with 6 nodal sutures when adapting it along the edge of the serous-muscular membrane of the upper third of the stomach, the diameter of which is at least 7 cm in this area. Creating a valve from the mucous-submucous layer, which is reduced to 3 due to tissue retraction, 5 cm, in combination with compression by a serous-muscular flap in the region of the left, back and right walls of the esophagus-gastric junction, provides restoration of the closure and areflux function.

Clinical example

Patient Sh., 62 years old, was treated at the General Surgery Clinic of the FSBEI, Siberian State Medical University with a diagnosis of the underlying disease: cardiac achalasia of the III stage, subcompensation stage, S-shaped esophagus. Concomitant pathology: coronary heart disease, angina pectoris (FC2), post-infarction cardiosclerosis (2004); chronic heart failure IIA; hypertension III art., risk 4; chronic obstructive pulmonary disease, remission stage.

He was hospitalized in a planned manner for surgical treatment with complaints of dysphagia in the form of difficulty in passing the food lump, accompanied by discomfort, sometimes pain behind the sternum, belching, bad breath, weight loss. From the anamnesis it is known that he considers himself sick for more than 5 years, when he began to note the difficulty in passing food after swallowing. To facilitate swallowing, the food lump was washed down with a small amount of water. Sometimes it caused vomiting when the food lump was delayed, accompanied by a feeling of overflow or bursting pain behind the sternum. The disease developed slowly, the patient was monitored by a gastroenterologist at the community clinic, periodically underwent examination and outpatient treatment. Over the past 2.5 years, he lost 40 kg (before the disease, his body weight was 105 kg; currently weighs 65 kg). In connection with the progression of the disease, the patient was referred to the General Surgery Clinic for surgical treatment.

Instrumental research data.

X-ray of the esophagus and stomach from January 22, 2018. When examining the chest, the middle shadow expands to the right, air and fluid level in the esophagus are visible, which is confirmed when taking the first pharynx of contrasting suspension. The act of swallowing is not broken. The esophagus has an S-shape, significantly expanded throughout - fasting 30-35 mm, with a contrast study - 50-60 mm, filled with food debris and mucus, ending in a cone-shaped narrowing. The cardia is narrowed to about 7-9 mm, the first sip passes after 6 minutes from the start of the study, then a long spasm and the next sip passes after 9-10 minutes. In a delayed study after 2 hours and 4 hours, 2 / 3-1 / 2 of the contrast is preserved in the esophagus. The contractile function of the esophagus is severely impaired. Relief folds cannot be seen even after 3.5 hours. At the beginning of the study, the gastric gas bubble is not visible at all. Persistent narrowing is maintained at the level of the cardia, the maximum defined width is 13 mm, longitudinal folds are visible here, the contours of the esophagus are smooth and smooth, but at the level of the subcardia and lesser curvature, fragments of the wall with undercut, uneven contours are not clearly contrasted. Fragments of a contrasting suspension in the form of flakes in the contents of the stomach are visible in the stomach, the contours of the walls, and the relief are not determined. The stomach is small, after 4 hours traces of contrast in the duodenum are visible. It is not possible to judge the size and condition of the stomach, duodenum. After 24 hours, there is no contrast suspension in the esophagus, but its pronounced expansion and the presence of air and fluid on an empty stomach remain. The entire contrast suspension is distributed throughout the colon to the sigmoid. Conclusion: Achalasia of the cardia of the III art., Stage of subcompensation. Esophagitis, suprastenotic expansion of the esophagus with S-shaped deformation (Fig. 1).

Esophagogastroduodenoscopy with endosonography of the esophagus (OLYMPUS EVISEXERA - III, Olympus EU-ME 1, OLYMPUSGIFH-180, Olympus UM-DP20-25R) dated 04.25.2018. Examination using a narrow spectrum (NBI). Entrance to the esophagus is free. In the lumen of the remnants of food. The esophagus of the upper third is expanded to 4-4.5 cm, we pass to the lower third, where the lumen is slit-like due to persistent spasm. With a little boost, I manage to get to the cardia. The mucous is whitish pink with areas of hyperkeratosis. The zone of transitional epithelium is clear, even, located 40 cm from the incisors. At the time of examination, the hiatal opening of the diaphragm closes completely, corresponds to the zone of the transitional epithelium. The stomach straightened with air, the walls are elastic, in the lumen a small amount of transparent liquid. Peristalsis is traced evenly in all departments, in the antrum in circular waves. The gastric mucosa is pink, shiny, the patchy pattern is clear, the gastric fields are not expanded, the folds are correct, they straighten freely. With retroflexion, the mucosa of the cardia completely covers the tube of the gastroscope. The angle is not deformed. In the prepiloric part of the antrum on the lesser curvature, erosion on an elevated base is 9 × 10 mm, with a recessed area in the center, with hematin (biopsy 1 fr. + 1 tbsp.). Similar erosion on large curvature. The gatekeeper is closed, we pass freely. A duodenal bulb of sufficient volume, on the upper wall of the brunneroma 6 × 7 mm, on the lower wall of the brunneroma 6 × 7 mm with fibrin in the center. The mucosa of the duodenal bulb is hyperemic, with acute erosion of 2-3 mm, covered with fibrin (biopsy 2 fr. + 2 tbsp.). The mucous horseshoe is pink, velvety, the relief corresponds to the small intestine. At the time of inspection in the lumen of the duodenum bile. Peristalsis is weakened. Large duodenal nipple in a typical location, not changed. In conclusion, an endosonography of the esophagus was performed. The endoscope tube was inserted into the esophagus, the lumen was filled with water, the walls were scanned with a sensor with a frequency of 20 MHz. In the upper third, the wall is uniformly five-layer with a thickness of 3.2 mm, a clear differentiation into layers. In the lower third, the layers also differentiate clearly, but there is a thickening of the esophagus wall up to 8.2 mm due to hypertrophy of the muscle layer up to 6.6 mm. Conclusion: echo - and endoscopic signs of achalasia of the cardia stage III. Focal atrophy of the gastric mucosa. Erosive-hyperplastic gastropathy. Brunneromas and erosion of the duodenal bulb.

In a planned manner, on 03.10.2018, under general anesthesia, laparotomy, reduction and demuscularization of the lower thoracic and abdominal parts of the esophagus and upper third of the stomach with invagination of the demuscularized mucous-submucous layer, the formation of a muscle loop around the esophageal-gastric junction were performed. Verkhnesomedinaya laparotomy. Seagal expander installed. The ARC 350 BOWA Tissue Seal PLUS ligator performed parietal mobilization of the cardia and subcardia of the stomach, abdominal and diaphragmatic segments of the esophagus. On examination, starting from the cardia of the stomach with a transition to the abdominal esophagus, a rigid section of narrowing 27 mm long is determined, which passes into an expanded esophagus tube up to 42 mm with a thickened wall. At the esophageal-gastric junction, a turnstile-holder was carried out. By pulling up the turnstile, the mobilization and lowering of the lower thoracic esophagus to the state of moderate tension was continued. The serous-muscular membrane on the anterior and posterior walls of the stomach, 3.5 cm from the cardia, is circularly dissected. Using scissors and an electric knife, precision removal in the form of a “stocking” of the serous-muscular membrane of the upper third of the stomach and hypertrophied muscle layer of the reduced esophagus was performed over 16 cm (Fig. 2). The demuscularized area of the mucous-submucosal layer is invaginated into the lumen of the stomach by alternately applying and tying 6 nodal sutures along the contact line of the muscular membranes of the esophagus and stomach. On the front wall of the stomach 14 mm below the sutures, a non-free serous-muscular flap was cut 45 mm long, 20 mm wide with an axial type of blood circulation in the bottom of the stomach. The submucosal site is sutured. A sero-muscular flap was made between the left wall of the esophagus and the bottom of the stomach on the back wall and was fixed by interrupted sutures on the front wall of the stomach below its base in the phase of moderate tension (Fig. 3). A tubular drainage is installed to the area of the esophageal opening of the diaphragm through a puncture in the right hypochondrium. Layer closure of the surgical wound.

In the postoperative period, healing by primary intention. From the first day, the patient eats liquid food, from the second day a sparing diet is prescribed. Motor evacuation disorders were not noted. The patient was discharged on October 08, 2018 in satisfactory condition under the supervision of a surgeon and gastroenterologist at the polyclinic in the community.

Examined 3 months after surgery. He does not follow a diet, there is no dysphagia. According to fluoroscopy data from 01/28/2019, the restoration of the shape and tone of the esophagus, as well as the closure and areflux function of the esophageal-gastric transition (Fig. 4) was noted. Sack-like expansion of the esophagus and S-shaped deformity was not noted. In the area of the esophageal-gastric anastomosis, an invagination valve 3 cm high is visible (Fig. 5). Between the left wall of the esophagus and the bottom of the stomach, the edge of the muscle flap is determined in the form of a constant zone of elastic compression varying in width from 8-9 mm to 11-12 mm during the passage of portions of contrast medium (Fig. 6). In the position of Trendelenburg lying on the back, gastroesophageal reflux was not found, the passage of barium into the stomach is not broken, it occurs in portions.

Thus, the developed method for surgical treatment of achalasia of cardia of the III-IV stage with S-, L-shaped deformation of the esophagus is an effective and safe method for the treatment of severe forms of the disease, allows you to restore the shape and tone of the esophagus, as well as the closure and areflux functions of the esophagus transition, at the same time, avoid complications and reduce the treatment time for patients due to new operational techniques.

application

Figure 1. Achalasia of the cardia of the III century, S-shaped esophagus of the patient Sh.

Figure 2. Demuscularization of the reduced esophagus and stomach of patient S.

Figure 3. The completed view of the operation of the patient Sh.

Figure 4. Restoration of the form and tone of the esophagus of patient C. 3 months after surgery

Figure 5. The invagination zone of the demusculated segment of the esophagus and stomach of patient C. 3 months after surgery

Figure 6. The area of compression of the flap at the time of passage of the contrast mass from the esophagus to the stomach

Claims (1)

A method of surgical treatment of achalasia of the cardia of the III-IV stage complicated by S-, L-shaped deformation of the esophagus, which consists in mobilizing and demusculating the esophageal-gastric transition around the narrowing zone, forming an invagination valve by immersing the demusculated mucous-submucous layer with interrupted sutures, characterized in that by traction for the turnstile, parietal mobilization and reduction of the lower thoracic esophagus to a state of moderate tension are performed, and serous-muscular tissue is circularly dissected a point of the anterior and posterior walls of the stomach 3.5 cm from the cardia, from the edge of the incision, the serous-muscular membrane of the stomach and the esophagus are removed in the form of a “stocking” for 16 cm, the demuscularized section of the mucous-submucous layer is invaginated into the lumen of the stomach using 6 - nodal sutures imposed along the contact line of the muscular membranes of the esophagus and stomach, on the anterior wall of the stomach 14 mm below the sutures, a non-free serous-muscular flap is cut out with a length of 45 mm, a width of 20 mm with an axial type of blood circulation in the fundus ka, submucosal pad after cutting out a flap sutured, sero-muscular flap is performed between the left bottom wall of the esophagus and stomach to the back wall with the fixation of the flap on the front wall of the stomach below its base in moderate tension phase.

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