RU2734545C1 - Method for eliminating oesophageal wall lesions and digestive tube proximal anastomosis inconsistency - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to abdominal and thoracic surgery. If observing the oesophageal wall lesions and inconsistent sutures of the anastomoses of the proximal digestive tubes, a porous bioinert sponge with pore size of 400–600 mcm is used for aspiration of the pathologically separated body cavity. That is ensured by endoscopic determination of the size of the defect and formation of a sponge sized to match the size and shape of the defect, plus 3 cm extending beyond its edge. A drain tube is inserted into the sponge and fixed by means of surgical units on the proximal and distal ends of the sponge. Then the sponge is soaked with physiologic saline and placed in a soft sealed silicone cover. Its open end is tightened tightly with a suture. Drainage is connected to vacuum pump with negative pressure minus 200 mm Hg, air is removed and freezing sponge soaked with physiologic solution in tight silicone jacket at minus 18 °C for 25 minutes, after which the cover is removed and immediately afterwards the sponge is orally introduced into the digestive tube under endoscopic control, laid on the defect and connected to a pressure of minus 125 mm Hg, wherein every 3 days, only 4–9 times, the sponge is replaced by the similar one.

EFFECT: method considerably reduces the time of manipulation, reduces the mucous membranes injury and enables to install a sponge of the required diameter without limitations, associated with anatomical features of organs, through which it is carried out, significantly increasing the effectiveness of vacuum therapy and reducing the period of medical and social rehabilitation of patients.

1 cl, 1 ex, 4 dwg

Description

The alleged invention relates to the field of medicine, namely abdominal and thoracic surgery, and can be used as an organ-preserving method for treating patients with injuries of the esophagus and incompetence of the sutures of the anastomoses of the proximal digestive tube.

Despite the existing advances in medicine, in the treatment of through defects in hollow organs and incompetence of the anastomoses of the proximal digestive tube, it is often necessary to perform extensive, crippling surgical interventions in which parts of the digestive tube are removed, which is accompanied by high mortality and significantly worsens the quality of life of patients (M. Huber-Lang et al., Easophageal Perforation: Principles of Diagnosis and Surgical Management // Surg. Today. - 2006, pp. 332-340). Damage to the esophagus can occur as a result of vomiting (Boerhaave and Mallory-Weiss syndromes) and external influences - iatrogenic damage during esophagoscopy or bougienage of the esophagus with cicatricial strictures (these causes account for 60% of defects), complications due to improper intubation, injury to the organ wall by sharp food elements ( bones, etc.) and others. The failure of the sutures of the esophageal-small intestinal anastomoses after gastrectomy occurs in 0.8-14.5% (Volkov S.V. - The failure of the esophageal-intestinal anastomosis in patients after typical and combined gastrectomy (clinical and surgical aspects. 2010 - pp. 80-88), mortality ranges from 20 to 64% (Lang N., Piso R., Stukenborg S. et al. Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma Eur J Surg Oncol 2000; 26 (2): p. 168) Lack of esophageal-intestinal anastomoses after operations for esophageal cancer and gastric cancer with transition to the esophagus , develops in 6.3-32.0%, esophageal-gastric - in 1.2-5.91% (Kavaikin A.G., Chichevatov D.A. Inconsistency of the sutures of the esophageal anastomosis after intrapleural esophagoplasty: prognosis and prevention // Povolzhsky oncological bulletin. - 2015. - No. 1.). Mortality in case of failure of the sutures of the esophageal anastomosis is observed in 26.0-35.0% of patients (Alanesi L., Urschel JD Mortality secondary to esophageal anastomotic leak / K. Alanesi, JD Urshel // Ann. Thorac. Cardiovasc. Surg. - 2004 - Vol. 10 (2). - P. 71-75.), Which makes it one of the most formidable complications in thoracic surgery.

Over the past decade, the method of endoscopic vacuum therapy has entered into practice, as one of the most frequently used among minimally invasive ones. To obtain positive results when using this method, the following are preferable: early detection of a defect, a small area of damage, an immediate start of treatment, an adequate blood supply to the tissues and the absence of pronounced septic complications. Vacuum therapy ensures the formation of granulation tissue, significantly reduces the risk of infection of lesions, which promotes accelerated healing of the organ wall defect by secondary intention.

С. Endoscopic vacuum sponge therapy for esophageal defects // Surgical endoscopy. - 2010. - T. 24. - №. 10. - C. 2531-2535.).The vacuum system for endoscopic intracavitary, intraluminal and intracorporeal vacuum therapy is designed for aspiration of liquids (exudate, saliva) and gases. In cases with the treatment of damage to the esophagus and the failure of the anastomoses of the proximal digestive tube, the sponge on the drainage tube acts against physiological negative intrapleural pressure in the direction of the esophageal lumen and, thus, prevents contamination of the mediastinum, chest and abdominal cavities with saliva and exudate and their infection. (Loske G., Schorsch T.,

C. Endoscopic vacuum sponge therapy for esophageal defects // Surgical endoscopy. - 2010. - T. 24. - No. 10. - C. 2531-2535.).

Unlike the treatment of external wounds with this method, with endoscopic vacuum therapy there is no possibility of constant visual and palpation control over the position of the sponge and it is difficult to assess the accuracy of its positioning relative to the organ wall defect and the effectiveness of aspiration of pathological exudate. For full drainage to work, it is required that the sponge is tightly fixed to the walls of the hollow organ and fully closes its defect.

To create a vacuum, a drainage with a sufficient number of holes (depending on the size of the sponge) is usually used, to the end of which a bioinert sponge with open pores is fixed with two edge sutures. For the treatment of through defects of hollow organs, a sponge with a length of 5.0 to 10 cm with a diameter of 1.5-3.0 cm is used.Pore sizes from 200 μm to 1000 μm are preferred, and a sponge with a pore size of 400 to 600 works most effectively μm (Wedemeyer J. et al. Endoscopic vacuum-assisted closure of upper intestinal anastomotic leaks // Gastrointestinal endoscopy. - 2008. - T. 67. - No. 4. - P. 708-711.).

Clinical studies have revealed the main disadvantage of this method - the difficulty of passing the sponge through the anatomical narrowing of the esophagus, which does not allow to install the sponge of the required "large" diameter and length. Considering that the most important requirement for effective vacuum therapy is the tight fit of the sponge to the wall of the hollow organ with full overlap of the defect, it is often extremely difficult to pass the sponge on the drainage through the pharyngeal-esophageal sphincter and physiological narrowing of the esophagus. The efforts that must be made when holding the sponge often lead to trauma to the pharynx and esophagus, as well as to an increase in the defect in the esophageal wall or in the area of anastomotic suture failure. The technical difficulties with large diameter sponges make this procedure risky and sometimes almost impossible.

The known method of through tension, which consists in installing a sponge on the drainage into the esophagus after imposing a percutaneous endoscopic gastrostomy on the anterior wall of the stomach (Glatz T. et al. Vacuum sponge therapy using the pull-through technique via a percutaneous endoscopic gastrostomy to treat iatrogenic duodenal perforation // Endoscopy. - 2015. - T. 47. - No. S 01. - S. E567-E568). A string is inserted through the gastrostomy tube into the digestive tube, then, using a gastroscope, it is excreted per os. The string is connected to the distal end of the sponge, after which, by pulling the string, the sponge is installed in the area of the defect.

Disadvantages: the need to form a gastrostomy, which significantly complicates the method, increases trauma and increases the risk of purulent-septic complications; the diameter of the inserted sponge is limited by the diameter of the lumen of the digestive tube and is not suitable for the treatment of insolvency of esophagogastroanastomoses and formed post-traumatic cavities; not suitable for the treatment of esophagoenteroanastomoses.

For the closest analogue, the method of installing a sponge on the drainage using a tubular pusher was adopted (Vacuum system and endoscopy arrangement for endoscopic vacuum therapy, Lohmann and Rauscher GmbH and Co KG, 2015). The pusher has a tube into which a rod is inserted to guide and place the sponge, an endoscope. The movement of the pusher is carried out along these guiding elements. With the help of a pusher, the sponge on the drainage tube is moved distally and at the place of placement is separated from the guide element. The pusher is equipped with a longitudinal slot, so that the sponge can be attached to the endoscope from the side or removed at any time during the procedure.

Disadvantages: high invasiveness of the method; lack of reliable fixation of the sponge with a high risk of its displacement; a long period of medical and social rehabilitation of the patient.

The essence of the invention lies in the fact that the dimensions of the defect are determined endoscopically and a sponge is formed with a size corresponding to the size and shape of the defect, plus 3 cm extending beyond its edge, a drainage tube is inserted into the sponge and fixed using surgical nodes at the proximal and distal ends of the sponge, then the sponge is moistened with saline and placed in a soft sealed silicone cover, its open end is tightly tightened with a thread, the drain is connected to a vacuum pump with negative pressure minus 200 mm Hg, air is removed and the sponge moistened with saline is frozen in a sealed silicone cover at a temperature minus 18 ° C for 25 minutes, after which the cover is removed and immediately after that the sponge is orally inserted into the digestive tube under endoscopic control, placed on the defect and connected to a pressure of minus 125 mm Hg, and every 3 days, only 4 -9 times, the sponge is replaced with a similar one.

Tasks. To reduce the number of traditional highly traumatic surgical interventions in case of wall damage and leakage of the anastomoses of the proximal digestive tube, by using the method of endovacuum therapy in all patients for whom this manipulation is indicated without restrictions with technical difficulties in sponge delivery. Ensure complete closure of large defects in the wall of the hollow organs of the proximal digestive tube using a minimally invasive method of therapy. To minimize the duration of manipulation and the invasiveness of installing a sponge on a drainage tube in hard-to-reach sections of the digestive tube.

The technical result is to reduce the trauma of the method of treating damage to the esophageal wall and the failure of the anastomoses of the proximal parts of the digestive tube due to a decrease in the volume of the sponge in the case by applying negative pressure and freezing, reducing the duration of the manipulation of the sponge installation, reducing the postoperative period, accelerating the medical and social rehabilitation of the patient, reducing the number of open surgical interventions in the treatment of damage to the esophageal wall and leakage of the anastomoses of the proximal digestive tube, the possibility of therapy with the size of the defect, in which effective endovacuum therapy is impracticable by other methods.

The implementation of the method for eliminating damage to the esophageal wall and the failure of the anastomoses of the proximal digestive tube is performed using a vacuum pump with the ability to adjust the power, an elastic drainage tube and a bioinert sponge, a soft sealed silicone cover, suture material, an endoscope.

The method is carried out as follows: Preliminarily, an endoscopic assessment of the shape and size of the digestive tube defect is performed. Further, on the basis of endoscopy data, a bioinert sponge with a pore size of 400-600 μm is given a shape and size corresponding to a defect in the wall of a hollow organ and its diameter in the area where it will be installed, taking into account the capture of 3 cm of adjacent healthy tissue. The distal end of the elastic drainage tube is inserted into the sponge, on which the sponge is fixed with a surgical interrupted suture at the distal and proximal edges. Next, the sponge, attached to the drainage tube, is moistened with saline and placed in a soft sealed silicone cover, squeezed by connecting the proximal end of the drainage tube to a vacuum pump at negative pressure (-200 mmHg) and the open end of the cover is tightly tightened around the drainage tube with a simple surgical assembly, disconnect the vacuum pump and freeze the drain tube with a compressed sponge in a sheath in a freezer at -18 ° C for 25 minutes. At the same time, the initial diameter of the sponge is reduced by 50-60%, which subsequently makes it possible to pass the sponge with drainage through the pharynx and anatomical narrowing of the esophagus almost unhindered. After being removed from the silicone cover by dissecting it with a scalpel, the sponge on the drainage tube in the frozen state is brought to the area of damage to the esophageal wall or anastomotic failure under endoscopic control. Under the influence of the natural temperature of the organ, the sponge spreads out and completely covers the defect zone. A vacuum pump (-125 mm Hg) is connected to the distal end of the drainage tube. The sponge on the drainage tube is replaced with a similar one every 3 days 4-9 times. The method was tested on 23 patients for two years in the conditions of the 1st surgical department of the Scientific Research Institute - Regional Clinical Hospital No. 1 named after Professor S.V. Ochapovsky "of the Ministry of Health of the Krasnodar Territory.

In 87% of patients, including elderly and debilitated patients with severe concomitant diseases, it was possible to achieve complete healing of the defect and rapid medical and social rehabilitation. During the clinical application of the method of therapy, there were no difficulties in installing a sponge on the drainage tube, which, taking into account the high clinical efficiency, makes its use one of the most promising methods of organ-preserving treatment of damage to the esophageal wall and the failure of the anastomoses of the proximal parts of the digestive tube. There were no postoperative complications during the clinical application of the proposed method. The developed method has proven in practice the reliability and the ability to quickly restore the integrity of the walls of the proximal digestive tube.

Example 1

Patient, 44 years old.

Diagnosis: Cicatricial stricture of the lower third of the esophagus. Decompensated esophageal stenosis. Condition after endoscopic bougienage of the esophagus. Cachexia.

Complications: Perforation of the wall of the lower third of the esophagus. Mediastinitis.

The patient underwent three staged endoscopic bougienage of the esophagus for cicatricial esophageal stricture at intervals of 2 days. After the third planned bougienage, the patient had an episode of a single vomiting, after which he felt sharp pains behind the sternum. The patient underwent computed tomography of the chest organs with oral contrast - a defect in the wall of the lower third of the esophagus with leakage of contrast agent was revealed. At the council, it was decided to carry out conservative treatment by placing a sponge on a drainage tube with negative pressure.

Operation: under endotracheal anesthesia under aseptic conditions, fibroesophagogastroscopy was performed, a linear defect of the right esophageal wall 25 mm long with a large cavity in the mediastinum (20 × 30 mm) with fibrinous-necrotic masses in the bottom region was revealed 37 cm from the incisors (Fig. 1).

Under the control of fibroesophagogastroscopy, a nasointestinal probe was installed in the duodenum for enteral nutrition. After preliminary preparation of the sponge on the drainage tube in accordance with the size of the defect, plus 3 cm extending beyond its edge, the sponge was moistened with saline, placed in a soft sealed silicone cover, its open end was tightly tightened with a thread, the drain was connected to a vacuum pump with negative pressure minus 200 mm Hg, the air was removed and the sponge moistened with saline was frozen in a sealed silicone case at minus 18 ° C for 20 minutes, after which the sponge was removed from the case (frozen 2.2 cm in diameter), brought under the endoscopic control and laid on the defect. Under the influence of the natural temperature of the mucous membranes (+ 38 ° C), the sponge probe expanded to a size of 6 cm in diameter and completely filled the defect zone. Subsequently, the procedure for replacing the sponge probe was carried out according to the same principle 9 times with an interval of 3 days. On the 27th day, a sponge extraction procedure with drainage was performed, after which an endoscopic assessment of the esophagus revealed healing of the defect (Fig. 2).

The average installation time of the sponge on the drainage tube was reduced by 15-20 minutes in comparison with the previous methods, the trauma rate during installation decreased to almost 0%, it was possible to completely cover the defect zone with each installation and change of the sponge on the drainage tube.

There were no complications in the immediate and late postoperative period.

On the 34th day, a control computed tomography with oral administration of a water-soluble contrast showed a good permeability of the contrast into the stomach, no leakage of the contrast agent beyond the lumen of the esophagus and stomach was found.

1 month after applying the method of therapy using a sponge on a drainage tube with negative pressure, the patient completely switched to independent enteral nutrition per os without restrictions and after 2 months gained 6 kg of body weight. Thanks to the presented method of therapy, it was possible to achieve complete closure of the wall defect, avoiding resection operations, and to improve the patient's quality of life. Example 2: Patient, 79 years old

Diagnosis: С-r of the cardiac part of the stomach pT3N0M0, IIA st., Class 2. Group Complications: Failure of esophagoenteroanastomosis The patient underwent a laparoscopic robotic-assisted gastrectomy with D2 lymphadenectomy for C-r of the cardiac stomach. In the postoperative period, the patient was in the intensive care unit, against the background of improving his health, he was transferred to the general ward. On the 13th day after the operation, against the background of general well-being, the patient developed pain syndrome. An emergency computed tomography with oral contrast enhancement revealed the failure of the esophagoenteroanastomosis with contrast agent leakage. At the council, it was decided to conduct conservative treatment by installing a sponge on the drainage with negative pressure.

Operation: under endotracheal anesthesia under aseptic conditions, fibroesophagogastroscopy was performed, 40 cm from the incisors, a defect in the left wall of the digestive tube was revealed in the area of esophagoenteroanastomosis 10 mm long with a cavity in the mediastinum (10 × 10 mm) with fibrinous-necrotic masses in the bottom.

After preliminary preparation of the sponge on the drainage tube in accordance with the size of the defect (Fig. 3), plus 3 cm beyond its edge, the sponge was moistened with saline, placed in a soft sealed silicone cover, its open end was tightly tightened with a thread, the drain was connected to a vacuum pump with negative pressure of minus 200 mm Hg, the air was removed and the sponge moistened with saline was frozen in a sealed silicone case at minus 20 ° C for 25 minutes, after which the sponge was removed from the case (frozen 1.2 cm in diameter (Fig. 4)), brought under endoscopic control and laid on the defect. Under the influence of the natural temperature of the mucous membranes (+ 38 ° C), the sponge expanded to a size of 3 cm in diameter and completely filled the defect zone. Subsequently, the procedure for replacing the sponge was carried out according to the same principle 4 times with an interval of 3 days. On the 12th day, a sponge extraction procedure with drainage was performed, after which an endoscopic assessment of the esophagus revealed healing of the defect.

3 weeks after applying the method of therapy using a sponge on a drainage with negative pressure, the patient completely switched to independent enteral nutrition per os without restrictions, and gained 4 kg of body weight within 2 months. Thanks to the presented method of therapy, it was possible to achieve complete closure of the wall defect due to the failure of the sutures of the esophagoenteroanastomosis.

A method has been developed for endoscopic vacuum therapy of damage to the esophagus wall and failure of the anastomoses of the proximal digestive tube using a sponge on a drainage with negative pressure, which facilitates delivery of a sponge with drainage to the area of a defect in the wall of the digestive tube due to preliminary diameter reduction and freezing of the sponge on the drainage tube ... This method reduces the frictional force of the sponge against the walls of the pharynx and esophagus during installation, significantly reduces the time of manipulation, reduces trauma to the mucous membranes and allows you to install a sponge of the required diameter without restrictions associated with the anatomical features of the organs through which it is passed, thereby significantly increasing the efficiency of therapy and shortening the period of medical and social rehabilitation of patients.

Claims (1)

A method of treating damage to the esophageal wall and the failure of the anastomoses of the proximal digestive tube, including the use of a porous bioinert sponge with a pore size of 400-600 microns for aspiration of pathological discharge through the cavity of the organ, characterized in that endoscopically determine the size of the defect and form a sponge with a size corresponding to the size and the shape of the defect, plus 3 cm beyond its edge, a drainage tube is inserted into the sponge and fixed with the help of surgical nodes at the proximal and distal ends of the sponge, then the sponge is moistened with saline and placed in a soft sealed silicone cover, its open end is tightly tightened with a thread , the drain is connected to a vacuum pump with a negative pressure of minus 200 mm Hg, air is removed and the sponge moistened with saline is frozen in a sealed silicone case at minus 18 ° C for 25 minutes, after which the cover is removed and immediately after that the sponge is orally inserted into the digestive tube under endoscopic control, placed on the defect and connected to a pressure of minus 125 mm Hg, and every 3 days, only 4-9 times, the sponge is replaced with a similar one.

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