RU2760469C2 - Method for prevention of empty pelvis syndrome by using uterine body transposition after radical surgery for radial injuries of the iv degree of rectal intestine - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to gynecological oncology. After the resection stage, the body of the uterus with the appendages is rotated and placed on the bottom of the small pelvis. Further, the body of the uterus is ixed by stitching its lateral surfaces to the soft tissues of the lateral walls of the small pelvis with separate interrupted sutures. Then the skin of the perineum is sutured tightly with the installation of two drains into the small pelvis through the counterpertures of the right and left gluteal regions. Hemostasis is performed and the anterior abdominal wall is sutured in layers.

EFFECT: method allows eliminating complications associated with “empty” pelvic floor syndrome by filling the pelvic space after eviscerations.

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Description

The invention relates to medicine, namely to oncology during the surgical treatment of malignant neoplasms or late radiation damage to the pelvic organs.

In the Russian Federation, malignant tumors of the pelvic organs account for about 30%. Surgery, radiation therapy and their combination remain the main methods of treatment for patients with this pathology. Surgical treatment is the method of choice for relapses of pelvic organ disease in patients who have previously undergone radiation therapy, as well as in patients with grade IV local radiation injuries. The scope of the surgical aid involves the implementation of an aggressive intervention on the pelvic organs, which consists in complete or partial evisceration followed by the formation of a cavity. This method is used in the treatment of local relapses as a radical treatment, as well as in the presence of extensive locally advanced tumors in combination with distant metastases, which is palliative in nature. In cases of exceeding the tolerant doses as a result of irradiation, some patients develop local radiation injuries of varying severity. The most formidable complication of radiation therapy is the formation of fistulas between the pelvic organs, extensive ulcers of the rectum and bladder, which significantly reduce the quality of life, forcing patients to suffer and seek any way to solve the problem. In addition, profuse, difficult-to-stop bleeding from hollow organs, accompanied by severe anemia, is a direct threat to life and sometimes requires urgent intervention. In this situation, not only combined resection of the pelvic organs is performed, but also their complete removal. Ultimately, after a successful evisceration, an empty space remains, which provokes dislocation and filling of the small intestine with loops of the pelvic cavity, followed by the formation of fibrosis and inflammation of the soft tissues. As a result of such a transformation, at various stages of the postoperative period, the development of small bowel obstruction, fistulas and perineal hernia is possible.

Syndrome of "empty" small pelvis is described in the journal "Oncogynecology", No. 4'2016, Syndrome of an empty small pelvis after pelvic exenteration // Eliseev Denis Eduardovich, Alekseev Boris Yakovlevich, Ogay Dmitry Sergeevich.

Also known is the method of filling the space of the small pelvis, this is the formation of a VRAM-flap on the feeding pedicle (Korotkov V.A., Petrov L.O., Kasymov M.R. (case study) Andrology and Genital Surgery 2020; 21 (2): 77-82). Cut out a musculocutaneous flap of the rectus abdominis muscle with fixation to the soft tissues of the perineum. However, the disadvantage of this method is that the cut out flap does not fully replace the “empty” space of the small pelvis.

Various synthetic absorbable and non-absorbable materials are also used: vicryl, teflon, gore-tex, polypropylene. A mesh fixed in the form of a hammock at the level of the entrance to the small pelvis, which separates the intestinal loops from the pelvic cavity and holds them above the pelvis (A New Proposal of Pelvic Floor Reconstruction Using Biosynthetic Mesh after Abdominoperineal Radical Surgery in Gynecological Cancer: A Case Series. Begoña Díaz de-la-Noval, I. Zapardiel, +3 authors M. Tejeda. Published 2017. Medicine). Non-absorbable meshes are convenient as a strong diaphragm, but they cannot be used in isolation, as they provoke adhesion of the intestinal loops. By preventing translocation and adhesion of small intestine loops, synthetic meshes do not solve the problem of "empty" space.

Also used are breast implants (Empty pelvis syndrome: the use of breast prosthesis in the prevention of complications. F. Carboni. O. Federici. M. Giofre '. S. Zazza. M. Valle. First published: 22 June 2019), which Foley catheters are inserted into the pelvis (Use of Inflated Foley Catheters to Prevent Early Empty Pelvis Complications Following Pelvic Exenteration. NICOLAE BACALBASA, DANA TOMESCU and IRINA BALESCU. Anticancer Research October 2015, 35 (10) 5543-5546). The replacement of the small pelvis of the cecum is used (Empty pelvis syndrome: the use of breast prosthesis in the prevention of complications. F. Carboni. O. Federici. M. Giofre '. S. Zazza. M. Valle. First published: 22 June 2019) ...

However, all known methods have one drawback - the space of the small pelvis after evisceration is not completely replaced, which leads to an increase in the frequency of complications in the form of a syndrome of “empty” small pelvis.

The closest is the method of filling the pelvic space by transposition of the greater omentum into the operation area (Frasson M., Flor-Lorente B., Carreno O. Reconstruction techniques after extralevator abdominoperineal rectal excision or pelvic exenteration: meshes, plasties and fl aps. Cir Esp. - 2014 Mar; 92 Suppl 1: 48-57). The technique of omentoplasty consists in mobilizing the omentum from the transverse colon and the greater curvature of the stomach, followed by bringing the greater omentum into the pelvic cavity and fixing it to the walls of the pelvis and the pelvic floor with separate sutures. The omental flap, filling the pelvic cavity, eliminates the "dead" space, covers the pelvic walls devoid of peritoneal cover, preventing adhesion of the small intestine loops. In addition, the greater omentum, being a well-supplied organ, improves reparative processes in the pelvic cavity, reduces the likelihood of hematoma and lymphocele formation in the pelvic cavity.

However, this method is sharply limited by the anatomical features of the structure of the greater omentum, its involvement in the adhesive process after surgery or performed omentectomy, limit the use of this method.

The technical result of the proposed invention is the elimination of complications associated with the syndrome of "empty" pelvic floor by filling the pelvic space after eviscerations.

The indicated technical results are achieved due to the fact that, as in the known method, the resection stage and the stage of transposition of the uterus into the area of the pelvic floor are performed, in which the space of the small pelvis is filled.

The peculiarity of the proposed method is that after the resection stage, the body of the uterus with appendages is rotated and placed on the bottom of the small pelvis, then the body of the uterus is fixed by hemming its lateral surfaces to the soft tissues of the lateral walls of the small pelvis with separate interrupted sutures, after which the skin of the perineum is sutured tightly with the installation of two drains into the small pelvis through the counterpertures of the right and left gluteal regions, hemostasis is performed and the anterior abdominal wall is sutured in layers.

The invention is illustrated by a clinical example and illustrations, which depict:

fig. 1 - MR picture of a deep ulcerative defect of the rectal wall at a distance of about 1.5 cm from the anal edge within the internal sphincter up to 2 cm long (marked with an arrow);

fig. 2 - X-ray picture of a deep ulcerative defect in the rectal wall (marked with an arrow);

fig. 3 - Visualization of the uterus with appendages and assessment of their condition after laparotomy;

fig. 4 - Stage of mobilization of the body of the uterus to the upper third of the vagina, and mobilization of the ovaries;

fig. 5 - The stage of transposition of the body of the uterus with appendages into the area of the pelvic floor and fixation to the soft tissues of the small pelvis.

The method is carried out as follows.

The resection stage of the operation is performed in the amount of removal of the affected organ, the stage of mobilization of the body of the uterus and the stage of transposition of the uterus into the area of the pelvic floor.

The vesicouterine fold is opened and the bladder is separated from top to bottom. The uterus is isolated from the surrounding tissue and mobilized to the cervix. Further, the rectum and rectosigmoid section are mobilized up to the sigmoidostomy upward and the urogenital diaphragm downward. Departing from the anus 3-4 cm, the skin and subcutaneous tissue are dissected along the oval, a section of the rectum is mobilized and excised at the level of the anal canal. Next, the rectum is extirpated with the rectosigmoid section and removed. After that, the body of the uterus with appendages is rotated and placed on the bottom of the small pelvis, fixing to the soft tissues. The skin of the perineum is sutured tightly with the installation of two drains into the small pelvis through the counterpertures of the right and left gluteal regions. Hemostasis. The abdominal cavity is sanitized by washing with 2 liters of chlorhexidine. The integrity of the anterior abdominal wall is restored by layer-by-layer suturing. Skin suture according to Donati. Aseptic dressings.

Clinical example

Patient S., 52 years old. Main diagnosis: C21.8 Cancer of the anal canal yT4N1aM0, stage IIIC. Combined radiation therapy in 2019 (DLT SOD 50 Gy, intracavitary gamma therapy up to SOD 15 Gy). III class group.

Complication: K62.7 Grade 4 late radiation rectitis - rectal ulcer. Colostomy 07.2020

Anamnesis: cancer of the anal canal (squamous cell carcinoma) was diagnosed in 2019. 2019-2020 combined radiation therapy was performed in 2019 (DLT ROD 2.5 Gy SOD 50 Gy, intracavitary gamma therapy ROD 5 Gy SOD 15 Gy). After 4 months, there were complaints of bloody discharge from the rectum. She was treated conservatively with varying degrees of success. In July 2020, the patient formed a colostomy. At the time of hospitalization, intestinal bleeding continues and is accompanied by severe pain syndrome.

MRI of the pelvic organs: in the anal canal, at a distance of about 1.5 cm from the anal edge, a deep ulcerative defect is determined within the internal sphincter up to 2 cm long, from which a purulent leakage into the intersphincter space is formed along the left semicircle with an arcuate bend in the craniocaudal direction (upper pole 4 cm from the anal edge) and a horseshoe-shaped spread along the posterior semicircle without an external drainage hole. The walls of the vagina in a limited area are adjacent to the wall of the ulcer (Fig. 1). The walls of the rectum for 11 cm from the anal edge with signs of postradiation edema of the submucosal layer.

Rectography: a non-laton catheter was inserted through the colostomy into the abducent segment of the colon, and a contrast was injected. At the level of the anal canal, a filling defect (anal canal ulcer) is determined, with a length of about 2 cm, more on the left. The contrast does not go beyond the lumen of the distal intestine (Fig. 2).

PET-CT data for progression were not obtained.

The treatment was performed: laparotomy, abdominal-perineal extirpation of the rectum, plastic surgery of the pelvic floor with a rotary flap from the body of the uterus.

Upper median total laparotomy was performed under combined endotracheal anesthesia with artificial ventilation. The retroperitoneal spaces were opened by an acute way, the ureters were exposed on both sides, taken on the holders. Their course was traced to the bladder. The vesicouterine fold was opened, the bladder was separated from top to bottom. The uterus was isolated from the surrounding tissue, its integrity was visually assessed (Fig. 3). Performed the mobilization of the body of the uterus to the upper third of the vagina, and the mobilization of the ovaries (Fig. 4). The rectum and rectosigmoid region are mobilized up to the sigmoidostomy upward and the urogenital diaphragm downward. Departing from the anus 3-4 cm, the skin, subcutaneous tissue is dissected along the oval. A section of the rectum was mobilized and excised at the level of the anal canal. Extirpation of the rectum with rectosigmoid section was performed. The drug has been removed. The body of the uterus with appendages is rotated and laid on the pelvic floor, fixed by hemming its lateral surfaces to the soft tissues of the lateral walls of the small pelvis with separate interrupted sutures (Fig. 5). The skin of the perineum is sutured tightly. Installed 2 drainages into the small pelvis through the counterpertures of the right and left gluteal regions. Hemostasis. Sanitation of the abdominal cavity by washing with 2 liters of chlorhexidine. A report on the number of wipes received from the nurse. The integrity of the anterior abdominal wall was restored by layer-by-layer suturing. Skin suture according to Donati. Aseptic dressings.

The preparations were sent for histological examination.

The duration of the operation was 2 hours 50 minutes, blood loss was 250 ml.

In the postoperative period, the patient was managed as usual with control of the discharge along the drains, with daily dressings.

There was a smooth course of the postoperative period. The drains from the resection area were removed on days 4 and 5. The beginning of peristalsis on the 2nd day. The colostomy began to function on the 3rd day. The patient was discharged on the 10th day after the operation, in a satisfactory condition, under the supervision of a surgeon and oncologist at the place of residence, dynamic observation is recommended.

The histological conclusion: in the projection of the intestinal wall perforations, necrosis, focal lymphoplasmacytic infiltration - the morphological picture corresponds to an ulcer. The resection margins showed no signs of tumor growth. In the distal margin of resection, necrosis and pronounced lymphoplasmacytic infiltration are the morphological picture of the ulcer.

Control examination after 1 month - wound healing, formed postoperative scar, there is a satisfactory functional and cosmetic result. No complaints. According to laboratory, instrumental methods of examination, pathology was not revealed. The patient lives a full life, she is adapted. During the observation period, there were no manifestations of the empty small pelvis syndrome.

Thus, the proposed method has eliminated the complications associated with the syndrome of "empty" pelvic floor.

The proposed method of treatment is easily reproducible, well tolerated by patients, safe, allows patients to reduce the number of complications after evisceration of the small pelvis.

Claims (1)

A method of preventing the syndrome of "empty" small pelvis using transposition of the uterus after radical surgery for radiation injuries of IV degree of the rectum, including resection of the affected organ, characterized in that after removal of the affected organ, the body of the uterus with appendages is rotated and placed on the bottom of the small pelvis, then the body of the uterus is fixed by stitching its lateral surfaces to the soft tissues of the lateral walls of the small pelvis with separate interrupted sutures, after which the skin of the perineum is sutured tightly with the installation of two drainages into the small pelvis through the counter-openings of the right and left gluteal regions, hemostasis is performed and the anterior abdominal wall is sutured in layers.

Images