RU2770554C1 - Method for esophagoplasty with combined visceral graft after subtotal esophagectomy in combined espogenod and stomach lesions - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to surgery, and can be used in reconstructive surgery of the esophagus after subtotal esophagectomy with combined lesions of the esophagus and stomach. To do this, after subtotal esophagectomy and resection of the stomach, a gastric graft is formed in the form of a gastric tube, cutting it off from the duodenum while maintaining the feeding pedicle of the right gastroepiploic vessels. A small intestinal insert 20 cm long is formed on the third pair of jejunal arteries, followed by its transfer to the upper abdominal cavity through the window into the mesocolon, preventing the vascular pedicle from twisting along the axis. After that, a single-row "end-to-end" gastrojejunoanastomosis and a two-row "end-to-end" gastrojejunoanastomosis are sequentially formed. An incision is made on the neck along the medial edge of the left sternocleidomastoid muscle and the cervical esophagus is mobilized, followed by its removal to the neck and intersection. The formed gastrointestinal graft is passed through the posterior mediastinum to the neck, the excess stump of the cervical esophagus and the gastrointestinal graft is cut off and a two-row "end-to-end" esophagogastroanastomosis is formed with separate interrupted sutures.EFFECT: method provides full nutrition through the mouth while maintaining the duodenal passage due to the formation of a combined graft on a natural source of blood supply, as well as reducing the risk of esophageal anastomosis failure due to the formation of a two-row anastomosis in the area of ​​the most favorable blood supply to the graft, in conditions of combined damage to the esophagus and stomach.1 cl, 8 dwg, 2 ex

Description

The field of technology to which the invention belongs

The invention relates to medicine, namely to surgery, and can be used in reconstructive surgery of the esophagus in various pathologies.

State of the art

Simultaneous plastic surgery after esophagectomy is a priority task of operative gastroenterology. The stomach is considered the most advantageous plastic material for esophageal plastic surgery due to its natural continuation in the gastrointestinal tract (GIT) and reliable blood supply [Wormuth J.K., Heitmiller R.F. Esophageal conduit necrosis. Thorac. Surg. Clin. 2006 Fer. 16(1). 11-22. doi. 10.1016/j.thorsurg.2006.01.003]. However, the stomach may be unsuitable for esophagoplasty due to its combined with the esophagus lesion, concomitant disease, or damage due to previous surgical interventions. In the absence or unsuitability of the stomach for esophagoplasty, colon or small intestine plastic surgery is performed, which is associated with a large number of complications and is technically more laborious [Swisher SG, Hofstetter WL, Miller MJ. The supercharged microvascular jejunal interposition. Semin Thorac Cardiovasc Surg 2007; 19:56-65. Yasuda T, Shiozaki H. Esophageal reconstruction using a pedicled jejunum with microvascular augmentation. Ann Thorac Cardiovasc Surg 2011; 17:103-109]. It should be noted that these methods of reconstruction are not always feasible. The reason for this is the ischemic disorders of the graft and insufficient length, ascertained during the operation, which forces surgeons to refuse primary esophageal plastic surgery. Existing options for complete or partial revascularization of displaced visceral segments are not widely used due to the high incidence of necrosis (up to 20%), strictures and fistulas in the postoperative period [Yoshimoto S., Kawabata K., Mitani H. Analysis of 59 cases with free flap thrombosis after reconstructive surgery for head and neck cancer. Auris Nasus Larynx 2010; 37: 205-211]. This is what determines the constant search for options for the rational utilization of plastic material in case of combined or combined lesions of the esophagus and stomach to implement the basic principle of esophagoplasty - its completeness.

An analogue of the proposed method of esophagoplasty is the formation of an isoperistaltic graft from the greater curvature of the stomach with nutrition on the right gastroepiploic vessels according to A.F. Chernousov [Chernousov A.F., Bogopolsky P.M., Kurbanov F.S., Surgery of the esophagus: A guide for physicians. M.: Medicine, 2000. - 352 s]. Stepping back 2.5-3 cm above the pylorus in the direction from the lesser to the greater curvature in the proximal direction, with the help of a stapler form a tube 4 cm wide, pulling the stomach to the bottom (figure 1.). The mechanical suture is additionally covered with a continuous serous-muscular suture. The graft is placed posterior-mediastinally and a cervical fistula is formed with two-row separate interrupted sutures. There are works describing the use of the operated stomach as a plastic material for esophagoplasty after previously formed gastrostomes or transferred fundoplications [Mariyko V.A. -26], provided that the right gastroepiploic artery was preserved.

The disadvantage of the above method is the shortfall in the length of the gastric graft after previous resection interventions on the stomach, its combined with the esophagus lesion, as well as a concomitant pathology that requires not only subtotal esophagectomy, but also resection of the stomach.

Closest to the claimed solution is a method of reconstructing the stomach after pharyngolaryngectomy with total esophagectomy [Watanabe M., Baba Y., Yoshida N., Ishimoto T., Sakaguchi H., Kawasuji M., Baba H. Modified gastric pull-up reconstructions following pharyngolaryngectomy with total esophagectomy. Dis Esophagus. 2014 Apr; 27(3):255-61. doi: 10.1111/dote.12086. Epub 2013 May 15. PMID: 23672461]. According to the method described in the publication, the formed gastric graft is cut off from the duodenal bulb (duodenum) using a linear stapler, after which the antrum is resected and the formed mobile gastric tube is moved through the posterior mediastinum to the neck, followed by the formation of the esophageal-gastric fistula with a single-row continuous suture . The feeding pedicle of the graft is kept on the right gastroepiploic vessels. This technique makes it possible to give the gastric graft greater mobility and move it to the neck to form an esophageal-gastric anastomosis in the zone of the most favorable blood supply, avoiding tissue tension. The aboral end of the graft was connected to a loop of jejunum isolated according to Roux. To do this, at a distance of 20 cm from the ligament of Treitz, the small intestine was transected and the efferent loop was anastomosed with an end-to-side graft. The adductor section was connected to Roux by a side-to-side anastomosis loop (Fig. 2).

The disadvantage of the above method is:

1. Shutdown of the duodenal passage, which is considered the main cause of the development of severe digestive disorders in the postoperative period [Ruchkin DV, Jan Ts. Ejunogastroplasty as an alternative method of reconstructing the digestive tract after gastrectomy. Surgery. Journal them. N.I. Pirogov. 2015, 9, 57-62. Doi: 10.171116/hirurgia2015957-62].

2. Formation of an end-to-side gastrointestinal anastomosis, which in the postoperative period can cause a violation of the passage of food from the graft to the underlying sections of the gastrointestinal tract. The reason for this is the “blind” end of the outlet loop, which, under the action of food masses, stretches, forming a “blind bag”, and deforms the anastomosis [Zakharov E.I., Zakharov A.E. Ejunogastroplasty in diseases of the operated stomach. M. Medicine. - 1970. - 232 p.].

3. A single-row suture of the gastroesophageal anastomosis in 20% of cases is complicated by failure [Watanabe M., Baba Y., Yoshida N., Ishimoto T., Sakaguchi H., Kawasuji M., Baba H. Modified gastric pull-up reconstructions following pharyngolaryngectomy with total esophagectomy. Dis Esophagus. 2014 Apr; 27(3):255-61. doi: 10.1111/dote.12086. Epub 2013 May 15. PMID: 23672461].

The technical problem, the solution of which is provided by the implementation of the invention, is the creation of a method for simultaneous esophagoplasty with a combined visceral graft in conditions of a combined lesion of the esophagus and stomach, devoid of the above disadvantages.

Disclosure of the essence of the invention

The technical result, which the claimed invention is aimed at, is to provide the patient with adequate nutrition through the mouth and maintain the duodenal passage of food by forming a combined graft on a natural source of blood supply from the stomach stump and jejunal segment, reducing the risk of failure of the esophageal anastomosis due to the formation of a two-row anastomosis in the zone of the most favorable blood supply to the graft, in conditions of combined damage to the esophagus and stomach.

The proposed method allows the use of the resected stomach as a plastic material in the implementation of esophagoplasty by cutting it off from the duodenum while maintaining the nutrition of the stump on the right gastroepiploic artery and vein. The segment of the jejunum on the vascular pedicle allows you to replace the emerging diastasis between the short gastric conduit and the duodenum. The invention is also directed to the prevention of esophageal anastomosis suture failure and postoperative necrosis of the gastric graft in case of its length deficiency. The transfer of the gastric graft to the posterior mediastinum on a natural source of blood supply makes it possible to perform the cervical anastomosis in the zone of the most favorable blood supply with a double-row suture, to avoid its tension. The formation of the gastro-intestinal anastomosis "end to end" reduces the risk of violations of the passage of food in the long term. The claimed invention allows to save the colon as a visceral reserve of esophagoplasty without significant damage to the digestive function.

The technical result is achieved by using the method of simultaneous esophagoplasty with a combined visceral graft after subtotal esophagectomy and resection of the stomach with combined lesions of the esophagus and stomach, including the formation of a short gastric graft on a natural source of blood supply and moving it to the neck, characterized in that after subtotal esophagectomy a gastric graft is formed in the form of a gastric tube, it is cut off from the duodenum (duodenum) while maintaining the feeding legs of the right gastroepiploic vessels; then a small intestinal insert 20 cm long is formed on the third pair of jejunal arteries (to eliminate the resulting diastasis between the duodenal stump and a short gastric graft), followed by its movement into the upper abdominal cavity through the window into the mesocolon, preventing the vascular pedicle from twisting along the axis, after which it is sequentially form a single-row gastrojejunoanastomosis "end to end" and a double-row jejunoduodenal anastomosis "end to end"; on the left side of the neck along the medial edge of the left sternocleidomastoid muscle, an incision is made and the cervical esophagus is mobilized, followed by its removal through the neck and intersection on the L-shaped clamp 3.0-5.0 cm below the pharynx, the formed gastro-intestinal graft is passed through the posterior mediastinum on the neck, the excess of the stump of the cervical esophagus and the gastrointestinal graft is cut off and a two-row end-to-end esophagogastroanastomosis is formed with separate interrupted sutures.

Using the proposed method will allow you to save the natural passage of food; to avoid disruption of the evacuation of food from the graft to the underlying sections of the gastrointestinal tract; reduce the risk of esophageal anastomosis failure by forming a two-row anastomosis in the area of the most favorable graft blood supply.

Brief description of the drawings

The invention is illustrated by drawings, radiographs and intraoperative photographs:

- fig. 1 - schematically shows the stage of formation of the gastric tube according to A.F. Chernousov;

- fig. 2 (a - formed gastric tube, b - turned off loop of the small intestine according to Roux) - intraoperative photograph of the combined gastro-intestinal graft on the loop according to Roux according to M. Watanabe;

- fig. 3 (a - formed gastric tube, b - switched off loop of the small intestine according to Roux) - schematically shows the final version of the reconstruction according to M. Watanabe;

- fig. 4 (a - formed gastric tube, c - interposed segment of the jejunum) - a schematic representation of the final version of the reconstruction method with the formation of a gastrointestinal graft (the proposed method);

- fig. 5 (a - formed gastric tube, c - interposed segment of the jejunum) - intraoperative photograph of the formed graft with inclusion in the passage of the duodenum;

- fig. 6 (d - duodenum, c - interposed segment of the jejunum, c - distal gastric tube) - formed gastrointestinal graft;

- fig. 7 (a - direct projection, b - lateral) - control radiographs on the 5th day after the operation;

- fig. 8 (a - direct projection, b - lateral) control radiographs 2 years after the operation.

Implementation of the invention

The method is carried out as follows.

When performing combined gastro-intestinal plastic surgery of the esophagus after subtotal esophagectomy with resection of the stomach, the following sequence of surgical steps is used.

The operation is performed through laparotomy access. For the formation of the cervical anastomosis, left-sided cervical access is used. After subtotal esophagectomy, the formation of a gastric tube approximately 4 cm wide is started using a linear stapler. The mechanical suture is covered with a continuous gray-serous suture, leaving a ligature on the Kocher clamp on the distal part, which is connected to the ligature on the resected abdominal segment of the esophagus. The length of the gastric tube is approximately 25 cm. The length of the gastric tube of 25 cm is not essential, but its length is not sufficient to move its oral section to the neck and form the cervical fistula. To do this, the gastric tube is cut off below the pylorus with a stapling apparatus while maintaining the feeding pedicle of the right gastroepiploic vessels.

Then proceed to the formation of the small intestine insert. A segment of the jejunum is cut out on the third pair of jejunal arteries. The mesentery of this section of the intestine is located in the middle part of the abdominal cavity, is mobile and has sufficient length so that the proximal end of the mobilized segment can be connected without tension to a short gastric graft even if it is located high in the mediastinum. The length of the used segment is approximately 20 cm; it is this segment that is sufficient to compensate for the shortfall in the length of the gastric graft and form an anastomosis with its proximal end and duodenum without tension. A longer segment can cause food obstruction due to its kink in the long term.

A segment of the jejunum suitable for plasty is moved to the upper abdominal cavity through a window into the mesocolon, preventing the vascular pedicle from twisting along the axis. The integrity of the small intestine is restored with a single-row end-to-end suture. One-row "end-to-end" gastrojejunoanastomosis and a two-row "end-to-end" gastrojejunoanastomosis are sequentially formed. The window in the mesentery of the mesocolon is sutured.

An incision is made on the neck on the left along the medial edge of the left sternocleidomastoid muscle. The cervical esophagus is mobilized, the esophagus is removed through the neck and crossed on the L-shaped clamp 3.0-5.0 cm below the pharynx. This level of transection of the esophagus is due to the required level of subtotal resection, which is determined, respectively, by the level of damage to the esophagus. The stump of the esophagus is left on the L-shaped clamp.

The formed gastrointestinal graft is passed through the posterior mediastinum to the neck. The excess stump of the cervical esophagus and gastric graft, if any, is cut off and a two-row end-to-end esophagogastroanastomosis is formed with separate interrupted sutures.

The claimed method operated 7 patients. The average age was 52.8 years, there were 3 men (43%), 4 women (57%). All patients in the early postoperative period underwent a complex examination. In the remote period, 4 (57.1%) patients were under observation.

Example #1. Patient K., aged 45, was admitted with complaints about the impossibility of passing food through the esophagus (takes only liquid food). From the anamnesis in June 2019, she drank acetic acid by mistake. In one of the hospitals at the place of residence, the patient underwent 2 courses of bougienage of esophageal stricture without clinical effect.

FGBU National Medical Research Center for Surgery named after N.N. A.V. Vishnevsky Ministry of Health of the Russian Federation (hereinafter - NMIC) performed EGDS, which revealed a circular cicatricial stricture of the middle third of the esophagus, not passable by the device (diameter of the device is 8.8 mm). X-ray revealed an extended narrowing of the middle and lower third of the esophagus without significant dilatation of the overlying sections.

On 08.10.2019, a transhiatal subtotal esophagectomy with resection of the pyloric part of the stomach was performed at the NMIC (intraoperatively, cicatricial and ulcerative deformity of the pylorus and antrum with a length of 3 cm was detected) with simultaneous subtotal posterior mediastinal esophagoplasty with a combined gastro-intestinal graft (Fig. 6).

With contrast fluoroscopy on the 5th day, the anastomoses are consistent, passable (FIG. 7 a, b), the passage of the contrast agent and its evacuation from all segments of the structure are not disturbed. The patient was discharged on the 10th day after the operation in a satisfactory condition and with good nutrition through the mouth.

Example #2. A 55-year-old patient, D., applied to the NMIC with complaints of the inability to take solid and liquid food, vomiting of food eaten, weight loss by 5-7 kg in three months, and general weakness. Additional examination revealed stage IV achalasia of the cardia with complete dysphagia. MSCT visualized an enlarged esophagus with a diameter of more than 6 cm with a pronounced S-shaped curvature and elongation; stagnation of food masses in its lumen.

On October 31, 2017, transhiatal subtotal esophagectomy with resection of the pyloric part of the stomach with esophageal plasty with a combined gastro-intestinal graft was performed at the NMIC. Intraoperative revision revealed cicatricial stenosis of the duodenal bulb with an ulcer penetrating into the hepatoduodenal ligament.

The patient was discharged on the 10th day, with full nutrition through the mouth. With contrast fluoroscopy 2 years after the operation, the anastomoses are passable (FIG. 8a, b), the passage and evacuation of the contrast along the combined graft are not disturbed.

Thus, all patients were able to perform simultaneous esophagoplasty with a gastric tube, even in cases of its insufficient length. The interposition of the jejunal segment between the graft and the duodenum not only made it possible to replace the resulting diastasis, but also to preserve duodenal digestion. In the long-term period, the majority of patients under observation showed no signs of impaired evacuation from the combined graft.

Claims (4)

A method for esophagoplasty with a combined visceral graft after subtotal esophagectomy with combined lesions of the esophagus and stomach, including the formation of a short gastric graft on a natural source of blood supply and moving it to the neck, characterized in that after subtotal esophagectomy, a gastric graft is formed in the form of a gastric tube, cut off from the duodenum (DPC) with the preservation of its feeding pedicle on the right gastroepiploic vessels; then a small intestinal insert is formed, for which a segment of the jejunum is cut out on the third pair of jejunal arteries, followed by its transfer to the upper abdominal cavity through the window into the mesocolon, preventing the vascular pedicle from twisting along the axis, after which a single-row end-to-end gastrojejunoanastomosis and a two-row end-to-end gastrojejunoanastomosis are sequentially formed; on the left side of the neck, along the medial edge of the left sternocleidomastoid muscle, an incision is made and the cervical esophagus is mobilized, followed by its removal to the neck and crossing on the L-shaped clamp, retreating 3.0-5.0 cm below the pharynx, the formed gastrointestinal graft is passed through the posterior mediastinum to the neck, the excess stump of the cervical esophagus and the gastrointestinal graft is cut off and a two-row "end-to-end" esophagogastroanastomosis is formed with separate interrupted sutures.

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