RU2794632C1 - Method for surgical treatment of esophageal achalasia using endoscopy-guided hydropreparation of esophagus tissues - Google Patents

Abstract

FIELD: medicine; abdominal surgery.

SUBSTANCE: invention relates to the field of abdominal surgery and can be used for surgical treatment of primary esophageal achalasia degree I-IV as well as for safer treatment of recurrent forms of esophageal achalasia Before endoscopy-guided esophagocardiomyotomy perform hydropreparation of esophagus submucosal layer in the area of spasm localization by introducing normal saline into the esophagus submucosal layer in volume providing visible swelling of the organ wall. Introduction of solution is carried out at least in two points with a needle, which is inserted through the adventitious and muscular coats of esophagus without affecting the mucous layer. Then perform anterior esophagocardiomyotomy of the esophagus spasm area. Form fundoplication cuff. Then form posterior partial half-cuff. Perform posterior cruroraphia along the esophagus diameter.

EFFECT: method reduces the risk of intraoperative and postoperative complications, number of disease relapses, length of the patient's stay in the hospital due to the hydropreparation of theesophagus submucosal layerlaparoscopically without affecting the mucous layer.

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Description

The invention relates to the field of abdominal surgery and can be used for the surgical treatment of primary achalasia of the cardia of I-IV degree, as well as for the safer treatment of recurrent forms of achalasia of the cardia.

State of the art

A known method of surgical treatment of achalasia cardia (RF Patent No. 2128950), according to which, after the implementation of laparoscopic access produce a sequential selection of the legs of the esophageal opening of the diaphragm (AH), the esophagus is brought down into the abdominal cavity from the mediastinum. Further along the anterior wall of the stomach, the serous-muscular membrane of the stomach is crossed strictly in the longitudinal direction to the submucosal layer, followed by a smooth crossing of the muscular-adventitial layer of the esophagus also to the submucosal layer, so that the submucosal layer freely protrudes outward along the entire length of the myotomy, using for this monopolar laparoscopic hook. A thick gastric tube is inserted into the esophagus, the formed defect of the esophageal-gastric junction is closed by the anterior wall of the stomach with single interrupted intracorporeal sutures. Then a complete anterior symmetrical fundoplication cuff is formed with an increase in the degree of wrapping in the proximal direction, starting from the lower corner of the mobilized stomach.

The disadvantages of this method include: lack of control of the depth of the cardiomyotomy incision when performing cardiomyotomy; the inability to accurately determine the boundaries of the zone of pathological changes in the tissues of the esophagus and healthy tissues; the use of a monopolar energy instrument to perform cardiomyotomy due to the low precision of using monopolar coagulation in this area; insufficient symmetry of the fundoplication cuff due to the need for skeletonization of the lesser curvature, possible compression of the esophagus by a tightly formed circular cuff according to Chernousov, the possibility of cuff migration into the mediastinum.

A known method of endoscopic treatment of achalasia cardia by performing oral endoscopic myotomy (peroral endoscopic myotomy - POEM). The essence of the method lies in the formation of a tunnel in the submucosal layer of the esophagus in the area of increased tone with the dissection of the circular muscle fibers of the esophagus. Dissection of the mucous membrane of the esophagus for 1.5 cm is performed at a distance of 25-30 cm from the incisors along the posterior wall of the esophagus, after which the endoscope is passed into the submucosal layer. For more accurate visualization of the submucosal layer, hydropreparation with physiological saline with the addition of neutral contrast (indigo carmine, methylene blue solution, etc.) is used. At a distance of 30 cm from the incisors, a portioned dissection of the circular muscle layer is performed until longitudinal muscle fibers appear throughout the formed submucosal canal. The mucosal defect, through which the device is inserted into the submucosal layer, is sutured using clips (Korolev M.P., Fedotov L.E., Spesivtsev Yu.A., Ogloblin A.L., Smirnov A.A., Mamedov Sh. D., Konanov E.V. Different endoscopic methods of treatment of achalasia cardia Bulletin of St. Petersburg University Medicine 2016 11(2): 20-28 https://doi.org/10.21638/11701/spbu11.2016.203).

The disadvantages of this method include serious postoperative complications associated with dissection of the mucous membrane of the esophagus, which cannot be eliminated by endoscopic methods (esophageal perforation, bleeding, subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum); frequent development of gastroesophageal reflux disease (GERD) and reflux esophagitis due to the lack of an antireflux mechanism; the complexity of the method and the impossibility of widespread use due to the high cost of the necessary equipment.

Closest to the claimed method is a method for the treatment of achalasia cardia Galliamova E.A. et al. (Patent of the Russian Federation No. 2757527 "Method of surgical treatment of achalasia of the cardiac esophagus"), according to which, after the implementation of laparoscopic access and revision of the abdominal organs, the esophagus is mobilized with the release of the right leg of the esophageal opening of the diaphragm (HAD). Next, the left leg of the POD is mobilized behind the esophagus until it is completely released. The lower third of the esophagus is isolated from the posterior mediastinum by separation and blunt separation from the mediastinal pleura. The mobilized esophagus is brought down and fixed to the right and left POD legs. Access is made in the avascular zone behind the POD to the posterior wall of the gastric fundus with the intersection of short gastric vessels. Starting from the cardial part of the stomach at a distance of 1.5-2 cm from the cardioesophageal junction, an anterior esophagocardiomyotomy is performed up the esophagus with a length of 6-9 cm. walls to the right side of the esophagocardiomyotomy incision throughout. Then a posterior partial half-cuff is formed by passing the posterior wall of the fundus of the stomach behind the esophagus and fixing it to the right wall of the lower third of the esophagus of the cardiac section of the stomach with at least two interrupted sutures. Posterior crurorrhaphy is performed with Z-shaped sutures along the diameter of the esophagus.

The disadvantages of this method are: lack of control of the depth of the cardiomyotomy incision when performing cardiomyotomy; the inability to accurately determine the boundaries of the zone of pathological changes in the tissues of the esophagus and healthy tissues, the risk of damage to the mucous membrane of the esophagus, the possibility of contamination of the abdominal cavity with the contents of the oral cavity and the lumen of the esophagus;

The technical problem to be solved by the invention is the development of a minimally invasive, precise and most effective method of surgical treatment of all stages and forms of achalasia of the cardia, which will improve the immediate and long-term results of treatment (including minimizing the number of intraoperative, early and late postoperative complications). ), reduce the number of relapses of the disease and improve the quality of life of patients after surgical treatment.

Disclosure of invention

The technical result to which the claimed invention is directed is to reduce the risk of intraoperative and postoperative complications, to reduce the number of relapses of the disease by performing hydropreparation of the submucosal layer of the esophagus laparoscopically without injuring the mucous layer. EFFECT: method provides a more accurate determination of the boundary of the zone of pathological changes in the tissues of the esophagus and healthy tissues and visualization of the depth of the esophagocardiomyotomy incision, which minimizes the risk of damage to the esophageal mucosa and contamination of the submucosa with the contents of the oral cavity and the lumen of the esophagus, allows safe treatment of recurrent forms of achalasia of the cardia.

The technical result is achieved by implementing a method for laparoscopic treatment of cardia achalasia, including mobilizing the lower third of the esophagus, accessing the posterior wall of the gastric fundus, performing anterior esophagocardiomyotomy of the spasmodic area of the esophagus, forming a fundoplication cuff by suturing the anterior wall of the gastric fundus to the left side of the esophagocardiomyotomy incision on the entire along with subsequent fixation of the same wall to the right side of the esophagocardiomyotomy incision throughout, formation of the posterior partial cuff by passing the posterior wall of the gastric fundus under the esophagus from the side of the lesser curvature and fixing it to the lateral part of the esophagus with at least two interrupted sutures, performing posterior crurorrhaphy along esophagus diameter. At the same time, before performing esophagocardiomyotomy, under endoscopic control, hydropreparation of the submucosal layer of the esophagus is carried out in the area of localization of the spasmodic area by introducing an isotonic solution of sodium chloride into the submucosal layer of the esophagus in a volume that provides visible swelling of the organ wall, while the introduction of the solution is carried out at least at two points using a needle that is inserted through the adventitial and muscular membranes of the esophagus without affecting the mucous layer.

The solution can be administered in a volume of 20-30 ml.

As a needle, a needle 5 mm long and with an inner diameter of 0.5 mm or 0.7 mm can be used.

Additionally, fixation of the posterior wall of the esophagus to the legs of the esophageal opening of the diaphragm can be carried out when performing posterior cruroraphy.

Performing anterior esophagocardiomyotomy after hydropreparation of esophageal tissues under endoscopic control provides the safest approach to surgical correction of the disease, since swelling of the submucosal layer of the esophagus allows better visualization of the depth of esophagocardiomyotomy and, thereby, prevents perforation of the esophageal mucosa. The performed incision along the anterior wall of the esophagus allows achieving a stable remission of achalasia of the cardia, thereby significantly reducing the risk of relapse. At the same time, hydropreparation of the submucosal layer of the esophagus allows excising the maximum number of affected muscle fibers, which also reduces the risk of recurrence of the disease. Wide mobilization of the lower third of the esophagus, stretching and fixation of the esophagus to the right and left legs of the esophageal opening of the diaphragm along the medial edges of the legs of the esophageal opening provides straightening of the esophagus (elimination of pathological bends of the organ, which are characteristic of this pathology) and prevents its return to the pathological position in severe achalasia severity (III and IV degree). The formation of a fundoplication cuff, in which the cardial part of the stomach is fixed to both edges of the esophagotomy incision by the anterior wall of its fundus, with the formation of an additional partial fundoplication cuff by the posterior wall of the gastric fundus and the implementation of posterior crurorrhaphy, allow creating a powerful combined antireflux mechanism that prevents the development of the main complication of classical cardiomyotomy, namely gastroesophageal reflux disease (GERD) and hiatal hernia (HH). At the same time, additional fixation of the posterior wall of the esophagus to the legs of the esophageal opening of the diaphragm during posterior crurorrhaphy ensures a fixed position of the esophagus in the abdominal cavity, thereby eliminating its pathological bends, providing a functional passage of food in the postoperative period.

Brief description of the drawings

The invention is illustrated by illustrations, where in Fig. 1 shows a general view of the zone of cardiospasm, Fig. 2 - hydropreparation of the spasmodic area of the esophagus (introduction of a solution at three points) and the location of the esophagocardiomyotomy incision, in Fig. 3 is a diagram of the performed anterior esophagocardiofundomyotomy, in Fig. 4-5 - the stage of suturing the anterior wall of the cardial part of the stomach to the left side of the esophagocardiomyotomy incision, in Fig. 6 - stage of fixation of the anterior wall of the cardial part of the stomach to the right side of the esophagocardiomyotomy incision, in Fig. 7 - formed anterior fundoplication cuff, in Fig. 8 - stage of fixation of the posterior wall of the fundus of the stomach to the lateral part of the esophagus, in Fig. 9 - formed posterior partial half-cuff, figure 10 - a schematic representation of the location of the needle when performing hydropreparation spasmodic area of the esophagus, where 1 - adventitia shell; 2 - outer longitudinal layer of the muscular membrane of the esophagus; 3 - inner circular layer of the muscular membrane of the esophagus; 4 - submucosal layer (base); 5 - mucous membrane of the esophagus; 6 - lumen of the esophagus; 7 - solution.

Implementation of the invention

The proposed method is implemented as follows.

Before surgery, the patient is placed a nasoesophageal probe to clean the esophagus, followed by its removal before surgery. The patient is given general anesthesia.

Then, under aseptic conditions, through the upper paraumbilical incision-puncture up to 12 mm, the abdominal cavity is entered with trocar No. 1 (diameter 10 mm), carboxyperitoneum up to 12 mm is applied. rt. Art. with the introduction of a laparoscopic video camera. Survey laparoscopy of the abdominal organs (liver, small and large intestine, spleen, pelvic organs) is performed. Under visual control, additional trocars are inserted into the abdominal cavity (No. 2 with a diameter of 10 mm into the epigastrium, No. 3 with a diameter of 5 mm into the right hypochondrium, No. 4 with a diameter of 13 mm into the left hypochondrium and No. 5 with a diameter of 5 mm into the left mesogastrium, if necessary). A hepatic retractor is installed through the epigastric trocar, and the left lobe of the liver is pulled upward.

Using an ultrasonic dissector or intelligent bipolar coagulation, the lesser omentum (hepatoduodenal ligament) is opened above the passage of the hepatic branch of the vagus nerve, the right pedicle of the alimentary opening of the diaphragm (AHD) is visualized, the esophagus is mobilized with the release of the right AH pedicle, while visualizing and freeing the left AH pedicle . Mobilization is continued along the left leg behind the esophagus until it is completely released.

To mobilize the abdominal esophagus, the ligaments surrounding the esophagus (including the Laimer-Bertelli membrane) are crossed, as well as artificial expansion of the POD. In both blunt and acute ways, the lower segment of the esophagus is isolated from the posterior mediastinum, separated from the mediastinal pleura, and lowered into the abdominal cavity. The anterior (left) vagus nerve is isolated atraumatically, displaced to the right of the esophagus. The mobilized esophagus is lowered into the abdominal cavity and fixed with two interrupted sutures to the right and left legs of the POD in such a way that most of the esophagocardiomyotomy incision is in the abdominal cavity.

Under the control of intraoperative endoscopy, they reach the localization of the affected (spasmodic) area of the esophagus and laparoscopically, using a needle with an attached syringe, an isotonic 0.9% solution of sodium chloride (NaCl) is injected into the submucosal layer (4) of the esophageal wall through the adventitia (1) and the muscular membranes, passing longitudinal (2) and inner circular (3) layers of the muscular membrane, without affecting the mucous membrane (5) until the spread of the solution and visible swelling of the organ wall (Fig.10). As a needle, a needle with an inner diameter of 0.5 mm or 0.7 mm, an outer diameter of 0.6 mm or 0.8 mm, and a working length of 5 mm can be used, providing a puncture to the thickness of the adventitial and muscular membranes without injuring the mucosa shells (for example, a modified needle for puncture of the company NPF "MFS", Fig. 11). This procedure is carried out under endoscopic control to confirm that the correct layer has been reached. In this case, the volume of the injected solution can be 20-30 ml. The solution is injected at least at two points, preferably at three points, to ensure uniform distribution of the solution in the area of spasm (figure 2). For better visualization, neutral contrast dyes, for example, indigo carmine, methylene blue solution, etc., can be added to the injected solution.

Further, starting from the cardial section of the stomach, at a distance of 1.5-2 cm from the cardioesophageal junction under endoscopic control, an anterior esophagocardiomyotomy is performed up the esophagus with a length of 6-9 cm (figure 3).

Then, with separate interrupted sutures along the contour of the myotomy incision, an anterior fundoplication cuff is formed by the anterior wall of the cardial part of the stomach, first to the left (Fig.4, 5), and then to the right of the esophagocardiomyotomy incision throughout (Fig.6, 7). Then the back wall of the fundus of the stomach is carried out under the esophagus from the side of the lesser curvature, after which the posterior partial half-cuff is formed by fixing the posterior wall of the fundus of the stomach to the lateral part of the esophagus (Fig.8, 9). Thus, the posterior wall of the fundus of the stomach is sutured with at least two interrupted sutures to the side wall of the esophagus. Posterior crurorrhaphy is performed with one or two Z-shaped sutures along the caliber of the esophagus with capture of the posterior wall of the esophagus for the most complete preservation of the abdominal position of the organ (there is additional fixation of the posterior wall of the esophagus to the legs of the esophageal opening of the diaphragm).

At the final stage of the operation, a nasogastric tube is passed to the stomach under the control of laparoscopy, a drain (5 mm) is installed in the left subdiaphragmatic space through an access in the left hypochondrium. Carry out control of hemostasis, desufflation and then remove the trocars.

In accordance with the claimed method, 18 operations were carried out, during which the following were performed:

1) preservation of the hepatic branch and the left (anterior) trunk of the vagus nerve;

2) mobilization of the fundus of the stomach through the avascular zone of the omental bag;

3) wide mobilization of the esophagus to the lower third and its fixation to the legs of the POD;

4) hydropreparation of the spasmodic area of the esophagus under endoscopic control;

5) anterior esophagocardiomyotomy 6-9 cm long;

6) an anterior fundoplication cuff was formed, which fit on the zone of the esophagocardiomyotomy incision, and a posterior partial cuff was also formed;

7) posterior crurorrhaphy with capture of the posterior wall of the esophagus.

There were no complications during the operations, the integrity of the mucosa during esophagocardiomyotomy was not violated, none of the operated patients had a relapse of the disease and did not develop gastroesophageal reflux.

Examples of the implementation of the invention

Example 1. Patient K., aged 28. He was admitted to the clinic with a diagnosis of achalasia of the cardia II degree. The diagnosis was confirmed by fluoroscopy and esophagogastroscopy.

The patient was fully examined and prepared for surgery. Before the operation, a nasoesophageal probe was installed, the esophagus was cleaned, followed by removal of the probe. The operation was performed - laparoscopic esophagocardiomyotomy in the Heller modification with an anterior fundoplication in the Dora modification and a posterior partial fundoplication with posterior cruroraphy. After installing 5 laparoscopic ports and applying carboxyperitoneum up to 12 mm Hg. Art. laparoscopy of the abdominal organs was performed. Next, a hepatic retractor was installed through the epigastric trocar, and the left lobe of the liver was traction upward. Using an ultrasonic dissector, the lesser omentum was opened above the hepatic branch of the vagus nerve, the right pedicle of the alimentary opening of the diaphragm (AHD) was visualized, the esophagus was mobilized, and the middle bundle of the right AH pedicle was exposed. Next, the left POD leg was visualized and released. Mobilization was continued along the left leg behind the esophagus until it was completely released. Transection of the ligaments surrounding the esophagus and its mobilization were performed, then artificially expanded the legs of the POD. Then, using blunt and sharp methods, the lower segment of the esophagus was isolated from the posterior mediastinum, separated from the mediastinal pleura, and brought down into the abdominal cavity. The anterior (left) vagus nerve was displaced atraumatically to the right of the esophagus. After that, in the avascular zone behind the pod, access was made to the posterior wall of the gastric fundus, and the phrenic-fundic ligament was partially transected. The fundus of the stomach was released with the intersection of the short gastric arteries. The esophagus was brought down into the abdominal cavity and fixed with two interrupted sutures to the right and left podiatric pedicles in such a way that most of the esophagocardiomyotomy incision was in the abdominal cavity.

Then, under the control of intraoperative endoscopy, laparoscopically, using a needle (length 5 mm, inner diameter 0.5 mm) with an attached syringe, the esophageal wall was punctured at two points (in the center of the spasmodic area and 2 cm lower along the esophagus) through the adventitial and muscular membranes of the esophagus, without damaging the mucosa, while introducing 20 ml of isotonic 0.9% sodium chloride solution (NaCl) into the submucosal layer of the esophageal wall until the solution spread and visible swelling of the organ wall. After that, anterior esophagocardiomyotomy was performed under endoscopic control, starting from the cardial part of the stomach at a distance of 2 cm from the cardioesophageal junction and further up the esophagus, 6 cm long. first to the left and then to the right of the esophagocardiomyotomy incision throughout. Then, the posterior wall of the fundus of the stomach was passed under the esophagus from the side of the lesser curvature, subsequently a posterior partial half-cuff was formed by fixing the posterior wall of the fundus of the stomach to the lateral part of the esophagus. Thus, the posterior wall of the stomach was sutured with two interrupted sutures to the posterior wall of the esophagus (the posterior wall of the esophagus was additionally fixed to the crura of the esophageal opening of the diaphragm). Posterior crurorrhaphy was performed with one Z-shaped suture along the caliber of the esophagus with capture of the posterior wall of the esophagus. At the final stage of the operation, a nasogastric tube was inserted into the stomach, a drain (5 mm) was placed into the left subdiaphragmatic space through an access in the left hypochondrium. Produced control of hemostasis, desufflation and then removal of trocars. The postoperative period was uneventful, complex postoperative conservative therapy, control of laboratory data and early activation of the patient were carried out. The next day after the operation, X-ray was performed with a water-soluble contrast agent - there are no streaks, the contrast is freely passable into the stomach. Food on this day was carried out through a tube. On the second day after the operation, the patient had a nasogastric tube removed, and the patient began self-feeding. In a satisfactory condition on the 6th day, the patient was discharged for outpatient treatment. Conducted after 3 months, the control X-ray examination showed no retention of the contrast agent in the esophagus. There were no complaints of dysphagia and heartburn.

Example 2 Patient B, 40 years old. She was admitted to the clinic with a diagnosis of achalasia of the cardiac part of the IV degree, megaesophagus. The diagnosis was confirmed by fluoroscopy and esophagogastroscopy. Previously, the patient in another clinic was offered to perform extirpation of the esophagus, the patient refused.

The patient was comprehensively examined and prepared for surgery. Before the operation, a nasoesophageal probe was installed, the esophagus was cleaned, followed by removal of the probe. The operation was performed - laparoscopic esophagocardiomyotomy in the Heller modification with an anterior fundoplication in the Dora modification and a posterior partial fundoplication with posterior cruroraphy. After installing 5 laparoscopic ports and applying carboxyperitoneum up to 12 mm Hg. Art. laparoscopy of the abdominal organs was performed. Next, a hepatic retractor was installed through the epigastric trocar, and the left lobe of the liver was traction upward. Using an ultrasonic dissector, the lesser omentum was opened above the hepatic branch of the vagus nerve, the right pedicle of the alimentary opening of the diaphragm (AHD) was visualized, the esophagus was mobilized, and the middle fascicle of the right AH pedicle was exposed. Next, the left POD leg was visualized and released. Mobilization was continued along the left leg behind the esophagus until it was completely released. Transection of the ligaments surrounding the esophagus and its mobilization were performed, then artificially expanded the legs of the POD. Then, using blunt and sharp methods, the lower segment of the esophagus was isolated from the posterior mediastinum, separated from the mediastinal pleura, and brought down into the abdominal cavity. The anterior (left) vagus nerve was displaced atraumatically to the right of the esophagus. After that, in the avascular zone behind the pod, access was made to the posterior wall of the gastric fundus, and the phrenic-fundic ligament was partially transected. The fundus of the stomach was released with the intersection of 2 short gastric arteries. The esophagus was brought down into the abdominal cavity and fixed with two interrupted sutures to the right and left podiatric pedicles in such a way that most of the esophagocardiomyotomy incision was in the abdominal cavity. Further, under the control of intraoperative endoscopy, laparoscopically, using a needle (length 5 mm, inner diameter 0.7 mm) with an attached syringe, the esophageal wall was punctured at three points (in the central part of the spasmodic area and at two points at a distance of about 2 cm above and below the first puncture along the esophagus) through the adventitial and muscular membranes of the esophagus, without damaging the mucous layer, while introducing 30 ml of isotonic 0.9% sodium chloride solution (NaCl) into the submucosal layer of the esophagus wall until the solution spread and visible swelling of the organ wall. After that, anterior esophagocardiomyotomy was performed under endoscopic control, starting from the cardial part of the stomach at a distance of 1 cm from the cardioesophageal junction and further up the esophagus, 8 cm long. first to the left and then to the right of the esophagocardiomyotomy incision throughout. Then the posterior wall of the fundus of the stomach was passed under the esophagus from the side of the lesser curvature, after which the posterior partial half-cuff was formed by fixing the posterior wall of the fundus of the stomach to the lateral part of the esophagus. Thus, the posterior wall of the stomach was sutured with two interrupted sutures to the posterior wall of the esophagus. Posterior crurorrhaphy was performed with a Z-shaped suture along the caliber of the esophagus with capture of the posterior wall of the esophagus. At the final stage of the operation, a nasogastric tube was inserted into the stomach, a drain (5 mm) was placed into the left subdiaphragmatic space through an access in the left hypochondrium. Produced control of hemostasis, desufflation and then removal of trocars. The postoperative period was uneventful, complex postoperative conservative therapy, monitoring of laboratory results and early activation of the patient were carried out. Three days after the operation, fluoroscopy was performed with a water-soluble contrast agent - there are no streaks, the contrast is freely passable into the stomach. Nutrition was carried out through a tube the next day after the operation. On the 3rd day after the operation, the patient underwent a second X-ray examination and then the nasogastric tube was removed, the patient began self-feeding. The patient was discharged for outpatient treatment on the 8th day in a satisfactory condition. Conducted after 3 months, the control X-ray examination showed no retention of the contrast agent in the esophagus. There are no complaints about dysphagia and heartburn in the late postoperative period.

Example 3. Example 1. Patient A. 25 years old. He was admitted to the clinic with a diagnosis of achalasia of the cardiac part of III degree. The diagnosis was confirmed by fluoroscopy and esophagogastroscopy.

The patient was examined and prepared for surgery. Before the operation, the nasoesophageal zone was installed, the esophagus was cleaned, followed by removal of the probe. The operation was performed - laparoscopic esophagocardiomyotomy in the Heller modification with an anterior fundoplication in the Dora modification and a posterior partial fundoplication with posterior cruroraphy. At the same time, after installing 4 laparoscopic ports and applying carboxyperitoneum up to 12 mm Hg. Art. a review of the abdominal organs was performed. Next, a hepatic retractor was installed through the epigastric trocar, and the left lobe of the liver was traction upward. Using an ultrasonic dissector, the lesser omentum was opened above the hepatic branch of the vagus nerve, the right pedicle of the alimentary opening of the diaphragm (AHD) was visualized, the esophagus was mobilized, and the middle fascicle of the right AH pedicle was exposed. Next, the left POD leg was visualized and released. Mobilization was continued along the left leg behind the esophagus until it was completely released. Transection of the ligaments surrounding the esophagus and its mobilization were performed, then artificially expanded the legs of the POD. Then, using blunt and sharp methods, the lower segment of the esophagus was isolated from the posterior mediastinum, separated from the mediastinal pleura, and brought down into the abdominal cavity. The anterior (left) vagus nerve was displaced atraumatically to the right of the esophagus. After that, in the avascular zone behind the pod, access was made to the posterior wall of the gastric fundus, and the phrenic-fundic ligament was partially transected. The fundus of the stomach was released with the intersection of 2 short gastric arteries. The esophagus was brought down into the abdominal cavity and fixed with two interrupted sutures to the right and left podiatric pedicles in such a way that most of the esophagocardiomyotomy incision was in the abdominal cavity. Next, anterior esophagocardiomyotomy was performed, starting from the cardial part of the stomach at a distance of 2 cm from the cardioesophageal junction, and further up the esophagus with a length of 6 cm. When performing esophagocardiomyotomy, the submucosal and mucosal layers of the esophagus were injured with the formation of a perforated hole into the lumen of the esophagus. This defect was sutured with an interrupted suture. Then, with separate interrupted sutures along the contour of the myotomy incision, the anterior fundoplication cuff was formed with the anterior wall of the cardial part of the stomach, first to the left and then to the right of the esophagocardiomyotomy incision throughout. Then, the posterior wall of the fundus of the stomach was passed under the esophagus from the side of the lesser curvature, subsequently a posterior partial half-cuff was formed by fixing the posterior wall of the fundus of the stomach to the lateral part of the esophagus. Thus, the posterior wall of the stomach was sutured with two interrupted sutures to the wall of the esophagus. Posterior crurorrhaphy was performed with one Z-shaped suture along the caliber of the esophagus. At the final stage of the operation, a nasogastric tube was inserted into the stomach, a drain (5 mm) was placed into the left subdiaphragmatic space through an access in the left hypochondrium. Produced control of hemostasis, desufflation and then removal of trocars. The postoperative period was uneventful, complex postoperative drug therapy was carried out, tests were monitored and the patient was activated. On the first day after the operation, fluoroscopy with a water-soluble contrast agent was performed - a slight extravasation of the contrast agent into the abdominal cavity was revealed. Control X-ray examination on the fourth day after the operation revealed no extravasation, the contrast is freely passable into the abdominal cavity. Given the negative psycho-emotional reaction to the probe and its self-removal on the 2nd day, the patient was fed parenterally until the second X-ray contrast study was performed, after which the patient began self-feeding. In a satisfactory condition on the 12th day, the patient was discharged for outpatient treatment. Conducted after 3 months, the control X-ray examination showed no retention of the contrast agent in the esophagus. There are no data on dysphagia and heartburn .

Thus, the proposed method allows for the safe treatment of even recurrent forms of achalasia of the cardia with minimal risks of intraoperative complications in the form of perforations of the esophageal wall, and, as a result, prevents possible postoperative complications, reduces the length of the patient's stay in the hospital, and also reduces the risk of developing a relapse of the disease. . The method allows to control the depth of the esophagocardiomyotomy incision when performing esophagocardiomyotomy and to more accurately determine the boundaries of the zone of pathological changes in the tissues of the esophagus and healthy tissues.

Claims (4)

1. Method for laparoscopic treatment of achalasia cardia, including mobilization of the lower third of the esophagus, access to the posterior wall of the fundus of the stomach, performing anterior esophagocardiomyotomy of the spasmodic area of the esophagus, formation of a fundoplication cuff by suturing the anterior wall of the fundus of the stomach to the left side of the esophagocardiomyotomy incision throughout, followed by fixing the same wall to the right side of the esophagocardiomyotomy incision throughout, the formation of the posterior partial cuff by passing the posterior wall of the fundus of the stomach under the esophagus from the side of the lesser curvature and fixing it to the lateral part of the esophagus with at least two interrupted sutures, performing posterior crurorrhaphy along the diameter of the esophagus, characterized in that before performing esophagocardiomyotomy under endoscopic control, hydropreparation of the submucosal layer of the esophagus is carried out in the area of localization of the spasmodic area by introducing an isotonic solution of sodium chloride into the submucosal layer of the esophagus in a volume that provides visible swelling of the organ wall, while the introduction of the solution is carried out at least at two points using a needle, which is inserted through the adventitious and the muscular membranes of the esophagus without affecting the mucous layer. 2. The method according to claim 1, characterized in that the introduction of the solution is carried out in a volume of 20-30 ml. 3. The method according to claim 1, characterized in that additional fixation of the posterior wall of the esophagus to the legs of the esophageal opening of the diaphragm is carried out when performing posterior crurorrhaphy. 4. The method according to claim 1, characterized in that a needle with a length of 5 mm and an inner diameter of 0.5 mm or 0.7 mm is used as a needle.

Images