RU2801772C1 - Method of reduodenization with formation of anti-reflux valve in diseases of stomach subjected to surgery after gastrectomy in brown loop reconstruction - Google Patents

Abstract

FIELD: medicine; abdominal surgery.

SUBSTANCE: disconnection of the interintestinal anastomosis is performed, the abduction loop of the esophagojejunoanastomosis (EJA) is crossed and connected to the duodenal stump by a two-row anastomosis end-to-end, the afferent loop is crossed at the EJA, after which the continuity of the small intestine is restored, connecting the inlet and outlet sections with the anastomosis end-to-end, then an antireflux valve is formed closer by 5 cm to the jejunoduodenoanastomosis by dissecting the serous muscular membrane to the mesenteric edge in two places, followed by suturing the serous muscular part of the intestine with separate seroserous interrupted sutures, after which separate nodular seroserous sutures are applied followed by immersion of the intestinal wall with a dissector.

EFFECT: method allows to restore the natural passage of food and create an antireflux valve.

3 cl, 2 ex, 16 dwg

Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of diseases of the operated stomach.

State of the art

Gastrectomy (GE) is still the only radical treatment for gastric cancer, which accounts for up to 80% of all radical interventions in specialized departments [Boyakova N.V. Modern approaches to the surgical treatment of gastric cancer. Siberian Medical Review. No. 5. 2015. S. 99-104]. Severe digestive disorders after HE develop in 60% of cases and require medical rehabilitation in 100% [Velikolug K.A. Modern approaches to the problems of medical and social rehabilitation of gastroenterological patients and disabled people: author's abstract: dis. … dr. honey. Sciences. M.: - 2013. C - 42]. The reason for this is the routine use of Brown's loop reconstruction, in which the duodenum (duodenum) and at least 50 cm of the jejunum are turned off from the passage of food, which leads to the development of hypoglycemia, dumping syndrome (DS), asthenia and cachexia [Yang Qin Eujunogastroplasty as a method reconstruction of the digestive tract after gastrectomy: dis. cand. honey. Sciences 12.10.17 Surgery. Moscow 2015 - 154 p.]. In addition, according to Aliev S.A., after HE according to Brown in the long-term period, 61.2% of patients develop reflux esophagitis (RE), and 44.4% have persistent anastomosis, with a characteristic clinical picture [Aliev S.A. ., Magomedov S.M. Comparative X-ray endoscopic evaluation of methods for reconstructing the digestive tract after gastrectomy. Modern problems of science and education. 2021. No. 3. URL: https://science-education.ru/ru/article/view?id=6118 (accessed 03.03.2023)]. Known methods of surgical treatment of progressive forms of AOD are aimed at restoring the duodenal passage of food, which provides portioned evacuation of food to the lower intestine and eliminates severe manifestations of dumping syndrome (DS) (Zakharov E.I. Eyunogastroplasty in diseases of the operated stomach / E.I. Zakharov, A.E. Zakharov // - M.: Medicine. - 1970. - 232 p.). However, reduodenization alone is not always effective in the treatment of DS and RE, because its design does not contain a closing and, at the same time, restraining food passage mechanism that can prevent DS and reflux of intestinal contents into the esophagus.

The prior art method of reduodenization in diseases of the operated stomach after gastrectomy in the loop reconstruction according to Brown [Zherlov G.K. Fundamentals of functional surgical gastroenterology, 2009, Tomsk, p. 274]. The monograph describes a method for transposition of the efferent loop into the stump of the duodenum with the formation of a sphincter and valve in the area of esophagojejunoanastomosis (EJA) and jejunoduodenoanastomosis (EDA), after GE with Brown reconstruction. After mobilization, the outlet loop is crossed 14-16 cm from the EJA and its distal edge is connected to the duodenal stump by an invagination-valve anastomosis. The afferent loop is crossed 3 cm proximal to the EJA and resected together with the interintestinal fistula and part of the efferent loop. Restore the continuity of the intestine, connecting the leading and abducting sections. Then dissect the muscular membrane of the esophagus and jejunum in the EEA zone, and sequentially sew them together, immersing the excess submucosal layer into the lumen of the anastomosis, which, according to the author, is the basis for the formation of the invagination valve (figure 1).

However, the known method has low efficiency in the treatment of RE. In the study of long-term results of treatment of patients after reconstructive EGP with the formation of an invagination-valvular sphincter in the area of the EJA according to the method of G.K. Zherlov, patients (27.8%) with RE one year after surgery were identified, of which 5.3% had fibrin plaque on the posterior wall of the esophagus, and 15.8% had bile in the proximal intestinal insert [Kurtseitov N .E. The role of reduodenization with the formation of areflux anastomoses in the treatment of some forms of diseases of the operated stomach: dis. … dr. honey. Sciences. Tomsk. 2013. 330 s]. In addition, invagination methods of EEA in 23.3% are complicated by cicatricial stenosis, causing dysphagia [Khuseynov G.A. Endoscopy in the diagnosis and treatment of complications of esophageal anastomoses: dis. cand. honey. Sciences. Saint Petersburg. 2016. 126 s]. In addition, the reconstruction option proposed by the author implies resection of the initial sections of the small intestine (adductor loop and interintestinal anastomosis), which negatively affects digestion. After all, it is in this section of the intestine that the main parts of food are split even without the participation of gastric juice enzymes [Markova G.F. Clinic and treatment of the consequences of complete removal of the stomach. M. Med. 1969. S. 160.].

Closest to the claimed invention is a method of reduodenization with the formation of an antireflux valve in diseases of the operated stomach after gastrectomy in a loop reconstruction according to Brown, performed at the A.V. Vishnevsky in 2016 [Kozlov V.A. Repeated reconstructions of the digestive tract after gastric surgery. dis. cand. honey. Sciences 12.10.17. Moscow. 2019 174 p.]. The method included interposition of the EEA outlet loop into the duodenal stump with the formation of an antireflux valve on it, disengagement of the interintestinal anastomosis with the transfer of the afferent loop into an orthotopic position (Fig. 2). The total length of the Brownian loop was approximately 60 cm with an interintestinal anastomosis 30 cm from the ligament of Treitz, the efferent segment was 40 cm. Below the interintestinal anastomosis, it was connected to the duodenal stump, an antireflux valve was formed in its distal third, 4 cm away from the jejunoduodenoanastomosis (EDA), it was dissected serous - the muscular membrane to the mesenteric edge in two places at a distance of 1 cm from each other. Then, the upper and lower edges of the seromuscular plate were sutured with separate gray-serous interrupted sutures at a distance of 1 cm, invaginating it into the intestinal lumen, then the distal and proximal sections of the intestine were sutured with separate interrupted gray-serous sutures at a distance of 1 cm from each other, invaginating earlier sutured serous-muscular plate into the intestinal lumen (Fig. 3). After the operation, the patient was under observation at the National Medical Research Center for 3 years, gained 8 kg in weight while following the diet, and returned to work. However, according to FGDS, the patient had erosive esophagitis after 2 years (Fig. 4a). In addition, according to endoscopic examination, the formed valve looked rigid, and bile was detected above the valve (Fig. 4b). According to X-ray data, the intestinal insert is long, not dilated, the contrast evacuation after the first sip immediately entered the duodenum and the underlying intestines. Thus, it can be stated that the method of forming the valve is not perfect and needs to be improved, and the long interposed segment (40 cm) does not prevent the reflux of bile into the esophagus, over time it acquires a “hook-shaped” (angular) shape, while the distal part of the segment is located horizontally, thus forming a "food depot" in the form of an acute angle (Fig. 5). In this part of the segment, food mixes with bile, causing regurgitation of the contents into the esophagus and, as a result, reflux esophagitis (RE).

The technical problem is the development of a method for re-reconstruction of the digestive tract in diseases of the operated stomach with the restoration of the natural passage of food and the formation of an antireflux valve after GE with Brown loop reconstruction.

Disclosure of the essence of the invention

The technical result, which the claimed invention is aimed at, is the surgical treatment of severe forms of BOS due to the repeated reconstruction of the digestive tract after GE with the restoration of the natural passage of food and the creation of an antireflux valve.

The claimed invention makes it possible to eliminate severe manifestations of AAD due to a valve formed on the interposed segment of the intestine, which, on the one hand, slows down the passage of food along the segment with its subsequent evacuation into the duodenum, and on the other hand, prevents the reflux of intestinal contents into the esophagus, preventing RE.

The claimed invention improves the effectiveness of the treatment of BOS by restoring the passage of food through the duodenum; creates conditions for slowing down the passage of food through the intestinal segment located between the esophagus and the duodenum, which ensures portioned evacuation of food into the duodenum and the underlying intestines. The invention is also aimed at preventing regurgitation of bile and intestinal contents into the esophagus.

The technical result is achieved by the following methods. Disconnection of the interintestinal anastomosis is performed, the outlet loop of the esophagojejunoanastomosis (EEA) is crossed and connected to the duodenal stump by a two-row anastomosis end to end. The afferent loop is crossed at the EJA, after which the continuity of the small intestine is restored, connecting its afferent and abducting sections with an end-to-end anastomosis. Then, an antireflux valve is formed 5 cm proximal to the jejunoduodenoanastomosis by dissecting the serous-muscular membrane to the mesenteric edge in two places, followed by suturing the serous-muscular part of the intestine with separate gray-serous interrupted sutures. After that, separate nodal gray-serous sutures are applied to the upper and lower edges of the dissected serous-muscular membrane, followed by immersion of the intestinal wall with a dissector.

In a particular case, an intestinal segment about 25 cm long is used for transposition.

In a particular case, the antireflux valve is formed by circular dissection of the seromuscular membrane to the mesenteric edge in two places, while the first dissection is performed at a distance of 5 cm proximal to the jejunoduodenoanastomosis, and the second is 1.5 cm proximal to the first, followed by suturing the seromuscular part of the intestine separate gray-serous interrupted sutures at a distance of 5 mm from each other, after which separate interrupted gray-serous sutures are placed on the upper and lower edges of the dissected serous-muscular membrane, stepping back 5 mm between the sutures.

Brief description of the drawings

The invention is illustrated by drawings, where figure 1 is a schematic representation of the method according to G.K. Zherlov, including the transposition of the efferent loop into the stump of the duodenum with the formation of a sphincter and valve in the area of the EJA after GE with Brown reconstruction: A) - the efferent loop of the EJA; C) - duodenal stump; C) - distal afferent loop; D) - distal efferent loop; figure 2 shows a diagram of the operation performed at the Vishnevsky Research Institute of Surgery (prototype), which includes the interposition of the discharge loop EEA in the stump of the duodenum with the formation of an antireflux valve: A) - discharge loop EEA; B) - duodenal stump; C) - distal afferent loop; D) - distal efferent loop; in fig. 3 - intraoperative photograph of the formation of the valve in patient I., 36 years old, in accordance with the method of the National Medical Research Center for Surgery named after A.V. Vishnevsky; in fig. 4 - results of endoscopic examination of patient I., 36 years old in the long-term period: a) - erosive esophagitis; b) - antireflux valve; in fig. 5 - results of X-ray examination of patient I., 36 years old in the long-term period: a) - direct projection; b) - lateral; in fig. 6 - intraoperative photograph of the afferent and efferent loops after separation of the interintestinal anastomosis; in fig. 7 - intraoperative photograph after crossing the outlet loop, its feeding vessel; in fig. 8 - intraoperative photographs of the formation of an antireflux valve: a) - after dissection of the seromuscular membrane; b) - sutured inner part of the valve; in fig. 9 - a photograph of valve invagination into the intestinal lumen; in fig. 10 - schematically shows the stages of valve formation; in fig. 11 - a schematic version of the reconstruction (the claimed method): A) - outlet loop EEA; B) - duodenal stump; C) - distal afferent loop; D) - distal efferent loop; in fig. 12 - results of endoscopic examination of patient Sh. before reconstructive surgery; in fig. 13 - intraoperative photograph of the completed reconstruction in patient Sh. (the claimed method); in fig. 14 - results of endoscopic examination of patient Sh. after reconstruction in the long-term period: a) - esophagus; b) - antireflux valve; in fig. 15 shows the results of an X-ray examination of patient B., before reconstructive surgery: a) after oral administration of contrast; b) 1 minute after taking the contrast cock; in fig. 11 - radiograph of patient B., in the long-term period after reconstructive surgery: a) after oral administration of barium suspension; b) 5 minutes after oral administration; c) after 15 minutes.

Implementation of the invention

The method is carried out as follows.

From the median access, a laparotomy is performed with excision of the postoperative scar, then the abductor and adductor loops of the small intestine of the esophagojejunoanastomosis with the interintestinal Brownian fistula are mobilized. After that, the interintestinal (Brown) anastomosis is separated by a linear stapler, the mechanical suture is additionally peritonized with a continuous gray-serous suture (Fig.6). Next, the afferent loop is crossed with a stapler at a distance of 1.5 cm from the EJA so as not to stenose the EJA lumen after additional peritonization of the mechanical suture of the proximal stump of the afferent loop with separate gray-serous sutures. The distal part of the former afferent loop is moved below the mesentery of the transverse colon into an orthotopic position. The duodenal stump is mobilized at a distance of 1.5-2 cm, freeing it from the surrounding tissues for the subsequent unhindered formation of the terminal two-row jejunoduodenoanastomosis. Then, at a distance of 25 cm from the esophago-intestinal anastomosis, a linear stapling apparatus crosses the outlet loop while maintaining the feeding pedicle of the small intestinal segment (Fig. 7) in such a way that it can be anastomosed without tension with the stump of the duodenum. Usually this is a segment of the intestine that feeds from the 3rd intestinal artery. The vascular architectonics in this zone, as a rule, is represented by a single or double arch and is located distally along the course of the superior mesenteric artery. The mesentery of this section of the intestine is located in the middle part of the abdominal cavity, mobile and has sufficient length, and, as a rule, it is this section of the small intestine that is used to create the Brownian loop. When assessing blood circulation, one should be guided by the macroscopic criteria of graft viability - color, turgor, peristaltic activity and pulsation of the marginal arteries. Even local venous stasis is regarded as a sign of questionable viability. Next, the integrity of the small intestine is restored by forming a single-row anastomosis between the inlet and outlet sections of the intestine with separate interrupted sutures. After that, the distal end of the outlet loop is connected to the duodenal stump by an end-to-end anastomosis with separate interrupted sutures, in two rows. Then proceed to the formation of antireflux valve. On the interposed segment, the seromuscular membrane is dissected in two places circularly to the mesenteric edge of the intestine, while the first dissection is performed 5 cm above the jejunoduodenoanastomosis, and the second is 1.5 cm proximal to the first dissection (Fig. 8a). Next, the upper and lower edges of the serous-muscular plate are sutured with separate gray-serous sutures without capturing the muscle layer at a distance of 5 mm, thereby forming a “circular leaflet” of the valve (Fig. 8b). Valve invagination is carried out by suturing the upper and lower serous-muscular edges with separate interrupted sutures at a distance of 5 mm, immersing the intestinal wall into its lumen with a dissector (Fig. 9). Schematically, the formation of the valve is shown in Fig. 10.

According to the proposed method, 5 patients were operated on. The average age was 58 years. All patients in the early postoperative period underwent a complex examination, 4 patients remained under observation in the long-term period.

Clinical examples:

Example #1. Patient Sh., 60 years old, in January 2019 underwent HE with Brown loop reconstruction for gastric cancer IIA pT3N0M0. Two months after the operation, heartburn appeared after each meal, after six months, heartburn became permanent. Added weakness after eating, weight loss by 20 kg. According to FGDS data from 09/01/2020, contact bleeding of the esophageal mucosa, multiple linear erosions at a distance of 27 cm from the incisors were noted (Fig. 12). At 38 cm, the anastomosis is passable. with multiple erosions. He took Hermital, Rebagite, Ursofalk without effect. MSCT showed no signs of progression and recurrence of the oncological process.

On February 24, 2020, the patient was hospitalized at the A.V. Vishnevsky for reconstructive surgery with complaints of weakness after eating, constant heartburn, bitterness in the mouth, diarrhea up to 4 times a day, weight loss by 30 kg after surgery. On admission: BMI - 16.7, weight - 50 kg, protein - 52.1 g/l, albumin - 30.2 g/l, hemoglobin 113 g/l, lymphocytes 1.009*109/l, glucose 4.34 mmol / l.

According to radiography of the abdominal organs after oral administration of barium sulfate, the latter immediately fills the initial sections of the small intestine, while episodes of enteroesophageal reflux were noted during the study. Diagnosis: Severe reflux esophagitis. Dumping syndrome, progressive asthenia. Erosive esophagitis. Condition after gastrectomy from January 2019. On March 9, 2020, reduodenization of the EEA abduction loop was performed at the NMIC, with the formation of an antireflux valve according to the above method. An intraoperative photo (of the proposed reconstruction) is shown in Fig. 13. The postoperative period was satisfactory, the patient was discharged on the 9th day after the operation.

At the control X-ray examination with contrast at discharge from 03/17/20: The esophagus and EJA are passable, not deformed, evacuation is not disturbed. At the first sip, there is a uniform contrasting of the jejunal segment, up to the valve, after which portioned evacuation of the contrast into the duodenum and the underlying sections of the intestine occurs.

3 years after the operation, he feels well, he keeps a diet and diet. Appetite is good, I have gained 12 kg in weight since the operation. The chair is decorated regular, 1 time per day. BMI - 20.7, weight 62 kg, protein - 72.5 g / l, albumin - 44.6 g / l, hemoglobin 123 g / l, lymphocytes 2.484 * 109 / l, glucose 5.45 mmol / l. According to the MSCT of the abdominal organs dated February 1, 2023, there are no data for recurrence, progression of oncological disease. During FGDS from 02/13/2023, the apparatus freely passes through the EJA, the latter is pale pink, without inflammation (Fig. 14 a). At 60 cm from the incisors, a section of folded mucosa (valve) up to 2 cm long, in this zone, during insufflation with air, the intestine does not expand well, the lumen width is up to 1.5 cm (Fig. 14 b), below in the lumen of the bile segment, the zone of jejunoduodenoanastomosis DPC without features. X-ray examination with contrast dated February 8, 2023: the esophagus is passable, not deformed. The esophagojejunoanastomosis closes, there is no reflux of contrast into the esophagus. The contrast fills the jejunal segment up to the valve, after 1-2 minutes there is a batch evacuation of the contrast into the distal part of the segment and duodenum. Further, the contrast is deposited in the duodenum and, as it is filled, portionwise enters the underlying sections of the intestine. Thus, the contrast is initially deposited in the proximal part of the segment (above the valve), then in the duodenum, which significantly slows down its passage through the intestines and ensures portioned evacuation into the small intestine. The antireflux valve prevents the backflow of food into the proximal part of the interposed segment and the esophagus. After 2.5 hours, the contrast in the loops of the ileum and the dome of the blind.

Example #2. Patient B., 58 years old, in Kazakhstan in July 2016, underwent HE with Brown loop reconstruction for gastric cancer, the stage is unknown. After the operation, a year later, she noted the appearance of nausea after eating, bouts of general weakness, up to fainting, debilitating heartburn. She was repeatedly treated in hospitals in Kazakhstan, symptomatic therapy, diet therapy were carried out, against which the above complaints only progressed.

On May 23, 2018, the patient was hospitalized at the A.V. Vishnevsky in a relatively satisfactory condition with complaints of weakness, constant nausea and heartburn, loose stools up to 4-5 times a day, weight loss by 19 kg since the operation. On admission: BMI - 19.0, weight - 52 kg, protein - 43.2 g/l, albumin - 28.0 g/l, hemoglobin 95 g/l, lymphocytes 1.213*109/l, glucose 4.4 mmol / l. MSCT showed no signs of progression and recurrence of the oncological process.

According to FGDS, erosive esophagitis. In an x-ray examination of the abdominal organs after taking barium sulfate per os, the contrast from the esophagus enters the loops of the small intestine (Fig. 15 a) and within 1 minute its initial sections are almost completely filled (Fig. 15 b). Diagnosis: Severe dumping syndrome. Erosive reflux esophagitis. Condition after gastrectomy in July 2016. On May 24, 2018, a reconstructive operation was performed at the NMIC: reduodenization of the EJA outlet loop, with the formation of an antireflux valve according to the above method. The postoperative period was satisfactory, the patient was discharged on the 7th day after the operation.

At the control X-ray examination with contrast at discharge dated June 1, 2018: The esophagus and EJA are passable, not deformed, evacuation is not disturbed. At the first sip, a segment of the jejunum is filled with contrast up to the valve, after which its portion-wise evacuation to the duodenum is observed, as it is filled, a portion-wise passage of barium suspension into the underlying sections of the intestine occurs.

4 years after the operation, he feels well, strictly adheres to the diet and diet. 3 months after the reconstructive operation, she began her previous labor activity and continues to work. I have gained 14 kg in weight since the operation. The chair is decorated, regular, there is no diarrhea. BMI - 23.9, weight 65 kg, protein - 56.0 g / l, albumin - 31.6 g / l, hemoglobin 109 g / l, lymphocytes 1.21 * 109 / l, glucose 4.1 mmol / l . According to MSCT of the abdominal organs dated October 07, 2022, there is no evidence of relapse, progression of cancer. With FGDS from 10/10/2022, the apparatus freely passes through the EJA, the valve is located 55 cm from the incisors up to 1.2 cm wide, above the valve the intestine expands well up to 4 cm during insufflation with air, in the valve area up to 1.5 cm, lower in the lumen bile segment, zone of jejunoduodenoanastomosis and duodenum without features. X-ray examination with oral intake of barium sulfate dated 10/10/2022: the esophagus is passable, not deformed. The esophagojejunoanastomosis closes, there is no reflux of contrast into the esophagus. After the segment above the valve is filled with contrast, it is portionwise evacuated to the distal part of the segment (Fig. 16a), the segment is up to 3 cm wide above the valve, the valve opens up to 1 cm. ). After 15 minutes, a deposit of contrast was detected in the segment above the valve and in the duodenum, as well as blots of contrast in the initial sections of the small intestine (Fig. 16c). The jejunal segment (25 cm) does not form an acute angle and does not create conditions for slowing down the passage along it, while the antireflux valve prevents accelerated evacuation.

In all patients who remained under observation, in the long term, there is a slowdown in the passage of food through the intestines due to the valve and duodenum. Also, there is no reverse reflux of the contents of the duodenum into the esophagus. Anthropometric and laboratory parameters of patients in the long-term period indicate an improvement in the nutritional status, and FGDS data confirm the absence of EC.

Thus, the proposed method of reduodenization with the formation of an antireflux valve in diseases of the operated stomach after Brown gastrectomy makes it possible to eliminate the development of postoperative reflux esophagitis and ensure portioned evacuation of food from the graft to the duodenum, which, in turn, leads to a slowdown in the passage of food throughout the intestine, preventing the development of severe forms of DS, and RE.

Claims (3)

1. A method of reduodenization, including the formation of an antireflux valve after gastrectomy in a loop reconstruction according to Brown, characterized in that the interintestinal fistula is separated, the outlet loop of the esophagojejunostomy (EEA) is crossed and connected to the stump of the duodenum by a two-row anastomosis end to end, the afferent loop is crossed at the EEA, after that, the continuity of the small intestine is restored, connecting its inlet and outlet sections with an end-to-end anastomosis, then an antireflux valve is formed 5 cm proximal to the jejunoduodenoanastomosis by dissecting the serous-muscular membrane to the mesenteric edge in two places, followed by suturing the serous-muscular part of the intestine with separate serous- serous interrupted sutures, after which separate interrupted gray-serous sutures are applied to the upper and lower edges of the dissected serous-muscular membrane, followed by immersion of the intestinal wall with a dissector. 2. The method according to claim 1, characterized in that an intestinal segment 25 cm long is used for transposition. 3. The method according to claim 1, characterized in that the antireflux valve is formed by circular dissection of the seromuscular membrane to the mesenteric edge in two places, while the first dissection is performed at a distance of 5 cm proximal to the jejunoduodenoanastomosis, and the second - 1.5 cm proximal the first, followed by suturing the serous-muscular part of the intestine with separate gray-serous interrupted sutures at a distance of 5 mm from each other, after which separate interrupted gray-serous sutures are placed on the upper and lower edges of the dissected serous-muscular membrane, stepping back 5 mm between the seams.