RU2806015C1 - Method of applying esophagojejunostomy during laparoscopic gastrectomy - Google Patents

Abstract

FIELD: medicine; abdominal surgery; gastroenterology; oncology.

SUBSTANCE: Gilyarovich loop is formed at a distance of 45 cm from the Treitz ligament. In the outlet colon, at a distance of 15 mm from the lower corner of the Gilyarovich loop, a technological window with a diameter of 10 mm is made. A hole with a diameter of 10 mm is made on the posterior wall of the oesophagus under the suture line. The suturing device is sequentially inserted into the opening of the oesophagus and the technological window of the afferent loop of the jejunum. Suturing device is used to suture and an oesophageal-intestinal anastomosis is formed. The adductor colon covers the area of anastomosis with a continuous suture to the lower corner of Gilyarovich's loop.

EFFECT: method is less traumatic, allows to reduce the time of surgical intervention, thereby reducing the period of exposure to anaesthesia on the patient’s body and reducing the level of blood loss, allowing to reduce the risk of complications in the early and late postoperative period.

1 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, namely to oncology, and can be used for stomach cancer that requires complete removal of the stomach.

Stomach cancer still ranks among the leading causes of mortality from malignant neoplasms.

Gastric cancer (GC) is a heterogeneous group of malignant epithelial tumors arising from the cells of the gastric mucosa. GC is a multi-etiological disease, the main factors include the following: heredity, Helicobacter pylori infection, bad habits - smoking, nutritional - alcohol, abuse of salted, fried, canned, pickled, spice-rich foods; consumption of products contaminated with mycotoxins; deficiency of microelements and vitamins. Background diseases: chronic atrophic hyperplastic gastritis, adenomatous polyps, pernicious anemia, conditions after gastrectomy, Menetrier's disease (hypertrophic gastropathy, hyperplastic giant-fold gastritis).

GC, being one of the most common malignant human tumors, ranks 5th in the structure of morbidity in the Russian Federation (RF) and 3rd in the structure of mortality from malignant neoplasms. Men get sick 1.3 times more often than women, with the peak incidence occurring at the age of 65 years.

The main, and sometimes the only, treatment for stomach cancer is gastrectomy.

From medical practice, a method of surgical treatment of stomach cancer is known - gastrectomy - complete removal of the stomach with regional lymph nodes - in all cases, except for cancer of the antrum of the stomach in the absence of foci of severe dysplasia and cancer in situ in the remaining part of the stomach, cancer of the cardioesophageal junction, as well as small tumors of the cardia or fundus of the stomach of exophytic or mixed growth form.

There are known methods for applying esophagojejunostomies during laparoscopic gastrectomy (RU 2.675.772 C1 (01.08.2018), RU 2.742.624 C2 (09.15.2020)), in which various defects and shortcomings were identified when using these methods. Despite the differences and features of these methods, each of them has its own advantages and disadvantages, but all of them are aimed at strengthening the anterior wall of the EEA as the weakest point of the operation.

When making a connection between the esophagus and the jejunum, the incomplete “cuff” method was used, which in turn can provoke failure (rupture of the connection) of the anastomosis in the most unstrengthened part. In our case of application, the unstrengthened part is completely covered by the afferent loop of the jejunum. Analogues use minilaparotomy access to work on the jejunum and additional connections between the loops of the small intestine, which lengthens the time period of the surgical intervention itself and increases the number of actions. In our case, a loop is formed from the jejunum for a comfortable connection with the esophagus, without spending additional time and without additional connections between the loops of the small intestine.

As a prototype, the method of esophageal-jejunal connections was used, namely anastomosis of the esophagus with an outlet loop according to M.3. Sigal (1 option). (Sigal M.Z., Akhmetzyanov F.Sh. Gastrectomy and gastric resection for cancer. - Kazan: Tatar book. Publishing house, 1991. - P. 190) https://search.rsl.ru/ru/record /01004942595.

The disadvantage of this method is the lack of complete visualization of the opening between the esophageal-small intestinal junction; during the process of anastomosis, the mucous membrane is not opened at the time of suturing. Taking into account the fact that the destruction of the walls with a passing probe can only be controlled using direct tactile control, which is impossible with laparoscopic surgery. In our version, through the technological window of the jejunum, a stapler is inserted into the technological window of the esophagus, which completely allows us to visualize the connection of the walls and the communication of one cavity with another. I would like to note one more difference of our proposed method - the speed of anastomosis using a stapler.

The purpose of the invention is to simplify and reduce the time of application of esophagojejunostomy during laparoscopic gastrectomy.

This goal is achieved by the fact that according to this method, a Gilarovich loop is formed at a distance of 45 cm from the ligament of Treitz, a technological window with a diameter of 10 mm is made in the abducent colon at a distance of 15 mm from the lower corner of the Gilarovich loop, a hole with a diameter of 10 mm is made on the posterior wall of the esophagus above the suture line mm, a stapler is sequentially inserted into the opening of the esophagus and the technological window of the afferent loop of the jejunum, stitched with a stapler, an esophageal-intestinal anastomosis is formed, the anastomosis area is covered with the adductor intestine with a continuous suture to the lower corner of the Gilarovich loop.

The invention is illustrated by drawings, where:

Rice. Figure 1 shows the sequence of surgical techniques in preparation for esophagojejunostomy;

Rice. Figure 2 shows the insertion of the stapler into the technological window and into the opening of the esophagus;

Rice. Figure 3 shows the process of stitching the technological window and the opening of the esophagus using a stapler;

Rice. Figure 4 shows suturing of a technological window;

Fig. 5 shows the covering of the esophageal-intestinal anastomosis with the Gilarovich adductor loop, where

1 - efferent loop of the jejunum,

2 - afferent loop of the small intestine,

3 - technological window with a diameter of 10 cm,

4 - posterior wall of the esophageal stump,

5 - hole with a diameter of 10 cm,

6 - jaws of the stapler

The proposed method is carried out as follows:

1. At a distance of 45 cm from the ligament of Treitz, a Gilarovich loop is formed (the abductor 1 and afferent 2 Gilarovich loops are sutured) 60 mm long. (Fig. 1). In the outlet colon 1 loops at a distance of 15 mm from the lower corner a technological window 3 with a diameter of 10 mm is made. Along the posterior wall of the esophageal stump 4, immediately above the suture line of the stapled suture, a hole 5 with a diameter of 10 mm is also made. (Fig. 1).

2. The branches 6 of the linear stapler (45 mm cassette) are sequentially inserted into the technological window 3 of the Gilarovich loop, and then the hole 5 of the esophagus 4. The branches 6 are compressed and stitched, thus forming an anastomosis of the esophagus and the abducens colon 1 of the Gilarovich loop. (Fig. 2 and 3)

3. Probe 7 is passed through the esophagus and esophageal-intestinal anastomosis into the efferent colon of 1 Gilyarovich loop.

4. Technological window 3 is sutured with interrupted sutures (Fig. 4)

5. With the afferent colon, 2 Gilyarovich loops cover the area of the esophageal-intestinal anastomosis with the application of a manual suture with the afferent colon. (Fig. 5)

6. The manual continuous seam is continued to the lower corner of the Gilarovich loop.

Clinical example.

Patient T., born in 1941. He was admitted to the oncology department on 04.2022 at the age of 81 with a diagnosis of stomach cancer. He made no active complaints. From the anamnesis it is known that there was a 2-fold episode of gastrointestinal bleeding while taking anticoagulants. At the place of residence, FGDS revealed a gastric ulcer 0.5×0.3 cm. The growth of adenocarcinoma was histologically confirmed. According to ultrasound of the abdominal cavity and cervical lymph nodes without oncopathology. Video gastroscopy in the conditions of RKOD: stomach - a picture of superficial gastritis, in the cardia along the posterior wall, immediately below the cardiac sphincter - an ulcer about 0.5 cm in D with a shaft around, deep. Histologically, low-grade gastric adenocarcinoma was revealed. Patient T. has concomitant pathology in the form of hypertension and a myocardial infarction a year ago. Taking into account the localization of the tumor, the extent of the tumor process, and the histological conclusion of the tumor biopsy, the first stage is usually surgical treatment. The patient underwent laparoscopic extended gastrectomy with lymphodenectomy. During this operation, at a distance of 45 cm from the Treitz ligament, a Gilarovich loop is formed (two loops of jejunum are sutured) 60 mm long. In the outflow colon of the loop, at a distance of 15 mm from the lower corner, the intestinal lumen with a diameter of 10 mm is opened, thus forming a technological window. Along the posterior wall of the esophageal stump, immediately above the suture line of the stapler suture, a lumen with a diameter of 10 mm is also opened, the jaws of a linear stapler (45 mm cassette) are sequentially inserted into the technological hole of the Gilarovich loop, and then the esophagus, the jaws are compressed and stitched, thus An anastomosis of the esophagus and the abductor loop of Gilarovich is formed, a probe is passed through the esophagus and esophageal-intestinal anastomosis into the abductor intestine of the Gilyarovich loop. The technological hole is sutured with interrupted sutures. With the afferent colon, Gilarovich's loops cover the area of the esophageal-intestinal anastomosis with the application of a manual suture to the afferent colon. The manual continuous seam is continued to the lower corner of the Gilarovich loop. At this stage, the use of our proposed method ends; the operation is completed in the standard way, leaving drainage and suturing the trocar holes. The postoperative period was uneventful. The patient is discharged home in satisfactory condition under the supervision of a polyclinic oncologist at the RKOD. During the first 3 months of observation, when endoscopic examination methods were performed on this patient, no narrowing of the anastomosis was detected.

Taking into account the age of the patient and the presence of concomitant pathology, thanks to this method it was possible to reduce the time of surgical intervention, reduce the amount of blood loss and trauma.

From 2020 to 2022, we operated on 12 people using this method, age range from 51 to 81 years. The postoperative period in each case passed without complications, with minimal blood loss during surgery (from 50 ml to 150 ml). This method allowed us to arrive at the following results:

1. This method allows you to reduce the time of surgical intervention, thereby reducing the period of exposure to anesthesia on the patient’s body.

2. Less traumatic, as it is performed with minimal surgical access.

3. The level of blood loss is reduced.

4. Taking into account the variety of equipment (various devices for intersecting hollow organs) in laparoscopic surgery, it is possible to technically separate the removed macropreparation from the source, or connect two organs together.

5. The technique of applying an esophageal-jejunal junction allows you to avoid various types of complications in the early and late postoperative period; the movement of food and water in two loops - a reverse cast or a delay in movement.

Claims (1)

A method of applying esophagojejunostomy during laparoscopic gastrectomy, including the formation of a Gilarovich loop by suturing the efferent and afferent parts of the jejunum 60 mm long, characterized in that the Gilarovich loop is formed at a distance of 45 cm from the ligament of Treitz, in the efferent colon at a distance of 15 mm from the lower corner of the loop Gilarovich, a technological window with a diameter of 10 mm is made, a hole with a diameter of 10 mm is made on the posterior wall of the esophagus above the suture line, a stapler is sequentially inserted into the opening of the esophagus and the technological window of the afferent loop of the jejunum, stitched with a stapler, an esophageal-intestinal anastomosis is formed, the area is covered with the adductor intestine anastomosis with a continuous suture to the lower corner of Gilarovich's loop.

Images