RU2813035C1 - Method of surgical treatment of morbid obesity in patients with type 2 diabetes mellitus - Google Patents

Abstract

FIELD: medicine; abdominal surgery; bariatric surgery.

SUBSTANCE: after installing the trocars, the stomach is mobilized along the greater and lesser curvature. The stomach is sutured with a stapler in the direction perpendicular to the lesser curvature. A vertical intersection of the stomach is performed along the lesser curvature, directing the stapler towards the angle of His and the fundus of the stomach, forming a small stomach on a calibration probe with a thickness of 33 FR. The suture of the formed small stomach and the suture above the preserved pylorus are peritonized with a continuous suture using a thread with notches, capturing the surrounding tissues. The disconnected part of the stomach is removed through a trocar access in the left hypochondrium. Along the antimesenteric edge of the small intestine, an ultrasonic scalpel is used to make a hole with a diameter of 12 mm, to which a small stomach is brought, and an end-to-side gastrojejunostomy is formed using a double-row continuous suture with a notched thread.

EFFECT: method is easy to use, reduces the risk of hardware suture failure and death, prevents intraoperative and postoperative complications, including bleeding, provides a restrictive effect of the operation, and does not require the use of foreign materials.

4 cl, 11 dwg, 2 ex

Description

The invention relates to the field of medicine, in particular to abdominal, bariatric surgery, and can be used in the surgical treatment of patients with type 2 diabetes mellitus and morbid obesity.

Methods for performing gastric bypass are varied. The operation is known for its complexity, labor intensity, and duration of execution. Bariatric surgeons are always trying to innovate to perform the surgery better, to be more efficient and to make the patient's recovery easier.

In classical combined operations, the disconnected part of the stomach is preserved. This reduces the effectiveness of the operation, since the part of the stomach that produces the hunger hormone, ghrelin, is preserved. Another disadvantage is the inability to inspect this disconnected part with an endoscope in the future.

There is a known patent RU 2640783, publication: 2018.01.11, which describes a method of surgical treatment of morbid obesity by mini-gastrobypass, characterized in that preoperative contact pH-metry of various parts of the stomach is carried out, the border of the gastric mucosa with a pH level of more than 3.0 is determined, according to this at the border, 1 ml of methylene blue is injected into the submucosa of the anterior wall of the stomach through the operating channel of the endoscope, the stomach is cut off at the marked level in the transverse direction to a width of 6 cm, and then longitudinally to the bottom of the stomach; a stump of a two-chamber stomach is formed, consisting of an upper preesophageal chamber with a length of 7 cm and a volume of 20 ml, and a chamber of the body of the stomach with a length of up to 10 cm and a volume of up to 100 ml, the volume of the created stomach chambers is calibrated and corrected on a probe with a latex balloon, filled with the required volume liquids, by reducing the chambers of the stomach with additional screwing single endosutures with non-absorbable suture material; then a loop of the small intestine is brought to the gastric stump at a distance of 180 cm from the duodenum, with an electrocautery in the distal part of the gastric stump along the anterior wall, and the antimesenteric edge of the small intestine, the lumen of the organs is opened with a 3.5 cm long incision and a single-row serous-muscular-submucosal gastroenteroanastomosis is applied with knot tying in its lumen, with single sutures at intervals of 0.8 cm, capturing the intestine 0.5 cm and the stomach 0.8 cm, so as to involve no more than 1/4 of the perimeter of the small intestine along the antimesenteric edge in the anastomosis.

Disadvantages: anastomosis of 3.5 cm leads to a decrease in the restrictive effect due to the rapid evacuation of contents from the stomach.

Requires the use of methylene blue, a foreign substance.

The analogue is characterized by a single-row anastomosis, the risks of leakage are increased, as are the risks of bleeding.

There is a known patent RU 2616988, publication: 2017.04.19, which describes a method of gastric bypass surgery, including laparoscopic access to the stomach, the formation of a small stomach in the area of the cardiac part from the lesser curvature with a linear stapler, reconstruction of the small intestine with the formation of a gastroenteroanastomosis with a small stomach and interintestinal anastomosis, characterized in that the stomach is mobilized from the side of the greater curvature from the pylorus to the angle of His, the left diaphragmatic leg, the stomach is crossed in the transverse direction, spaced proximally from the pylorus by about 2 cm, mobilized from the side of its lesser curvature in the proximal direction to the level of formation small stomach, the part of the stomach mobilized and cut on all sides is removed from the abdominal cavity.

In this analogue, the anastomosis is retrocolic, which requires disconnection of the small intestine according to Roux and the formation of two anastomoses. This lengthens and complicates the operation, increases the risk of complications and anastomotic failure.

In addition, the length of the new small stomach in this technique per 1 cassette is about 6 cm, which reduces the restrictive effect of the operation and worsens the result of weight loss.

There is a known patent RU 2629045, publication: 2017.08.24, which describes a method for the immediate prevention of biliary reflux and protection of gastroenteroanastomosis when performing mini-gastric bypass surgery, in which, after installing trocars and creating pneumoperitoneum, the lesser omentum and omental bursa are opened along the lesser curvature of the stomach in the area its corner, after which the first stitching is carried out with a linear stapler in the transverse axis of the stomach, and the second stitching is carried out with a cartridge of a linear stapler perpendicular to the first in the longitudinal direction to the axis of the stomach, then a thick probe is inserted along the lesser curvature of the stomach, and subsequent stitching is carried out parallel to the probe in the direction to the area of the angle of His, while forming the small ventricle in the form of a tube with a stapler line along the lateral edge, after which two holes are formed: on the anterior wall of the distal small ventricle and in the area 150-200 cm of the small intestine from the ligament of Treitz, respectively, into which the branches of the stapler, stitching is carried out and a linear hardware gastroenteroanastomosis is formed, while the end of the small ventricle is anastomosed with the intestinal wall in an “end-to-side” manner, that is, the distal end of the small ventricle is sutured into the side of the intestine, the remaining defect from the introduction of the device is sutured with a single-row continuous suture, then the adductor section of the small intestine is sutured with one interrupted suture to the lateral wall of the formed small ventricle with the staple line captured, which is applied 10-12 cm above the anastomosis along the line of the stapler suture of the stomach and 10-12 cm proximal to the anastomosis along the wall of the adductor section of the intestine, after which 0.3 ml of “Sulfacrylate” glue is applied to the staple line of the small ventricle and the intestinal wall adjacent to it, between the suture and the anastomosis, after which dries, this section of the adductor intestine is fixed to the lateral wall of the small ventricle along the staple suture line, forming anti-reflux spur, the next 0.3 ml of Sulfacrylate glue is applied to the line of a continuous single-row suture, the next 0.2 ml of Sulfacrylate glue is applied to the anterior wall of the antrum of the stomach, after which the efferent loop of the small intestine is brought to it distal to the gastroenteroanastomosis, which after Once the glue dries, it becomes fixed to the antrum of the stomach.

This analogue has a linear hardware gastroenteroanastomosis, which increases the risk of gastroenteroanastomosis failure, bleeding and death.

In addition, there is a need to use glue - a foreign material to prevent complications.

The closest analogue is the decision on patent RU2772754, publication: 2022.05.25, which describes a method of surgical treatment of hyperobesity and gastroesophageal reflux disease by laparoscopic sleeve gastroplasty with cutting off the greater curvature of the stomach on a 36 Fr probe, characterized in that patients with a body mass index of more or equal to 60 kg/m2, before surgery, an additional fluoroscopy of the stomach with a barium suspension and endoscopic ultrasound are performed, signs of pylorospasm and hypertrophy of the pyloric sphincter are identified, the stomach is mobilized along the greater curvature, starting 2 cm above the pyloric sphincter to the angle of His with mobilization of the left leg diaphragm and the left semicircle of the esophagus, after which a traction of the stomach in the cranial direction is performed using a grabber for the antrum, the area of the pyloric sphincter is visualized, a pylorotomy is performed for 2 cm with an electrocautery, the serous and muscle fibers of the pyloric region are dissected to the submucosal layer, after which the pyloric opening is sutured with a continuous serous - serous gastroduodenal endosuture and additionally covered with the anterior wall of the antrum of the stomach, then a 36 Fr probe is inserted into the stomach and duodenum, on which longitudinal resection is carried out along the greater curvature of the stomach with a linear stapler using stapler cassettes 6 cm long; The resected stomach is removed through a trocar wound, with suturing of the skin in the area of the trocar wounds.

This method refers to restrictive bariatric surgery, while the claimed method is for a combined, more effective operation (combining restrictive and malabsorptive components).

Disadvantages of the prototype: the need to perform pyloroplasty and dissection of the pylorus increases the risk of developing failure of the pyloric suture, and increases the risk of complications - dumping syndrome after surgery.

In the claimed method, the pylorus is disabled, does not participate in the intake of food, does not require dissection, and there is no risk of developing dumping syndrome.

The technical result of the invention is to expand the arsenal of methods for treating patients with type 2 diabetes mellitus and morbid obesity, which provides a modification of laparoscopic mini-gastric bypass with removal of the disconnected part of the stomach.

The claimed method is characterized by a double-row anastomosis, which reduces the risk of hardware suture failure and lower risks of death.

In addition, double-row manual anastomosis is safer than linear one and does not require the use of additional foreign material (glue).

The claimed method is characterized by the presence of one anastomosis, which is a technically simpler operation; the risk of leakage is reduced due to the absence of a second anastomosis.

This technical result is achieved due to the fact that a method of surgical treatment of type 2 diabetes mellitus and morbid obesity is claimed, including resection of part of the stomach, the formation of a gastroenterostomy, characterized in that the mobilization of the stomach is carried out from the lesser curvature directly between the third arterial branch above the pylorus with an ultrasonic scalpel , then the stomach is mobilized along the greater curvature; stitching is carried out in a direction perpendicular to the lesser curvature; then a vertical intersection of the stomach is performed along the lesser curvature, directing the cassettes towards the angle of His and the fundus of the stomach, with the formation of a small stomach on a calibration probe with a thickness of 33 FR; after crossing the stomach, a thorough revision of the staple suture is carried out, for which the staple suture of the “small” stomach and the staple suture above the preserved pylorus are peritonized with a continuous suture using a thread with notches in all cases, capturing the tissue surrounding the hardware suture; the removed part of the disconnected stomach is removed through access to install a 13 mm trocar.

To form a gastrojejunostomy, the small intestine is passed over the transverse colon, and the hardware suture of the new small stomach in the area of the future gastrojejunostomy is cut off and coagulation hemostasis is performed.

Gastrojejunostomy is formed at a distance of 2 m from the ligament of Treitz, and along the antimesenteric edge of the small intestine at this distance an ultrasonic scalpel is used to make a hole of 12 mm in diameter, to which the gastric spider is brought.

To control the patency of the anastomosis and the integrity of the sutures, the probe is pulled into the stomach, the afferent and efferent loops are clamped with soft clamps, and a volume of approximately 200 ml of saline solution is injected into the probe under pressure.

The invention is illustrated by operation diagrams and photographs with examples of operation stages.

In FIG. Figure 1 shows a diagram of the location of the trocars.

In FIG. Figure 2 shows the mobilization of the stomach from the lesser curvature directly between the third arterial branch above the pylorus with an ultrasonic scalpel.

In FIG. Figure 3 shows mobilization of the stomach along the greater curvature.

In FIG. Figure 4 shows the stitching and formation of a new small stomach.

In FIG. Figure 5 shows peritonization of a staple suture (a staple suture of the “small” stomach and a staple suture over the preserved pylorus, which is peritonized with a continuous suture with a thread with notches in all cases, capturing the tissue surrounding the hardware suture).

In FIG. Figure 6 shows the formation of a gastrojejunostomy (the small intestine is passed over the transverse colon).

In FIG. Figure 7 shows the insertion of the gastric pouch (gastrojejunostomy is formed at a distance of 2 m from the Treitz ligament).

In FIG. Figure 8 shows the formation of a double-row continuous end-to-side anastomosis with a thread with notches on a calibration probe.

In FIG. Figure 9 shows the “Water” test (to control the patency of the anastomosis and the consistency of the sutures, the probe is pulled into the stomach, the afferent and efferent loops are clamped with soft clamps, and a volume of saline solution of approximately 200 ml is injected into the probe under pressure).

In FIG. Figure 10 shows the removal of part of the disconnected stomach through access for installing a 13 mm trocar.

In FIG. 11 shows the operation diagram.

Carrying out the invention

In the claimed method of surgical treatment of type 2 diabetes mellitus and morbid obesity, the operation is performed laparoscopically according to the diagram in Fig. 11. To form a small ventricle, staplers are used that form a double three-row staple stitch. During operations, monoelectrocoagulation with an energy dosing control system, as well as an ultrasonic scalpel, are used.

Install 4 trocars at standard points according to the diagram in Fig. 1. The first 10 mm for optics is above the navel, then a 5 mm trocar is near the xiphoid process, a 10 mm trocar is in the right hypochondrium, a 13 mm trocar is in the left hypochondrium.

Mobilization of the stomach is carried out (see Fig. 2) from the lesser curvature directly between the third arterial branch above the pylorus with an ultrasonic scalpel. Next, the stomach is mobilized along the greater curvature (see Fig. 3). For the first stitching, always use a green cassette. The stitching is carried out in a direction almost perpendicular to the lesser curvature so that the stomach is crossed completely above the pylorus (see Fig. 4). Next, a vertical intersection of the stomach is performed along the lesser curvature, directing the cassettes towards the angle of His and the fundus of the stomach, forming a small stomach on a calibration probe with a thickness of 33FR. Crossing is carried out using blue cassettes of the stapler.

After crossing the stomach, a thorough revision of the staple suture is carried out. The staple suture of the “small” stomach and the staple suture above the preserved pylorus are peritonized with a continuous suture using a thread with notches in all cases, capturing the tissue surrounding the hardware suture (see Fig. 5).

To form a gastrojejunostomy, the small intestine is passed over the transverse colon (see Fig. 6). The hardware suture of the new small stomach in the area of the future gastroenteroanastomosis is cut off, and coagulation hemostasis is performed. Gastrojejunostomy is formed at a distance of 2 m from the ligament of Treitz (see Fig. 7). At this distance, a hole approximately 12 mm in diameter was made along the antimesenteric edge of the small intestine using an ultrasonic scalpel. The gastric spider is brought to it, forming a double-row continuous end-to-side anastomosis with a thread with notches on the calibration probe (see Fig. 8).

The restrictive effect of the operation is maintained due to the diameter of the anastomosis and the diameter of the spider.

To control the patency of the anastomosis and the consistency of the sutures, the probe is pulled into the stomach, the afferent and efferent loops are clamped with soft clamps, and a volume of saline solution of approximately 200 ml is injected into the probe under pressure (see Fig. 9). After the test, a visual inspection of the entire anastomosis is performed again.

The gastric tube is removed immediately after surgery. The removed part of the disconnected stomach is removed through access to install a 13 mm trocar (see Fig. 10).

Using the proposed method, the operation was performed on 35 patients with obesity and type 2 diabetes mellitus, including 10 of them with decompensated type 2 diabetes mellitus; in all cases, a minimally invasive operation was performed with minimal pain, and clear visualization of anatomical structures was obtained. No intraoperative or postoperative complications were identified.

Clinical example 1

Patient D., 32 years old, underwent surgery for obesity and decompensated type 2 diabetes mellitus. Before surgery, the dose of insulin is long-acting - 20 units 2 times a day, short-acting - 5 units 3 times a day, with blood glucose up to 12 mmol/l. Under endotracheal anesthesia, trocars were installed using the above method, and a mini-gastrobypass with a larger-capacity spider was performed. There are no postoperative complications. He spent 2 bed days in the hospital and was discharged in satisfactory condition. There was no need to use narcotic analgesics in the postoperative period. Pain syndrome on the Vash scale was assessed as 2 points, as insignificant.

A year after the intervention: I lost weight to normal, type 2 diabetes is in complete stable remission - complete refusal of insulin, blood glucose up to 6 mmol/l.

Clinical example 2

Patient N., 37 years old, underwent surgery for obesity and type 2 diabetes mellitus. Before surgery, the dose of insulin is long-acting 5 units 2 times a day, short-acting insulin 10 units 3 times a day, with blood glucose up to 10 mmol/l. Under endotracheal anesthesia, trocars were installed using the above method, and a mini-gastrobypass was performed with removal of the disconnected stomach. There are no postoperative complications. He spent 2 bed days in the hospital and was discharged in satisfactory condition. There was no need to use narcotic analgesics in the postoperative period. Pain syndrome on the Vash scale was assessed as 2 points, as insignificant.

A year after the intervention: I lost weight to normal, type 2 diabetes is in complete stable remission - complete refusal of insulin, blood glucose up to 6 mmol/l.

Claims (4)

1. A method of surgical treatment of morbid obesity in patients with type 2 diabetes mellitus, including resection of part of the stomach, the formation of a gastrojejunostomy, characterized in that 4 trocars are installed - above the navel, under the xiphoid process, in the right and left hypochondrium, mobilization of the stomach from the small side curvature above the pylorus with an ultrasonic scalpel, then the stomach is mobilized along the greater curvature; the stomach is sutured with a stapler in the direction perpendicular to the lesser curvature; then a vertical intersection of the stomach is performed along the lesser curvature, directing the stapler towards the angle of His and the fundus of the stomach with the formation of a small stomach on a calibration probe with a thickness of 33 FR; a revision of the hardware suture is carried out, after which the suture of the formed small stomach and the suture above the preserved pylorus are peritonized with a continuous suture using a thread with notches, capturing the surrounding tissues; the disconnected part of the stomach is removed through a trocar access in the left hypochondrium; Along the antimesenteric edge of the small intestine, an ultrasonic scalpel is used to make a hole with a diameter of 12 mm, to which a small stomach is brought, and an end-to-side gastrojejunostomy is formed using a double-row continuous suture with a notched thread. 2. The method according to claim 1, characterized in that when forming a gastrojejunostomy, the small intestine is passed over the transverse colon, the hardware suture of the small stomach in the area of the future gastrojejunostomy is cut off, and hemostasis is performed by coagulation. 3. The method according to claim 1, characterized in that the gastrojejunostomy is formed at a distance of 2 m from the Treitz ligament. 4. The method according to claim 1, characterized in that the probe is pulled into the stomach, the afferent and efferent loops are clamped with soft clamps, and a volume of 200 ml of saline solution is injected into the probe under pressure, assessing the patency of the anastomosis and the integrity of the sutures.