RU2248759C2 - Method for esophagojejunoanastomosis at gastrectomy - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should suture both adducting and abducting intestinal parts with separate sutures without any primary fixation of esophagus to an abducting intestine. Then one should apply esophagointestinal anastomosis. Moreover, by applying external suture of anastomosis' anterior wall one should suture serous-muscular layer of adducting intestine, esophageal muscular layer and serous-muscular layer of abducting intestine. After covering internal anterior row of sutures and nearing the walls of abducting and adducting intestinal loops one should apply 2-3 serous-muscular sutures on them at the top. On should finish the development of a cuff due to both adducting and abducting part of small intestine. The suggested method enables to decrease intraluminal pressure in duodenum, decrease the risk of duodenal stump's failure, and obtain antireflux-type mechanism of anastomosis.

EFFECT: more simplified and shortened terms for applying the anastomosis.

1 ex

Description

Despite the success of the surgery, gastrectomy remains a complex operation with high postoperative mortality and severe postoperative complications. The frequency of failure of the esophageal-intestinal anastomosis reaches 20%, with a mortality rate of 30 to 70%. One of the reasons for the failure of the anastomosis is the error of the surgical technique. The development of postgastrectomy syndromes forces surgeons to look for ever new ways to restore the continuity of the digestive tract, which improve the quality of life. An increase in the reliability of esophagogoejunoanastomosis is achieved by additional covering of the anastomosis zone with a loop of the small intestine.

There is a known method of Gilyarovich-Shalimov, in which a mesenteric suture is placed on the mesenteric edge of the loop, the esophagus is laid on the discharge loop of the jejunum and fixed with 3 rows of sutures and a two-row anastomosis is applied, end-to-side type, with a covering of the suture line by the lead loop due to a separate suture from the upper left upper suture esophageal-intestinal suture to the right upper esophageal-intestinal suture, stitching the adducting loop with the outlet around the anastomosis, first along the right adjoining edges, tightening the imposed half-sutured suture, then from the bottom [1].

However, the indicated sleeve-like anastomosis has inherent disadvantages of the esophageal-intestinal anastomosis: failure of the anastomosis, adrenal gut obstruction, reflux esophagitis. When applying an anastomosis, sometimes it is necessary to impose 3 rows of sutures, which lengthens the time of surgery and complicates the technique of creating the esophageal-intestinal anastomosis.

In this regard, the objective of the invention is a modification of the method of esophageal-intestinal anastomosis on a long loop with Brownian anastomosis due to the simplification of surgical technique.

The problem is solved by stitching the outlet and adduction loops of the intestine, applying the esophagus-intestinal anastomosis with the simultaneous creation of a cuff due to the adduction and abduction knee of the small intestine according to the Nissen fundoplication with a “three” suture, dissection of the Treitz ligament.

The method is as follows.

After mobilization of the stomach, a dissection of the Treitz ligament is performed. The leading and discharging knee of the small intestine is sutured 35-40 cm from the Treitz ligament with separate sutures along the mesenteric edge to the width of the intestinal lumen with 3 sutures. Through the incision in the avascular part of the mesentery of the transverse colon, a loop of the small intestine is brought to the esophagus. The esophagus is placed in front of the discharge loop of the intestine. At the level and stepping to the right 1 cm from the lower inter-intestinal suture, transversely sero-muscular sutures are placed on the esophagus and intestine (outer row of the posterior wall of the anastomosis). The serous-muscular layer of the esophagus is dissected, the stomach is cut off. The jejunum is opened transversely to the width of the esophagus, retreating 0.5-1 cm from the line of serous-muscular sutures. The esophagus with the jejunum is sutured with an intraluminal nodal suture through all layers of the walls of the esophagus and intestine, first the posterior lip (inner row of the posterior wall of the anastomosis), after the nasointestinal probe is inserted through the anastomosis zone, the front lip (inner row of sutures of the anastomosis anterior wall). The outer row of sutures of the anastomosis anterior wall is applied as follows: the sero-muscular layer of the adducting intestine, the muscle layer of the esophagus, the sero-muscular layer of the abducting intestine are sutured, the suture is tied to the left corner of the anastomosis (suture “triad”). Subsequent sutures are applied in a similar manner to the opposite angle of the anastomosis, creating the outer row of sutures of the anastomosis (outer row of sutures of the anastomosis anterior wall). After covering the inner, front row of sutures and converging the walls of the adducting and abduction loops of the intestine, 2-3 serous-muscular sutures are placed on them upwards, completing the creation of the cuff due to the adduction and abduction knee of the small intestine according to the Nissen fundoplication. An inter-intestinal anastomosis is applied side to side by a double-row, interrupted suture with its fixation in the mesocolon.

Thanks to this method, the simplicity and reliability of creating an esophageal-intestinal anastomosis is ensured due to the circular covering of the anastomosis by the lead and outlet knees of the intestine. Dissection of the Treitz ligament allows the Brownian anastomosis to be placed close to the horizontal part of the duodenum, which reduces the possibility of the contents entering the adrenal gut, reduces intraluminal pressure in the duodenum, thereby reducing the risk of duodenal stump insufficiency. The application of a two-row suture, without additional fixation of the esophagus to the intestine, with the simultaneous creation of a cuff, gives the anastomosis an antireflux mechanism, simplifies and reduces the time of application of the anastomosis. The specified method clutch-like anastomosis was reliable, technically simple, used for gastrectomy in 3 patients. As an example, we provide an extract from the medical history:

Patient S., 67 years old, was admitted to the Pavlovsk Central District Hospital on 08/20/02 with complaints of weakness and abdominal pain. Performed fibrogastroduodenoscopy, ulcer biopsy, malignant gastric ulcer was detected. In connection with the arising bleeding 04.09. the patient was transferred to the intensive care unit. Conservative therapy was performed. However, September 7. repeated, profuse gastric bleeding occurred. The patient underwent laparotomy, gastrasplenectomy with the formation of esophageojunoanastomosis according to the specified technique, drainage of the abdominal cavity. The postoperative period is smooth. Discharged September 26, 02

Literature

1. Shalimov A.A., Saenko V.F. Digestive tract surgery. - Kiev, “Health”, 1987 - 508 p.

Claims (1)

The method of esophageal-intestinal anastomosis after gastrectomy, including the application of a two-row anastomosis of the type “end to side”, characterized in that the first lead and drain the knee of the intestine are sutured with separate sutures without initial fixation of the esophagus to the discharge intestine, after which the esophageal-intestinal anastomosis is applied, with this, imposing the external suture of the anastomosis anterior wall, suture the sero-muscular layer of the adducting intestine, the muscular layer of the esophagus, the sero-muscular layer of the adducting gut, after covering the inner anterior p venom of sutures and the convergence of the walls of the adducting and diverting loops of the intestine impose 2-3 serous-muscular sutures on them, completing the creation of the cuff due to the adducing and abducting knees of the small intestine.