RU2845894C1 - Method for preventing enterointestinal anastomosis inefficiency in infected abdominal cavity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to abdominal surgery, and can be used for prevention of enteric anastomotic leak. Abdominal cavity is sanitated, and side-to-side anastomosis is formed by means of titanium nickelide clip. Anastomosis is coated with BIO-LAB medical glue. Microirrigator is placed within the anastomosis into a mesentery and brought out onto the anterior abdominal wall. Clexane 40 mg, Thienam 500 mg, Dexamethasone 20 mg are administered through microirrigator for 7 days.

EFFECT: method provides reducing tissue injuries and purulent-septic postoperative complications ensured by the combined use of the titanium nickelide clip, BIO-LAB glue and mesentery microirrigation.

1 cl, 12 dwg, 2 ex

Description

The invention relates to the field of medicine, in particular to surgery, and can be used to prevent failure of small intestinal anastomoses, in peritonitis and acute intestinal obstruction, after forced resections of the small intestine.

A method is known (Dissertation: Abdullaev E.M., 2011, "Use of fibrin glue in the prevention of gastrointestinal anastomosis failure") to prevent suture failure when forming intestinal anastomoses; fibrin glue was used. The use of fibrin glue over the anastomosis line in case of peritonitis of a day or more duration promotes regeneration in the intestinal anastomosis zone, and a decrease in the incidence of intestinal anastomosis failure is noted. An effective method for preventing intestinal suture failure in conditions of peritonitis or intestinal obstruction is the local use of fibrin collagen substance impregnated with antibacterial drugs. According to the results obtained, dry cryoprecipitate and 24 thrombin solution promote rapid formation of a fibrin film within 20-30 seconds.

The disadvantages of this method are that the fibrin glue "BIO-LAB" does not have a positive effect on the healing of gastrointestinal anastomoses when used without additional means to improve microcirculation. Therefore, the positive effect of the fibrin glue "BIO-LAB" used to seal gastrointestinal anastomoses may be due to the effect of mechanical sealing, rather than improved healing. In conditions of peritonitis, with dilation of the intestinal wall and increased intra-abdominal pressure, the failure of gastrointestinal anastomoses increases. If it is necessary to perform resection interventions on the intestine against the background of the above-mentioned nosologies, the problem of anastomotic failure and the risk of mortality remain. Currently, the most common and widely used technique is manual single- or double-row anastomotic sutures, as well as mechanical hardware suture. However, these methods, unfortunately, also have a number of shortcomings proven by various independent studies, with the risk of developing insufficiency.

In recent years, there has been interest in the use of alloys with memory and shape effects. The method of seamless compression anastomosis performed with titanium nickelide implants is reliable, hermetic, technically simple, and easily reproducible, and can

be widely used in emergency hospitals. An important aspect should be considered the ability of the titanium nickelide implant to implement pressure dosing depending on the thickness of the intestinal or stomach wall, which, of course, significantly expands the indications for their implementation and use. One of the nuances of using such anastomosis methods should be considered the exclusion of the possibility of hemorrhage from the anastomosis zone, the absence of severe anastomosis, as well as the risk of stricture formation in the remote period. The pharmacoeconomic preference of using titanium nickelide anastomoses is obvious, due to the comparability of their cost with the costs of modern suture material, which, combined with ease of use and the possibility of use by young surgeons, makes the compression technique of forming anastomoses with titanium nickelide rings extremely effective and easily accessible. (New technology for creating compression anastomosis in gastrointestinal surgery using superelastic implants with shape memory, Ziganypin R.V., Gunter V.E., 2000)

Technique of forming anastomosis: perform suturing of the afferent and efferent loops of intestines for 3-4 cm, stepping back 2-2.5 cm from the stumps of the small intestine and 1 cm from the mesenteric edge with separate serous-muscular sutures with a step of 1 cm, forming the first row of sutures of the posterior semicircle of the future anastomosis. Then, using an electric knife and special tweezers with thin branches, form openings for insertion of the implant into the lumen of the organs being sutured (Fig. 1). Openings on the intestine are formed opposite the second serous-muscular suture of the posterior semicircle of the anastomosis, stepping back from it towards the antimesenteric edge by 1 cm. (Fig. 2) Thus, openings of about 5 mm are obtained in the walls of the intestine, which are located opposite each other. The holes formed in the walls of the organs being sutured are brought together with ligatures and holders and according to the method of R. V. Ziganshin, V. E. Gunter (New technology for creating a compression anastomosis in gastrointestinal surgery with superelastic implants with shape memory, R. V. Ziganshin, V. E. Gunter, 2000) due to rapid resorption, is a preventive measure against delayed rejection of the device in case of its infringement between the branches. In this case, the first suture is applied between the adjacent edges of the hole, and the second - between the opposite ones, and the needle is inserted first from the inside out, and then from the outside in, so that after tying the thread, the knot is inside the lumen of the intestine. This is necessary so that after stretching the ligatures in opposite directions, the holes are located in a vertical plane. The edges of the holes are slightly spread apart with special thin hooks-retractors. The container with the coolant (96% ethyl alcohol) and the compression device located in the freezer are transferred to the operating table, the device branches are spread apart using Bilroth clamps to a distance of no more than 0.6-0.7 cm from each other, without removing the implant from the coolant. (Fig. 3) Preparation of the device for implantation directly in the cooling medium is necessary to avoid forced spreading of the coils, as this may lead to the formation of residual deformation and disruption of the function of long-term elastic compression. After this, holding the device with the spread branches with a clamp, it is inserted through the formed openings in the longitudinal direction with respect to the intestinal axis, with one branch into the adductor section of the intestine, and the other into the abductor section. To avoid pinching of the ligatures of the posterior semicircle of the anastomosis between the branches of the compression implant, during implantation it is necessary to direct the device with the longitudinal axis upward.

After implantation, to ensure better closure of the implant branches, the anastomosis area is covered with napkins containing a warm 0.9% sodium chloride solution.

After the compression device has been fully activated, serous-muscular sutures are applied to the anterior semicircle of the anastomosis up to the openings. We consider this moment to be extremely important, since there is a real danger of the subsequently dissected walls of the organs being sutured slipping out between the branches of the device. Applying serous-muscular sutures before the stage of creating primary patency is a reliable prevention of this.

To create primary patency, we used scissors with special cuts on the cutting part. (Fig. 4) The distance from the cuts to the end of the cutting part should be 1 cm less than the implant size. The cuts are necessary so that the isthmus of the device can easily enter them during tissue dissection inside the implant. In our opinion, this design of scissors allows creating an opening in the strangulated tissues exactly in the center of the larger diameter of the compression device, the length of which is sufficient for primary patency. Thus, after applying serous-muscular sutures to the anterior semicircle of the anastomosis, using hooks, the edges of the openings in the sutured organs are again spread apart, while supporting the catgut ligatures-holders. The branches of the working part of the special scissors were inserted into the lumen of the intestine, dissecting the strangulated tissues inside the nickel-titanium implant. Having unclenched the scissors, they are carefully removed so as to avoid the danger of removing the implant; for this purpose, it is necessary to hold it with a Bilroth clamp. The presence of primary patency is necessarily checked using a hook for spreading the edges of the openings; its working part, bent at an angle of 90°, should freely pass from the adductor section of the intestine to the abductor section. After this manipulation, the openings for inserting the implant are sutured with three serous-muscular-submucous nylon ligatures, which are additionally peritonized with separate serous-muscular sutures. After this, the anastomosis is considered to be finally formed.

The ring is a two-turn elongated wire spiral, which is closed along its entire length for compression interaction and has free ends of the wire at the first end of the spiral. Both branches of each turn of the spiral at the predominant length towards the second end of the spiral are straightened and brought together to mutual contact to form linear branches. The total length of the ring is 27.00 mm, the radius of rounding of the first end of the ring is 3.50 mm, the cross-sectional diameter of the wire is 1.60 mm.

For a side-to-side anastomosis of hollow organs, punctures are made in the walls of adjacent fragments to be connected, parallel to each other. The ring, cooled and activated by parallel spreading of the branches, is installed in the holes by advancing it until it stops with the bridge of the first edge in the closed walls of the fragments. When heated to body temperature, the ring restores its original shape. By necrobiolysis (necrotic destruction of tissue under compression), the device is evacuated on the 10th day after installation through natural passages.

After the formation of an intestinal anastomosis in the mesentery of the small intestine, a microirrigator is fixed in the anastomosis zone between the layers of the peritoneum using an absorbable suture material - Polysorb.

The other end of the microirrigator is brought out to the anterior wall and fixed to the skin with a nodal suture. (Fig. 5) On the anterior abdominal wall, the microirrigator is connected to a bottle of 0.9% - 400 ml of physiological solution, low molecular weight heparin (40 mg of Clexane), an antibiotic from the carbapenem group (500 mg of Tienam) and dexamethasone (20 mg) are added. The solution is injected into the intestinal mesentery for 7 days or the prepared solution is injected into the microirrigator with a syringe, 1-2 ml every hour. After the anastomosis has healed, the microirrigator is removed by pulling its end.

The technical result of the invention consists in reducing tissue trauma and purulent-septic postoperative complications, as well as in simplifying the formation of a compression anastomosis of a hollow organ of the gastrointestinal tract.

In all cases, a unified technique of forming anastomoses by applying an implant-ring was used. After the resection stage is completed, the anastomoses formation sites are determined on the anti-mesenteric areas, after which the areas of two intestinal loops are brought together with the application of stay sutures.

Fenestration of the intestinal wall is performed at a distance of no more than 4-6 mm with fixation of the corners with interrupted sutures to facilitate the introduction of the implant (we used this stage at the initial stage of mastering the technique, later it was abolished). A pre-cooled compression device with parallel spread coils is inserted into the formed holes with positioning in the intestinal lumen. Against the background of an increase in the ambient temperature, the nickel-titanium implant acquires its original shape, thereby forming compression of the intestinal walls - the future walls of the anastomosis. Patency of the anastomosis is ensured by dissecting the tissues with special scissors with a notch for safe fenestration. The defect of the walls of the anastomosed intestines is sealed by applying several serous-submucous single sutures. In addition, medical fibrin glue "BIO-LAB" is applied to the anastomosis from the outside, consisting of: Component No. 1 - gelatin-resorcinol base (bottle), Component No. 2 - hardener - a mixture of glutaraldehyde and formalin solutions (syringe tube). Additionally, a microirrigator is inserted into the mesentery of the small intestine in the anastomosis area for the introduction of low-molecular heparin (40 mg of Clexane), an antibiotic from the carbapenem group (500 mg of Tienam) and dexamethasone (20 mg) for 7 days (Fig. 8).

This method was used in 76 patients, the device in observations of previously formed gastroenteroanastomosis in case of its failure, resection of a section of the small intestine with an interintestinal anastomosis due to intestinal wall necrosis of various origins in 36 patients, as well as ileotransversostomy and interintestinal anastomosis of the colon in 35 patients. The product is convenient and simple, bioinert, can be used in any anatomical sections of the hollow organs of the gastrointestinal tract, has a reliable degree of compression, as well as a clear rejection period for a certain day after installation and unimpeded exit through natural pathways. The implant will facilitate the surgeon's work, reduce the duration of the abdominal stage of the operation. The use of this device in surgical hospitals will lead to improved results of the operations performed, a decrease in the failure of anastomoses and the frequency of purulent-septic complications.

The advantages of this utility model include:

1) The optimal streamlined smooth shape and dimensions of the product ensure a reliable grip of the implant with tweezers when inserting it. This allows for smaller incisions (not exceeding 4.00 mm). At the same time, the formed holes are sutured with a significantly smaller number of sutures - only 8% of the perimeter around the implant instead of 15%.

2) The product clearly returns to its original shape when heated and reliable compression in the installation area eliminates its migration.

3) The side of the implant branches at the site of the upcoming compression has an aseptic coating of silver ions and fluoroquinolone (ciprofloxacin), which sharply reduces bacterial contamination and promotes earlier tissue healing and a device rejection period of 7-8 days.

4) The flattened structure of the branches in the anterior-posterior direction, grooves in the form of additional small even notches at the site of the upcoming compression, increase the area of contact and adhesion of the implant to the tissues and eliminate migration of the device in the installation area.

5) Use of medical fibrin glue "BIO LAB".

6) A microirrigator is installed in the mesentery of the small intestine in the anastomosis area for the administration of low molecular weight heparin (40 mg clexane), an antibiotic from the carbapenem group (500 mg Tienam) and dexamethasone (20 mg) over 7 days.

Clinical example #1

Patient K., 67 years old, was admitted to City Clinical Hospital No. 50 as an emergency on 11.04.19, 9 days after the onset of the disease with complaints of weakness, pain in the right half of the abdomen, nausea, vomiting of gastric contents, frequent, loose stools with streaks of blood. Diagnosis on admission: Space-occupying lesion in the abdominal cavity, intestinal bleeding? Condition on admission is moderate. Skin is pale, turgor is slightly reduced. Weakened vesicular breathing in the lungs. No wheezing, respiratory rate 18 beats per minute. Hemodynamics are relatively stable. Blood pressure 110/70 mm Hg. Pulse 94 beats per minute. The tongue is dry, the abdomen is symmetrical, participates evenly in the act of breathing, swollen, painful on palpation in all areas, more in the right half of the abdomen, in the mesogastrium on the right a volumetric formation of 8.0/7.0 cm is palpated, slightly mobile, painful. Peristalsis is weakened, a "splash" noise is heard, percussion does not detect free fluid in the abdominal cavity. There are no signs of peritoneal irritation. Stool is frequent, liquid with streaks of blood.

Ultrasound of the abdominal cavity: there is no free fluid in the abdominal cavity; in the mesogastric region on the right, an echo-heterogeneous volumetric formation with uneven contours measuring 75/60/66 mm is detected.

A general radiograph of the abdominal cavity shows pronounced pneumatosis of the small and large intestines, isolated small intestinal levels.

In the clinical blood test (Hemoglobin 96 g/l; erythrocytes 3.7; color index 0.84; hematocrit 31; platelets 269; leukocytes 7.2; s/o 74; lymphocytes 22;

band 5; monocytes 9; ESR 14; general urine analysis (color straw-yellow; transparency - complete; density 1018; reaction - acidic; protein - 0.048; glucose - no; leukocytes - 1-2 in the field of view); biochemical blood analysis (total protein 69; urea 4.8; total bilirubin 19; ALT-16; AST-24; alkaline phosphatase - 232; amylase-19; K 2.8; Na

117). Of the concomitant diseases: ischemic heart disease: postinfarction cardiosclerosis, hypertension stage 3 with heart damage, prostate adenoma. Examined by a therapist and urologist. Preoperative preparation was performed with infusion, detoxification, and antispasmodic therapy. After correction of electrolyte disorders, an urgent operation was performed 24 hours after admission on 13.04.07 - laparotomy, right hemicolectomy with formation of ileotransverseostomy. During revision, there is no effusion in the abdominal cavity. In the ascending colon, a dense, nodular tumor is determined, up to 10 cm in diameter, completely obstructing the lumen of the colon. (Figs. 9, 10, 11) No distant metastases were found. An increase in regional lymph nodes along the superior mesenteric artery is noted. In the root of the small intestinal mesentery, the lymph nodes are soft, up to 5 mm (histology: follicular hyperplasia). The loops of the small intestine are moderately dilated. Nasoenteric intubation was performed, the contents of the small intestine were evacuated. The ascending colon, hepatic angle and 1/2 of the transverse colon were mobilized with preliminary ligation of the branches of the superior mesenteric artery and vein. The distal ileal colon was transected, the transverse colon was transected, a transverse sigmoid anastomosis "side to side" compression anastomosis was formed using a nickelide titanium implant. To prevent suture failure during the formation of intestinal anastomoses, fibrin glue "BIO LAB" was used. Dry cryoprecipitate and 24 thrombin solution were prepared and applied to the anastomosis area, and a fibrin film formed within 20-30 seconds. After forming the intestinal anastomosis and applying fibrin glue over the anastomosis, a microirrigator was fixed in the mesentery of the small intestine in the anastomosis area between the peritoneum layers using the absorbable suture material Polysorb. The other end of the microirrigator was brought out to the anterior wall and fixed to the skin with a nodal suture.

The right lateral canal was drained through the counter-opening and brought out in the right iliac region, drainage was in the small pelvis and brought out through the counter-opening in the left iliac region. The wound was sutured layer by layer. After the anastomosis healed, on the 7th day after the operation, the microirrigator was removed by pulling it up by its end. In the postoperative period, dynamic monitoring of the anastomosis patency was performed, and an X-ray examination was performed on the 3rd-6th day to exclude early adhesive intestinal obstruction. (Figure No. 12).

Macroscopic specimen: a single block of the right half of the colon with the greater omentum, mesentery and unchanged lymph nodes in it; in the ascending part of the colon, a nodular tumor 10.0 × 8.0 cm is determined, gray in section, growing through all layers of the colon.

Histology - proliferation of moderately differentiated adenocarcinoma, invading the entire thickness of the organ. No signs of tumor growth were found along the resection margins.

Diagnosis after surgery: Cancer of the ascending colon T4N0M0 (stage II).

Clinical example #2

Patient G., 54 years old, was admitted to City Clinical Hospital No. 50 as an emergency on 06.01.20, 2 days after the onset of the disease with complaints of severe pain throughout the abdomen, mainly in the epigastrium, nausea, vomiting, fever up to 38.0. Diagnosis on admission: acute pancreatitis, intestinal obstruction? Condition on admission is moderate. Skin is pale, skin turgor is decreased. Weakened vesicular breathing in the lungs. No wheezing, respiratory rate is 18 per minute. Hemodynamics are relatively stable. BP 110/70 mm Hg. Pulse 92 beats per minute. Tongue is dry, abdomen is asymmetrical, does not participate evenly in the act of breathing, moderately distended, sharply painful on palpation in all areas, especially in the mesogastric region. Peristalsis is not heard, a "splash" noise is determined. The Shchetkin-Blumberg symptom is positive. There was stool before admission to the hospital (according to the patient, it was liquid, with hemorrhagic discharge).

An emergency plain abdominal radiograph shows pneumatosis coli, small intestinal fluid levels, conclusion: picture of small intestinal obstruction. Abdominal ultrasound from 06.01.20 - echogram of diffuse changes in the liver and pancreas, small intestinal loops are dilated to 2.5 cm, with pendulum-like movement, free fluid in the abdomen, mainly up to 200 ml in the small pelvis). In the clinical blood test (Hemoglobin 97 g / l; erythrocytes 3.90; color index 0.81; hematocrit 25; platelets 185; leukocytes 13.0; segmented - 68; lymphocytes 19; monocytes 8; band neutrophils - 12; ESR 49); General urine analysis (color straw-yellow; transparency - complete; density 1019; reaction - acidic; protein - 0.9 g / l; glucose - no; leukocytes - 2-5 in the field of view); blood biochemistry (total protein 68; urea 4.9; total bilirubin 21 μmol / l, ALT - 19; Ac AT -53; alkaline phosphatase 242; amylase 52; K 4.1; sodium 132). Infusion and detoxification therapy were performed. 01/06/20. abdominal pain intensified, spreading to the entire abdomen, signs of peritonitis appeared in the upper abdomen. In this regard, an emergency operation was performed 10 hours after admission. Upper and mid-midline laparotomy was performed. On revision of the abdominal cavity, there is an insignificant amount of effusion with a hemorrhagic tint, it is dried and cultured. At a distance of 1.0 m from the Treitz ligament, a section of the small intestine approximately up to 60 cm with a violation of mesenteric blood circulation, there is no peristalsis of this section, the walls are thinned, dark purple in color, pulsation of the mesenteric vessels is absent. Intraoperative picture of a violation of mesenteric blood circulation. Necrosis of a section of the small intestine. (Fig. 6, 7) The state of microcirculation of the serous membrane of the small intestine was measured using the LDF method proximally and distally to the tumor. Resection of the small intestine was performed with the formation of an interintestinal compression anastomosis using a nickel-titanium implant. To prevent suture failure during the formation of intestinal anastomoses, fibrin medical glue "BIO-LAB" was used.

After the intestinal anastomosis is formed and fibrin glue is applied over the anastomosis, a microirrigator is fixed in the mesentery of the small intestine in the anastomosis zone between the peritoneal layers using the absorbable suture material Polysorb. (Figure No. 5). The other end of the microirrigator is brought out to the anterior wall and fixed to the skin with a nodal suture.

Abdominal cavity sanitization, separate intubation of the small and large intestines, abdominal cavity drainage. Small intestinal microcirculation was measured using the LDF method after resection of the small intestine with a necrotic area. A nasoenteric probe was inserted beyond the anastomosis suture line. The abdominal cavity was washed with 5 liters of an aqueous solution of 0.02% chlorhexidine and physiological solution, and dried. The small pelvis and left lateral canal were drained through a counter-opening in the right iliac region. The wound was sutured layer by layer.

Below (about 1.5 m to the ileocecal angle), the small intestine is unchanged. The liver has connective tissue constrictions and is enlarged mainly due to the right lobe. The spleen is not enlarged. The jejunum was mobilized and resected 30 cm above and 20 cm below the visible boundaries of the lesion (Fig. 2). A side-to-side enteroenteroanastomosis was performed with suturing with a double-row suture. The wound was sutured with the installation of a catching drain into the small pelvis through a separate puncture of the anterior abdominal wall. Upon examination of the macropreparation from the side of the mucous membrane, edema of the latter, hemorrhage, and necrosis were detected. Histological examination of the small intestinal wall showed diffuse abundant leukocyte infiltration spreading to all layers of the wall, with circulatory disorders, stasis of the vessels of the intestinal wall; in the mesenteric arteries - blood clots. After the operation, the patient was treated in the intensive care unit, and from 01/09 - in the surgical hospital. The postoperative period was uneventful. For several days after the operation, up to 2 liters of serous fluid per day were separated through the catching drainage. Gradually, the discharge decreased, and on 01/12 it stopped. The drainage from the pelvis was removed on 01/12. The postoperative wound healed by primary intention. Discharged from the hospital on 01/14/2020.

Diagnosis after surgery: Impaired mesenteric circulation, necrosis of the small intestine.

Claims (1)

A method for preventing small intestinal anastomosis failure, including sanitization of the abdominal cavity and formation of a side-to-side anastomosis using a nickel-titanium clip, characterized in that BIO-LAB medical glue is additionally applied to the anastomosis, a microirrigator is installed in the mesentery of the small intestine in the anastomosis area and brought out to the anterior abdominal wall, Clexane 40 mg, Tienam 500 mg, Dexamethasone 20 mg are administered through the microirrigator for 7 days.