RU2532885C1 - Method for unilateral surgical isolation of high, limited, immature, draining jejunal fistulas - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery. The method involves a unilateral surgical isolation of high, limited, immature, draining jejunal fistulas. A jejunal segment leading to the fistula is marked to be palpated intraoperatively. A gastroduodenoscope is used to insert an endoscopic catheter into the jejunum leading to the fistula through the same or orally. A dense catheter is palpated through the intestinal wall. A leading portion of the small intestine fixed by the adhesions is exposed by manual isolation from a posterior and blunt approach.

EFFECT: method provides the accurate unilateral isolation of the high, immature jejunal fistula, which keeps functioning as a definitive Maydle's jejunal tube, unloading the enteroenteroanastomosis, reducing the length of the operation, reducing the invasiveness, and eliminating the risk of de-serous treatment of the intestine.

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Description

The present invention relates to medicine, namely to surgery of high delimited unformed jejunal fistula (SBHTC), quickly leading to the depletion of the patient. Disbanded are called intestinal fistulas that open outward through a purulent wound, a cavity of a purulent leak or an opened intra-abdominal abscess. Exhausting high jejunal fistulas become due to an uncorrectable loss of jejunal contents in an amount of more than 500 ml per day or with a similar daily loss of body weight (E.N. Vantsyan. External and internal fistulas. - M .: Medicine. - 1990. - 224 p .; VD Fedorov, VV Tsvirkun, AO Zhukov. Disbanded intestinal fistulas // Lectures on purulent surgery / Edited by VD Fedorov, AM Svetukhin. M .: Miklosh. - 2004. - C .77-88). This is especially characteristic of SBSTS, formed spontaneously, after surgery for adhesive small bowel obstruction. The jejunal fistulas are dangerous, complicating the eventation that occurs as a result of suppuration and divergence of the edges of the laparotomy wound. If the passage through the abducting jejunum becomes difficult due to visceroparietal adhesions, unformed fistulas acquire the properties and signs of complete fistulas. Persistent conservative treatment in such a situation leads to disruption of homeostasis with the possible onset of death (E.P. Rudin, A.V. Bogdanov, A.P. Koshelev and others // Surgery. - 1991. - No. 5. - S. 56-60). Therefore, patients with VONKS have to undergo surgery, despite the severity of their condition and high postoperative mortality, reaching 50% -70% (B.A. Vitsyn, V.V. Atamanov. Treatment of patients with unformed intestinal fistulas. // Surgery. - 1984. - No. 7. - P. 129-133; VV Zhebrovsky, KD Toskin. Postoperative external intestinal fistulas. // In the book of O. B. Milonov et al. "Postoperative complications and dangers in abdominal surgery" . - M.: Medicine. - 1990. - Chapter 8. - S.257-290). Postoperative mortality in severe, sometimes septic patients with VHTS is caused by the duration and morbidity of viscerolysis, as well as infection of the abdominal cavity from the wound surrounding the fistula (G.A. Baranov, M.Yu. Karbovsky // Surgery. - 2006. - No. 7. - S.56-60). “The radical treatment of unformed jejunal fistulas, in the form of a resection of a fistula bearing an intestinal loop immured by commissures, rarely leads to success,” as E.Kh. Koch in 1934. However, "practical surgeons try to perform such risky operations quite often." ... "Attempts to suture the fistulous opening on the intestinal loop were absolutely futile" (Quotation according to N. N. Kanshin: "Unformed intestinal fistulas and purulent peritonitis." - M .: Profile. - 2007. - 160 p.). Dissatisfaction with the results of such surgical treatment prompted individual surgeons to operate SBHTCs in two stages using atypical laparotomy incisions removed from the fistula and the purulent wound surrounding it. The first step is to perform one- or two-sided (partial or full) disconnection from the passage of a skinny loop carrying a fistula. With one-sided shutdown, only the intestine leading to the fistula is crossed, and with two-way shutdown, both the leading and the abducting ones. The jejunum continuity is restored by anastomosis. After several months, the previously switched off loop carrying the non-functioning fistula is removed or reconstructed by the second stage. Such therapeutic tactics were developed in an experiment in 1861 by Hacken (Hacken, 1861), and Sennom (Senn, 1893) was successfully implemented in the clinic (V.D. Fedorov, D.S. Sarkisov, V.V. Tsvirkun, etc. Morphofunctional aspects in the treatment of patients with intestinal fistulas // Surgery. - 1994. - No. 10. - P.36-39; NN Kanshin. Disbanded intestinal fistulas and purulent peritonitis. - M .: Profile. - 2007. - 160. from.).

The authors cited report that the adhesion process often prevents the complete fistula shutdown or forces it to leave the disconnected gut of excessive length. Partial adhesion obliteration of the abdominal cavity can cause errors in choosing the level of anastomosis. The massive adhesive process of the peritoneum interferes not only with the operation, but also with the intraoperative detection of intestinal loops to be disconnected. Therefore, preoperative and intraoperative fistuloenterography using Foley catheters, which are inserted through the fistula in both directions, are used to detect the leading and outlet parts of the intestine carrying the fistula. Insufflation of air is also used, the introduction of a solution of methylene blue and barium suspension, which are visible through the wall of the small intestine. In some cases, enterotomy is necessary to intubate the gut. In case of multiple fistulas with localization of the upper fistula deep in the lateral inflow (i.e., if it is impossible to insert a Foley catheter into it), air is introduced into the duodenum through the Blackmore probe, inflating its cuff.

Despite all the difficulties, a two-stage treatment ensures asepticity and reduces the invasiveness of the operation, sometimes saving patients doomed to death. (NN Kanshin. Unformed intestinal fistulas and purulent peritonitis. - M .: Profile. - 2007. - 160 p.) The disadvantages inherent in the conventional methods of surgical treatment of unformed high jejunal fistulas, as well as the complexity of intraoperative diagnosis, prompted us to develop a method reliable surgical shutdown of the fistula, not associated with difficulties in detecting the intestine leading to it and without performing dangerous viscerolysis in the face of an insurmountable visceroparietal adhesion lesion of the peritoneum.

As the closest analogue, the surgical treatment method recommended by V.D. Fedorov et al. ("Morphological and functional aspects in the treatment of patients with intestinal fistulas" // Surgery. - 1994. - No. 10. - P.36-39), as well as N.N. Kanshin ("Unformed intestinal fistulas and purulent peritonitis." - M .: Profile. - 2007. - 160 p.). The description of the closest analogue is taken from the text of the above monograph by N.N. Kanshina (2007).

Disconnection of the intestinal loop carrying the fistula ... "ideally, it should be two-way, with the intersection of the adductor and abduction loops and the restoration of intestinal continuity through anastomosis." ... "If it is impossible to perform such an intervention, one-way shutdown is also quite effective, with the intersection of only the leading loop (above the fistula) and with the application of the anastomosis below the fistula at a distance of at least 40 cm from it." ... "An operation should be preceded by an X-ray examination that allows establish the location and condition of the intestinal loops above and below the fistula. "..." In this case, it is necessary to exclude the presence of difficulty in passage along the discharge sections of the intestine. " “The operation plan is compiled on the basis of an assessment of the obtained X-ray data.” ... “On the operating table, Foley catheters are again inserted into the inferior and abdominal knee. Sometimes such an introduction due to bowel bends has to be done on the finger. To tightly block the lumen of the intestinal segments, the cylinders of both catheters are filled with liquid "..." "The planned incision is indicated by a scratch."

“Surgical access depends on the data of the preoperative examination.” ... “With high fistulas, we often had to use one or another, non-standard, more often left-sided access.” ... “The incision can be oblique hypochondrium with an arcuate bend down. ... Often we had to resort to the incision such as access to the ureter, but with a dissection of the peritoneum. "..." Having penetrated into the abdominal cavity, which is most often obstructed with unformed intestinal fistulas, carefully separating the adhesions, they try to find catheter balloons in Foley. If this succeeds, then ... the introduction of air through catheters allows, with absolute accuracy, to confirm which of the loops is the leading, which is the outlet. "..." "In the most favorable cases, both loops are located at a close distance from each other. Then, if possible, both loops cross closer to the fistula, with all four stumps sutured tightly and imposed an anastomosis “side to side”.

“If the lead loop of the intestine with the Foley catheter located in it, which in some cases cannot be felt, is at a considerable distance from the surgical access ... then the surgeon performs two-way disconnection of a sufficiently long section of this loop.” ... “As for the long discharge end of the jejunum if the fistula is turned off bilaterally, then over time a significant amount of ... infected mucus can accumulate in this segment. ” There is chronic inflammation with purulent intoxication. Therefore, "such a disconnection of the fistula, with a long discharge loop, is undesirable." ... "Two-way disconnection of a large portion of the discharge small intestine, with its adhesive immobility, should not be done, but preference should be given to one-way disconnection." Then ... "at a considerable distance from the unilaterally disconnected fistula to the anastomosis, as with the Maidel’s jujunostomy, intestinal contents will not be released through the fistula" ... "In some cases, the central end of the crossed jejunum must be anastomosed with the transverse colon or sigmoid colon." ... "B in the distant period after disconnection, either a reconstructive operation is performed with the part of the disconnected intestine included in the passage, or the entire closed segment of the intestine is completely removed. ”

From the contents of the monograph by N.N. Kanshina (2007) and from our experience it follows that recognition of the adducting and abducting loops of the jejunum using Pettser catheters seems to be a rather complicated, multivariate procedure requiring skill, ingenuity and time. Intraoperative detection of the intestinal loop leading to fistula by the X-ray method significantly prolongs the operation time and increases the radiation load on the patient. Difficulties in isolating jejunal loops from visceroparietal adhesions related to the fistula can change the plan of operation and cause immediate and distant postoperative complications.

The objective of the invention is, firstly, to simplify, make more accurate and shorter the intraoperative search and recognition of jejunal fistula leading to fistula, while eliminating the harm of prolonged exposure of patients to x-rays. The second objective of the invention was to reduce the morbidity of surgical cutoff of the fistula and reduce the risk of postoperative complications by developing new surgical access to the adducting intestinal loop, not associated with passage through the difficult to overcome concentration of visceroparietal adhesions.

The essence of the invention is a method for unilateral surgical disabling of high, delimited, unformed, depleting jejunal fistulas, including marking the jejunal area leading to the fistula, anterolateral laparotomy on the left, surgical disabling of the fistula together with the intestinal conglomerate of the scar-adhesion origin surrounding it through the intersection of the adducting fistula tightly suturing its distal part and anastomosing the cut proximal section of the adducting gut from the nearest d, free of adhesions, diverting from the fistula of the intestine, characterized in that for palpation detection during surgery leading to a fistula of the jejunum, it is injected into it using a gastroduodenoscope through the fistula until the duodenojejunal junction, or in the usual oral way through the duodenojejunal junction, well palpated through the intestinal the wall, a regular dense catheter, and expose this adducting jejunum with the posterior, mainly blunt manual separation of the entire fixed viscero-visceral adhesions of the part of the small intestine from the left latera ceiling elements with channels colon and left half of the posterior abdominal wall to Treytsa ligaments and duodenojejunal transition.

The technical result of the invention is an error-free one-way shutdown of a high unformed jejunal fistula at the level of the leading intestinal loop with the formation of a bypass anastomosis. At the same time, the intestinal fistula for 2-4 days of the postoperative period continues to function as Maidl's definitive jejunostoma, relieving interintestinal anastomosis. The distinctive advantages of the proposed method are the reduction in the time required to complete the operation by an average of 40%, as well as the rejection of intraoperative x-ray irradiation of the patient. In addition, access to disable an unformed high skinny fistula and form a bypass anastomosis is performed by non-violently obtuse, manual separation of the entire small intestine conglomerate from the posterior abdominal wall to the Tricus ligament connected by interintestinal adhesions. At the same time, there is no risk of deserting the bowel leading to a fistula, since the direction of the operative action passes between the intestine and the posterior wall of the abdomen, where intractable visceroparietal adhesions are usually absent. Therefore, the operation proceeds faster, more reliable and less traumatic, as a result of which the postoperative mortality significantly decreases from 59.1 ± 9.2% to 23.1 ± 11.2% (t = 2.5; p <0.05).

The prerequisite for the implementation of the proposed method for unilateral surgical shutdown of high, delimited, unformed, depleting jejunal fistulas was the topographic and anatomical patterns and intensity of the visceroparietal adhesive process that we identified during surgical interventions in other 172 patients operated on for acute adhesive intestinal obstruction. It was established that a continuous array of visceroparietal planar, inflammatory infiltrated insurmountable adhesions is localized immediately behind and near the coarse scar formed after healing of the laparotomy wound by secondary intention (Fig. 1, position 1). The reasons for the failure of healing in the past by primary intention were suppuration, inconsistency of the intestinal suture, eventation, infiltration in the depth of the sutured laparotomy wound and ligature fistulas. As you move away from the laparotomic scar, the adhesive process becomes less pronounced. In the area of the lateral canals, as well as between the entire small intestine and the posterior abdominal wall, single visceroparietal adhesions are sometimes found (Fig. 1, position 2 in the appendix). Due to this, it is almost always possible to freely open the abdominal cavity with oblique incisions in the projection of the lateral canals, as well as move the small intestine in the medial direction to the root of the mesentery, separating it from the posterior abdominal wall without trauma and deserosation. Under such conditions, it becomes possible to approach the Terets ligament (duodenojejunal junction) on the left and back to avoid dangerous contact with the part of the abdominal cavity obliterated by the commissures located between the small intestinal conglomerate bearing the fistula and the laparotomic scar on the anterior abdominal wall.

The proposed method for unilateral surgical shutdown of high, delimited, unformed, debilitating jejunal fistulas is carried out during the first stage of their surgical treatment. For a better understanding of the proposed method, its description is supplemented by fig. 1-3. In Fig. 1, by varying the concentration of point symbols, the topography and intensity of the visceroparietal adhesive process, as well as its relation to the scar of the laparotomy wound, are presented. Position 1 of this figure shows the largest number of visceroparietal adhesions in the projection and the immediate environment of the postoperative scar, and position 2 indicates the region of the left lateral canal of the abdominal cavity, in the projection of which they are very rare.

Fig. 2 schematically shows the structure of a high unformed jejunal fistula and its relation to surrounding organs and tissues. Position 3 shows the outer opening of an unformed jejunal fistula, and position 4 shows the ligament of Traits. Position 5 denotes the left half of the colon, position 6 denotes the initial loop of the jejunum leading to the fistula, position 7 denotes the small intestine, which is free from fistulous adhesions, and the small intestine free of adhesions, and position 8 - the intestinal conglomerate fixed around the unformed fistula by commissures.

Figure 3 gives an idea of one-sided proximal disabling of a high unformed jejunal fistula. Positions 9, 10, 11, 12 and 13 of this figure respectively duplicate positions 3, 4, 5, 7 and 8 of Fig. 2. Position 14 in Fig. 3 indicates a bypass anastomosis, superimposed between the proximal segment of the crossed adductor jejunum, with a free small intestine extending from the peri-intestinal adhesive intestinal conglomerate. Position 15 denotes a sutured tightly distal segment leading to a jejunum fistula.

The proposed method for unilateral surgical shutdown of high, delimited, unformed, debilitating jejunal fistulas is as follows.

Under combined anesthesia, the abdominal cavity is opened with a left-side oblique incision in the form of an extended access of Pirogov or Israel. For the purpose of error-free intraoperative palpation recognition of the jejunal loop leading to fistula, it is marked before surgery. To do this, the jejunum leading to the fistula is inserted retrogradely through the fistula with a fiber-optic gastroduodenoscope or through the usual anterograde method through the mouth, a regular, well-palpable catheter of dense consistency. It is important that the catheter inserted through the manipulation channel of the endoscope at least 10-15 cm penetrates the first loop of the jejunum and marks the duodenojejunal transition. After opening the abdominal cavity in the projection of the left lateral canal, the palm penetrates between the descending colon and loops of the small intestine. In the presence of rare viscerovisceral adhesions between the colon and small intestine, they are dissected without major problems. Further, the entire array of the small intestine is removed with the hand and deep mirrors inside, to the root of its mesentery. In this case, friable adhesions between the loops of the small intestine and the posterior abdominal wall, as well as with the mesentery of the transverse colon, are usually inferior to blunt dissection, but sometimes they have to be crossed. The medial movement of the loops of the small intestine is performed until the Treitz ligament and duodenojejunal transition appear in the field of vision (Fig. 2, Item 4). The palpation of the marking catheter in the duodenojejunal junction and in the intestinal fistula helps to verify this. After this, the displaced small intestine is transferred to the assistant, and the surgeon proceeds to isolate the first loop of the jejunum from the intestinal adhesions. It is possible to cross these adhesions with scissors bloodless after their digitoclasia for 10-30 cm. You should not move away from the Treitz ligament to a greater distance, since when approaching the peri-intestinal intestinal conglomerate, the adhesion process becomes visceroparietal, inflammatory-infiltrative, planar, in which the adducting intestine grows together with a scar of the anterior abdominal wall (Fig. 2, pos. 6). Subject to these rules, it is always possible to mobilize without deserting up to 10 cm or more of the length of the jejunum, which is enough to build an anastomosis. Farther away from the fistulous intestinal conglomerate, a diverting, sufficiently mobile small intestine is found that is not involved in the planar adhesion process (Fig. 2, item 7), its patency is traced to the ileocecal transition and marked with a “holding” thread. Isolated from adhesions, starting from the ligament of the Traits, the leading intestinal loop at the fistulous intestinal conglomerate is crossed across. The lumen of the distal segment of the adducting gut is sutured tightly, which turns off the entire intestinal conglomerate with fistula from the passage (Fig. 3, item 15). A lateral anastomosis is placed between the central end of the crossed adducting intestine and the first marked labeled intestinal loop freely extending from the conglomerate, but no closer than 30-40 cm from the fistulous opening (Fig. 3, item 14). In the early postoperative period, an unbroken intestinal loop that diverges from the fistula, like Maidl’s definitive jejunostoma, serves to relieve anastomosis. With the restoration of peristalsis, losses from the fistula cease. Thus, the continuity of the digestive tract is restored. A double-lumen drainage is brought to the intestinal anastomosis, which is removed 2-4 days after the operation. The laparotomy wound is sutured with removable, draining muscle-aponeurotic sutures that prevent suppuration of the surgical wound and ensure its healing by the type of primary tension (Bensman V.M., Scherba S.N. // Bulletin of Surgery. - 2000. - T.159. - No. 1. - S.64-67).

After 8-12 months, when the condition of the patients is steadily improving, and the adhesion process of the peritoneum is noticeably reduced, the second stage of surgical treatment is performed. From the spindle-shaped access bordering the fistulous opening, the switched-off intestinal loop carrying a non-functioning fistula is resected in the usual way, while maintaining the intestinal bypass anastomosis. The second stage of surgical treatment has no significant differences from the methodology described in the literature (V.D. Fedorov, D.S. Sarkisov, V.V. Zvirkun, and others. Morphofunctional aspects in the treatment of patients with intestinal fistula // Surgery. - 1994. - No. 10. - P.36-39; NN Kanshin. Unformed intestinal fistulas and purulent peritonitis // M .: - 1999. - 114 p .; GL Hill. Operative Strategy in the Treatment of Enterocutaneous Fistulas. // World J. Surg. - 1983. - Vol.7. - No. 4. - p. 466-450).

Between 1979 and 2013, under our supervision, there were 35 patients with high, delimited, unformed, debilitating jejunal fistulas who underwent surgical treatment. The comparison group consisted of 22 patients who performed the closure of fistulas or their shutdown by known methods. Of these, 9 patients had an intestinal loop carrying a fistula, bordered with a spindle-shaped incision and mobilized using extended enterolysis. Enterolysis-related deserosation required extensive resection of the damaged bowel. Depleted patients did not always tolerate such traumatic and prolonged interventions, as a result of which in 6 cases a fatal outcome occurred. The causes of death were peritonitis associated with eventuation (1), stressful perforation of the intestine (3), failure of the anastomotic suture (1), and early adhesive intestinal obstruction (1). Disabling unformed intestinal fistulas through surgical approaches located lateral to the fistulous wound, using a technique that has no significant differences with the closest analogue, was performed in 13 patients. The approach to the lead and discharge loops of the intestine carrying the fistula was carried out from the front, which was always accompanied by technical difficulties associated with the long separation of many adhesions. Of these 13 patients, seven did not undergo surgery. The causes of death were peritonitis, which developed after stressful perforation of the intestine (2) and its deserting (2), as well as due to the failure of the anastomotic sutures imposed under conditions of purulent inflammation of the peritoneum (1). One patient died of exhaustion after a failed fistula shutdown, and another from pulmonary embolism. The total postoperative mortality in the comparison group was 59.1 ± 9.2%.

In the main group of observations, consisting of 13 similar patients, also for health reasons, a unilateral proximal disconnection of the jejunal loop carrying fistula was performed according to the method developed by the authors. Thanks to the preoperative endoscopic labeling leading to the fistula of the intestinal loop along with the duodenojejunal transition, the intraoperative orientation took much less time than in the comparison group. The posterolateral surgical access to the jejunal loop leading to the fistula eliminated the risk of deserting, as long as there was no need for extended enterolysis. This access not only shortened the duration of the operation, but also significantly reduced its invasiveness. In patients of the main observation group, the postoperative period was easier and with fewer complications than in the comparison group. For this reason, only 13 people out of 13 operated patients died. The causes of death were extremely severe, irreversible depletion of the patient (1), as well as continued, secondarily abscessed widespread peritonitis (1), which had previously caused eventuation and the formation of a skinny fistula. In one case, during the development and development of the proposed method, an error was made in choosing the level of disconnection of the leading intestinal loop. As a result of this error, the fistula continued to function, and exhaustion reached an extremely severe, irreversible degree. The reason for the error was an underestimation of the significance of preoperative labeling, which we never again allowed. Thus, mortality in the main group of observations, where the method of unilateral surgical shutdown of high, delimited, unformed, depleting jejunal fistulas was used, was 23.1 ± 11.2%, which was significantly lower than in the comparison group (t = 2.5 ; p <0.05).

Clinical example. Patient Zakh-at 57 years old (case history No. 2375 for 2005 and 10475 for 2006) was transferred on February 18, 2005 to the purulent surgery department of the Krasnodar Regional Clinical Hospital from another medical institution. Diagnosis: Stable eventuation into the laparotomy wound with high unformed jejunal fistulas. Abdominal sepsis, exhaustion. Before the transfer, on January 20, 2005, the patient was operated on for a correctable postoperative ventral 1 hernia, and on January 30, 2005, a relaparotomy was performed due to the development of acute adhesive intestinal obstruction. The early postoperative period was complicated by suppuration of the laparotomy wound, eventation and peritonitis. Eventration was delimited by fusion with the edges of the diverging laparotomy wound and caused the formation of three unformed jejunal fistulas, localized on the same intestinal loop, close to each other. Loss of intestinal contents through fistulas reached 2-2.5 liters per day, progressive alimentary depletion, dehydration, anemia and hypoproteinemia progressed. It was not possible to compensate for homeostasis disorders by all intensive care methods, which served as a vital indication for the surgical disconnection of the jejunal fistula.

Operation No. 56 (medical history No. 2375): “Unilateral disabling of the jejunal loop carrying unformed, high, depleting fistulas”, was performed on February 21, 2005. An endoscopic examination was performed immediately before the operation. A gastroduodenoscopy is carried out through the fistula into the adducting intestinal loop until the duodenojejunal junction, leaving a regular endoscopic catheter in it. Thus, it was possible to mark the entire adducting intestinal loop 16 cm long. The abdominal cavity was opened in the projection of the left lateral canal with an oblique, elongated up to 30 cm incision of the Israel type. The entire proximal half of the small intestine, together with the transverse colon, is involved in the adhesion process. In the projection of fixed eventation, the intestine over a considerable extent in the form of a conglomerate has grown to the anterior abdominal wall with planar, infiltrate-like visceroparietal adhesions. About 1.5 meters of the ileum turned out to be almost free of adhesions, which made it possible to trace its patency to the ileocecal angle. This section of the intestine freely moves to the ligament of the treitz, so it was outlined for bypass anastomosis and took a “hold” on the suture. Filmy adhesions between the left half of the colon and small intestine are dissected. By blunt, manual separation of friable adhesions between the loops of the small intestine and the posterior abdominal wall, the entire small intestinal mass is displaced inward to the root of the mesentery. The Treitz ligament, duodenojejunal junction and the beginning of the jejunum, in which the marking catheter is distinctly palpated, were found. By digitoclasia of inflammatory infiltrated inter-intestinal adhesions, with their dissection, it was possible to free the initial part of the jejunum leading to the fistula without deserting for about 12 cm.The further isolation from adhesions is prevented by the fusion of this intestine with the scar edge of the eventual defect of the anterior abdominal wall. Departing from this line by 2-3 cm, the leading intestinal loop is crossed in the transverse direction. The lumen of its distal segment is sutured tightly with a two-row continuous suture, thereby achieving the disconnection of the jejunal loop carrying intestinal fistula. Between the proximal segment of the crossed jejunum and the planned ileum, a lateral anastomosis is formed by a nodular double-row suture. A double-lumen tubular drainage was left for 3 days near the anastomosis, and the left-sided laparotomic wound was sewn up with removable draining muscle-aponeurotic and rare skin sutures. The operation, which lasted 2 hours, the patient underwent satisfactorily.

The postoperative period was calm. On the 4th day, peristalsis recovered, and intestinal fistulas in the eventual wound ceased to function. Appetite appeared, body weight increased slightly. The surgical wound healed by first intention. The eventuation defect is gradually narrowed to a slit-like size by tensile sutures. The patient was discharged under outpatient observation 23 days after surgery. It is recommended that after 8-12 months come to perform the 2nd stage of surgical treatment, which was successfully performed on April 6, 2006 (case history No. 10475).

The reconstructive operation consisted in excising a scar with three non-functioning fistulas and a diverting small intestine 37 cm long. The previous inter-intestinal anastomosis was preserved and plastic surgery of the anterior abdominal wall defect was performed with local tissues. Examined after 7 years, May 18, 2013. No complaints, body weight adequate, good appetite, regular stool. There is no ventral hernia. There is drug-corrected psychosthenia. He is engaged in housekeeping in a large rural family.

Medical and social effect

Practical application of the method of unilateral surgical shutdown of high, delimited, unformed, depleting jejunal fistulas developed by the authors using endoscopic marking and posterolateral access to the jejunum reduces the invasiveness of the intervention and reduces the risk of intestinal desorption. Unilateral disabling of the jejunal fistula allows him to function during the first 2-5 postoperative days, like Maidl's definitive jejunostoma. In this case, the fistula, providing unloading of the intestinal anastomosis in the period of postoperative intestinal paresis, reduces the risk of intestinal suture failure. With the resumption of intestinal peristalsis, the abundant flow of chyme from the fistula is replaced by scanty secretion of intestinal mucus. These positive aspects of the proposed method provide a significant reduction in the number of postoperative complications and mortality in comparison with known methods of the same therapeutic purpose.

Claims (1)

A method for unilateral surgical disabling of high, delimited, unformed, depleting jejunal fistulas, including marking the jejunum leading to the fistula, anterolateral laparotomy on the left, surgical deactivation of the fistula together with the intestinal conglomerate of scar-adhesive origin surrounding it by crossing the fistula leading to fistula tightly of its distal part and anastomosing the cut proximal section of the adducting gut from the nearest, free of adhesions, abducting from the fistula of the intestine, characterized in that for palpation of the jejunum leading to fistula during surgery, the jejunum is introduced into it using a gastroduodenoscope through the fistula to the duodenojejunal junction or by the usual oral method through the duodenojejunal junction, a regular dense catheter is well-palpated through the intestinal wall, and this lead jejunum with the posterior, mainly blunt manual separation of the entire part of the small intestine fixed by the viscero-visceral commissures from the left lateral canal with the colon and the left half of the posterior abdominal wall to the ligament of the Treitz and duodenoeyunal transition.

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