RU2799258C1 - Method of intraoperative assessment of the tightness of esophagoenteroanastomosis during operations on the esophagus and stomach - Google Patents

Abstract

FIELD: medicine; surgery; gastroenterology.

SUBSTANCE: sterile gastric tube made of polyvinyl chloride 12 Fr 110 cm long is passed into the esophagus and to the anastomosed area of the small intestine, at the end of which there are holes 10 cm from the end of the probe. The probe is installed in such a way that its distal end with holes at the end is located in the area of esophagoenteroanastomosis. With the help of hands, the esophagus is clamped 5–7 cm proximal to the esophagoenteroanastomosis and the small intestine 8 cm distal to the esophagoenteroanastomosis. Through the channel of the probe 50–70 ml of 1% aqueous solution of methylene blue diluted in saline solution filling the esophagoenteroanastomosis through the holes at the distal end of the probe. Leak tightness is assessed by visual inspection.

EFFECT: method increases the accuracy of assessing the tightness of the area of esophagoenteroanastomosis due to the creation of hydrodynamic pressure, allows to timely detect anastomotic failure, reduce the number of complications, thereby improving the results of surgical treatment.

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Description

Technical field

The invention relates to the field of surgery, in particular to a method for intraoperative evaluation of the tightness of esophagoenteroanastomosis during operations on the esophagus and stomach.

State of the art

The most common complication of these operations is the failure of the anastomoses. Literature data indicate a high incidence of anastomotic leaks. Its frequency reaches 30% in operations on the upper gastrointestinal tract [1] and 20% in operations on the colon [2]. Unsatisfactory results of operations directly depend on the quality of the formed anastomosis between different parts of the gastrointestinal tract.

The use of various surgical suture techniques, the use of new suture materials, modern hardware methods of suturing, the use of antibacterial drugs, optimization of tactical issues did not significantly affect the percentage of anastomosis failure after surgery.

Despite significant advances in surgery of the gastrointestinal tract, the solution of this problem is currently relevant.

To assess the tightness of the anastomosis, the methods of V. Clumsky [3] are almost universally used, who proposed using intraluminal pressure when inflating the intestine with a gas or liquid, or the force necessary to rupture the anastomosis. These techniques have found application in surgical interventions in the lower gastrointestinal tract, where it is possible to temporarily “block or drown out” the proximal end of the gastrointestinal tract, and inject gas or liquid into the distal one. With anastomoses on the neck, these techniques were not used due to the limitation of the operative space.

A known method of intraoperative assessment of the tightness of the anastomosis on the neck using endoscopic techniques. The method consists in intraluminal assessment of the state of the anastomosis. It allows not only to examine the anastomosis for tightness and bleeding from the suture line directly at the time of the operation, but also to apply the necessary methods for correcting these complications if they are detected. The appearance of air bubbles in the area of the anastomosis suture line indicates its leakage.

However, studies have shown that this method is not accurate enough and does not reflect the degree of tightness of the anastomosis area, since air escapes through the injection and puncture sites of the anastomotic walls. And also, intraluminal pressure is not created sufficiently due to the release of gas proximally through the mouth and nose.

The principal differences of the claimed method is the creation of high hydrodynamic pressure in the projection of esophagoenteroanastomosis by introducing a contrast agent (methylene blue) through a 14 Fr probe previously installed in the area of esophagojejunoanastomosis, followed by proximal clamping of the esophagus above the esophagoenteroanastomosis by 5-7 cm and distal clamping of the small intestine below the level of the anastomosis by 10 cm. Thus, we create an increased hydrodynamic pressure in the area of esophagoenteroanastomosis, above and below it, which ensures the control of the viability of the formed esophagojejunoanastomosis. If leakage of the contrast agent is detected, additional sutures are placed in the area of insolvency. In the source [4], only clamping of the small intestine below the level of esophagoenteroanastomosis without creating hydrodynamic pressure is indicated, which affects the intraoperative detection of anastomosis failure and its correction.

In the source [4], it is indicated that the distal and proximal parts of the small intestine are only clamped (the failure of the small intestine anastomosis according to domestic and international authors is 0.1 - 0.3%), which does not correspond to our method for assessing the tightness of the anastomosis between the esophagus and small intestine (failure of the esophago-intestinal anastomosis, according to domestic and international authors, ranges from 1% to 7%).

The non-clamping of the proximal esophagus above the level of the esophagoenteroanastomy by the above mentioned materials is apparently due to technical difficulties in mobilization, which is not a big problem for us.

Disclosure of the essence of the invention

The objective of the invention is to increase the strength of the formed anastomosis by assessing its tightness, which allows timely application of the necessary methods for correcting complications if they are detected, thereby improving the results of surgical treatment.

The problem is solved by the method consisting in the fact that through the nasal cavity to the area of the formed anastomosis through a sterile gastric tube with a size of 12 Fr., 110 cm long, made of polyvinyl chloride at the end of which there are holes for 10 cm from the end of the probe, which is passed through the nasal passage into esophagus and to the anastomosed portion of the small intestine. The probe is installed in such a way that its distal end with holes at the end is located 5 cm in the esophagus and 6 cm in the small intestine. Then, with the help of hands, the operating surgeon compresses the esophagus proximal to the esophagoenteroanastomosis at a distance of 6 cm and the small intestine 8 cm distal, then by diluting 2-3 ml of a 1% aqueous solution of methylene blue diluted in 50 ml of saline is injected using a 60 ml syringe through the channel the probe to the area of the formed anastomosis, which enters through the holes located at the distal end of the probe, gradually filling the space in the area of esophagoenteroanastomosis until it is tightly filled, while the surgeon preliminarily pinches the proximal and distal end of the formed anastomosis section with the help of hands. Control over the filling of the anastomosis site and leakage of the contrast agent beyond its limits is carried out using visual control. If the test is positive, the area of leakage is sutured with additional sutures with a re-assessment of the tightness. An aqueous solution of methylene blue is a contrast agent.

Brief description of the drawings.

On FIG. 1 implementation of the proposed method. Port 1 for the introduction of a contrast agent, proximal area of clamping 2, probe holes 3, distal area of clamping 4.

Implementation of the invention

Clinical example

Patient K., 68 years old. Diagnosis: Cancer of the body of the stomach pT3N1M0 Stage IIB G3 (poorly differentiated adenocarcinoma)

From the anamnesis: complaints of weakness, weight loss of about 10 kg, difficulty in passing solid food through the esophagus appeared in September 2019. Gastroscopy revealed the formation of the body of the stomach. He was consulted at the RSCH, hospitalized for additional examination and decision on the tactics of further treatment. The operation was performed: gastrectomy, lymphadenectomy. After the formation of a mechanical circular esophagoenteroanastomosis on the outlet loop according to Roux, a nasogastric tube (12 Fr) was inserted through the nasal cavity to the area of the formed anastomosis so that the holes at the distal end of the probe were located in the area of the formed esophagoenteroanastomosis. Distal and proximal to the anastomosis, the surgeon with the help of his hands pinched the area of the formed anastomosis. Next, about 50-70 ml of a 1% aqueous solution of methylene blue, diluted in physiological saline, was injected into the probe channel, which enters through the holes located at the distal end of the probe, gradually filling the space in the anastomosis area. Leakage of methylene blue outside the anastomosis indicated its failure, which required additional sutures to be applied to the anastomosis area, which was accompanied by a re-evaluation of tightness.

The postoperative period proceeded without complications. At the control X-ray examination on the 3rd day after the operation, the esophagoenteroanastomosis was consistent, no leakage of the contrast agent was detected. The patient was discharged on the 7th day after surgery.

Information sources:

1. Manta R., Magno L., Conigliaro R., Caruso A., Bertani H., Manno M. et al. Endoscopic repair of post-surgical gastrointestinal complications. Dig. LiverDis. 2013; 45(11): 879-85. DOI: 10.1016/j.dld.2013.03.008

2. Jafari M.D., Wexner S.D., Martz J.E., McLemore E.C., Margolin D.A., Sherwinter D.A. et al. Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR 11): a multi-institutional study. J. Am. Coll. Surg. 2015; 220(1): 82-92.el. DOI: 10.1016/j.jamcollsurg.2014.09.015

3. Egorov V.I. Mechanical methods for assessing the healing of gastrointestinal junctions. Annals of Surgery. 2001; 3:25-28.

4. Karachun A.N. et al. Technical aspects of laparoscopic interventions for gastric cancer, Clinical Hospital, 2016 2(16), page 18, second column, first paragraph

5. UA21675 U (Likhonenko O.V. et al.) 03/15/2003, description, page 4, lines 20-25

Claims (1)

A method for intraoperative assessment of the tightness of esophagoenteroanastomosis during operations on the esophagus and stomach, including the introduction of a contrast agent into the anastomosis zone, characterized in that a sterile gastric tube made of polyvinyl chloride 12 Fr 110 cm long is passed through the nasal passage into the esophagus and to the anastomosed area of the small intestine, at the end of which there are holes for 10 cm from the end of the probe, the probe is installed in such a way that its distal end with holes at the end is located in the area of esophagoenteroanastomosis; then, with the help of hands, the esophagus is clamped proximal to the esophagoenteroanastomosis by 5-7 cm and the small intestine is distal to the esophagoenteroanastomosis by 8 cm, then 50-70 ml of a 1% aqueous solution of methylene blue diluted in saline is injected through the probe channel, filling through the holes at the distal end of the probe the area of esophagoenteroanastomosis, the assessment of tightness is carried out using visual control.

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