RU2219847C2 - Method for nasointestinal intubation - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: one should direct nasointestinal probe through nasal canal, esophagus, stomach. Posterior retrocolonic gastrojejunoanastomosis is developed, the diameter of anastomosis corresponds or is slightly lower against probe's diameter. Probe is directed into jejunum by avoiding duodenal curvatures. The method enables to simplify direction of probe out of stomach into jejunum and, also, enables to keep the function pyloric press. EFFECT: higher efficiency of intubation. 2 dwg, 2 ex

Description

 The invention relates to the field of medicine, namely surgery.

 A known method of nasointestinal drainage by conducting a probe through the nasal passages through the esophagus, stomach, twists of the duodenum into the small. The olive of the intestinal probe is abundantly lubricated with liquid paraffin, and its free end is attached to the electric pump. An anesthesiologist through the outer opening of the nasal passage, the probe moves into the esophagus. As the probe moves, the surgeon from the side of the abdominal cavity guides it along the greater curvature of the stomach and fixes it with the right hand in the area of the outlet. With the left hand, the end of the probe is directed through the pylorus into the duodenal bulb. Often a spasm of the pyloric pulp interferes with the advancement of the probe. The reason for this may be traumatic manipulations and the lack of coordinated actions of the surgeon and anesthesiologist. As soon as the end of the probe is in the bulb of the duodenum, the surgeon with his right hand simultaneously with the movement of the anesthesiologist moves the enterostomy tube in the distal direction. The fingers of the left hand are controlled and directed by its end down and backward to the lower horizontal bend and further to the left towards the ligament of the trie. Forced advancement of the probe through the intestine when sensing an obstacle is unacceptable. In such cases, the duodenum is mobilized according to Kocher.

 When the probe appears in the initial section of the jejunum, it is captured by three fingers of the right hand and advances 10-15 cm. In the stomach, the probe fits along the lesser curvature.

 An obstacle to the advancement of the probe in the area of the duodenojejunal transition may be additional bends of the initial jejunum, fixed by the ligamentous apparatus of the peritoneum or commissures.

 For the convenience of capturing and holding the probe, a number of devices are recommended. So A.L. Prusov and P.S. Papandopulo (1983) suggested that every 4 cm on the "working part" of the probe put on red rubber rings. A.I. Antukh (1991) - uses edible gelatin to form thickenings. For the same purpose, it was proposed to supply the initial part of the probe with one or more latex rubber cuffs (Miller-Abbot probe) (Nelson A.L., Nyhys L.M., 1979; Seidton E. J. et al., 1984). To facilitate intestinal intubation and prevention of damage, some authors inflate it with oxygen or air (Prusov A.A., Papandopulo P.S., 1983; Weller D.G. et al., 1985).

 In the absence of bowel paresis, the probe is advanced by "stringing" intestinal loops on it. Having corrugated 8-10 cm of the intestine, the surgeon simultaneously with the anesthetist pushes the probe, straightening the intestine in the proximal direction. Transnasal intubation should be considered complete when the last lateral opening of the probe appears in the initial jejunum. Drainage of the small intestine by the transnasal method is carried out in most cases along its entire length (E.A. Nechaev, A.A. Kurygin, M.D. Khanevich. Drainage of the small intestine with peritonitis and intestinal obstruction. - St. Petersburg, 1993, p. 80-89).

 However, intestinal intubation is a rather traumatic intraoperative intervention (E.A. Nechaev et al., 1993). Technical difficulties in conducting a probe along the bends of the duodenum occur in 11.3% of cases / E.A. Nechaev et al., 1993 /, and the percentage of unsuccessful attempts of nasointestinal intubation can be from 20 to 50% (Babiev E.S., 1983; Enochsson L. etdl., 1982; Waclawiczek H.W. et al., 1997).

 In addition, duodeno-gastric reflux and infection of the upper gastrointestinal tract and respiratory tract are observed, leading to the development of hypersecretion of the stomach, an increase in stagnant contents, erosive-ulcerative gastritis and esophagitis, pneumonia and purulent tracheobronchitis as a result of iatrogenic failure of pyloric sphincter. There is a need for a wide laparotomy, especially during operations in the lower floor of the abdominal cavity; as well as in the dissection of adhesions in the upper floor of the abdominal cavity in previously operated patients and in the mobilization of the duodenum according to Kocher with difficulties in conducting the probe along its bends. Traction of the probe 1.5-3 m long along the duodenum causes trauma to its mucosa.

 As a prototype, the selected method of drainage of the small intestine according to Yu.M. Dederer described in the monograph by E.A. Nechaev, A.M. Kurygina and M.D. Kanevich "Drainage of the small intestine with peritonitis and intestinal obstruction." - St. Petersburg, 1993, p. 98-100.

 After a wide laparotomy, gastric contents are evacuated before performing a gastrostomy. After carefully delimiting the surgical field with tampons at the same distance between the small and large curvatures, a purse string suture is applied to the front wall of the stomach at the border between the body and the bottom. In the center of the purse string suture, the lumen of the stomach is opened. Further, towards the pyloric pulp, the end of the probe is inserted, and the free proximal end is connected to the electric suction pump. The probe is passed through the pyloric pulp into the duodenum. The intubation technique is similar to that used for nasoenteric drainage, with the only difference being that the probe is supplied by an assistant. To prevent leakage of intestinal contents from the lateral openings, you can use a short probe-conductor, which is previously displayed beyond the ligament of Treitz. After emptying the nearest sections of the small intestine from the contents, an enterostomy tube with a diameter of 0.6-0.8 cm with side openings is carried out through a drainage probe. The probe conductor after end of intubation is removed. After draining and tying the first purse string suture around the tube, a second purse string suture is applied that closes the first. The probe is placed on the wall of the stomach towards its bottom and is covered with three to four separate serous-muscular sutures in the folds of the anterior wall (according to Witzel). Around the probe, an additional serous-muscular purse-string suture is additionally applied, the ends of which are placed with the enterostomy tube on the anterior abdominal wall in the left hypochondrium 3-5 cm below the costal arch. The peritoneum and the aponeurosis of the rectus abdominis muscle are sutured with the ends of the threads of the last purse string suture, the stomach is additionally fixed with separate nodal sutures around the probe to the anterior abdominal wall (Fig. 1) (EA Nechaev, AA Kurygin, MD Khanevich. of the small intestine with peritonitis and intestinal obstruction. - St. Petersburg, 1993, S. 98-100).

However, the method of drainage of the small intestine according to Yu.M. Dederer was left by surgeons in view of the presence of many shortcomings:
a) the need for wide laparotomic access, especially with surgical intervention in the lower floor of the abdominal cavity;
b) severe deformation of the anterior wall of the stomach, causing dysfunction of the latter;
c) fixation of the anterior wall of the stomach to the anterior abdominal wall;
d) difficulties remain when conducting the probe through the bends of the duodenum without a special conductor;
d) the possibility of forming a long non-healing gastric fistula, sometimes requiring additional surgical intervention;
f) there is a high probability of suppuration of the parastomatic wound and the separation of the stomach from the abdominal wall with the development of peritonitis;
g) dysfunction of the pyloric pulp, leading to the throwing of small intestinal contents into the stomach, massive infection of the stomach, esophagus, and respiratory tract by the intestinal flora;
h) the presence of an additional cosmetic defect in the left hypochondrium;
i) the development of a pronounced adhesive process in the upper floor of the abdominal cavity, which creates difficulties when there is a need for surgical intervention on the stomach;
j) ulceration of the wall of the stomach in the area of formation of the gastrostomy.

 The objective of the invention is to provide a method that greatly facilitates the conduct of a nasointestinal probe from the stomach into the small intestine in the presence of an adhesion process in the upper floor of the abdominal cavity, pyloric or duodenostenosis, deformation of the duodenum by congenital or postoperative adhesions, as well as during surgery on the lower floor of the abdominal cavities without a wide laparotomy, while maintaining the function of the pyloric pulp to prevent reflux of small intestinal contents to the overlying Suitable portions of the gastrointestinal tract, the development of reflux gastritis, erosions of the stomach and esophagus, upper respiratory tract infection in order to improve the efficiency of the drainage of the small intestine in the postoperative period.

 The essence of the invention consists in the formation of a posterior posterolateral mini-gastrojejunoanastomosis (m-GEA) on a short loop of a jejunum with a diameter equal to the diameter of the nasointestinal probe, and conducting the latter, bypassing the bends of the duodenum into a thin one for the purpose of decompression and drainage (Fig.2).

 To form m-GEA, a large omentum is pushed to the upper part of the surgical approach, assistants lift the transverse colon. The surgeon leads the first loop of the jejunum into the wound 8-10 cm from the ligament of Treitz. After carefully wrapping the surgical field with napkins on a dedicated loop of the jejunum, puncture enterostomy and decompression of the nearest loops of the jejunum are performed. Distant to the decompression zone, an elastic clamp is applied to prevent the small intestine contents from being thrown into the loop allocated for m-GEA. In the avascular zone of the mesocolon, a window with a diameter of up to 2.5 cm is formed, to which the nearest portion of the posterior wall of the stomach is brought. Between the last and the loop of the jejunum on which the puncture jejunostomy is located, a second row of serous-muscular sutures of the future m-GEA (4-5 nodal sutures) is superimposed. The walls of the stomach and the loops of the jejunum fixed to it are dissected to the diameter of the nasointestinal probe used in this particular case. The inner row of catgut sutures is superimposed on the back wall of the formed m-GEA. The residual contents of the stomach are aspirated by an electric suction and through the gastrotomy opening with the help of a forceps, the nasointestinal probe is removed from the stomach and is passed through the enterotome opening into the initial section of the jejunum. The front wall of m-GEA is closed by applying the first and second rows of sutures to its front lip. But the window of the mesocolon is hemmed to the perimeter of the anastomosis. Further, the proximal end of the probe is connected to an electric suction pump, the previously applied elastic clamp is removed and, promoting the intestinal probe in the distal direction, total decompression of the small intestine is performed.

 If necessary, resection of the small intestine m-GEA can be applied after decompression of the small intestine through the ends of the resected loop. The nasointestinal probe is brought to the anastomosis for prolonged irrigation of the line of the intestinal suture with a solution of antibiotics, enzymes, stimulants of repair of the intestinal wound, respectively, according to the phase of the reparative process in the anastomosis zone.

 Using the invention allows to obtain the following technical result. The method can significantly facilitate the conduct of the nasointestinal probe from the stomach into the small intestine for the purpose of decompression and drainage, especially during surgical interventions on the organs of the lower floor of the abdominal cavity and the presence of adhesions in the upper floor of the abdominal cavity and obstructions in the duodenum without additional traumatic manipulations and wide laparotomy and also preserving the physiological function of pyloric pulp, excluding the reflux of intestinal contents into the stomach, the development of erosive gastritis that of esophagitis and infection of the upper gastrointestinal tract and respiratory tract.

 The present invention can be successfully used for the purpose of total decompression and drainage of the small intestine with intestinal obstruction and peritonitis, as well as for intestinal therapy, decompression of the intestinal anastomosis, and intestinal lavage intestinal suture in the early postoperative period.

Example 1
Patient S., 29 years old, diagnosis: acute adhesive complete small intestinal obstruction. General serous peritonitis, toxic phase. The patient was admitted on the 4th day after the onset of the disease, periodically aggravated by constant pain in the abdomen, nausea and repeated vomiting of intestinal contents, bloating, non-passage of gases and the absence of stool during the last 3 days. On the survey roentgenogram, multiple fluid levels (Kloiber's bowls). In NGZ, the stomach is emptied from its contents and washed with a solution of furatsilina to “pure waters”. After preoperative preparation under ETN, the old postoperative scar was excised, a lower middle laparotomy was performed with an extension of access above the navel by 4-5 cm. In the abdominal cavity, up to 400 ml of serous effusion, which was evacuated by an electric suction pump. The upper floor of the abdominal cavity is obliterated by an adhesion process. 20 cm from the ileocecal angle, the adhesion cord compresses the loop of the small intestine, causing complete small bowel obstruction. The commissure is dissected. On the wall of the ileum, a strangulation groove without signs of necrosis. Above strangulation, the small intestine is expanded to 6-7 cm, filled with liquid and gases. The proximal loop of the jejunum 10 cm from the ligament of Treitz was brought into the wound. After thoroughly wrapping napkins, puncture decompression of the proximal loops of the jejunum was performed for 40-50 cm and an intestinal clamp was applied. Mesacolon in the avascular zone is dissected by a transverse section 2.5-3.0 cm long, through which a portion of the posterior wall of the stomach is drawn along the greater curvature. The posterior outer row of sero-muscular sutures with capron 2 is laid. Along the line of the future m-GEA, the walls of the stomach and jejunum are dissected at the puncture point for 1 cm.

 An inner row of sutures of the posterior lip was applied with m-GEA catgut 2. A forceps inserted into the lumen of the stomach grabbed a double-lumen nasointestinal probe with a diameter of 0.8 cm with many lateral openings and passed through the enterotomal opening into the proximal loops of the jejunum fallen after puncture decompression. Two-row knotted sutures were placed on the front lip of m-GEA, to which the mesacolon window is fixed. The proximal end of the nasointestial probe is connected to a working electric suction pump, and its total decompression is performed by the distal end, stringing loops of the small intestine. The abdominal cavity is thoroughly washed with a 0.05% aqueous solution of chlorhexidine. The small intestine is arranged according to the Noble type. After drainage of the abdominal cavity, the surgical wound is sutured in layers. The postoperative period was uneventful. According to the nosointestinal probe, up to 500 ml of intestinal contents were released on the first day, and up to 300 ml of gastric contents without bile impurity through the gastric canal. On the second day, 300 and 100 ml, respectively. On the 3rd day, the motor-evacuation function of the small intestine was restored, the discharge through both channels of the probe ceased. On the 4th day, the probe was freely removed. Gastric fluoroscopy performed on the 5th day after the operation and one day after the removal of the probe showed the presence of a small cone-shaped niche on the stomach wall in the area of m-GEA formation without signs of evacuation of liquid barium suspension through it. On the 4th day after removal of the probe, radiological contours of the stomach are even, the evacuation of barium suspension through the jejunum is free, no deformation of the loops is detected. The patient was discharged with recovery on the 8th day after the operation. X-ray and endoscopic examinations of the stomach 1 month after surgery showed no signs of m-GEA functioning or a defect in the gastric mucosa.

 EXAMPLE 2

 Patient P., 52 years old, diagnosis: acute adhesive complete small intestinal obstruction. Strangulated necrosis of the ileum. General serous-purulent peritonitis in the toxic phase.

 Received on the 5th day after the onset of abdominal pain, a serious condition. Facial features are pointed, tongue dry, pulse-112 beats. in minutes, A / D 115/70 mm Hg Concerned about constant abdominal pain, bloating, nausea and repeated vomiting of intestinal contents, lack of stool. 2 years ago, he was operated on for acute adhesive small bowel obstruction. On the survey radiograph of the abdominal cavity, multiple Kloiber bowls. The abdomen is swollen, there are signs of general peritonitis. On NGZ small intestinal contents leaves. After intensive preoperative preparation under ETN, the old postoperative scar was excised, and lower middle laparotomy was performed with technical difficulties due to soldering of the small intestine loops to the abdominal wall scar. In the abdominal cavity, up to 350 ml of a cloudy purulent-hemorrhagic effusion with a sharp unpleasant odor, which is evacuated by an electric pump. The upper floor of the abdominal cavity is obliterated by commissures. Adhesive cord compresses the base of the already necrotic loop of the small intestine in its middle third. Above strangulation, the loops of the small intestine are expanded to 8 cm, filled with liquid and gases. The commissure is dissected. A necrotic loop was resected within healthy tissues 90 cm long. A total decompression of the proximal small intestine loops was performed through the end of the adducting loop of the resected intestine. The primary terminological small intestinal anastomosis was laid in two rows of nodal sutures (the first row with catgut 2, the second with capron 2). Patency of the anastomosis is satisfactory. The abdominal cavity is thoroughly washed with a 0.05% aqueous solution of chlorhexidine. In the wound derived transverse and proximal loop of the jejunum. A posterior posterior-oblique m-GEA with a diameter of up to 0.8 cm was formed, along which the small intestine was intubated to the formed intestinal anastomosis. The window to the mesocolon is fixed along the perimeter of m-GEA. The abdominal cavity was again thoroughly washed with a solution of chlorhexidine, the small intestine was laid in a physiological position. Drainages installed. The wound of the abdominal wall is sutured in layers.

 In the postoperative period, twice daily for 3-4 days after active aspiration of the contents of the small intestine, enteric lavage of the intestinal anastomosis was performed with a solution of kanamycin and chymotrypsin in 200 ml of 0.25% novocaine by drip of the mixture for one hour. After 30 minutes, the probe was opened for free outflow. On the first day, up to 500 ml of the contents of the small intestine was released by the probe; on 2-3 days, the casting decreased significantly. Ultrasound anastomosis indicated a decrease in edema. Intestinal motor-evacuation function was restored on the 4th day, there was an independent chair. The probe is freely removed. In the early postoperative period, reflux along the nasogastric canal was 500-300-200-150 ml. When giving liquid barium suspension on the 3rd day after the operation, evacuation from the stomach is rhythmic without signs of regurgitation. On the 5th day after surgery, m-GEA does not function. The postoperative period was uneventful. The patient was discharged on the 10th day in a satisfactory condition.

 The technical result was achieved by conducting a nasointestinal probe from the stomach into the jejunum through m-GEA on a short loop for decompression and drainage of the small intestine and enteral lavage of the primary small intestinal anastomosis in conditions of peritonitis. Conducting a nasointestinal probe from the stomach into the small intestine by forming the posterior posterior-oblique m-GEA on a short loop with the aim of decompression and drainage, as well as for enteral lavage of the primary intestinal anastomosis with the drug mixture (kanamycin + chymotrypsin + novocaine) can significantly facilitate the nosoinbestion procedure the function of pyloric pulp, to exclude duodenogastric reflux of intestinal contents, to prevent injury to the mucosa of the duodenum and others anatomical formations, to ensure the evacuation of small intestinal contents and active intestinal therapy in the early postoperative period in patients with paresis or paralysis of the small intestine after dissection of adhesions or its resection with the formation of a primary anastomosis in conditions of widespread peritonitis.

Claims (1)

A method of nasointestinal intubation, including conducting an intestinal probe through the nasal passage, esophagus, stomach into the jejunum, characterized in that they form a posterior posterior free gastrojejunostomy, the diameter of which corresponds to or slightly less than the diameter of the probe used and conducts a probe into the small intestine, bypassing the bends of the duodenum.

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