RU2219858C2 - Method and device for protecting intestinal anastomosis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves creating closed isolated limited space in terminoterminal anastomosis zone. Selective decompression, draining and enteric lavage of intestinal sutures with medicament mixture is carried out. The device has flexible thermolabile radiopaque probe and tubes. The probe has main canal of 8-10 mm diameter. Proximal and distal collars are 3-5 cm far from the probe end. An opening has diameter that is not less than 2 mm large and is equidistant from both collars. The collars are not less than 5 cm far from each other and are brought out to its initial part as separated canals. Three polyvinyl chloride tubes come along the main canal. Two tubes are used for inflating rubber collars. They have self-locking valves and control cuffs. The third tube has internal diameter not less than 2 mm and cover. It is usable for carrying out selective decompression, draining and enteric lavage of intestinal sutures with medicament mixture. EFFECT: reduced risk of postoperative complications; enabled selective decompression, draining and enteric lavage to be done independently on nasointestinal draining. 3 cl, 2 dwg

Description

 The invention relates to medicine, namely to gastrointestinal surgery.

 A known method of decompression and drainage of the small intestine using a Becker probe (Baker JW, 1959; 1963; 1968; 1979; 1984) (Nechaev E.A., Kurygin A.A., Kanevich M.D. Drainage of the small intestine with peritonitis and intestinal obstruction. - St. Petersburg. 1993.-S. 117-118).

 The method consists in the fact that the probe is introduced into the lumen of the small intestine by enterostomy at a distance of 20-50 cm from the ligament of Treitz.

 The probe, proposed by Becker, has such a design that allows you to quickly drain the small intestine along its entire length. It has two channels. One of them is designed for decompression of the small intestine, the second is closed and communicates with the cuff, which is located in the initial part of the probe. After the probe is inserted into the intestine, the cuff is inflated and serves to capture and hold it during intubation. At the ileocecal angle, it is released from the air, the end of the probe is inserted into the cecum, and the cuff is inflated again to hold the probe distal to the bauginium damper. To prevent the formation of a high lip-shaped small intestinal fistula, the author suggested completing the enterostomy according to the Witzel method and removing the stoma along with the probe on the anterior abdominal wall with subsequent fixation to the skin.

 However, the known method only allows you to hold the probe in the lumen of the small intestine for a certain time and has a number of disadvantages. The probe allows for decompression and debridement of the lumen of the small intestine as a whole. When using a Becker probe, there is no possibility of conducting local selective decompression of the line of intestinal sutures and drug exposure on the course of reparative processes in the anastomosis. Due to paresis and paralysis of the walls of the small intestine, the solutions of medications and sorbents introduced into the probe move only to a limited extent, not exceeding 70 cm, that is, they flow from the enterostomy tube through its nearest lateral openings (Nechaev E.A., Kurygin A.A. , Kanevich M.D. Drainage of the small intestine with peritonitis and intestinal obstruction. - St. Petersburg. 1993. - S. 110; 188). In addition, the formation of an enterostomy leads to deformation of the intestinal wall, there is a high risk of tearing the stoma from the abdominal wall with the development of peritonitis, there is a high probability of infection of the abdominal cavity with intestinal contents, and the lumen of the small intestine with an ascending infection from the colon. The Becker probe can only be used for antegrade intestinal intubation, it does not allow to isolate the area of intestinal sutures from the rest of the lumen of the small intestine.

 As a prototype, a method and a probe for intestinal decompression of a doctor of medical sciences R.V. Senyutovich (Surgery. -1997. - 9. -P.53).

 The author proposed a probe for decompression of the colon after removal of the tumor and the formation of colono-anastomosis.

 The probe consists of an inner tube with a diameter of 4 mm and a length of 2.5 m. On the distal part of the tube for 1 m there are lateral holes with an interval of 5 cm. A balloon is fixed above the last hole in the inner tube, the diameter of which is 1.5 cm after inflation The tube through which the balloon is inflated with air is located on the outer surface of the inner tube. 10 cm higher than the cylinder, a second wide tube with an outer diameter of 1 cm, made of very soft plastic, is fixed on the inner tube and fixed on the inner tube. The length of the outer tube is 1 m. For 60 cm, side holes are applied to the tube. At a distance of 20 cm from the end, all three tubes (inner, outer and duct to the cylinder) fan-like diverge.

 The probe is used as follows. After resection of the colon tumor and the application of an anastomosis, the probe through the anal opening is carried out into the colon, it is inserted behind the anastomosis, moving higher to the cecum. Inflate the balloon with air. The tube is pulled outward by obturating the Bauginius damper.

 The contents of the small intestine along the inner tube are evacuated outward, bypassing the anastomosis. Three times a day, 100 ml of an antiseptic solution is poured into a thick tube, blocking its lumen for 1 hour. Then the tube is opened and the antiseptic solution flows freely.

 The probe provides the removal of feces from the anastomosis and irrigation of the intestine and anastomotic zone with antiseptic solutions.

 However, the probe of the proposed design has limited application in gastrointestinal surgery. It is used for decompression of the colon after removal of the tumor and the formation of colono-anastomosis and does not allow selective lavage and decompression of the suture line of the anastomosis, as well as the selective administration of drugs to stimulate reparative and metabolic processes in the anastomotic region. In addition, the design of the probe R.V. Senyutovich does not allow its use in surgery of the esophagus, stomach and small intestine to protect the esophageal, gastrointestinal, small intestinal, small intestinal anastomoses from insolvency.

 The design of the probe also does not allow a selective study of intraluminal pressure in the area of intestinal sutures, as well as an X-ray examination of the anastomosis.

 Using the probe R.V. Senyutovich can lead to infection of the lumen of the small intestine with an ascending infection from the colon due to the iatrogenic failure of the bauginium damper.

 The objective of the invention is to develop a multifunctional universal nasointestinal probe (UNIZ), which allows for decompression, lavage and drainage of the intestinal anastomosis, regardless of nasointestinal drainage.

 The probe is made in the form (Fig. 1) of an elastic thermolabile and radiopaque polyvinyl chloride tube (A) having a main intestinal canal (IR) with an internal diameter of at least 8-10 mm. Three thin PVC pipes pass through the main channel, two of which are up to 1 mm in diameter (B), and a third is at least 2 mm in inner diameter (C). The main channel has many side holes (5) with a diameter of 2.5 mm to the initial part of the probe (4) 60 cm long. Tubes B are used to inflate rubber cuffs (3) located 3-5 cm from the end of the probe at a distance of at least 5 cm apart (proximal and distal cuffs). Tube B is used for selective decompression, drainage and enteric lavage of the intestinal suture area with a drug mixture, as well as for measuring intraluminal pressure and radiopaque studies of the anastomosis. Tubes B along the main channel of the probe with separate vinyl chloride tubes are brought to its initial part in the form of separate cannulas and are equipped with self-locking valves with control cuffs (6). Tube B is brought to the initial part of the probe and provided with a cover (7).

 The design of the probe allows you to increase the length of its intestinal part (IC) to 1.55 m, without changing the length of its nasogastric (NGF) and working (RF) parts.

 The UNIZ probe is shown in FIG. 2.

 UNIZ is carried out into the small intestine by the generally accepted method of nasointestinal intubation and is used as follows: after decompression of the small intestine before its resection, the distal cuff (DM) inflates in the advancing loop, which prevents leakage of intestinal contents during intestinal resection, without disturbing the blood supply to the loop and without injuring her.

 After the formation of intestinal anastomosis is completed, the distal cuff is released from the air and the probe is advanced aborally behind the anastomosis and the cuff is inflated again. The proximal cuff (PM) is also inflated. After inflating both rubber cuffs, a closed isolated space is created in the intestinal lumen in the area of the anastomosis. A swollen distal cuff prevents the anastomosis from sliding off the probe in the oral direction. Swollen cuffs should not lead to overstretching of the intestinal wall and impaired blood circulation, while ensuring complete isolation and tightness of the anastomosis from the rest of the lumen of the intestinal tube. After suturing the laparotomic wound in the postoperative period, the air pressure in the intestinal cuffs (3) is controlled through the cuffs (6) in the initial part of the probe.

 In the postoperative period, enteric lavage and enterosorption are performed 2-3 times a day on the main channel of the UNIZ, and selective tube decompression and enteric lavage of the anastomotic suture area with a medication mixture including antibiotic sh.s.d., an antioxidant and a repair and epithelization stimulator are performed 2-3 times a day. intestinal wounds.

 UNIZ is removed as the phenomena of peritonitis are stopped, the motor-evacuation function of the intestine is restored, and the general condition of the patient improves. The average timing of the extraction of the probe is 4-7 days.

 Using the invention allows to obtain the following technical result.

DOWN allows
a) selectively protect the anastomosis from the effects of intestinal chyme and microflora;
b) carry out selective decompression of the anastomotic zone, regardless of intraluminal pressure in the small intestine;
c) carry out selective antibacterial therapy of the anastomosis zone;
d) to introduce into the anastomotic zone preparations stimulating the processes of repair of the intestinal wound in order to prevent anastomositis and suture failure;
d) measure the dynamics of intraluminal pressure in the area of the anastomosis;
f) conduct radiopaque studies of the anastomosis to diagnose anastomositis and intestinal suture failure;
g) carry out decompression of the intestine in a predetermined mode of the probe position until the manifestations of enteric insufficiency are stopped;
h) to perform a resection of the small intestine without the use of intestinal clamps that injure the inflammatory changed intestinal wall with peritonitis.

 UNIZ can be widely used to protect the esophago-gastric, gastrointestinal, small intestine, small colon, large intestine anastomoses from insolvency.

 In case of intestinal suture insufficiency, the VLHD can localize the process in the abdominal cavity, preventing the development of general peritonitis.

 UNIZ allows timely diagnosis of suture failure and visualization of this complication, as well as creating aseptic conditions for healing, and introducing into the intestinal wound zone (1) solutions of medicines that accelerate healing and epithelization.

 The technical result is achieved due to the design features of the UNIZ, which consist in the fact that the probe, in addition to the main washing-aspiration intestinal canal, has two separate channels for inflating the PM and DM of the anastomosis protection and the washing-aspiration channel for selective decompression, drainage and enteral lavage of the medication anastomosis suture line a mixture.

 EXAMPLE 1

 Patient B., 45 years old, diagnosis: acute strangulation small bowel obstruction, ileum gangrene. General fibrinous-purulent peritonitis. Toxic phase.

 After intensive preoperative preparation under endotracheal anesthesia, the old postoperative scar was excised and a mid-median laparotomy was performed. In the abdominal cavity up to 300 ml of fibrinous-purulent effusion with an ichorous odor that is aspirated by an electric suction pump. Adhesive cord from the omentum to the ileum mesentery squeezed the mesentery and loop of the small intestine 30 cm long, causing complete small bowel obstruction. The loop of the small intestine is gangrenous. The proximal loops of the small intestine are inflated to 6-7 cm, filled with liquid and gas. UNIZ was introduced naso-intestinally, and complete decompression of the leading loops of the small intestine was performed. A compressive adhesion was dissected, the contents of the necrotic loop were evacuated. The distal cuff of the UND inflated in the lead loop is inflated.

 A small bowel resection was performed within healthy tissues and a terminal-terminal small bowel anastomosis was formed 1 m from the ileocecal angle with double-row interrupted sutures. We pass the anastomosis, diameter up to 1.5-2 cm. The distal cuff is freed from the air, transferred aborally for the anastomosis and again inflated to the required diameter. A thorough enteral lavage of the adductor loop and anastomosis was performed. Above the anastomosis, the proximal cuff is inflated. A drug mixture consisting of 80 mg of gentamicin in 20 ml of 1% dimexide in a 0.5% solution of novocaine was introduced into the anastomosis zone through a selective washing and suction channel.

 A thorough lavage of the abdominal cavity with a solution of furacilin was performed. The loops of the small intestine are laid out in horizontal rows. A large omentum is laid in front of the loops of the small intestine. The abdominal cavity is drained at three points. Layered seams on the wound.

 In the early postoperative period, for the first 5 days, intestinal lavage with physiological saline and enterosorption with 15% suspension of polyphenap in 5% glucose solution was performed 2-3 times a day through the main channel of UNIZ 2-3 times a day, and the anastomosis zone was washed with warm saline or furatsillin solution with selective channel subsequent administration of the drug mixture.

 The postoperative period was uneventful. Intestinal paresis resolved for 2-3 days. In a short time, the manifestations of endogenous intoxication were stopped. The wound healed by primary intention. Recovery.

Claims (3)

1. A method of protecting the intestinal anastomosis, including conducting a nasointestinal probe through the formed anastomosis after a bowel resection, characterized in that a closed isolated limited space is created in the terminal-terminal intestinal anastomosis zone and selective decompression, drainage and enteral lavage of the intestinal suture area with a drug mixture are performed. 2. The device for implementing the method according to claim 1 in the form of a probe with tubes, characterized in that the probe is made in the form of an elastic heat-labile and radiopaque tube having a main channel with an inner diameter of at least 8-10 mm, with 3-5 cm from the end, the probe has separately inflated and manicured proximal and distal rubber cuffs located at a distance of at least 5 cm from each other, and a separate hole located at equal distance from the cuffs with an inner diameter of at least 2 mm, which along the main channel separate polyvinyl chloride tubes are led to its initial part in the form of separate cannulas, and three polyvinyl chloride tubes pass through the main channel, two of which are made for inflating rubber cuffs and are equipped with self-locking valves with control cuffs, and the third tube has an inner diameter of at least 2 mm, equipped with a lid and made for selective decompression, drainage and enteric lavage of the intestinal suture area with a drug mixture. 3. The device according to claim 2, characterized in that the probe is made in the form of an elastic polyvinyl chloride tube with side holes.

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