Method for reconstructing gastrointestinal tract after distal gastrectomy

Abstract

FIELD: surgical gastroenterology.SUBSTANCE: used in the surgical treatment of oncological diseases and gastric ulcers requiring distal resection. Distal gastrectomy is performed. A gastrojejunostomy is formed with an isolated Roux-en-Y loop of the jejunum and a jejunal anastomosis. Between the proximal part of the transected duodenum and the diverting loop of the jejunum, at a distance of 25–35 cm below the gastrojejunostomy, an end-to-side duodenojejunal anastomosis is formed.EFFECT: method allows for the restoration of duodenal passage after distal gastrectomy and, at the same time, minimizing the frequency and intensity of biliary reflux into the gastric stump, preventing the development of reflux gastritis and reflux esophagitis, as well as improving the nutritional status of operated patients by forming a duodenojejunal anastomosis 25–35 cm distal to the gastric anastomosis, which ensures a strictly controlled hydrodynamic balance of the two food flows and creates an extended peristaltic antireflux barrier for the backflow of bile.1 cl, 1 dwg, 2 ex

Description

[0001] The proposed invention relates to medicine, namely to surgery, and can be used in planned abdominal surgery and oncology when performing distal resection of the stomach for benign diseases and malignant neoplasms of the stomach.

[0002] Gastrointestinal tract (GI) reconstruction after distal gastrectomy (DGS) is associated with difficulties in restoring the physiological passage of intestinal contents, the presence of duodeno- and jejunogastric reflux, impaired pancreatic and bile secretion, and the development of functional post-resection syndromes that impair the quality of life and nutritional status of patients undergoing surgery. The most commonly used reconstruction methods after DGS are the Roux-en-Y or Billroth II method with a Brown anastomosis. However, both methods exclude the duodenum and its reflexogenic zones from the passage, disrupting the physiology of bile and pancreatic enzyme secretion. It has been proven that inclusion of the duodenum in the passage during gastrointestinal tract reconstruction after DRG leads to improved postoperative recovery of patients, especially those weakened by the manifestations of the oncological process, accelerates the rate of weight gain and reduces the phenomenon of dyspepsia and malabsorption.

[0003] Analogues. To date, many methods for restoring the continuity of the gastrointestinal tract after gastrectomy are known. One such method is the "Method for forming a gastroenteroanastomosis during subtotal gastrectomy" [Patent RU2532523C1, IPC A61B17 / 00 A61B17 / 04, published 10. 11. 2014 Bulletin No. 31, authors: Skipenko O.G., Bejanyan A.L., Chekunov D.A.]. The method is based on forming an anastomosis on a Roux-en-Y loop of the jejunum. Disadvantages: this method of reconstruction does not restore passage through the duodenum.

[0004] A "Method of distal gastric resection" is known [Patent RU 2 238 679 C1, IPC A61B17 / 00 (2000.01), published: 09.20.2004, authors: Cherkasov V.A., Luzhansky A.L., Freund G.G., Savastyanov A.G.]. This method involves forming a direct gastro-duodenoanastomosis. Disadvantages: it is often not possible to safely bring the gastric stump closer together after radical distal gastrectomy for cancer; with direct anastomosis of the gastric stump and duodenum, duodenogastric biliary reflux is observed, leading to biliary reflux gastritis and reflux esophagitis.

[0005] The closest analogue is the “Method of distal gastric resection” [Patent RU 2 290 879 C1, IPC A61B 17 / 00(2006.01), A61B 17 / 11(2006.01), published 10. 01.2007, authors: Onopriyev V.I., Uvarov I.B., Lyutov D.A., Shatov M.N.]. With this method, a gastric tube is formed from the greater curvature of the stomach stump, the first loop of the jejunum is crossed, and the distal end of the crossed jejunum is anastomosed with the duodenum. A "window" is created between the straight vessels of the mesentery anastomosed with the duodenum. A gastric tube is passed through this opening, creating an end-to-loop gastrojejunostomy. An end-to-side entero-enteroanastomosis is created using a single-layer precision monolithic seromuscular-submucosal suture between the proximal end of the jejunum and the efferent colon. This method prevents the development of post-gastrectomy syndromes, ensures portioned evacuation of food from the gastric stump, and prevents reflux into the gastric stump, but has its drawbacks.Disadvantages: The complexity and length of this method can create an additional risk of postoperative complications. Furthermore, an end-to-end duodenojejunal anastomosis with a transected outlet loop places the jejunal segment interposed between the duodenum and the gastrojejunostomy in an antiperistaltic position, which impedes normal evacuation through the duodenum and complicates the restoration of duodenal passage.

[0006] Objectives of the invention: development of a method for reconstructing the gastrointestinal tract after distal gastrectomy, ensuring restoration of duodenal passage, prevention of biliary reflux into the gastric stump and improving the functional results of distal gastrectomy surgery.

[0007] The essence of the method: a distal resection of the stomach is performed, an end-to-side gastrojejunostomy is formed with an isolated Roux-en-Y loop of the jejunum and a side-to-side jejunostomy at a distance of 35-40 cm from the gastrojejunostomy, characterized in that an end-to-side duodenojejunostomy is formed between the proximal section of the transected duodenum and the effluent loop of the jejunum at a distance of 25 cm from the gastrojejunostomy, as a result of which 2 parallel pathways for the passage of the food bolus are created - through the duodenum and through the effluent loop of the jejunum.

[0008] This method is relevant given that distal gastrectomy (DG) is the primary surgical treatment for malignant and many benign gastric diseases. Post-resection disorders and syndromes arising from routine gastrointestinal reconstruction methods disrupt digestion, significantly reducing the quality of life of patients undergoing surgery. Bilroth-II reconstruction (gastrojejunostomy) is associated with an increased incidence and severity of bile reflux, biliary gastritis, dumping symptoms, and the risk of gastric stump cancer. Bile reflux and biliary gastritis are significantly less common after Roux-en-Y reconstruction, although this technique more frequently results in impaired gastric stump emptying.The Billroth-I reconstruction (gastroduodenal anastomosis) ensures the passage of gastric contents into the duodenum. However, performing a direct anastomosis to the duodenum can be technically challenging in gastric bypass surgery for cancer, when a small gastric remnant remains. Furthermore, direct gastroduodenal anastomosis is associated with a high incidence of bile reflux into the gastric remnant, the development of reflux gastritis and reflux esophagitis, accompanied by symptoms that reduce the patient's quality of life. In this context, the proposed method is relevant because it preserves the positive characteristics while eliminating the drawbacks of existing reconstruction methods for gastric bypass surgery.

[0009] Technical result: this method allows to restore duodenal passage after DRG, and simultaneously minimize the frequency and intensity of biliary reflux into the gastric stump, which helps to prevent biliary reflux gastritis, reflux esophagitis, and improve the nutritional status of operated patients.

[0010] The method is carried out as follows:

[0011] For clarity, the implementation of the method is shown in Figure 1 - a general diagram of the method, where: 1 - stomach stump; 2 - gastrojejunostomy; 3 - aboral end of the transected jejunum; 4 - duodenojejunal junction; 5 - afferent (oral) part of the jejunum; 6 - jejunostomy; 7 - effluent loop of the jejunum; 8 - duodenum; 9 - duodenojejunostomy; 10 - effluent part of the Roux-en-Y loop.

[0012] Distal gastrectomy is performed according to the technical standards accepted for the pathology for which the surgery is being performed, and a gastric stump 1 is formed. Next, at a distance of 15-25 cm distal to the duodenojejunal junction 4, usually in the projection of the second or third jejunal vessels, the arcadian jejunal vessels are divided and ligated, and the jejunum is transected. The jejunum is transected with a linear stapling and cutting apparatus, and the aboral end of the transected jejunum 3 is advanced anterocolic to the upper abdominal cavity. The stapler suture line is peritonized with a continuous sero-serous suture of monofilament absorbable thread. A gastrojejunostomy 2 is formed with a single-row continuous suture of monofilament absorbable thread. The jejunal abduction loop 7 is positioned in an arc, tension-free, approaching the duodenal stump 8, which was stapled with a linear stapler during the previous resection stage of the surgery. The stapler suture is cut off, and the duodenal lumen is opened.At a distance of 25–35 cm (depending on the distance between the gastric stump and the duodenum and the characteristics of the mesentery of the jejunum) aboral to the gastrojejunostomy 2, along the antimesenteric margin, the lumen of the jejunum is opened at a site corresponding to the diameter of the duodenum. A duodenojejunostomy 9 "end of duodenum to side of jejunum" is formed between the proximal part of the transected duodenum 8 and the efferent loop of the jejunum 7 using a single-row continuous monofilament suture.

[0013] The reconstruction is completed by restoring intestinal continuity by forming a jejuno-jejunoanastomosis 6 between the adductor (oral) section of the jejunum 5 and the efferent (aboral) Roux-en-Y loop 10 of the end-to-side type using a single-row continuous suture with a monofilament absorbable thread; the anastomosis is formed at a distance of 20–25 cm from the duodenojejunoanastomosis 9.

[0014] The result of the reconstruction is the creation of two parallel pathways for the passage of the food bolus from the stomach stump - the first through the diverting loop of the jejunum 7 and the second through the duodenojejunoanastomosis 9, the duodenum and then through the jejunojejunoanastomosis 6 into the diverting loop of the jejunum 10.

[0015] 30 patients with stomach cancer were operated on using this method.

[0016] Clinical example 1.

[0017] Patient G. was admitted to the 1st Department of Abdominal Oncology on 17.01.23 with a diagnosis of C16.4 Malignant neoplasm of the stomach, T3N0M0 II St., diagnostic laparoscopy (12.2022), II class group, operated on 23.01.23, the method implemented: distal resection of the stomach was performed, a gastric stump was formed, then, at a distance of 15 - 25 cm distal to the duodenojejunal junction, in the projection of the second-third jejunal vessels, the arcade jejunal vessels were crossed and ligated, the jejunum was crossed with a linear stapling and cutting apparatus, the aboral end of the crossed jejunum was moved anterocolic to the upper floor of the abdominal cavity. The stapler suture line is peritonized with a continuous sero-serous suture made of monofilament absorbable thread.A gastrojejunostomy was created using a single-row continuous monofilament absorbable suture. The efflux loop of jejunum was positioned in an arc and tension-free approached to the duodenal stump, which had been stapled with a linear stapler during the previous resection stage of the surgery. The stapler suture was cut, and the duodenal lumen was opened. At a distance of 25 cm aboral to the gastrojejunostomy, along the antimesenteric margin, the jejunal lumen was opened at a site corresponding to the duodenal diameter. A duodenojejunostomy "end of duodenum to side of jejunum" was created between the proximal section of the transected duodenum and the efflux loop of jejunum using a single-row continuous monofilament suture.The reconstruction was completed by restoring intestinal continuity. An end-to-side jejunojejunostomy was created between the adductor (oral) jejunum and the efferent (aboral) Roux-en-Y loop using a single-row continuous absorbable monofilament suture. The anastomosis was formed at a distance of 20-25 cm from the duodenojejunostomy. The patient began feeding on the third postoperative day. She was discharged from the hospital in satisfactory condition on January 31, 2023, the eighth postoperative day. The postoperative period was uneventful.

[0018] Clinical example 2.

[0019] Patient Z. was admitted to the 1st abdominal department on 13.01.23 with a diagnosis of C16.2 Malignant neoplasm of the stomach T1N0M0, stage I, group II. Surgical treatment was performed on 24.01.23 in the amount of distal resection of the stomach, the method was performed as described above. The patient was discharged from the hospital on 01.02.23 in satisfactory condition on the eighth day after the surgery. The postoperative period is uneventful. She was examined in the late period 6 months after the surgery. The patient has no clinical complaints, nutrition according to the diet, symptoms of dumping syndrome, reflux esophagitis, gastrostasis were not detected. FGDS - anastomoses are patent, the duodenum and the area of ​​​​the major duodenal papilla are available for examination.

Claims

A method for reconstructing the gastrointestinal tract after distal gastrectomy, including the formation of a gastrojejunostomy with an isolated Roux-en-Y loop of jejunum and a jejunostomy, characterized in that an end-to-side duodenojejunostomy is formed between the proximal section of the transected duodenum and the efferent loop of jejunum at a distance of 25–35 cm from the gastrojejunostomy.

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