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32
I. ХИРУРГИЯ
AN ABORAL POUCH RECONSTRUCTION AFTER GASTRECTOMY
UDC 616.344-007.64-00207-089.8
Hambardzumyan G.A.
National Center of Oncology named after V.A. Fanarjyan, Yerevan, Republic of Armenia
Abstract
A new method - aboral pouch with preserved duodenal passage - has been introduced for reconstruction after the total gastrectomy. After excising the stomach, preparation of the uncut-Roux loop and construction of end-to-side esophago-jejunostomy, the Roux loop is anastomosed to the duodenal stump side-to-side approximately 40-50 cm distal from the esophago-jejunostomy. Right beneath this second anastomosis the Roux limb is closed with manual purs-stringe suture to provide unidirectional passage through the duodenum. An aboral pouch is constructed by a 15 cm long side-to-side anastomosis between the Roux limb under purs-stringe suture segment and the aboral part of the Y limb. The advantages of both the reservoir constructing and the interposition methods (duodenal passage preserved) are combined with this new form of reconstruction.
Асказанды резекциялаудан кейш 6Yrnp^TaHbity аборальды калпына келлру
Keywords
gastric cancer, gastrectomy, aboral pouch reconstruction
Амбарцумян Г.А.
В.А. Фанарджян атында?ы Улттык, онкология орталы^ы, Ереван к,., Армения Ацдатпа
Жана эдю - ултабарды сактап калуымен аборальды кабы -жаппай гастроэктомиядан кейнп кайта жасау Yшiн енпзшген. Ултабардын курылу коймаларынын жэне ажырату эдютерiнiн артьщшылыгы (ултабар вту жолы сакталып калады) осындай кайта жасаудын жана нысанымен араласып жасалады.
Туйш сездер
асказан обыры, асказан резекциясы, бурынгы калпына келпру бойынша аборальды кабы.
Аборальное восстановление дивертикула после резекции желудка
Амбарцумян Г.А.
Национальный центр онкологии им. В.А. Фанарджяна, Ереван, Армения
Аннотация
Новый метод - аборальный мешок с сохранением двенадцатиперстной кишки - был введен для реконструкции после тотальной гастрэктомии. После иссечения желудка, подготовки несрезанной-Ру петли и проведения терминолатеральной эзофагоеюностомии, Ру-петлю анастомозировали в культю двенадцатиперстной кишки поперечно примерно на 40-50 см дистальнее от эзофагоеюностомии. Прямо под этим вторым анастомозом Ру-петля закрыта с ручным конце-петлевым швом, чтобы обеспечить однонаправленный проход через двенадцатиперстную кишку. Аборальный мешок сделан длинной 15 см анастомоза поперечно между Ру-петлями под конце-петлевым сегментом шва и аборальной части У конечности. Преимущества обоих резервуаров построения и методов разъединения (двенадцатиперстный проход сохраняется) сочетаются с этой новой формой реконструкции.
Ключевые слова:
рак желудка, резекция желудка, аборальный мешок восстановления.
Introduction
Gastrectomy is the most common surgery of gastric cancer. The development of surgical techniques and anesthesiology, application of extended and combined - extended surgeries led to a considerable improvement of direct and long term results of surgical treatment of gastric cancer.
The indications for gastrectomy in upper third gastric cancer are also being extended. Gastrectomy with an extended lymphadenectomy at patients with small-sized tumors (up to 4 cm in maximum measurement) which are localized in the proximal third of the stomach, considerably improves the long term results as compared with proximal resection implemented at the same localization and size(1,5,6). Due to more aggressive surgery of gastric cancer the indices of 5-year survival have improved on all stages (7), thus triggering the surgeons' interest towards the research and development of new types of reconstruction after a gastrectomy from the viewpoint of their physiology and life quality of patients.
The consequences of gastrectomy are considerable and include reflux esophagitis, dumping syndrome, anemia, irregularities in protein, carbohydrate and fat metabolism, malabsorption and maldigestion, etc. Also, gastrectomy initiates numerous disturbances in the physiology of digestion, since many different mechanisms are involved in the process of digestion and absorption of nutrients. Alterations and malfunctions arise in the processes of food grinding and its mixing with digestive enzymes, bile, as well as in digestive enzymes' secretion time. The pouch function of the stomach is being lost, and the motor functions of intestine and bacterial media of the small intestine are being altered (8).
Hence, at present gastrectomy turned into a pathophysiological problem, thus directing the surgeons towards the search of new technical ways, aimed to prevent (through the technical improvements) those numerous disturbances in the patients' organisms which the surgeons will inevitably face during the remote postoperative period.
Over 60 modifications of reconstructive -restorative operations after the gastrectomy are reported at present, and new ones are still under development. The most common types of reconstruction after a gastrectomy are a loop esophagojejunostomy with a Broun enterostomy, esophagoduodenostomy, Roux reconstruction, intestine's interposition, pouch intestine substitutes of the gaster with a passage through duodenum or without it. The number of cases of reflux - esophagitis
which are very common for different types of end
- loop shunts, decreased after the introduction of Roux reconstruction and application of antireflux techniques in formation of esophagus' stoma. The Roux reconstruction, though most frequently used throughout the world after a gastrectomy, does not satisfy the surgeons from the viewpoint of the following nutrition status of patients. Moreover, in 30% of cases a disturbance in motor function of the reconstructed loop is observed, which is known as Roux - stasis syndrome caused by the disturbance in afferent innervations of Roux loop due to the pacemaker, located in the duodenum. Clinically this appears as a high - level ileus of a functional character. Probably this problem will be solved after a reconstruction of the gastrointestinal tract by an uncut Roux (1995) loop (9), (10).
In recent years many surgeons envision the improvement ways of the functional results of gastrectomies in the extension of indices for creation of pouch (by M. Steinberg's terminology
- "drawers") anastomoses, which improve the hormonal, secretory, motor and absorption functions of the entire digective system and supports a faster rehabilitation of patients.
In 1940, G.D. Shoushkov experimentally developed a jejunogastroplastical method in a pouch variant (on the account of "doubling" the intestine graft) with a reduodenization, which most properly matches the requirements of functional surgery. This operation was introduced into the clinical practice only 12 years later (Hant). During the following 5 years, a method similar to jejunogastroplastics, was applied by Hays (1953), Mikkelsen (1954), Gassinski (1955), Popov (1956), Poth (1957) on a vasicular pedicle with some differences related to the way of formation of esophagointestinal anastomosis and location of the intestinal loop.
V.I. Onopriev et al. developed (2004) (3) original but technically very complicated methods of jejunoplastics. An interesting type of aboral reconstruction after a gastrectomy has been reported by Kaml6r K. (2008) (21.)
The current stage of the development of gastric surgery is characterized by active search of jejuna pouch reconstructions after a gastrectomy, which, as compared with Roux reconstruction, are more preferable both in nutrition status and life quality. However, the problem of an ideal reconstruction of the superior part of the gastrointestinal tract still remains unsolved. Discussions are being held on the efficiency of different methods. It should be noted that each new method gives rise to more new questions, thus defining the following tactics for the given group of patients (8 18).
Material and Methods
After a gastrectomy in accordance with the method of aboral pouch reconstruction with provision of food passage through the duodenum, during the period 2001 - 2007 in the Department of Abdominal Oncology of the National Center of Oncology after V. A. Fanarjyan, 40 operations have been implemented in patients with gastric cancer, and their functional results have been assessed.
Basing on the study of modern experience in reconstructive operations after a gastrectomy and assessing their positive and negative features as reported in publications, we optimized and modified the aboral type of reconstruction with reduodenization on a reconstructed and uncut Roux loop.
The theoretical rationale of our suggested reconstruction is that it provides a better mixing of the nutritive hymus with digestive enzymes of the hepatic - pancreatic - duodenal zone, thus stimulating the neurohumoral digestive agents, normalizing the process of digestion and metabolism of fats, proteins and carbohydrates, all this resulting in improvement of digestion status, life quality and psycho-social rehabilitation.
The technique of surgery. After excising the stomach, a frontal colon invaginative esophago-entero-anastomosis is formed by the initial loop of the jejunum (35 - 40 cm). The lumen of the loop is closed with manual purs-stringe suture at 3 - 4 cm aside the esophageal stomy. This section of the loop is sutured to esophagus higher than the sutures of the anastomosis and to the diaphragm, so that the zone of sutures is being closed, and an artificial Hiss angle is created. A jejuno-duodeno-anastomosis is constructed on the end-to-side loop, at 40 - 50 cm distal from the esophago-jejunal anastomosis. Right beneath this second anastomosis the Roux limb is closed with manual
References
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purs-stringe suture to provide unidirectional passage through the duodenum. Then the Treitz ligament is dissected, and in its close proximity a jejunal aboral pouch is constructed by a 15 cm long side-to-side anastomosis between the Roux limb under purs-stringe suture segment and the aboral part of the Y limb.
Results
During the contrast X-ray examination of patients operated with the above described methods, the baric mixture enters into the duodenum and follows to the pouch where it is retained for a short period of time and then goes to the jejunal loops. At the reexamination after 30 min., the amount of barium in the pouch is moderate, and its excretion is in portions. In two weeks after the operation, the patients' feces are completely formed. The data of coprological examination after 6 months evidence the normalization of fats, proteins and carbohydrates assimilation processes. Signs of dumping syndrome have been observed at 3 patients (7.5%), and that of a reflux - esophagitis - at 2 patients (5%). The general somatic state is satisfactory.
Conclusion
Thus, the suggested reconstruction provides considerably better conditions for the normalizing impact of natural nutritive stimuli, which are one of the main pacemakers of bile secretion. This decreases the level of violations in the cooperative functioning of the united hepatic - pancreatic -duodenal system, thus ensuring a good functional result and a satisfactory nutrition status, which is confirmed by clinical-laboratory, contrast X-ray and coprological examinations.
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