Gastric bypass for cancer. Intestinal anastomoses. What should the anastomosis be like?

Gastric bypass is a surgical procedure for treating obesity that is used to bypass and thus eliminate a large portion of the stomach and small intestine from the digestive process. With the remaining part of the stomach, the patient feels full without even eating a large number of food. As a result, the patient quickly and effectively loses weight.

Gastric bypass (more precisely, Roux-en-Y gastric bypass) is a very commonly used operation for weight loss. It is named after the Swiss surgeon Cesar Roux, who developed basic technique this intervention. The Y in the English name refers to how the parts of the intestine are stitched together.

The success of gastric bypass is based on the following two principles:

• Reducing the stomach reduces the amount of food consumed (restrictive principle)
• Due to the removal of the upper part of the small intestine (duodenum), gastric juices, which are needed to break down food, mix with the bolus much later (reduced absorption nutrients= malabsorption)

A loss excess weight after gastric bypass is very pronounced and reliable, but it is associated with some restrictions for life: patients with gastric bypass can only eat in small portions, since the part of the stomach remaining as a result of the operation (gastric pouch) has a very small volume. Because of poor absorption patients are forced to take dietary supplements and vitamins (especially vitamin B12, micronutrients and protein supplements) throughout their lives to avoid symptoms of deficiency. Some nutrients remain undigested, causing fermentation in the rectum. However, the surgery is irreversible even after successful weight loss.

It is necessary to exclude all possible pathological changes in the stomach before surgery. Therefore, it is necessary to conduct examinations of the stomach for diseases such as gastritis, stomach ulcers, as well as possible infection Helicobacter bacteria pylori, which can cause stomach ulcers. In addition to gastroscopy and examination of gastric juices, ultrasonography upper abdominal cavity to detect stones in gallbladder. Stones are removed during gastric bypass, as they can lead to inflammation of the gallbladder and bile ducts.

Gastric bypass lasts from 90 to 150 minutes depending on the individual patient and is performed under general anesthesia. The patient remains in the clinic, as a rule, one day before the operation (preparation for the intervention and anesthesia) and five to seven days after it. After gastric bypass, you can return to work in approximately three weeks.

Gastric bypass is now almost always performed using minimally invasive techniques. These techniques, also known as keyhole techniques, do not require large abdominal incisions. Instead, all the instruments and a small camera are inserted into the abdomen through several two-centimeter incisions in the abdomen. Minimally invasive surgery is generally associated with lower risks of complications compared to open surgery, making it more suitable for obese patients, who are already more susceptible to complications during and after surgery.

Gastric bypass is performed in several stages:

1. After the patient has been placed under anesthesia, the surgeon makes several incisions in the skin to insert instruments and a camera with a light source into the abdominal cavity. After this, gas (usually CO₂) is released into the abdominal cavity to lift its walls above the organs, which gives the doctor more space in the abdominal cavity and better visibility internal organs.
2. After this, the stomach is cut off directly below the esophagus using a special surgical stapler. The stapler cuts and stitches at the same time, so the edges of the wound are closed immediately. This leaves only a small part of the stomach (called the gastric pouch) at the end of the esophagus. Its volume is less than 50 milliliters. The remaining part of the stomach remains in the body, but is closed in the upper part, that is, it is, as it were, “turned off”.
3. At the next stage small intestine is cut in the area of ​​the so-called jejunum. The lower part of the incision is pulled up and sutured to the gastric pouch. This connection is sometimes called a gastrojejunal anastomosis.
4. Then, even lower, the remaining part of the jejunum is sutured to the third part of the small intestine (ileum), thereby forming a Y-shape. And only here gastric juice from the duodenum (pancreatic secretion and bile) connect with the food bolus

Gastric bypass is suitable for people with a body mass index (BMI) over 40 kg/m² (obesity III degree or morbid obesity). In any case, the prerequisite for gastric bypass is that all non-operative weight loss measures have not been sufficiently effective within 6-12 months. These measures include, for example, professional nutritional advice, exercise and behavioral therapy(multimodal concept for the treatment of obesity, MMC).

To undergo gastric bypass, you must be over 18 and under 65 years of age. However, in some cases, the operation can be performed on younger or older people. Gastric bypass is especially recommended for people whose excess weight is caused by consuming calorie-rich foods (sweets, fatty foods) and drinks. This type of food is poorly digested, so the body can only use a small part of it, storing it as fat tissue.

If metabolic disorders such as diabetes, hypertension or sleep apnea are caused by obesity, then gastric bypass may be prescribed for patients with a BMI of 35 kg/m².

Various mental and physical illnesses prohibit bariatric surgeries such as gastric bypass. Gastric bypass should not be performed after previous surgeries or in cases of gastric defects, stomach ulcers and addictions, or eating disorders such as binge eating disorder or bulimia. Pregnant women are also prohibited from undergoing gastric bypass surgery.

Gastric bypass is a very effective procedure, although only a small percentage of patients return to normal weight (BMI ≤ 25 kg/m2). Research shows that it is possible to lose 60-70% of excess weight long-term after gastric bypass surgery, which is the weight that separates an obese patient from a normal-weight person.

Weight loss after gastric bypass has not only a cosmetic effect, but also has a beneficial effect on metabolism. For example, in many cases there is a significant improvement in diabetes, sometimes even to the point of complete recovery. In many cases, blood glucose levels drop almost immediately after surgery, even though the patient has lost very little weight. The reasons for this phenomenon are still unclear. It is assumed that various hormonal changes that occur as a result of surgery (for example, hormones such as ghrelin, glucagon, GIP, etc.) have a beneficial effect on metabolism.

Since gastric bypass combines two principles (restriction and malabsorption, see above), the procedure is very effective, even if the patient's obesity is caused by consuming large amounts of liquid or soft high-calorie foods. For such a “sweet tooth,” a reduction in stomach volume alone, achieved through gastric banding, an intragastric balloon, or a gastric sleeve will not be enough.

There are some side effects associated with gastric bypass. Their strength may vary in each individual case, so they cannot be accurately predicted. The most important side effects are:

• Digestive disorders caused by malabsorption: flatulence, abdominal pain, nausea, bloating
• Iron deficiency and anemia: Most iron from food is usually absorbed in the duodenum. Gastric bypass diverts food from the duodenum, complicating iron absorption. Iron deficiency can be prevented by adding extra iron to the diet.
• Vitamin B12 deficiency (a special form of anemia): Vitamin B12 is absorbed in the last part of the small intestine (terminal ileum). However, this process requires the presence of a special enzyme, the so-called gastric mucoprotein (Castle factor), which is produced by the stomach. With gastric bypass, food is not retained in the stomach, so less gastric mucoprotein is produced. Therefore, vitamin B12 should be regularly administered intramuscularly or intravenously. There are also nutritional supplements with vitamin B12, which are absorbed directly by the oral mucosa (sublingual administration). However, their effectiveness is still debated.
• Vitamin D deficiency: It is still unknown why gastric bypass surgery causes vitamin D deficiency. Vitamin D can be easily taken by mouth with food (orally).
• Dropping syndrome: Some symptoms (dizziness, nausea, sweating or cardiopalmus), which can be caused by the instantaneous (sudden) discharge of food from the esophagus directly into the small intestine, is called dumping syndrome. This occurs because the gastric pouch does not have a lower gastric sphincter (pylorus). In the small intestine, due to osmotic force, the food bolus absorbs water from the surrounding tissue and blood vessels. This reduces the amount of fluid in the circulatory system, which can lead to a sharp drop in blood pressure. Dropping syndrome most often occurs after drinking very sweet drinks or fatty foods.
• Gastric pouch ulcer: After gastric bypass, the risk of gastric pouch ulcer increases dramatically. To cope with this, the patient needs to take acid-reducing medications called proton pump inhibitors (PPIs) and take them continuously if the ulcer occurs after gastric bypass.
• A loss muscle mass: Rapid weight loss is often closely associated with loss of muscle mass, as the body tries to compensate for the lack of carbohydrates by breaking down body proteins (usually the less important muscle cells). Regular physical exercise help overcome this by-effect. Sports that are gentle on the joints, such as light weight training, cycling, swimming or running in water, are especially recommended for obese patients.

Gastric bypass is an operation to reduce the volume of the stomach, during which the doctor sutures it and combines it with different parts of the small intestine. There are two main types of bypass surgery - Roux-en-Y and biliopancreatic bypass. At miVIP outpatient clinics, both types of this operation are performed.

Gastric reduction, or bypass anastomosis in miVIP clinics

Anastomosis according to Roux involves the doctor changing the capacity of the stomach from 600 grams to 30 grams - that’s how much a small piece of cheese weighs. The surgeon then connects the reduced stomach to middle part small intestine. Since the small intestine is responsible for most of the absorption of nutrients, this reduces the amount of calories the body receives.

The second method of bypass anastomosis is biliopancreatic bypass.

Biliopancreatic bypass

In this case, the da Vinci robot removes most of the stomach and the remaining part is combined with the end of the small intestine. This reduces the intestinal absorption of nutrients even more than with a Roux-en-Y anastomosis. However, this operation seriously affects the absorption of nutrients. It is usually recommended for very obese patients - for example, with a BMI over 50.

Rehabilitation and results of gastric bypass surgery

The use of the da Vinci surgical robot eliminates discomfort after the intervention, and the patient recovers quite quickly. The only restriction that will need to be followed after the operation is following a diet low in fat and sugar, which will be prescribed by the doctor. But, since satiety will be achieved even from a small amount of food consumed, the patient will not feel hungry.

Gastric bypass provides maximum weight loss compared to any other surgical methods for weight loss. Typically, patients lose 5-10 kg per month for a year after surgery. As a result, the patient can lose half or even more of the original weight. Thanks to this reduction, you will not only look better - you will feel better and forget about high cholesterol in the blood, shortness of breath and high blood pressure. Diabetes sufferers will also experience significant relief from the symptoms of the disease after undergoing treatment abroad, at miVIP Surgery clinics.

mivip.ru

This information is solely general information and should not be considered as medical consultation from the site Med-Turizm.ru. All decisions regarding treatment, post-treatment activities, and activities during recovery should be made only after appropriate consultation with a qualified physician.

What's happened surgery gastric bypass?
Gastric bypass is a weight loss surgery that reduces the size of the stomach so it cannot take in large amounts of food. The body absorbs fewer calories because food no longer enters the stomach and small intestine.
Gastric bypass is also known as Roux-en-Y gastric bypass

What types of gastric bypass are there?
The most common surgical procedure for gastric bypass is:

• Open surgery:
  • The surgeon makes a large incision in the abdominal cavity and performs a bypass anastomosis through this incision.
  • The surgeon reduces the stomach by making a pouch at the top using staples.
  • The stomach is then attached to the middle of the small intestine, and a bypass is performed between the stomach and the upper part of the small intestine.
• Laparoscopic procedure:
  • The surgeon uses a laparoscope through small incisions to guide small instruments to create a bypass.
  • The stomach is reduced using staples and then attached to the middle of the small intestine in the same way as in open surgery.

Who is a suitable candidate for gastric bypass surgery?
Gastric bypass surgery is done for people with a BMI of 40 or more, or people with a BMI of 35 and an obesity-related condition such as diabetes or heart disease.

What are the chances that gastric bypass surgery will be successful?
According to statistics from the Mayo Clinic, people can lose approximately one-third of their excess weight within one to four years after gastric bypass surgery.
After surgery, weight decreases very quickly and continues to decrease over time.
Maintaining a healthy diet and regular physical exercise increase the chances of success.

ru.health-tourism.com

What is anastomosis

Anastomosis is surgical manipulation of the small or large intestine, as well as the stomach and neighboring organs in order to restore the integrity of the gastrointestinal tract and its functionality.

If enterectomy does not always require anastomosis, then after removal of part of the organ this cannot be avoided. Patients diagnosed with intestinal cancer, people with intussusception of food organs, intestinal infarction, necrosis, strangulation, thrombosis, Crohn's disease, obstruction and other anomalies are placed on the operating table. They can be attracted as hereditary pathologies, for example, Hirschsprung's disease, and advanced secondary diseases (gastritis).

According to the stitched parts, there is a connection between the stomach and intestines (gastrointestinal anastomosis), sections of the intestines (interintestinal), gall bladder and duodenum. The choice of seam depends on the elements involved in the operation.

Thus, to connect muscle and serous tissues, a Lambert suture is used; for the mucous and/or submucosal tissues, an isolated one is used. Previously, a through interrupted Albert suture was applied, but over time a stable correlation with complications was revealed (mucosal ulcers, infection, gross scarring, suppuration). Which dictated the need to change the anastomosis technique.

The operation is performed under general anesthesia. Allows you to completely relieve the patient of the problem or improve the quality of life (depending on the primary pathology).

Preparing for surgery

The technique of intestinal anastomosis is selected by the surgeon individually. The doctor takes into account three principles: maintaining patency, minimal intrusion into peristalsis, optimally selected type of stitch.

When choosing a seam, the specialist focuses on:

• type of fabrics to be joined;
• anatomy of the area where the manipulation will be performed;
• features of the organ: inflammation, color and structure of the wall, its performance (relevant for interintestinal connections).

In some cases, several different stitches are used (inverted method). It is possible to use intestinal anastomoses without opening. It is used for severe oncology of the pelvic organs or total irradiation, or rather their consequences in the form of obstruction or fistulas. A bypass anastomosis is performed and the mucous membrane is removed through the stoma.

The patient also has responsibilities to prepare for abdominal surgery. 3-7 days before the appointed day, it is important to follow a diet. Food should be boiled or steamed. Rice, lean beef (poultry), and coarse bread are allowed. You should not eat desserts, fats (including seeds and nuts), or overuse spices and sauces.

The day before the operation, the patient eats breakfast; he cannot eat anything else. Then comes the cleansing stage. It is recommended to use Fortrax. Available in sachets (one sachet per liter of water). You need to drink up to four units of the drug per day. This will allow you to safely, efficiently and quickly cleanse the intestines.

Overlay methods

There are three types of intestinal anastomosis. All types of intestinal anastomoses are reflected in the table.

When manipulating the small intestine, a single-tier suture is always used; for the large intestine, only a double suture is used (the back wall is turned on first, and then the front wall). Relevant when preparing individual elements for general stitching.

To connect two sections to each other, their back walls are joined with a Multanovsky suture, and the front walls with a Schmieden suture. Each method must ensure sufficient width of the anastomosis, isoperistaltic connection, its strength and tightness (both from the point of view of anatomy and physiology).

In the video you can see how intestinal anastomosis is performed using the side-to-side method:

Features of rehabilitation

Rehabilitation is aimed at preventing the development of complications. Failure of the esophageal-intestinal anastomosis occurs in 12% of cases and is almost always fraught with death. It occurs against the background of intolerance to sewing material or dysbiosis, narrowing of the lumen. To prevent it, you need to monitor the condition of the seams, install expanders or hem fabrics if necessary.

To prevent adhesions, scarring, and inflammation of the peritoneum, it is important to follow a number of rules during surgery (maintain sterility, cut the stitched ends only after squeezing out the intestinal loop and clamping it, internal audit fingers passability after fastening) and after (diet, exercise therapy, drug therapy, breathing exercises).

The use of a single-row suture for intestinal anastomosis avoids infection. It is considered more airtight. It is acceptable to internally introduce a medicinal protector at the time of rehabilitation or take antibiotics.

After the operation, you should not go to the toilet for three to four days and overload the gastrointestinal tract. Therefore, fasting on water without gas is recommended for the first 24-48 hours. Then the inclusion of very liquid porridges is allowed.

In the future, nutrition should be aimed at restoring strength. However, you need to avoid irritation of organs, constipation, hard stools, and flatulence. Gradually, dairy products, lean meat, fiber, soups and purees are added to the diet. You need to drink at least 2 liters of fluid per day.

It is important to maintain bed rest and avoid physical overexertion. The formation of intestinal anastomosis should take place under the supervision of a physician.

Possible complications

Complications depend on the condition of the organs at the time of surgery and the work of the surgeon. The main danger is unsuccessful intervention. The percentage of intestinal anastomosis failure, according to statistics, can reach 20 cases out of 100.

Failure can be suspected by the deteriorating health of the patient: flatulence, fever and increased heart rate, the formation of fistulas and the release of feces from them, septic shock(hypotension, anuria, pale skin, fainting).

The reasons for unsuccessful anastomosis may include improper postoperative care, non-compliance with doctor’s recommendations, individual characteristics of the body and lifestyle. Unfortunately, no one is immune from complications (even if the ideal surgical technique is followed).

Therefore, it is important to undergo recovery under the supervision of a specialist. And if negative changes in monitoring are detected, take urgent diagnostic and therapeutic measures (blood test, x-ray, CT scan, contrast study). If there is inconsistency in the blood there will be high level leukocytes, and an x-ray will show dilation of intestinal loops.

Other most common complications include:

• poor-quality seams and their divergence;
• inflammation, infection of the anastomosis;
• growth on the intestinal anastomosis (hernia, tumor);
• sepsis;
• obstruction due to incorrect connection or too narrow passage, scarring, pinching, adhesion;
• diarrhea;
• vascular trauma with subsequent bleeding;
• bulging of the intestinal anastomosis.

On average, a patient stays in the hospital for a week.

kishechnik.guru

Description

Roux-en-Y gastric bypass is an operation performed for obesity. It changes the stomach and small intestine to cause weight loss:

• Restriction of food intake - a small pouch is created that performs the functions of the stomach. Its size does not allow you to eat a large amount of food at one time;
• Limiting the absorption of nutrients from food - food bypasses the initial part of the small intestine where most nutrients are normally absorbed.

Reasons for performing Roux-en-Y gastric bypass

The operation is used for severe obesity. Doctors use a measure called body mass index (BMI) to determine how obese you are. Normal BMI is 18.5-25.

Gastric bypass is a weight loss option for people with the following:

• BMI more than 40;
• BMI 35-39.9 and life-threatening diseases such as heart disease or diabetes;
• BMI 35-39.9 and with severe physical limitations that affect employment, mobility, and family life.

The success of gastric bypass surgery depends on your future lifestyle. At the right approach there will be a significant improvement in health:

• Long-term weight reduction;
• Many obesity-related diseases will disappear (for example, glucose intolerance, diabetes, sleep apnea, high blood pressure, cholesterol will decrease);
• There will be improved mobility and increased strength;
• Improve mood, self-esteem, quality of life;
• The risk of death from cardiovascular disease (eg, heart attack, stroke) and other reasons.

Possible complications when performing laparoscopic Roux-en-Y gastric bypass surgery

Before performing the operation, you need to know about possible complications which may include:

• Nutritional deficiencies - you will need to take vitamins to get enough vitamin B12, iron and calcium;
• Bleeding;
• Infection;
• Formation of blood clots;
• Herniation;
• Intestinal obstruction;
• Disconnection of fastening staples, which will cause leakage of gastric juices into the abdominal cavity;
• Diarrhea, abdominal cramps and vomiting;
• Dumping syndrome - occurs after eating sweets, when food moves through the small intestine too quickly and causes sweating, fatigue, dizziness, cramps, diarrhea;
• Complications of general anesthesia;
• Death—occurs in less than 1% of patients.

Factors that may increase the risk of complications include:

• Smoking;
• Availability chronic diseases(for example, kidney disease);
• Diabetes;
• Old age;
• Heart or lung disease;
• Bleeding or bleeding disorder.

How is laparoscopic Roux-en-Y gastric bypass surgery performed?

Preparing for surgery

Each bariatric surgery method has specific requirements. Before performing the current operation, you will most likely need the following:

• Careful medical examination and analysis of medical history;
• Attempts to lose weight (about 10%) through the use of diet medications;
• Consultations with a nutritionist;
• Mental health assessment.

Before surgery:

• The patient may be asked to stop taking certain medications a week before the procedure:
  • Aspirin or other anti-inflammatory drugs;
  • Blood thinners such as warfarin, clopidogrel (Plavix);
• Do not take any new medications or supplements without consulting your doctor;
• Travel to and from the hospital must be arranged;
• It is necessary to organize assistance at home during the recovery period;
• You may need to take antibiotics before surgery;
• You need to take laxatives and/or an enema to cleanse the intestines;
• The night before surgery you can only eat light food. You should not eat or drink anything after midnight unless otherwise directed by your doctor.
• You should take a shower or bath the morning before surgery.

Anesthesia

During the operation it is used general anesthesia. During the operation the patient sleeps.

Description of the procedure

To prepare the patient for surgery, the nurse administers venous catheter into the hand of the person being operated on. The patient will be able to receive fluids and medications through it during the procedure. The doctor will place a breathing tube through your mouth and down your throat. This will help the patient breathe during surgery. A catheter is also inserted into bladder to drain urine.

The doctor will make several small incisions in the abdomen. Gas will be pumped into it, which will make it easier to see inside. A laparoscope and surgical instruments will be inserted into the incisions. A laparoscope is a special medical instrument with a tiny camera and a light source at the end. It sends images of the abdomen to a monitor in the operating room. The doctor performs the operation while viewing the area to be operated on this monitor.

The doctor will use surgical staples to create a small pouch at the top of the stomach that can hold approximately 250-300 grams of food. It will be a new, smaller stomach. A normal stomach can contain up to one and a half kilograms of food.

Next, the doctor cuts the small intestine and attaches it to the new stomach. With a small bowel bypass, food will move from the new stomach to the middle section of the small intestine, bypassing the normal stomach and the upper section of the small intestine.

Finally, the upper section of the small intestine will be attached to the middle section of the small intestine. This will allow the fluid that the old stomach produces to move down from the upper section of the small intestine into the middle section.

Once the bypass is completed, the incisions will be closed with staples or stitches.

It must be borne in mind that in some cases, the doctor must proceed to open surgery. During open surgery, he will make a large incision in the abdomen to directly see the internal organs.

After the procedure

The patient is sent to the recovery room for monitoring of vital signs. Painkillers are also administered as needed.

How long will the operation take?

About two hours.

Will it hurt?

Anesthesia prevents pain during surgery. Patients experience pain or tenderness at the incision site during recovery. Your doctor may prescribe medicine to relieve pain.

Time spent in hospital

The usual length of stay is 2-5 days. If complications arise, your hospital stay may be extended.

Postoperative care after laparoscopic Roux-en-Y gastric bypass surgery

In the hospital

While in the hospital, the following procedures are performed:

• Pain medications are provided;
• Diet:
  • On the day of surgery, you should not eat or drink anything;
  • The day after surgery, an X-ray examination is performed to check for leaks of gastric juice from the operated areas. To do this, the patient is given a special liquid to drink, after which an x-ray is taken. If the test results are positive, 30 ml of nutritional fluid is provided every 20 minutes. If leaks are found, nutrition will be given intravenously;
  • On the second day after surgery, you can take 1-2 tablespoons of pureed food or 30-50 ml of liquid every 20 minutes;
• While in the hospital, it is advisable for the patient to do the following:
  • Use a spirometer to take deep breaths. This helps prevent lung problems;
  • You need to wear elastic surgical stockings to improve blood flow in the legs;
  • Walk a little every day.

Care at home

Be sure to follow your doctor's instructions. It is necessary to immediately begin to lead a healthy lifestyle and get rid of bad habits.

After operation:

• You should ask your doctor about when it is safe to shower, swim, or expose the surgical site to water;
• Recovery time after gastric bypass surgery is 2-6 weeks;
• Do not drive or lift anything heavy until your doctor says it is safe to do so. This may take up to two weeks or more;
• After surgery, emotional ups and downs in mood are possible;
• You should meet with your doctor regularly for monitoring and support.

The new stomach is the size of a small egg, allowing you to quickly achieve a feeling of fullness. Thus, you need to take very small amounts and eat very slowly:

• You need to start with 4-6 meals a day, 50-80 grams at a time;
• In the first 4-6 weeks after surgery, all food products should be pureed;
• After switching to solid food, it should be chewed well;
• It is necessary to consume enough protein;
• You should avoid sweets and fatty foods;
• Eating too much or too quickly can cause vomiting or severe pain. There is no need to rush when eating.

You may need to take medications, which may include:

• Antacids;
• Painkillers;
• Vitamins and mineral supplements.

It is necessary to go to the hospital in the following cases

• Signs of infection, including fever and chills;
• Redness, swelling, increased pain, bleeding, or discharge from the incision;
• cough, shortness of breath, chest pain, or severe nausea or vomiting;
• Increased abdominal pain;
• Blood in the stool;
• problems urinating (eg, pain, burning, frequent urination, blood in the urine) or inability to urinate;
• Constant nausea and/or vomiting;
• pain and/or swelling in the legs, calves, feet, sudden chest pain or difficulty breathing;
• Any other alarming symptoms.

medicalhandbook.ru

Operation description

The operation to apply a bypass anastomosis is performed under general anesthesia, laparoscopic or laparotomy. After opening the abdominal cavity, the surgeon inspects the internal organs and finds the location of the pathology. Next, a loop is formed with an indentation of about 20-25 cm from the edge of the tumor. The surgeon performs anastomosis using the side-to-side method and performs layer-by-layer suturing. Finally, the ends of the intestine are sutured from the side of the affected area and the surgical wound is sutured. The duration of the operation is about 2-3 hours.

Postoperative period

After completion of the operation, you must remain under the supervision of a doctor for about 10-14 days. During this period, anti-inflammatory therapy is carried out, diagnostics of the intestinal condition after the surgical intervention. During the first period, it is recommended to follow a diet, but in the future this is not required.

The Scientific and Practical Surgery Center has modern diagnostic and surgical equipment that allows performing intestinal operations of any complexity. The inpatient department of the surgery center is equipped with comfortable rooms and friendly staff, who brighten up the patients’ stay at the center for such an unpleasant reason. The center's surgeons have extensive practical experience in performing surgical treatment intestinal diseases, and also have modern technologies performing surgery.

In anatomy, natural anastomoses are called anastomoses of large and small vessels in order to enhance the blood supply to an organ or support it in case of thrombosis of one of the directions of blood flow. Intestinal anastomosis is an artificial connection created by a surgeon between the two ends of the intestinal tube or intestine and a hollow organ (stomach).

The purpose of creating such a structure is:

• ensuring the passage of the food bolus to the lower sections for the continuity of the digestive process;
• formation of a workaround in case of a mechanical obstacle and the impossibility of its removal.

Operations can save many patients, provide them with fairly good health, or provide assistance to prolong life in the case of an inoperable tumor.

What types of anastomoses are used in surgery?

Anastomosis is distinguished based on the connected parts:

• esophageal - between the end of the esophagus and duodenum bypassing the stomach;
• gastrointestinal (gastroenteroanastomosis) - between the stomach and intestines;
• interintestinal.

The third option is a mandatory component of most intestinal surgeries. Among this type, anastomoses are distinguished:

• small-colic,
• small intestine,
• colonic.

In addition, in abdominal surgery (a section related to operations on the abdominal organs), it is customary to distinguish between certain types of anastomoses, depending on the technique for connecting the adductor and efferent sections:

• end to end;
• side to side;
• end to side;
• side to end.

What should the anastomosis be like?

The created anastomosis must correspond to the expected functional goals, otherwise there is no point in operating on the patient. The main requirements are:

• ensuring sufficient lumen width so that the narrowing does not impede the passage of contents;
• absence or minimal interference in the mechanism of peristalsis (contraction of intestinal muscles);
• complete tightness of the seams providing the connection.

If one specialist cannot decide what to do with the patient, a consultation is held

It is important for the surgeon not only to determine what type of anastomosis will be performed, but also with what suture to fasten the ends. This takes into account:

• intestinal section and its anatomical features;
• the presence of inflammatory signs at the surgical site;
• intestinal anastomoses require a preliminary assessment of the viability of the wall; the doctor carefully examines it by color and ability to contract.

The most commonly used classic seams are:

• Gambi or nodal - needle punctures are made through the submucosal and muscular layers, without capturing the mucous membrane;
• Lambert - the serous membrane (external to the intestinal wall) and the muscular layer are sutured.

Description and characteristics of the essence of anastomoses

The formation of an intestinal anastomosis is usually preceded by the removal of part of the intestine (resection). Next, it becomes necessary to connect the adducting and efferent ends.

End to end type

Used to sew together two identical sections of the large intestine or small intestine. Performed with a two- or three-row seam. Considered to be the most beneficial in terms of compliance anatomical features and functions. But technically difficult to implement.

The condition for connection is that there is no big difference in the diameter of the compared sections. The end that is smaller in clearance is cut to ensure full compliance. The method is used after resection of the sigmoid colon, in the treatment of intestinal obstruction.

First, the posterior wall of the anastomosis is formed, then the anterior one

End-to-side anastomosis

The method is used to connect sections of the small intestine, or the small intestine on one side and the large intestine on the other. Usually the small intestine is sutured to the side of the wall of the large intestine. Provides 2 stages:

1. At the first stage, a dense stump is formed from the end of the efferent intestine. The other (open) end is applied to the intended anastomosis site from the side and sutured along back wall Lambert seam.
2. Then an incision is made along the abductor colon along a length equal to the diameter of the adductor section and the anterior wall is sutured with a continuous suture.

It is used for various complex operations, for example, after complete removal (extirpation) of the esophagus with adjacent lymph nodes and fatty tissue.

Side to side type

It differs from previous options in the preliminary “blind” closure with a double-row suture and the formation of stumps from connected intestinal loops. The end above the stump is connected with the lateral surface to the underlying area by a Lambert suture, which is 2 times longer than the diameter of the lumen. It is believed that technically performing such an anastomosis is the easiest.

It can be used both between homogeneous sections of the intestine and to connect dissimilar areas. Main indications:

• the need for resection of a large area;
• danger of overstretching in the anastomosis area;
• small diameter of connected sections;
• formation of an anastomosis between the small intestine and the stomach.

The advantages of the method include:

• no need to suture the mesenteries of different areas;
• tight connection;
• guaranteed prevention of intestinal fistula formation.

With side-to-side anastomosis, the preliminary creation of stumps is one of the disadvantages of the technique

Side to end type
If this type of anastomosis is chosen, this means that the surgeon intends to sew the end of the organ or intestine after resection into the created hole on the lateral surface of the afferent intestinal loop. More often used after resection of the right half of the large intestine to connect the small and large intestines.

The connection can have a longitudinal or transverse (more preferable) direction with respect to the main axis. With a transverse anastomosis, fewer muscle fibers are crossed. This does not disrupt the peristalsis wave.

Preventing complications

Complications of anastomoses may include:

• seam divergence;
• inflammation in the anastomosis area (anastomositis);
• bleeding from damaged vessels;
• formation of fistula tracts;
• formation of narrowing with intestinal obstruction.

To avoid adhesions and intestinal contents entering the abdominal cavity:

• the surgical site is covered with napkins;
• the incision for suturing the ends is carried out after clamping the intestinal loop with special intestinal sponges and squeezing out the contents;
• the incision of the mesenteric edge (“window”) is sutured;
• the patency of the created anastomosis is determined by palpation before completion of the operation;
• Antibiotics are prescribed in the postoperative period wide range;
• The rehabilitation course necessarily includes a diet, physiotherapy and breathing exercises.

Modern methods of protecting anastomoses

In the immediate postoperative period, anastomositis may develop. Its cause is considered to be:

• inflammatory reaction to suture material;
• activation of conditionally pathogenic intestinal flora.

Inflammation in the anastomotic area leads to suture failure, which is why it is so important to protect the surgical area.

To treat subsequent cicatricial narrowing of the esophageal anastomosis, polyester stents (expandable tubes that support the walls in an expanded state) are installed using an endoscope.

To strengthen the sutures in abdominal surgery, autografts are used (suturing one’s own tissue):

• from the peritoneum;
• oil seal;
• fat deposits;
• mesenteric flap;
• seromuscular flap of the stomach wall.

However, many surgeons limit the use of the omentum and peritoneum on a pedicle with a blood supply to only the last stage of colon resection, since they consider these methods to be the cause of postoperative purulent and adhesive processes.

The process of anastomosis is painstaking work

Various drug-loaded protectors for suppressing local inflammation. These include glue with biocompatible antimicrobial content. It includes for the protective function:

• collagen;
• cellulose ethers;
• polyvinylpyrrolidone (biopolymer);
• Sangviritrin.

As well as antibiotics and antiseptics:

• Kanamycin;
• Cefamezine;
• Dioxidine.

Surgical glue becomes stiff as it hardens, so the anastomosis may become narrowed. Gels and solutions of hyaluronic acid are considered more promising. This substance is a natural polysaccharide, secreted by organic tissues and some bacteria. It is part of the intestinal cell wall, so it is ideal for accelerating the regeneration of anastomotic tissue and does not cause inflammation.

Hyaluronic acid included in biocompatible self-absorbable films. A modification of its compound with 5-aminosalicylic acid (the substance belongs to the class of non-steroidal anti-inflammatory drugs) is proposed.

Despite the protection and sufficiently developed surgical technique, some patients require treatment after surgery with an anastomosis technique. Let's consider treatment measures for some of them.

The intestinal sphincter is applied along the longitudinal axis, allowing you to safely isolate the area required for resection

Postoperative atonic constipation

Coprostasis (stagnation of feces) appears especially often in elderly patients. Even short bed rest and diet disrupt their intestinal function. Constipation can be spastic or atonic. Loss of tone is relieved as the diet expands and physical activity.

To stimulate the intestines, on days 3–4 a cleansing enema is prescribed in a small volume with hypertonic saline solution. If the patient needs to avoid food intake for a long time, Vaseline oil or Mucofalk is used internally.

For spastic constipation it is necessary:

• relieve pain with medications with an analgesic effect in the form of rectal suppositories;
• reduce the tone of the rectal sphincters using antispasmodic drugs (No-shpy, Papaverine);
• for softening feces make microenemas from warm petroleum jelly in a furatsilin solution.

Stimulation of stool can be carried out with the permission of a doctor using laxatives of different mechanisms of action.

Secretory-anti-absorption are considered:

• senna leaves,
• buckthorn bark,
• rhubarb root,
• Bisacodyl,
• Castor oil,
• Gutalax.

They have an osmotic effect:

• Glauber's and Carlsbad salts;
• magnesium sulfate;
• lactose and lactulose;
• Mannitol;
• Glycerol.

Laxatives that increase the amount of fiber in the colon - Mucofalk.

Early treatment of anastomositis

To relieve inflammation and swelling in the suture area, the following is prescribed:

• antibiotics (Levomycetin, aminoglycosides);
• when localized in the rectum - microenemas from warm furatsilin or by installing a thin probe;
• soft laxatives based on petroleum jelly;
• Patients are recommended to take up to 2 liters of liquid, including kefir, fruit drink, jelly, compote to stimulate the passage of intestinal contents.

If intestinal obstruction develops

The occurrence of obstruction can cause swelling of the anastomosis area and cicatricial narrowing. When acute symptoms A repeat laparotomy is performed (an incision in the abdomen and opening of the abdominal cavity) to eliminate the pathology.

In case of chronic obstruction in the long-term postoperative period, intensive antibacterial therapy, removal of intoxication. The patient is examined to decide whether surgical intervention is necessary.

Any complications require treatment

Technical reasons

Sometimes complications are associated with inept or insufficiently qualified surgery. This is caused by excessive tension. suture material, unnecessary application of multi-row sutures. Fibrin falls out at the junction and forms mechanical obstruction.

Intestinal anastomoses require compliance with the surgical technique, careful consideration of the condition of the tissues, and the skill of the surgeon. They are applied as a result of surgery only in the absence of conservative methods treatment of the underlying disease.

Anastomosis is the phenomenon of fusion or stitching of two hollow organs, with the formation of a fistula between them. Naturally, this process occurs between the capillaries and does not cause noticeable changes in the functioning of the body. Artificial anastomosis is a surgical suturing of the intestines.

Types of intestinal anastomoses

Exist different ways carrying out this operation. The choice of method depends on the nature of the specific problem. The list of methods for performing anastomosis is as follows:

• End-to-end anastomosis. The most common, but at the same time the most complex technique. Used after removal of part of the sigmoid colon.
• Side-to-side intestinal anastomosis. The simplest type. Both parts of the intestine are turned into stumps and stitched on the sides. This is where intestinal bypass comes into play.
• End to side method. It consists of turning one end into a stump and sewing the second on the side.

Mechanical anastomosis

There are also alternative methods for applying the three types of anastomoses described above using special staplers instead of surgical threads. This method of anastomosis is called hardware or mechanical.

There is still no consensus on which method, manual or hardware, is more effective and produces fewer complications.

Numerous studies have been conducted to identify the most effective way anastomosis often showed contradictory results. Thus, the results of some studies spoke in favor of manual anastomosis, others in favor of mechanical anastomosis, according to others, there was no difference at all. Thus, the choice of method of performing the operation rests entirely with the surgeon and is based on the personal convenience of the doctor and his skills, as well as on the cost of the operation.

Preparation for the operation

Before performing an intestinal anastomosis, careful preparation must be made. It includes several points, each of which is mandatory. These are the points:

1. It is necessary to follow a slag-free diet. Boiled rice, biscuits, beef and chicken are allowed for consumption.
2. Before surgery, you need to have a bowel movement. Previously, enemas were used for this; now laxatives, such as Fortrans, are taken throughout the day.
3. Before the operation, fatty, fried, spicy, sweet and starchy foods, as well as beans, nuts and seeds, are completely excluded.

Insolvency

Insolvency is called pathological condition, in which the postoperative suture “leaks” and the contents of the intestine escape beyond its boundaries through this leak. The reasons for the failure of the intestinal anastomosis are the divergence of postoperative sutures. The following types of insolvency are distinguished:

• Free leak. The tightness of the anastomosis is completely broken, the leak is not limited by anything. In this case, the patient’s condition worsens, and symptoms of diffuse peritonitis appear. Re-incision of the anterior abdominal wall is necessary to assess the extent of the problem.
• Limited leak. Leakage of intestinal contents is partially contained by the omentum and adjacent organs. If the problem is not eliminated, a peri-intestinal abscess may form.
• Mini leak. Leakage of intestinal contents in small amounts. Occurs in late dates after surgery, after the intestinal anastomosis has already been formed. In this case, the formation of an abscess usually does not occur.

Identification of insolvency

The main signs of anastomotic failure are seizures severe pain in the abdomen, accompanied by vomiting. Also noteworthy are increased leukocytosis and fever.

Diagnosis of anastomotic leakage is made using an enema with a contrast agent followed by an x-ray. A computed tomogram is also used. Based on the results of the study, the following scenarios are possible:

• The contrast agent freely enters the abdominal cavity. A CT scan shows fluid in the abdominal cavity. In this case, an operation is urgently required.
• The contrast agent accumulates in a limited area. There is little inflammation overall abdomen not amazed.
• No contrast agent leakage is observed.

Based on the obtained picture, the doctor draws up a plan for further work with the patient.

Resolving Insolvency

Depending on the severity of the leak, different methods are used to fix it. Conservative management of the patient (without reoperation) is provided in the following cases:

• Limited insolvency. The abscess is removed using drainage instruments. A delimited fistula is also formed.
• Incompetence when the intestine is disconnected. In this situation, the patient is re-examined after 6-12 weeks.
• Failure with the appearance of sepsis. In this case, supportive measures are carried out as a complement to the operation. These measures include: the use of antibiotics, normalization of heart function and respiratory processes.

The surgical approach may also vary depending on when the deficiency is diagnosed.

In case of early symptomatic failure (the problem was discovered 7-10 days after surgery), a repeat laparotomy is performed to find the defect. Then one of the following ways to correct the situation can be used:

1. Disconnecting the intestine and pumping out the abscess.
2. Disconnection of the anastomosis with the formation of a stoma.
3. An attempt at secondary anastomosis (with/without disconnection).

If rigidity of the intestinal wall (caused by inflammation) is detected, neither resection nor stoma formation can be performed. In this case, the defect is sutured/the abscess is pumped out or a drainage system is installed in the problem area in order to form a delimited fistula tract.

If the failure is diagnosed late (more than 10 days from the date of surgery), they automatically speak of unfavorable conditions during relaparotomy. In this case, the following actions are taken:

1. Formation of a proximal stoma (if possible).
2. Impact on inflammatory process.
3. Installation of drainage systems.
4. Formation of a delimited fistula tract.

A sanitation laparotomy with wide drainage is performed.

Complications

In addition to leaks, anastomosis may be accompanied by the following complications:

• Infection. It may be due to the fault of both the surgeon (inattention during surgery) and the patient (failure to comply with hygiene rules).
• Intestinal obstruction. Occurs as a result of bending or sticking together of the intestines. Requires repeat surgery.
• Bleeding. May occur during surgery.
• Narrowing of the intestinal anastomosis. Impairs cross-country ability.

Contraindications

There are no specific guidelines for when intestinal anastomosis should not be performed. The decision on the admissibility/inadmissibility of an operation is made by the surgeon based on: general condition the patient and the condition of his intestines. However, a number general recommendations you can still give it. Thus, colon anastomosis is not recommended if there is intestinal infection. As for the small intestine, preference is given to conservative treatment if one of the following factors is present:

• Postoperative peritonitis.
• Failure of the previous anastomosis.
• Violation of mesenteric blood flow.
• Severe swelling or
• Patient exhaustion.
• Chronic steroid deficiency.
• The general unstable condition of the patient with the need for constant monitoring of disorders.

Rehabilitation

The main goals of rehabilitation are to restore the patient’s body and prevent a possible relapse of the disease that caused the operation.

After the operation is completed, the patient is prescribed medications to relieve pain and discomfort in the abdominal area. They are not specialized drugs for the intestines, but are the most common painkillers. In addition, drainage is used to drain excess accumulated fluid.

The patient is allowed to move around the hospital 7 days after the operation. To speed up the healing of the intestines and postoperative sutures, it is recommended to wear a special bandage.

If the patient’s condition is consistently good, he can leave the hospital within a week after the operation. 10 days after the operation, the doctor removes the stitches.

Nutrition during anastomosis

In addition to taking various medications, nutrition plays an important role in the intestines. Patients are allowed to eat without the help of medical staff several days after the operation.

During intestinal anastomosis, food for the first time should consist of boiled or baked food, which should be served in crushed form. Acceptable vegetable soups. The diet should include foods that do not interfere with normal bowel movements and smoothly stimulate it.

After a month, it is allowed to gradually introduce other foods into the patient’s diet. These include: porridge (oatmeal, buckwheat, pearl barley, semolina, etc.), fruits, berries. As a source of protein, you can introduce dairy products (kefir, cottage cheese, yogurt, etc.) and light boiled meat (chicken, rabbit).

It is recommended to take food in a calm environment, in small portions, 5-6 times a day. In addition, it is recommended to consume more fluid (up to 2-3 liters per day). The first months after surgery, the patient may suffer from nausea, vomiting, abdominal pain, constipation, diarrhea, flatulence, weakness, heat. There is no need to be afraid of this; such processes are normal during the recovery period and will pass over time. Nevertheless, it is necessary to undergo irrigoscopy and colonoscopy at certain intervals (every 6 months or more often). These examinations are carried out as prescribed by a doctor in order to monitor the functioning of the intestines. In accordance with the data received, the doctor will adjust the rehabilitation therapy.

Conclusion

In conclusion, it should be noted that intestinal anastomosis is a rather difficult operation that imposes strong restrictions on a person’s subsequent lifestyle. However, most often this operation is the only way to eliminate the pathology. Therefore, the best way out of the situation would be to monitor your health and maintain healthy image life, which will reduce the risk of developing diseases requiring anastomosis.