Classmates
Fistulas are a cause of colon cancer.
There are two types of intestinal operations that require subsequent anastomosis - enteroctomy and resection.
Preparation and procedure
Espumisan eliminates gases.
You can eat boiled rice, boiled beef or chicken, and simple crackers. You should not break your diet, as this can lead to problems during surgery. Sometimes before surgery it is recommended to drink Espumisan to eliminate gases.
In the first days after surgery, the patient is observed in the hospital. Minor bleeding is possible, but it is not always dangerous. Seams are regularly inspected and processed.
It is impossible to completely protect yourself from complications after surgery, but you can significantly reduce the likelihood of their occurrence if you follow all the doctor’s recommendations, regularly undergo preventive examinations after surgery, and follow nutritional rules.
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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 the 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.
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. It is considered the most advantageous in terms of compliance with 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.
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:
- 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 the back wall with a Lambert suture.
- Then an incision is made along the afferent colon along a length equal to the diameter of the adductor section and the anterior wall is sutured with a continuous suture.
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.
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;
- in the postoperative period, broad-spectrum antibiotics are prescribed;
- The rehabilitation course necessarily includes diet, physical therapy 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.
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 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.
Various drug-filled protectors for suppressing local inflammation are highly favored. 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:
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 is 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.
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 increases.
To stimulate the intestines, a cleansing enema in a small volume with a hypertonic saline solution is prescribed on days 3–4. 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);
- To soften feces, microenemas are made from warm petroleum jelly in a furatsilin solution.
- 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. In case of 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 and removal of intoxication are prescribed. The patient is examined to decide whether surgical intervention is necessary.
Technical reasons
Sometimes complications are associated with inept or insufficiently qualified surgery. This is caused by excessive tension of the suture material and unnecessary application of multi-row sutures. Fibrin falls out at the junction and mechanical obstruction forms.
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 of treating the underlying disease.
The term “resection” (cutting off) means surgical removal of either the entire affected organ or part of it (much more often). Bowel resection is an operation during which the damaged part of the intestine is removed. A distinctive feature of this operation is the application of anastomosis. The concept of anastomosis in this case means the surgical connection of the continuity of the intestine after removing part of it. In fact, it can be explained as stitching one part of the intestine to another.
Resection is a rather traumatic operation, so it is necessary to be well aware of the indications for its implementation, possible complications and methods of managing the patient in the postoperative period.
Classification of resections
Operations to remove (resection) part of the intestine have many varieties and classifications, the main ones being the following classifications.
According to the type of intestine where surgical access is performed:
- Removal of part of the colon;
- Removal of part of the small intestine.
In turn, operations on the small and large intestine can be divided into one more classification (by sections of the small and large intestine):
- Among the sections of the small intestine there may be resections of the ileum, jejunum or duodenum;
- Among the sections of the large intestine, resections of the cecum, colon, and rectum can be distinguished.
Based on the type of anastomosis that is performed after resection, there are:
Resection and anastomosis formation
- End to end type. With this type of operation, the two ends of the resected colon are connected or two adjacent sections are connected (for example, colon and sigmoid, ileum and ascending colon, or transverse colon and ascending colon). This connection is more physiological and repeats the normal course of parts of the digestive tract, however, there is a high risk of developing scarring of the anastomosis and the formation of obstruction;
- Side to side type. Here the lateral surfaces of the sections are connected and a strong anastomosis is formed, without the risk of developing obstruction;
- “Side to end” type. Here, an intestinal anastomosis is formed between the two ends of the intestine: the abducent, located on the resected section, and the adductor, located on the adjacent section of the intestine (for example, between the ileum and the cecum, transverse colon and descending).
Indications for surgery
The main indications for resection of any part of the intestine are:
- Strangulation obstruction (“volvulus”);
- Intussusception (invasion of one part of the intestine into another);
- Nodulation between intestinal loops;
- Cancer of the colon or small intestine (rectum or ileum);
- Necrosis of intestinal sections.
Preparing for surgery
The preparation for resection consists of the following points:
- Diagnostic examination of the patient, during which the location of the affected area of the intestine is determined and the condition of surrounding organs is assessed;
- Laboratory studies, during which the condition of the patient’s body, his blood coagulation system, kidneys, etc. is assessed, as well as the absence of concomitant pathologies;
- Consultations with specialists who confirm/cancel the operation;
- Examination by an anesthesiologist, who determines the patient’s condition for anesthesia, the type and dose of the anesthetic substance that will be used during the intervention.
Carrying out surgery
The course of the operation itself usually consists of two stages: direct resection of the required section of the intestine and further anastomosis.
Resection of the intestine can be completely different and depends on the main process that caused damage to the intestine and the intestine itself (transverse colon, ileum, etc.), and therefore your own option for anastomosis is selected.
There are also several approaches to the intervention itself: classic (laparotomy) incision of the abdominal wall with the formation of an operating wound and laparoscopic (through small holes). Recently, the laparoscopic method has been the leading access used during the intervention. This choice is explained by the fact that laparoscopic resection has a much less traumatic effect on the abdominal wall, and therefore contributes to a faster recovery of the patient.
Complications of resection
The consequences of bowel removal can vary. Sometimes the following complications may develop in the postoperative period:
- Infectious process;
- Obstructive obstruction - with scar damage to the operated intestinal wall at the junction;
- Bleeding in the postoperative or intraoperative period;
- Hernial protrusion of the intestine at the access point on the abdominal wall.
Diet during resection
Nutrition provided after surgery will differ during resection of different parts of the intestine.
The diet after resection is gentle and involves taking light, quickly digestible foods with minimal irritating effects on the intestinal mucosa.
Dietary nutrition can be divided into a diet used for resection of the small intestine and for removal of part of the large intestine. Such features are explained by the fact that different parts of the intestine have their own digestive processes, which determines the types of food products, as well as the tactics of eating for these types of diets.
So, if part of the small intestine has been removed, the ability of the intestine to digest chyme (a bolus of food moving through the gastrointestinal tract) and also to absorb essential nutrients from this bolus will be significantly reduced. In addition, resection of the thin section will disrupt the absorption of proteins, minerals, fats and vitamins. In this regard, in the postoperative period, and then in the future, the patient is recommended to take:
- Lean types of meat (to compensate for protein deficiency after resection, it is important that the protein consumed is of animal origin);
- It is recommended to use vegetable oils and butter as fats in this diet.
- Products containing a large amount of fiber (for example, cabbage, radishes);
- Carbonated drinks, coffee;
- Beet juice;
- Products that stimulate intestinal motility (prunes).
The diet after removal of the large intestine is practically no different from that after resection of the small intestine. The absorption of nutrients itself is not impaired during resection of the thick section, but the absorption of water, minerals, and the production of certain vitamins are impaired.
In this regard, it is necessary to formulate a diet that would compensate for these losses.
Advice: many patients are afraid of resection precisely because they do not know what they can eat after intestinal surgery. and what not, considering that resection will lead to a significant reduction in the amount of nutrition. Therefore, the doctor needs to pay attention to this issue and describe in detail to such a patient the entire future diet, regimen and type of nutrition, as this will help convince the patient and reduce his possible fear of surgery.
A light massage of the abdominal wall will help to restart the intestines after surgery.
Another problem for patients is the postoperative decrease in motility of the operated intestine. In this regard, a logical question arises about how to start the intestines after surgery. To do this, in the first few days after the intervention, a gentle dietary regimen and strict bed rest are prescribed.
Prognosis after surgery
Prognostic indicators and quality of life depend on various factors. The main ones are:
- Type of underlying disease that led to resection;
- Type of surgery and the course of the operation itself;
- The patient's condition in the postoperative period;
- Absence/presence of complications;
- Proper adherence to the diet and type of nutrition.
Different types of the disease, during the treatment of which resection of various parts of the intestine were used, have different severity and risk of complications in the postoperative period. Thus, the most alarming in this regard is the prognosis after resection for oncological lesions, since this disease can recur and also give rise to various metastatic processes.
Operations to remove part of the intestine, as described above, have their differences and therefore also affect the further prognosis of the patient’s condition. Thus, surgical interventions, which include, along with the removal of part of the intestine and work on blood vessels, are characterized by a longer course of execution, which has a more exhausting effect on the patient’s body.
Compliance with the prescribed diet, as well as proper nutrition, significantly improves further prognostic indicators of life. This is explained by the fact that if dietary recommendations are followed correctly, the traumatic effect of food on the operated intestine is reduced, and substances missing in the body are corrected.
Attention! The information on the site is presented by specialists, but is for informational purposes only and cannot be used for independent treatment. Be sure to consult your doctor!
This article will tell you what kind of lifestyle cancer patients should lead so that bowel cancer after surgery does not recur and does not recur with renewed vigor. They will also give advice on proper nutrition: what should the patient do during the rehabilitation period, and what complications can occur if you do not adhere to the recommendations prescribed by the doctor?
Complications and possible consequences
Colon cancer surgery is risky and dangerous, like other surgical interventions of this complexity. Doctors call the first signs that are considered harbingers of postoperative complications the leakage of blood into the peritoneal cavity; as well as problems with wound healing or infectious diseases.
After surgical removal of an intestinal tumor, other complications arise:
Anastomosis is the fastening of two anatomical segments to each other. If the anastomotic sutures are insufficient, the two ends of the intestine, sewn together, may soften or tear. As a result, intestinal contents will enter the peritoneal cavity and cause peritonitis (inflammation of the peritoneum).
Most patients after surgery complain of a deterioration in the process of eating. They most often complain about flatulence and defecation disorder. As a result, patients have to change their usual diet, making it more monotonous.
Most often, adhesions do not bother the patient, but due to impaired motility of the intestinal muscles and poor patency, they can cause pain and be dangerous to health.
What should rehabilitation after surgery for bowel cancer include?
In the intensive care unit, a person returns from anesthesia to a normal state. After the operation, the patient is prescribed analgesics to relieve discomfort and pain in the abdominal cavity. The doctor may prescribe injection anesthesia (epidural or spinal). To do this, drugs that relieve pain are introduced into their body using droppers. A special drainage is placed in the area of the surgical wound, which is needed to drain the accumulated excess fluid, and after a couple of days it is removed.
Patients are allowed to eat without the help of medical staff several days after the operation. The diet must include liquid porridge and well-mashed soups. Only after a week is the patient allowed to move around the hospital. In order for the intestines to heal, patients are recommended to wear a special bandage, which is needed to reduce the load on the abdominal muscles. In addition, the bandage allows for equal pressure in the abdominal cavity over the entire area, and it promotes rapid and effective healing of sutures after surgery.
In order for rehabilitation to be successful, patients after the intervention are prescribed a special diet that they must adhere to. There is no clearly established diet for cancer patients, and it depends only on the patient’s preferences. But, in any case, you need to plan your diet with your doctor or nutritionist.
If during the operation the patient had a stoma (artificial opening), then in the first days it will look swollen. But within the first two weeks, the stoma shortens and decreases in size.
If the patient’s condition has not worsened, he will remain in hospital for no more than 7 days. The sutures or clips that the surgeon placed on the wound opening are removed after 10 days.
Nutrition after bowel cancer surgery
Regarding the diet after surgical treatment of intestinal oncology, we can say that patients can adhere to their usual diet. But for symptoms of digestive disorders (belching, indigestion, constipation), it is recommended to correct the dysregulation of stool, which is very important for patients with an artificial anus.
If after surgery you suffer from frequent loose stools, doctors advise eating foods low in fiber. Gradually, the patient’s previous diet is restored, and food products that previously caused problems in the functioning of the organ are introduced into the menu. To restore your diet, you should consult a nutritionist.
- Food should be consumed in small portions five times a day.
- Drink plenty of fluids between meals.
- When eating, you should not rush, you need to chew your food well.
- Eat food at medium temperature (not too cold and not too hot).
- Achieve systematicity and regularity in your meals.
- Doctors advise patients whose weight deviates from the norm to eat food to the fullest extent. Patients who are below normal weight are recommended to eat a little more, and those suffering from excess weight - a little less.
- It is better to steam, boil or stew food.
- You should avoid foods that cause bloating (flatulence); as well as from spicy or fried foods if you find them difficult to tolerate.
- Avoid eating foods to which you are intolerant.
The main question that worries people after being discharged from the hospital is whether they will be able to work after the operation? After surgical treatment of intestinal oncology, the patient’s ability to work depends on many factors: the stage of tumor development, the type of oncology, as well as the profession of the patients. After major operations, patients are not considered able to work for a couple of years. But, if a relapse does not occur, they can return to their old job (we are not talking about physically demanding professions).
It is especially important to restore the consequences of surgery, which lead to improper functioning of the intestines (inflammation processes in the area of the artificial anus, a decrease in the diameter of the intestine, inflammation of the colon, fecal incontinence, etc.).
If the treatment is successful, the patient should undergo regular examinations for 2 years: take a general stool and blood test; undergo regular examination of the surface of the colon (colonoscopy); chest x-ray. If relapse does not occur, diagnosis should be carried out at least once every 5 years.
Patients who are completely cured are not limited in any way, but are advised not to engage in heavy physical work for six months after discharge from the hospital.
Prevention of relapse
The chance of relapse after removal of benign tumors is extremely small; sometimes they occur due to non-radical surgery. After two years of therapy, it is very difficult to indicate the origin of tumor growth progress (metastasis or relapse). A neoplasm that appears again is classified as a relapse. Relapses of malignant tumors are often treated with conservative methods, using antitumor drugs and radiation therapy.
The main prevention of tumor recurrence is early diagnosis and urgent surgical intervention for local oncology, as well as full compliance with ablastic standards.
There are no specific recommendations for secondary prevention of relapse of this cancer. But doctors still advise following the same rules as for primary prevention:
- Constantly be on the move, that is, lead an active lifestyle.
- Keep alcohol consumption to a minimum.
- Quit smoking (if you have this bad habit).
- It is worth losing weight (if you are overweight).
During the recovery period, in order to avoid the recurrence of cancer, it is necessary to carry out special gymnastic exercises that will strengthen the intestinal muscles.
Important to know:
Anastomosis is also divided into several types:
- "Side to side." During stitching, parts of the intestine parallel to each other are taken. The postoperative result of this treatment has a fairly good prognosis. In addition to the fact that the anastomosis is strong, the risk of obstruction is minimized.
- "Side to end." The formation of an anastomosis is carried out between the two ends of the intestine: the abducent, located on the resected section, and the adductor, located on the adjacent section of the intestine (for example, between the ileum and the cecum, transverse colon and descending).
- "End to end." The 2 ends of the resected intestine or 2 adjacent sections are connected. This anastomosis is considered most similar to the natural position of the intestine, that is, the position before surgery. If severe scarring occurs, there is a chance of obstruction.
2 Indications and preparatory measures
The intestinal excision procedure is prescribed if one of the following pathologies is present:
- Cancer of one of the intestines.
- The insertion of one section of the intestine into another (intussusception).
- The appearance of nodes between parts of the intestine.
- Necrosis of departments.
- Obstruction or volvulus.
Depending on the diagnosis, the operation may be planned or emergency.
The set of preparatory measures includes a thorough examination of the organ and precise determination of the localization of the pathogenic area. Additionally, blood and urine are taken for analysis, and the body’s compatibility with one of the anesthetic drugs is checked, since the resection is carried out under general anesthesia. If an allergic reaction is present, another anesthetic drug is selected. If this is not done, then problems may begin even before the surgical intervention itself or during its implementation. Incorrectly selected anesthesia can cause death.
≡ Digestion > Gastrointestinal diseases > Intestinal anastomosis: features, preparation, purpose
Intestinal operations are considered one of the most complex and require special professionalism of the surgeon. It is important not only to restore the damaged integrity of the organ, but also to do this so that the intestines continue to function normally and do not lose their contractile function.
Intestinal anastomosis is a complex operation that is performed only in cases of extreme necessity and in 4-20% of cases leads to various complications.
What is intestinal anastomosis, and in what cases is it prescribed?
Fistulas are a cause of colon cancer.
Anastomosis is the joining of two hollow organs and their suturing. In this case, we are talking about stitching together two parts of the intestine.
There are two types of intestinal operations that require subsequent anastomosis - enteroctomy and resection.
In the first case, the intestine is cut to remove the foreign body from it.
During resection, you cannot do without an anastomosis; in this case, the intestine is not just cut, but part of it is also removed, after which only two parts of the intestine are sewn together in one way or another (varieties of anastomosis).
Bowel anastomosis is a major surgical procedure. It is performed under general anesthesia, and after it the patient requires long-term rehabilitation, and complications are possible. Bowel resection with anastomosis may be prescribed in the following cases:
- Colon cancer. Colon cancer occupies a leading place among cancer diseases found in developed countries. The cause of its occurrence may be fistulas, polyps, ulcerative colitis, and heredity. Resection of the affected area followed by anastomosis is prescribed in the initial stages of the disease, but can also be carried out in the presence of metastases, since leaving the tumor in the intestine is dangerous due to possible bleeding and intestinal obstruction due to tumor growth.
- Intestinal obstruction. Obstruction may occur due to a foreign body, tumor, or severe constipation. In the latter case, you can rinse the intestines, but for the rest, you will most likely have to undergo surgery. If the intestinal tissue has already begun to die due to compressed vessels, part of the intestine is removed and an anastomosis is performed.
- Intestinal infarction. With this disease, the flow of blood to the intestines is disrupted or completely stops. This is a dangerous condition that leads to tissue necrosis. It is more common in older people with heart disease.
- Crohn's disease. This is a whole complex of different conditions and symptoms that lead to intestinal dysfunction. This disease cannot be treated surgically, but patients have to undergo surgery, since life-threatening complications can arise during the course of the disease.
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Preparation and procedure
Espumisan eliminates gases.
Such a serious procedure as intestinal anastomosis requires careful preparation. Previously, preparation was carried out using enemas and diet.
Now the need to follow a slag-free diet remains (for at least 3 days before the operation), but the day before the operation the patient is prescribed the drug Fortrans, which quickly and efficiently cleanses the entire intestine.
Before surgery, you should completely avoid fried foods, sweets, hot sauces, some cereals, beans, seeds and nuts.
You can eat boiled rice, boiled beef or chicken, and simple crackers. You should not break your diet, as this can lead to problems during surgery. Sometimes it is recommended to drink Espumisan before surgery. to eliminate gases.
The day before the procedure, the patient only has breakfast and starts taking Fortrans from lunch. It is available in powder form. You need to drink at least 3-4 liters of the diluted drug (1 sachet per liter, 1 liter per hour). After taking the drug, painless watery stools begin within a couple of hours.
Fortrans is considered the most effective drug for preparing for various manipulations on the intestines. It allows you to completely clean it in a short time. The procedure itself is performed under general anesthesia. Anastomosis has 3 types:
- "End to end." The most effective and frequently used method. It is only possible if the parts of the intestine being connected do not have a big difference in diameter. If it is made up of slightly smaller parts, the surgeon slightly incises it and increases the gap, and then sews the parts together edge to edge.
- "Side to side." This type of anastomosis is performed when a significant part of the intestine has been removed. After the resection, the doctor sutures both parts of the intestine, makes incisions and stitches them side to side. This surgical technique is considered the simplest.
- "End to side." This type of anastomosis is suitable for more complex operations. One of the parts of the intestine is stitched tightly, making a stump and first squeezing out all the contents. The second part of the intestine is sewn to the side of the stump. Then a neat incision is made on the side of the deaf intestine so that its diameter coincides with the second part of the intestine and the edges are sutured.
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Postoperative period and complications
Eating cereals will reduce the load on the intestines.
After intestinal surgery, the patient must undergo a mandatory rehabilitation course. Unfortunately, complications after intestinal resection are very common even with highly professional surgeons.
In the first days after surgery, the patient is observed in the hospital. Minor bleeding is possible. but they are not always dangerous. Seams are regularly inspected and processed.
For the first time after surgery, you can only drink still water; after a few days, liquid food is acceptable. This is due to the fact that after such a serious operation you need to reduce the load on the intestines and avoid bowel movements for at least the first 3-4 days.
Proper nutrition is especially important during the postoperative period. It should provide loose stools and replenish the body's strength after abdominal surgery. Only those products are allowed that do not cause increased gas formation, constipation and do not irritate the intestines.
Liquid cereals, dairy products, after a while fiber (fruits and vegetables), boiled meat, and puree soups are allowed.
Complications after surgery can occur both due to the fault of the patient himself (non-compliance with the regime, poor diet, increased physical activity), and due to the fault of circumstances. Complications after anastomosis:
- Infection. Doctors in the operating room follow all safety rules. All surfaces are disinfected, but even in this case it is not always possible to avoid infection of the wound. With infection, redness and suppuration of the suture, fever, and weakness are observed.
- Obstruction. The intestines may stick together after surgery due to scarring. In some cases, the intestine becomes bent, which also leads to obstruction. This complication may not appear immediately, but some time after the operation. It requires repeated surgery.
- Bleeding. Abdominal surgery is most often accompanied by blood loss. Internal bleeding is considered the most dangerous after surgery, since the patient may not notice it immediately.
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It is impossible to completely protect yourself from complications after surgery, but you can significantly reduce the likelihood of their occurrence if you follow all the doctor’s recommendations and regularly undergo preventive examinations after surgery. follow nutrition rules.
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When it comes to bowel cancer, it usually means a malignant tumor of the colon (colon carcinoma) and rectum (rectal carcinoma). Further in the article we present to your attention an overview of methods surgical treatment of intestinal cancer. and also talk about the possible consequences for patients who have suffered one of the listed operations .
General information about bowel cancer surgery
Small bowel cancer and anal cancer (cancer of the anus) are rare. When it comes to bowel cancer, it usually means a malignant tumor of the colon (colon carcinoma) and rectum (rectal carcinoma). These types of cancer are also called colorectal cancer. Although colorectal cancer can develop in all parts of the colon and rectum, it most often occurs in the lower area between 30-40 centimeters. Precursors of colon cancer are often mushroom-shaped growths, so-called intestinal polyps, which are often benign tumor-like formations. The main treatment for colon cancer is surgery, that is, removal of the affected area of the large intestine along with its lymphatic and blood vessels. In the case of advanced cancer, when there is no prospect of recovery, surgery is generally abandoned, except in cases where it is necessary to prevent complications such as intestinal obstruction. Colon cancer surgery, with the exception of intestinal obstruction, is not an emergency surgery; there is sufficient time for diagnosis and treatment planning. This way it is possible to avoid complications and improve the chances of recovery. The following text contains information about the methods of surgical intervention for intestinal cancer and the consequences after surgery that the patient may encounter.
Surgical treatment of colon cancer: Indications and goals
Bowel cancer operations are carried out in many clinics (university clinics, district hospitals) and bowel cancer centers. Bowel Cancer Centers are clinics that have been certified for their special care for clients with bowel cancer.
The main goal of bowel cancer surgery is to completely remove the tumor and thereby cure the cancer. The purpose of surgery, in addition to removing the intestinal tumor, is also to remove metastases (secondary tumors, for example in the lungs and liver), examine the abdominal cavity and its organs, and remove lymph nodes for diagnostic purposes to check for possible spread through the intestines. This, in turn, is important for determining the stage of cancer (Staging), so that treatment can be further planned and predicted. In addition, bowel cancer surgery may be required if the fusion poses a risk of intestinal obstruction (complicated intestinal transit).
Curative and palliative operations for bowel cancer
If during surgery all tumor tissue is removed, including possible metastases in the lymph nodes or other organs, then in this case we are talking about curative surgery for bowel cancer. With this type of surgery, along with the affected area of the intestine, nearby healthy tissue is removed to reduce the risk of tumor reappearance (relapse). Since individual cancer cells may by this time have multiplied and invaded nearby lymph nodes, they are also removed.
The situation looks different when it comes to palliative surgery for bowel cancer at its progressive stage (for example, with metastases that cannot be removed). Here, specialists attempt to prevent tumor-related complications and pain for the patient, but there is no chance of recovery. If a tumor grows, for example, inside the intestine, it can obstruct the passage of intestinal contents, which in turn can lead to life-threatening intestinal obstruction. In this case, the surgeon will try to reduce the tumor to a size that will eliminate the narrow passage. Palliative operations also include avoiding narrowing through bypass anastomosis and installing an artificial anus (stoma).
Surgical treatment of intestinal cancer: preoperative stage
Before surgery for intestinal cancer, a very thorough examination must be carried out to determine the condition of the tumor or, more precisely, the location of the tumor in the intestine and its possible growth.
The most common examinations include:
- digital rectal examination (palpation of the lower part of the rectum) to assess the spread of the tumor and predict the preservation of sphincter function after surgery for intestinal cancer;
- Ultrasound examination (US) of the abdominal organs to assess possible tumor growth outside the affected organ;
- a chest x-ray (chest x-ray) to rule out or detect metastases in the lungs;
- determination of the level of CEA (carcinoembryonic antigen, CEA) before surgery for intestinal cancer serves as an initial indicator of subsequent monitoring of the course of the disease, as well as assessing the prognosis after surgery;
- rectoscopy (proctoscopy) to determine the extent of the tumor in rectal cancer;
- endosonography (endoscopic ultrasound) to determine the depth of tumor infiltration in rectal cancer;
- A colonoscopy is used to accurately examine the entire colon to look for other possible colon polyps or tumors.
Immediately before and during bowel cancer surgery, the following measures are taken:
- the intestines are thoroughly cleansed (with a special solution that has a laxative effect and is usually taken orally);
- an antibiotic is taken against infections (bacteria from the intestinal flora can cause dangerous infections in the abdominal cavity);
- the area of skin where the incision is to be made is shaved (for better disinfection);
- preventive measures are taken against thrombosis.
Surgical treatment of intestinal cancer: Methods
In bowel surgery, there are two main methods of treating bowel cancer. At radical surgery for bowel cancer Not only the tumor is removed from the body, but also the healthy tissue adjacent to it. Unlike radical, with local surgery for bowel cancer Only the tumor itself is removed at a safe distance (a narrow border of healthy tissue), but not adjacent healthy tissue.
Depending on the stage and severity of the tumor, bowel cancer surgery can be performed using laparotomy (opening the abdominal cavity) or minimally invasive.
Open and minimally invasive surgical treatment of colon cancer
Small tumors that have not yet penetrated into the deeper layers of the intestine can be removed during colonoscopy. If there is any doubt about the complete removal of the tumor tissue, then a conventional bowel cancer operation is performed. "Routine" bowel cancer surgery can be performed as a minimally invasive keyhole procedure ( laparoscopy) or with opening of the abdominal cavity ( laparotomy).
In the later stages of intestinal cancer, due to the extensiveness of the operation, laparotomy is performed almost without exception. In other cases, the currently established laparoscopic method of tumor removal in patients suffering from intestinal cancer is used. Although this method is widely used, it is advisable to perform such an operation by an experienced surgeon. The laparoscopic method of tumor removal gives almost the same result as traditional surgery with opening of the abdominal cavity. The main advantage of this method is that the operation is more gentle and the patient recovers faster.
Radical surgery for colon cancer
Since individual cancer cells in intestinal cancer can separate from the primary tumor and spread throughout the body, forming metastases there (including in the lymph nodes), when performing a radical operation, for the sake of reliability, the tumor is removed with a reserve (i.e., including healthy tissue around the tumor) along with adjacent lymph nodes, lymphatics and blood vessels. Radical surgery is often critical to successfully removing the tumor without the risk of the disease returning (recurrence). Often the decision about the size of the intestinal section to be removed is made during surgery.
Contactless operation (No-Touch)
To avoid dispersal of tumor cells during surgery, the blood and lymph vessels associated with the tumor are first ligated, and then the tumor-affected section of intestine is cut off from the healthy section of intestine. Carefully, so as not to touch the tumor and not damage it (the so-called No-Touch technology, the affected section of the intestine, including lymph nodes, lymphatic and blood vessels, is cut off and removed from the abdominal cavity. The purpose of non-contact surgery is to prevent destruction tumors and thereby the spread of cancer cells in the body.
Radical En-bloc operation
If the tumor is so large that neighboring organs are already affected, experienced surgeons perform the so-called radical En-bloc operation. In this case, not only the tumor is removed, but also the organs affected by it using the “en bloc” technique (“block removal”). The purpose of this operation is also to prevent damage to the tumor.
Local tumor removal
When removing a cancerous intestinal tumor locally, only the tumor itself is subject to surgery, taking into account a safe distance. This operation can be performed at an early stage for small tumors; the following methods are mainly used:
- colonoscopy and polypectomy (for colon cancer);
- laparotomy or laparoscopy (for colon cancer);
- polypectomy or transanal endoscopic microsurgery (for rectal cancer).
If subsequent histological examination confirms that the tumor has been completely removed and the risk of recurrence is minimized, the need for subsequent radical surgery for intestinal cancer is eliminated.
Surgical treatment of intestinal cancer: Artificial anus
An artificial anus (stoma or anus praeter) is a connection between a healthy intestine and an opening in the wall of the abdominal cavity through which the contents of the intestine are discharged. This method can be used both temporarily and for a long time.
At colon cancer A long-term stoma can only be used in rare cases. However, in difficult cases, a temporary stoma may be necessary to relieve pressure on the bowel or intestinal suture after bowel cancer surgery. If earlier during surgery small bowel cancer(for example, for tumors near the anus), along with the affected area of the rectum, the entire sphincter was also removed, but now in most cases, surgery for rectal cancer is performed in such a way as to preserve the sphincter apparatus. For experienced rectal surgeons, a safe distance of 1 cm from the anus is sufficient to prevent the creation of a permanent stoma.
Temporary artificial anus
A temporary artificial anus (temporary colostomy) is placed during bowel cancer surgery to relieve stress on the operated bowel and stitches. Through a colostomy, the contents of the intestine are removed, thus creating conditions for faster healing of the intestines and sutures. This type of stoma is also called unloading stoma. A temporary artificial anus is applied, usually in the form of double-barreled stoma. This means that the intestine (small or large intestine) is brought out through the wall of the abdominal cavity, cut at the top and turned inside out so that two holes in the intestine are visible. After a minor operation to close the temporary stoma and hole in the wall of the abdominal cavity, natural digestion is restored in about 2-3 months.
Permanent (permanent) artificial anus
If the tumor is located so close to the sphincter that saving the anus is not possible, both the rectum and the sphincter itself are completely removed. In this type of bowel cancer surgery, a permanent stoma is created. In a permanent stoma, the healthy lower part of the colon is brought out through an opening in the abdominal wall and sutured to the skin. Most patients have no problems with a permanent stoma after a period of getting used to it and appropriate instruction. Even regular bowel movements do not cause them any particular problems.
For water sports (for example, visiting the pool) and visiting the sauna, special patches or so-called caps are available to patients with an ostomy. In addition, for patients with an unnatural anus, there are no restrictions in their professional activities or choice of sports.
Surgical treatment of bowel cancer: Risks and consequences
Like any other surgery, bowel cancer surgery may also have its risks and dangers. The first signs of serious complications after bowel cancer surgery include, for example, bleeding into the abdominal cavity, problems with wound healing or infection.
Other risks and complications after bowel surgery include:
- Anastomotic failure: An anastomosis is a connection between two anatomical structures. If the anastomosis is insufficient, the two ends of the intestine sewn together or the seam between the intestine and the skin with an artificial anus may weaken or rupture. As a result, intestinal contents can leak into the abdominal cavity and cause peritonitis (inflammation of the peritoneum).
- Digestive disorder: Since the process of eating in the large intestine is basically completed, operations, from the point of view of the process of digesting food, are less problematic than on the small intestine. However, water is reabsorbed in the colon, which, depending on the portion of the colon removed, may interfere with the hardening of stool. This leads to more or less severe diarrhea. Many patients (especially patients with an ostomy) after bowel cancer surgery also complain of digestive disorders such as bloating, constipation and odors. As a result, patients change their usual diet, which can lead to a monotonous diet.
- Fecal incontinence, bladder dysfunction, sexual dysfunction (impotence in men): When performing surgery on the rectum, the nerves in the operated area can be irritated and damaged, which can subsequently cause patient complaints.
- Fusion (adhesions): In most cases, adhesions are harmless and painless, but sometimes, due to limited intestinal mobility and intestinal obstruction, they can cause pain and be dangerous.
Surgical treatment of bowel cancer: Postoperative care
Metastases (secondary tumors) or relapse (recurrence of a tumor in the same place) can only be detected in a timely manner if regular monitoring is performed after surgery.
After a successful bowel cancer operation, the following postoperative examinations are offered, in particular:
- regular colonoscopy;
- determination of the tumor marker CEA (carcinoembryonic antigen, CEA);
- ultrasound examination of the abdominal organs (stomach);
- X-ray examination of the lungs;
- computed tomography (CT) of the lungs and abdomen.
Surgical treatment of bowel cancer: Nutrition after surgery
As for nutritional norms after surgical treatment of intestinal cancer, there is practically no need for patients to give up their usual consumption of food and drinks. However, due to digestive disorders (bloating, diarrhea, constipation, odors), it is recommended to regulate bowel movements. This is especially true for patients with an artificial anus. To avoid a monotonous diet, you should take into account the following tips:
Recommendations for proper nutrition after bowel cancer surgery
- Eat 5-6 times a day in small portions. Avoid eating large portions.
- It is recommended to drink sufficiently large amounts of liquid between meals.
- Eat food slowly and chew well.
- Avoid eating very hot or very cold foods.
- Stick to regular meals and avoid dieting.
- Eat enough food, i.e. underweight patients are advised to eat a little more, and overweight people - a little less than usual.
- Stewing and steaming are gentle cooking methods.
- Avoid very fatty, sweet and bloating-causing foods, as well as fried, fried and spicy foods if you cannot tolerate them.
- Avoid foods that you have been unable to tolerate on several occasions.
Photo: www. Chirurgie-im-Bild. de We thank Professor Dr. Thomas W. Kraus for kindly providing us with these materials.
60. Bowel resection with side-to-side anastomosis. Suturing an intestinal wound.
Bowel resection– removal of a section of intestine.
Indications:
a) all types of necrosis (as a result of strangulation of internal/external hernias, thrombosis of mesenteric arteries, adhesive disease)
b) operable tumors
c) injuries of the small intestine without the possibility of suturing the wound
Operation stages:
1) lower-median or mid-median laparotomy
2) revision of the abdominal cavity
3) determination of the exact boundaries of healthy and pathologically altered tissues
4) mobilization of the mesentery of the small intestine (along the intended line of intestinal intersection)
5) bowel resection
6) formation of an interintestinal anastomosis.
7) suturing the mesenteric window
Operation technique:
1. Mid-median laparotomy, we go around the navel on the left.
2. Revision of the abdominal cavity. Removing the affected loop of intestine into the surgical wound, covering it with napkins with saline solution.
3. Determination of the boundaries of the resected part of the intestine within healthy tissues - proximally at 30-40 cm and distally at 15-20 cm from the resected section of the intestine.
4. In the avascular zone of the mesentery of the small intestine, a hole is made, along the edges of which one intestinal-mesenteric-serous suture is placed, piercing the mesentery, the marginal vessel passing through it, and the muscular layer of the intestinal wall. By tying a suture, the vessel is fixed to the intestinal wall. Such sutures are placed along the resection line from both the proximal and distal parts.
You can do it differently and perform a wedge-shaped dissection of the mesentery in the area of the removed loop, ligating all the vessels located along the cut line.
5. At a distance of about 5 cm from the end of the intestine intended for resection, two clamps for coprostasis are applied, the ends of which should not pass to the mesenteric edges of the intestine. One crushing clamp is applied 2 cm below the proximal clamp and 2 cm above the distal clamp. The mesentery of the small intestine is crossed between the ligatures.
H 
Most often, a cone-shaped intersection of the small intestine is made; the slope of the intersection line should always start from the mesenteric edge and end on the opposite edge of the intestine to preserve blood supply. We form the intestinal stump in one of the following ways:
a) suturing the intestinal lumen with a continuous continuous Schmieden suture (furrier suture) + Lambert sutures.
b) suturing the stump with a continuous continuous suture + Lambert sutures
c) ligation of the intestine with catgut thread + immersion of the intestine in a pouch (simpler, but the stump is more massive)
6. An interintestinal anastomosis is formed “side to side” (applied when the diameter of the parts of the intestine being connected is small).
Basic requirements for the application of intestinal anastomoses:
a) the width of the anastomosis must be sufficient to ensure unimpeded passage of intestinal contents
b) if possible, the anastomosis is performed isoperistaltically (i.e., the direction of peristalsis in the adductor section should coincide with that in the efferent section).
c) the anastomosis line must be strong and provide physical and biological tightness
Advantages of forming a side-to-side anastomosis:
1
. deprived of the critical point of suturing the mesentery - this is the place where the mesenteries of the intestinal segments are compared, between which an anastomosis is applied
2. anastomosis promotes a wide connection of intestinal segments and ensures safety against the possible occurrence of intestinal fistula
Flaw: accumulation of food in the blind ends.
Technique for forming a side-to-side anastomosis:
A. The afferent and efferent sections of the intestine are applied to each other with isoperistaltic walls.
b. The walls of the intestinal loops over a length of 6-8 cm are connected by a series of interrupted silk seromuscular sutures according to Lambert at a distance of 0.5 cm from each other, retreating inwards from the free edge of the intestine.
V 
. In the middle of the line of serous-muscular sutures, the intestinal lumen is opened (not reaching 1 cm to the end of the serous-muscular suture line) of one of the intestinal loops, then in the same way - the second loop.
d. Sew the inner edges (posterior lip of the anastomosis) of the resulting holes with a continuous upholstered Reverden-Multanovsky catgut suture. The seam begins by connecting the corners of both holes, pulling the corners together, tying a knot, leaving the beginning of the thread uncut;
d 
. Having reached the opposite end of the connected holes, secure the seam with a knot and use the same thread to connect the outer edges (anterior lip of the anastomosis) with a screw-in Schmieden suture. After stitching both outer walls, the threads are tied with a double knot.
e. Change gloves and napkins, process the seam and suture the anterior lip of the anastomosis with interrupted seromuscular sutures of Lambert. Check the patency of the anastomosis.
and. To avoid intussusception, the blind stumps are fixed with several interrupted sutures to the intestinal wall. We check the patency of the formed anastomosis.
7. We suture the mesenteric window.
An anastomosis between two sections of the digestive apparatus is one of the most common operations in abdominal surgery. An anastomosis is performed to restore the passage of the contents of the digestive apparatus. Depending on the methods of connecting the afferent and efferent sections of the digestive apparatus, the following types of anastomoses are distinguished:
1) end-to-end anastomosis;
2) side-to-side anastomosis;
3) end-to-side anastomosis;
4) side to end anastomosis.
Basic requirements for anastomosis:
The width of the anastomosis should be sufficient so as not to narrow the intestinal lumen;
If possible, the anastomosis should be performed isoperistaltically;
The anastomosis line must be strong and provide physical and biological tightness.
Most often, an anastomosis is formed using a 2-row suture, which is applied to the posterior and then to the anterior wall of the anastomosis. Using Lambert's seromuscular suture, sections of the intestine are connected at the site of the anastomosis. After opening the lumen of both sections of the intestine, the posterior and anterior lips of the anastomosis are formed. The posterior wall of the anastomosis is formed by suturing the posterior lips using a through Multanovsky suture (taking into account its good hemostatic properties). After forming the posterior wall of the anastomosis, the anterior lips are sutured. In this case, a Schmiden screw-in suture is used, which ensures hemostasis, screw-in of the connected walls and contact of their serous membranes.
The formation of the anastomosis is completed by applying separate Lambert serous-muscular sutures.
End to end anastomosis
First, 2 ligatures are applied to the mesenteric and free edges of the intestinal lumen. The formation of the interintestinal anastomosis begins with the application of interrupted Lambert serous-muscular sutures along the entire posterior wall of the anastomosis. The connected sections of the intestine are freed from the mesentery at a distance of approximately 1 cm from the free end, and the line of this suture should be approximately 0.5 cm from the edges of the intestinal incision. The threads of the 2 outer sutures are left as holders, the remaining threads are cut off. After this, a continuous marginal Multanovsky suture is applied to the posterior semicircle of the anastomosis. After suturing the posterior wall of the anastomosis, the anterior wall is sutured with the same thread using a Schmiden screw-in suture, making sure that the walls are in contact only with the serous membranes. Especially carefully, a continuous suture is placed in the corners of the anastomosis (the place where the suture passes from the posterior lips of the anastomosis to the anterior ones). Separate interrupted Lambert serous-muscular sutures are placed over the through screw-in suture. The operation ends with suturing the window in the intestinal mesentery (to prevent subsequent adhesions) and palpation determining the patency of the newly created anastomosis. It is possible to carry out the “dirty” stage of the operation first, and then the “clean” one, i.e., first a Multanovsky suture is applied to the posterior lips of the anastomosis, then a Schmiden suture is applied to the anterior lips, after which Lambert serous-muscular sutures are applied along the entire circumference of the anastomosis.
Side to side anastomosis
Apply when the diameter of the connected sections of the intestine is small, when an anastomosis is applied between the stomach and the small intestine.
Advantages:
The anastomosis is devoid of a critical point for suturing the mesentery (in this case, the “critical point” is the place where the mesenteries of the intestinal segments between which the anastomosis is applied);
Anastomosis promotes a wide connection of intestinal segments;
The anastomosis ensures safety against the possible occurrence of an intestinal fistula.
If the intestinal resection is supposed to be completed by creating a side-to-side anastomosis, after dissection and ligation of the mesentery, the intestine is clamped with a Kocher clamp in the place where mobilization of the intestine was completed. The clamp is removed and the intestine is tied with catgut thread in the pinched area. Then, stepping back approximately 1.5 cm proximally from the ligation site, a rigid clamp is applied to the intestinal wall, and a seromuscular silk purse-string suture is applied proximally from the same place to the intestinal wall. Between the pulp and the ligature, the intestine is crossed with a scalpel. The stump is lubricated with iodine and immersed with anatomical tweezers into a pouch, the threads of which are tightened to capacity and then tied. After removal of the resected intestine, a lateral anastomosis is performed. The afferent and efferent sections of the intestine are applied to each other with their side walls isoperistaltically, i.e., one is a continuation of the other. The walls of the intestinal loops over a length of 6–8 cm are connected by a series of interrupted silk seromuscular sutures according to Lambert at a distance of 0.5 cm from each other, moving inwards from the free edge of the intestine. Halfway along the line of serous-muscular sutures, the intestinal lumen of one of the intestinal loops is opened, and then the lumen of the other loop is opened in the same way. The lumen incision is extended to the sides, not reaching 1 cm to the end of the seromuscular suture line. After this, they begin to sew together the inner edges of the resulting holes using a continuous Multanovsky catgut stitch. The seam begins by connecting the corners of both holes, pulling the corners together, tying a knot, leaving the beginning of the thread uncut. Having reached the opposite end of the connected holes, secure the seam with a knot and proceed using the same thread to connect the outer edges of the holes with a Schmieden screw seam (2nd “dirty” seam). After suturing both walls, the threads are tied. To do this, a puncture is made from the mucous side of one intestine, then from the mucous side of the other intestine, and after this the suture is tightened; The edges of the hole are screwed inward. Having reached the beginning of the “dirty” seam, the end of the catgut thread is tied with a double knot to its beginning. Thus, the lumen of the intestinal loops closes. The infected stage of the operation ends, and the last stage begins - the application of the 2nd row of interrupted Lambert seromuscular sutures (2nd “clean” suture) on the other side of the anastomosis. Punctures are made at a distance of 0.75 cm from the line of the “dirty” seam. To avoid intussusception, the blind stumps are fixed with several interrupted sutures to the intestinal wall. The formation of the anastomosis ends with checking its patency and suturing the hole in the mesentery of the intestine.
End to side anastomosis
End-to-side anastomosis is often used when resection of the right half of the colon and anastomosis between the small and large intestines.
The location of the final loop relative to the axis of the anastomosed loop can be parallel with a longitudinal connection or perpendicular with a transverse connection. In this case, it is necessary to give preference to a transverse anastomosis, in which a smaller number of round muscle fibers are crossed, thereby providing a peristaltic wave of greater efficiency.
The wall of the small intestine is connected with separate Lambertian seromuscular sutures, 3–4 cm away from the line of its intersection with the wall of the colon, closer to the mesenteric edge. Then the lumen of the colon is opened longitudinally along the tape, the rear lips are sutured using a continuous continuous Multanovsky suture, then the anterior lips are sutured using the same thread, using one of the screw-in sutures. Threads bind. Lambert seromuscular sutures are placed on the anterior wall of the anastomosis over the screw-in suture.
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Intestinal anastomosis allows radical (surgical) resolution of complex intestinal abnormalities. In terms of frequency, various gastrointestinal pathologies in surgery are in third place. People preparing for resection (removal of part of the intestine or an entire organ) or enteroctomy (removal of a foreign object from the intestine) must know what intestinal anastomosis is. Anastamosis is an integral part of these operations. Among the types of intestinal anastomoses (anastamoses), several technical modifications and types of sutures are distinguished, and the procedure is also classified according to the organs being sutured.
Intestinal anastomosis is a special surgical technique that allows you to restore the functionality of the organ after surgery. In this article you will learn:
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 caused by both hereditary pathologies, for example, and advanced secondary diseases (gastritis).
If a foreign body enters the intestine, the patient undergoes an operation called enterotomy
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).
Various types of seams are used to join fabrics and fibers. 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).
Anastomosis is used for intestinal resection - removal of the affected area of the intestine or entire organ 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.
The patient must adhere to a special diet before the operation. Overlay methods
There are three types of intestinal anastomosis. All types of intestinal anastomoses are reflected in the table.
| Performance Variation | Description | When to use |
|---|---|---|
| Side to side | Least complex type. Both remaining parts of the intestine are turned into stumps (a two-tier suture is used). Afterwards, through minor incisions, they are stitched on the sides (Lambert seam). Top to bottom. | When cutting out a large piece of an organ or a high risk of tension. |
| End to side | An intestinal anastomosis of this type involves turning one end into a formed stump, the second intestinal element is sewn to it from the side (Lambert stitch) through an incision made in the stump. | The method is relevant for complex operations, complete removal of an organ. |
| End to end | The technique of this type of intestinal anastomosis is the most popular, but at the same time the most difficult to perform. Both ends of the intestine are shaped and stitched end-to-end (if necessary, adjusting the diameters through incisions) with a double suture. | More often after resection of the sigmoid colon. |
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 sticking and scarring, inflammation of the peritoneum, it is important to follow a number of rules during the operation (maintain sterility, cutting the stitched ends only after squeezing the intestinal loop and clamping it, internally checking the patency with fingers after fastening) and after (diet, exercise therapy, drug therapy, breathing training ).
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.
Intestinal anastomosis is a complex surgical procedure that requires high professionalism from the surgeon. 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.
After the operation, the patient is recommended to rest in bed. 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, contrast study). If there is a leak, there will be a high level of leukocytes in the blood, and an x-ray will show dilation of the intestinal loops.
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In the vast majority of patients with upper ampullary cancer, it is possible to perform rectal resection with the formation of a colorectal anastomosis. This surgical intervention is often called transperitoneal or intraperitoneal resection, but the most widespread in the world literature is the name “anterior resection”.
This term means the removal of part of the rectum using a transabdominal approach with the formation of a colorectal anastomosis and its immersion under the pelvic peritoneum. A surgical intervention that ends with the formation of an anastomosis within 4 cm of the anorectal line is designated by us as “low anterior resection.”
It should be noted that there are various methods for forming an anastomosis between the colon and rectum. The main ones are hand stitch, hardware compression or double-row staple (mechanical). In the future, we considered it appropriate to describe the methods most often used in clinical practice for creating a colorectal anastomosis when performing anterior rectal resection.
Despite the fact that low anterior resection of the rectum is performed when the tumor is localized in the lower and mid-ampullary sections (at a distance of 6-9 cm from the perianal skin), we considered it appropriate to describe it in this chapter, since the technique and principles of performing this intervention are identical to such during interventions performed when the tumor is located in the upper ampullary region.
With low anterior resection, removal of the rectum affected by the tumor is performed with a total mesorectumectomy. After a median laparotomy, revision of the abdominal organs, and dissection of the peritoneum, the inferior mesenteric vessels distal to the origin of the left colon artery are ligated and transected, and the mesentery of the left parts of the colon is straightened. After crossing the marginal vessel and checking the severity of arterial blood flow, the intestine is crossed 10-15 cm above the upper pole of the tumor. Its distal end is immersed in the purse-string suture.
The proximal end of the colon remains open, and the head of a circular stapler is inserted into its lumen (Fig. 125). The intestinal lumen can be closed in two ways. In the first case, a purse-string suture is tightened on the shaft of the head. In the second, the head of the circular stapler is inserted into the intestinal lumen on a ligature, its walls are stitched with a linear stapler TA NG 45-3.5 (TA Rg. 55-3.5) with a double-row staple stitch (Fig. 126).
Rice. 125. Insertion of the head of a circular stapler into the lumen of the colon
Rice. 126. Suturing the proximal colon with a linear stapler
After this, the rod is pulled out through the sutures behind the previously applied ligature, and the ligature is removed. The proximal stump with the rod is treated with antiseptic solutions, placed in a rubber container and placed in the left lateral canal.
After mobilizing the rectum to the pelvic floor, an L-shaped clamp is applied 2-3 cm below the tumor (Fig. 127), and the distal part of the anorectum is washed from the perineum with an antiseptic solution. Then, below the L-shaped clamp, the intestinal wall is stitched in the transverse direction using a linear apparatus TA NG 45-3.5 (TA Rg. 55-3.5) with a double-row staple stitch. It is most convenient to use a linear stapler with a rotating head (Roticulator 55-3.5 from Auto Suture) (Fig. 128), which allows you to apply a staple suture at any level up to the upper edge of the anal canal.
Rice. 127. Applying an L-shaped clamp to the rectum
Rice. 128. Stitching the rectum with a linear stapler with a rotating head
After stitching, the intestine is cut off (Fig. 129-130). Drainage tubes are inserted through the counter-aperture and the pelvic cavity is washed.
Rice. 129. Crossing the wall of the rectum
Rice. 130. View of the rectal stump stitched with a linear stapler
A circular stapler (CEEA) with a head diameter of 28-31 mm is inserted into the lumen of the rectum through the anus (Fig. 131). By rotating the screw of the device counterclockwise, a tip with a sharp spear is brought out and pierces the intestine along the line of previously applied staple sutures (Fig. 132). A spear is removed from the abdominal cavity, and the head (Fig. 133), previously placed in the lumen of the colon, is put on the device, they are brought together and stitched to form an anastomosis with a “mechanical suture” (Fig. 134).
Rice. 131. Introduction of a circular stapler into the rectal stump
Rice. 132. Piercing the rectal wall along the line of previously applied staple sutures:
a) diagram; b) stage of the operation
Rice. 133. Connection of the head to the device:
a) diagram; 6) stage of operation
Rice. 134. Formation of colorectal anastomosis using hardware suture:
a) diagram; b) stage of operation; 1. line of anastomosis
The device is removed, and the integrity of the “rings” of the proximal and distal sections of the intestinal wall is assessed. The pelvic cavity is filled with an antiseptic solution, the intestine above the anastomosis is clamped. A tube is inserted through the anus into the intestinal lumen and inflated with air. If the anastomosis leaks, air bubbles appear in the liquid poured into the pelvis. If a defect is detected, additional seromuscular sutures are applied and a leak test is repeated.
T.S. Odaryuk, G.I. Vorobyov, Yu.A. Shelygin
