Anastomosis is a phenomenon of fusion or suturing 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 body. An artificial anastomosis is a surgical stapling of the intestines.
Types of intestinal anastomoses
There are various ways to carry out this operation. The choice of method depends on the nature of the particular problem. The list of methods for conducting anastomosis is as follows:
- Anastomosis "end to end." The most common, but at the same time the most complex technique. Used after removal of part of the sigmoid colon.
- Intestinal anastomosis "side to side." The simplest type. Both parts of the intestine are turned into stumps and sutured on the sides. This is where the bypass intestinal anastomosis relates.
- The method of "end to side". It consists in turning one end into a stump and sewing the second on the side.
Mechanical anastomosis
There are also alternative ways of applying the three types of anastomoses described above using special staplers instead of surgical sutures. A similar method of applying an anastomosis is called hardware or mechanical.
There is still no consensus on which of the methods, manual or hardware, is more efficient and gives fewer complications.
Numerous studies conducted to identify the most effective way to apply anastomosis often showed conflicting results. Thus, the results of some studies spoke in favor of manually applying an anastomosis, others - in favor of mechanical, according to the third, there was no difference at all. Thus, the choice of the method of the operation lies entirely with the surgeon and is based on personal convenience for the doctor and his skills, as well as on the cost of the operation.
Preparation for the operation
Before conducting an anastomosis of the intestine, thorough preparation is necessary. It includes several points, each of which is mandatory. These items are:
- It is necessary to observe a non-slag diet. Boiled rice, biscuits, beef and chicken are allowed.
- Before the operation, you need to empty the intestines. Previously, enemas were used for this, now laxatives, such as Fortrans, are taken during the day.
- Before surgery, fatty, fried, spicy, sweet and flour foods, as well as beans, nuts and seeds, are completely excluded.
Insolvency
Insolvency is a pathological condition in which the postoperative suture "leaks" and the contents of the intestine go beyond its limits 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 delimited in any way. In this case, the patient's condition worsens, symptoms of diffuse peritonitis appear. Re-dissection of the anterior abdominal wall is necessary to assess the extent of the problem.
- Delimited leak. Leakage of intestinal contents is partially restrained by the omentum and adjacent organs. If the problem is not resolved, the formation of an intestinal abscess is possible.
- Mini leak. Leakage of intestinal contents in insignificant volumes. Occurs in the later stages after surgery, after the intestinal anastomosis has already been formed. The formation of an abscess usually does not occur.
Insolvency
The main signs of failure of the anastomosis are attacks of severe abdominal pain, accompanied by vomiting. Increased leukocytosis and fever are also noteworthy.
Diagnosis of insolvency of the anastomosis is performed using an enema with a contrast agent, followed by an x-ray. A computer tomogram is also used. According to the results of the study, the following scenarios are possible:
- Contrast material freely enters the abdominal cavity. A CT scan shows fluid in the abdominal cavity. In this case, an operation is urgently required.
- Contrast material accumulates delimited. There is a slight inflammation, in general, the abdominal cavity is not affected.
- Leak of a contrast medium is not observed.
Based on the picture obtained, the doctor draws up a plan for further work with the patient.
Bankruptcy resolution
Depending on the severity of the leak, different methods are used to eliminate it. Conservative management of the patient (without reoperation) is provided in case of:
- Delimited insolvency. Apply abscess removal using drainage tools. Also produce the formation of a delimited fistula.
- Insolvency with a disconnected gut. In this situation, after 6-12 weeks, a second examination of the patient is carried out.
- Insolvency with the onset of sepsis. In this case, in addition to the operation, supporting measures are taken. These measures include: the use of antibiotics, normalization of the heart and respiratory processes.
The surgical approach may also be different, depending on the time of diagnosis of the failure.
With early symptomatic insolvency (the problem was discovered 7-10 days after the operation), a repeated laparotomy is performed in order to find the defect. Further, one of the following correction methods may be applied:
- Disconnection of the intestine and pumping of the abscess.
- The separation of the anastomosis with the formation of the stoma.
- Attempted secondary formation of anastomosis (with / without disconnection).
If stiffness of the intestinal wall is detected (caused as a result of inflammation), neither resection nor stoma formation can be performed. In this case, the defect is sutured / the abscess is pumped out or the drainage system is installed in the problem area in order to form a delimited fistulous course.
In the late diagnosis of insolvency (more than 10 days from the date of surgery) automatically speak of adverse conditions with relaparotomy. In this case, the following actions are taken:
- Formation of a proximal stoma (if possible).
- Influence on the inflammatory process.
- Installation of drainage systems.
- The formation of a delimited fistulous course.
With diffuse sepsis / peritonitis , sanitation laparotomy with wide drainage is performed.
Complications
In addition to leaks, the anastomosis can be accompanied by the following complications:
- Infection. It may be due to the fault of both the surgeon (carelessness during the operation) and the patient (non-compliance with hygiene rules).
- Intestinal obstruction. It occurs as a result of bending or sticking of the intestines. Requires reoperation.
- Bleeding. May occur during surgery.
- Narrowing the intestinal anastomosis. The patency is getting worse.
Contraindications
There is no specific indication when it is not necessary to conduct an intestinal anastomosis. The decision on the admissibility / inadmissibility of the operation is made by the surgeon based on both the general condition of the patient and the condition of his intestines. However, a number of general recommendations can still be made. So, anastomosis of the colon is not recommended in the presence of intestinal infection. As for the small intestine, preference is given to conservative treatment in the presence of one of the following factors:
- Postoperative peritonitis.
- The failure of the previous anastomosis.
- Violation of the mesenteric blood flow.
- Severe swelling or distension of the intestine.
- Patient exhaustion.
- Chronic steroid failure.
- General unstable condition of the patient with the need for constant monitoring of violations.
Rehabilitation
The main goals of rehabilitation are to restore the patient’s body and prevent a possible relapse of the disease, which caused the operation.
After the operation, the patient is prescribed drugs that relieve pain and discomfort in the abdomen. They are not specialized intestinal medicines, but are the most common pain medication. In addition, drainage is used to drain excess accumulated fluid.
The patient is allowed to move around the hospital 7 days after surgery. To accelerate the healing of the intestines and postoperative sutures, it is recommended to wear a special bandage.
If the patient is in stable good condition, he can leave the hospital within a week after surgery. 10 days after surgery, the doctor removes the stitches.
Nutrition with anastomosis
In addition to taking various medications, nutrition plays an important role for the intestines. Without the help of medical staff, patients are allowed to eat a few days after the operation.
Nutrition with intestinal anastomosis at first should consist of boiled or baked food, which should be served in crushed form. Vegetable soups are acceptable. The diet should include foods that do not interfere with normal bowel movement and smoothly stimulate it.
After a month, it is allowed to gradually introduce other products into the patient's diet. These include: cereals (oatmeal, buckwheat, pearl barley, semolina, etc.), fruits, berries. As a source of protein, you can enter dairy products (kefir, cottage cheese, yogurt, etc.) and light boiled meat (chicken, rabbit).
Food is recommended to be taken 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, high fever. You should not be afraid of this; similar processes are normal for the recovery period and pass with time. Nevertheless, with a certain periodicity (every 6 months or more often), it is necessary to undergo irrigoscopy and colonoscopy. These examinations are carried out as prescribed by the doctor, in order to monitor the work 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, imposing severe restrictions on the subsequent lifestyle of a person. However, most often, performing this operation is the only way to eliminate the pathology. Therefore, the best way out of the situation is to monitor your health and maintain a healthy lifestyle, which will reduce the risk of developing diseases that require anastomosis.