Anastomosis is a 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. An artificial anastomosis is a surgical stitching of the intestines.
Types of intestinal anastomoses
There are different ways to carry out this operation. The choice of method depends on the nature of the particular problem. The list of anastomosis methods 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.
- Intestinal anastomosis "side to side". The simplest type. Both parts of the intestine are turned into stumps and stitched on the sides. This is where intestinal bypass comes in.
- The end-to-side method. It consists in turning one end into a stump and sewing the second on the side.
Mechanical anastomosis
There are also alternative methods of 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 gives fewer complications.
Multiple studies conducted to identify the most effective way of anastomosis, often showed opposite results. So, the results of some studies spoke in favor of manual anastomosis, others - in favor of mechanical, according to the third, there was no difference at all. Thus, the choice of the method of performing the operation lies entirely with the surgeon and is based on the personal convenience for the doctor and his skills, as well as on the cost of the operation.
Preparation for the operation
Before performing an anastomosis of the intestine, careful preparation must be made. It includes several points, the implementation of each of which is mandatory. These items are:
- You need to follow a slag-free diet. Boiled rice, biscuits, beef and chicken are allowed.
- Before the operation, you need to have a bowel movement. Previously, enemas were used for this, now laxatives, such as Fortrans, are taken during the day.
- Before the operation, fatty, fried, spicy, sweet and starchy foods, as well as beans, nuts andseeds.
Failure
Leakage is a pathological condition in which the postoperative suture "leaks", and the contents of the intestine go beyond it 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 in any way. In this case, the patient's condition worsens, symptoms of diffuse peritonitis appear. Re-incision of the anterior abdominal wall is needed 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 eliminated, the formation of a peri-intestinal abscess is possible.
- Mini leak. Leakage of intestinal contents in small volumes. Occurs late after surgery, after the intestinal anastomosis has already been formed. The formation of an abscess usually does not occur.
Finding Insolvency
The main signs of anastomosis failure are bouts of severe abdominal pain accompanied by vomiting. Also noteworthy is increased leukocytosis and fever.
Diagnosis of anastomotic failure is made with an enema with a contrast agent followed by an x-ray. A CT scan is also used. Bythe results of the study, the following scenarios are possible:
- The contrast agent freely enters the abdominal cavity. A CT scan shows fluid in the abdomen. In this case, an operation is urgently required.
- The contrast agent accumulates in a limited way. There is a slight inflammation, in general, the abdominal cavity is not affected.
- No contrast agent leaking.
Based on the received picture, the doctor draws up a plan for further work with the patient.
Fixing 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 case of:
- Limited insolvency. Apply the removal of an abscess with the help of drainage instruments. Also produce the formation of a delimited fistula.
- Insolvency when the gut is off. In this situation, the patient is re-examined after 6-12 weeks.
- Insolvency with the appearance of sepsis. In this case, supportive measures are carried out as an addition to the operation. These measures include: the use of antibiotics, the normalization of the heart and respiratory processes.
The surgical approach may also vary depending on the timing of the failure diagnosis.
In case of early symptomatic insolvency (the problem was detected 7-10 days after the operation), a second laparotomy is performed in order to find the defect. Then one of the following can be appliedways to correct the situation:
- Disconnecting the bowel and pumping out the abscess.
- Anastomosis separation with stoma formation.
- Attempt to reanastomosis (with/without shutdown).
If a rigid bowel wall (caused by inflammation) is found, neither resection nor stoma formation can be performed. In this case, the defect is sutured / abscess pumped out or a drainage system is installed in the problem area in order to form a delimited fistulous tract.
With late diagnosis of insolvency (more than 10 days after the operation), they automatically speak of unfavorable conditions during relaparotomy. In this case, the following actions are taken:
- Proximal stoma shaping (if possible).
- Influence on the inflammatory process.
- Installation of drainage systems.
- Formation of a limited fistulous tract.
In diffuse sepsis/peritonitis, a debridement laparotomy with wide drainage is performed.
Complications
In addition to leaks, anastomosis can be accompanied by the following complications:
- Infection. It can be the fault of both the surgeon (inattention during the operation) and the patient (non-observance of hygiene rules).
- Intestinal obstruction. It occurs as a result of bending or sticking of the intestines. Requires reoperation.
- Bleeding. May occur during surgery.
- Narrowing of the intestinal anastomosis. Impairs patency.
Contraindications
Notthere are specific guidelines for when an intestinal anastomosis should not be performed. 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 given. So, anastomosis of the colon is not recommended in the presence of an intestinal infection. In the small intestine, conservative treatment is preferred if one of the following is present:
- Postoperative peritonitis.
- Failure of the previous anastomosis.
- Impaired mesenteric blood flow.
- Severe swelling or distention of the bowel.
- Patient exhaustion.
- Chronic steroid deficiency.
- General unstable condition of the patient with the need for constant monitoring of violations.
Rehab
The main goals of rehabilitation are to restore the patient's body and prevent a possible recurrence of the disease that caused the operation.
After the operation, the patient is prescribed drugs that relieve pain and discomfort in the abdomen. They are not specialized medicines 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 accelerate the healing of the intestines and postoperative sutures, it is recommendedwear a special brace.
If the patient is in a stable good condition, 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 for the intestines. Without the help of medical staff, patients are allowed to eat a few days after the operation.
Food during intestinal anastomosis at first should consist of boiled or baked food, which should be served crushed. Vegetable soups are allowed. The diet should include foods that do not interfere with normal bowel movements and gently stimulate it.
After a month, it is allowed to gradually introduce other foods into the patient's diet. These include: cereals (oatmeal, buckwheat, 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 at rest, in small portions, 5-6 times a day. In addition, it is recommended to consume more fluids (up to 2-3 liters per day). The first months after the operation, the patient may suffer from nausea, vomiting, abdominal pain, constipation, diarrhea, flatulence, weakness, high fever. You should not be afraid of this, such processes are normal for the recovery period and pass over time. Nevertheless, with a certain frequency (every 6 months or more), it is necessary to undergo an irrigoscopy and a colonoscopy. Theseexaminations prescribed by a doctor, in order to monitor bowel function. 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 the subsequent lifestyle of a person. However, most often this operation is the only way to eliminate the pathology. Therefore, the best way out of the situation is to monitor your he alth and lead a he althy lifestyle, which will reduce the risk of developing diseases that require an anastomosis.
