bowel decompression. Examination of the intestine with modern methods

If various diseases are suspected, an examination of the intestine is required. It involves examining the mucous membrane and determining peristalsis. Distinguish between small and large intestine. Inspection of the initial sections is difficult. Instrumental diagnostic methods are supplemented by laboratory tests, palpation and questioning of a sick person.

Instrumental examination of the intestine

Intestinal examination is performed according to certain indications. Patients can be both adults and children. There are endoscopic and non-endoscopic techniques. In the first case, the mucous membrane is examined from the inside using a camera. This is the most informative way to identify various diseases. It is necessary to examine a person if he has the following symptoms:

• persistent or intermittent abdominal pain;
• violation of the stool by the type of constipation or diarrhea;
• vomiting of feces;
• bloating;
• the presence of blood or other pathological impurities in the feces.

The following studies are most often organized:

• fibroesophagogastroduodenoscopy;
• colonoscopy;
• sigmoidoscopy;
• anoscopy;
• irrigoscopy;
• computed or magnetic resonance imaging;
• capsule colonoscopy;
• radionuclide research;
• radiography.

Sometimes a laparoscopy is performed. Therapeutic and diagnostic procedure, in which the organs of the abdominal cavity are examined from the outside. During the examination of patients, the following diseases can be detected:

• benign and malignant tumors;
• ulcerative colitis;
• Crohn's disease;
• diverticula;
• polyps;
• duodenal ulcer;
• duodenitis;
• enterocolitis;
• proctitis;
• haemorrhoids;
• anal fissures;
• condylomatosis;
• paraproctitis.

Endoscopic examination of the duodenum

FEGDS allows you to check the condition of the duodenum. This is an endoscopic method for examining patients. It allows you to examine only the initial section of the small intestine. FEGDS is often performed for therapeutic purposes. During the study, you can stop the bleeding or remove the foreign body. There are planned and urgent FEGDS.

The benefits of this study are:

• rapidity;
• information content;
• good tolerance;
• safety;
• low invasiveness;
• painlessness;
• the possibility of implementation within the walls of the clinic;
• availability.

The disadvantages include discomfort during the introduction of the probe and discomfort during the withdrawal of anesthesia. FEGDS is performed if the following pathology is suspected:

• ulcer;
• gastroduodenitis;
• bleeding;
• cancer of Vater's papilla;
• duodenitis;
• gastrointestinal reflux.

Before FEGDS preparation is required. It includes not eating immediately before the procedure and following a diet for several days. Spicy foods, nuts, seeds, chocolate, coffee and alcoholic beverages should be excluded from the diet 2-3 days before the study. Dinner on the eve should be no later than 18 pm.

In the morning you can not eat breakfast and brush your teeth. It is necessary to examine the duodenum and stomach in the supine position on the left side with the knees pressed to the body. A thin tube with a camera is inserted through the patient's mouth. Local anesthesia is carried out. This ensures a painless procedure. During the examination, the person should not talk. Saliva should be swallowed only with the permission of a doctor. You can eat only 2 hours after the study.

Contraindications for FEGDS are:

• curvature of the spinal column;
• atherosclerosis;
• neoplasms of the mediastinum;
• a history of stroke;
• hemophilia;
• cirrhosis;
• myocardial infarction;
• narrowing of the lumen of the esophagus;
• bronchial asthma in the acute phase.

Relative limitations include severe hypertension, angina pectoris, lymphadenopathy, acute inflammation of the tonsils, mental disorders, inflammation of the pharynx and larynx.

Performing an intestinal colonoscopy

The main instrumental method for diagnosing diseases of the colon in women and men is colonoscopy. It is classic and capsule. In the first case, a fibrocolonoscope is used. This is a flexible tube that is inserted into the intestine through the anus.

The possibilities of colonoscopy are:

• extraction of foreign objects;
• restoration of intestinal patency;
• stop bleeding;
• biopsy;
• removal of tumors.

How you can prepare for this procedure, not everyone knows. The main goal is to cleanse the intestines. For this, enemas or special laxatives are used. In case of constipation, castor oil is additionally prescribed. An enema is performed when a bowel movement is delayed. To carry it out, you will need a mug of Esmarch and 1.5 liters of water.

Within 2-3 days you need to follow a slag-free diet. It is forbidden to eat fresh vegetables, fruits, herbs, smoked meats, pickles, marinades, rye bread, chocolate, peanuts, chips, seeds, milk and coffee. On the evening before the procedure, it is required to clean the intestines. Used drugs such as Lavacol, Endofalk and Fortrans.

Colonoscopy is performed under local anesthesia. The procedure is less pleasant than FEGDS. A probe with a camera at the end is inserted into the rectum. The doctor examines all parts of the large intestine, starting with the rectum. The expansion of the intestine occurs due to the injection of air. This study lasts 20-30 minutes. The following complications are possible with an incorrectly performed colonoscopy:

• bleeding;
• perforation of the intestine;
• bloating;
• fever;
• pain.

If the general condition worsens after the procedure, you should visit a doctor. Normally, in a healthy person, the mucosa of the large intestine is pale pink. It is shiny, without ulcerative defects, protrusions and outgrowths, smooth with slight striation. The vascular pattern is uniform. Seals, pus, blood, fibrin deposits and necrotic masses are not determined. Absolute contraindications to colonoscopy are peritonitis, severe heart and respiratory failure, heart attack, severe ischemic stroke, and pregnancy.

X-ray examination of the intestine

Methods for examining the intestines include irrigoscopy. This is a type of radiography that uses a dye. This study allows you to determine the pathological changes in the mucosa. The bowel relief is assessed in detail. Contrasting is simple and double. In the first case, barium sulfate is used. In the second, air is additionally introduced.

The advantages of irrigoscopy are:

• safety;
• painlessness;
• availability;
• information content;

The condition of the colon (ascending, transverse and descending), sigmoid and rectum is assessed. It is recommended to inject contrast not through the mouth, but through the rectum using an enema. During the examination, the patient is on his side with his upper leg pressed to his stomach. A rectal tube is installed through which a barium solution is injected.

Then an overview photo is taken. After that, the examined person empties the intestines. Next, a second photo is taken. There are the following indications for irrigoscopy:

• suspicion of a tumor;
• blood in the stool;
• the presence of stool with pus;
• pain during bowel movements;
• bloating with stool retention;
• chronic constipation and diarrhea.

There are 3 main methods of preparation for the procedure:

• cleansing enemas;
• taking the drug Fortrans;
• carrying out hydrocolonotherapy.

A conclusion is drawn from the picture. Irritable bowel syndrome can be suspected if uneven folds-gaustras, areas of narrowing of the intestine in combination with incomplete excretion of contrast during defecation are detected. If during the examination an uneven diameter of the colon, a narrowing of the lumen against a background of spasm, and areas of asymmetric contraction are found, this indicates ulcerative colitis. Barium enema should not be performed in pregnant women, with intestinal perforation, diverticulitis, ulcers, and severe heart failure.

Conducting a capsule study

Modern methods of examining the intestines include capsule colonoscopy. Its difference is that nothing is introduced into the anus of the patient. It is enough to take one capsule, equipped with two chambers. The advantages of this study are:

• safety;
• simplicity;
• no need for anesthesia;
• no radiation exposure;
• minimally invasive;
• the possibility of examining the intestine without a cleansing enema.

The disadvantages include the inconvenience of processing the received data and the difficulty of swallowing. A picture of the intestine with a capsule is recorded on a special device that is worn on a belt. This study is of limited use. It is costly. A capsule examination is performed when it is impossible to carry out colonoscopy and barium enema.

Complications include a delay in the removal of the capsule. Some patients develop allergic reactions. The study is carried out on an outpatient basis. The person does not need to be in the hospital. After swallowing the capsule, you can go about your daily activities. Preparation includes the use of laxatives.

Examination with a sigmoidoscope

To examine the final sections of the intestine, sigmoidoscopy is often organized. The procedure is performed using a sigmoidoscope. It is a lighting device with a metal tube. The thickness of the latter is different. Using a sigmoidoscope, you can examine the mucosa of the sigmoid and rectum at a distance of up to 35 cm from the anus.

• pain in the anus during bowel movements and at rest;
• persistent constipation;
• unstable chair;
• bleeding from the rectum;
• the presence of mucus or pus in the feces;
• feeling of a foreign body.

The study is carried out in chronic hemorrhoids and inflammation of the colon. Sigmoidoscopy is contraindicated in acute anal fissure, narrowing of the intestine, massive bleeding, acute paraproctitis, peritonitis, heart and lung failure. The preparation is similar to that for a colonoscopy.

Immediately before the introduction of the tube of the sigmoidoscope into the anus, it is lubricated with petroleum jelly. The advancement of the device is carried out during attempts. To straighten the folds of the intestine, air is pumped. In the presence of a large amount of pus or blood, an electric pump can be used. If necessary, material is taken for histological analysis.

Other research methods

Magnetic resonance imaging is a modern method for diagnosing bowel diseases. It can be done with double contrast. The dye is administered intravenously and through the mouth. This method cannot replace a colonoscopy. He is supportive. The advantages of MRI are painlessness, information content and the absence of radiation exposure.

Layered pictures of the organ are taken. The doctor receives a three-dimensional image on the screen. Tomography is based on the use of magnetic fields. The latter are reflected from the nuclei of tissue hydrogen ions. Before an MRI, you need to clean the intestines and follow a diet for several days. The procedure takes about 40 minutes. Pictures are taken while the patient is holding his breath.

The patient is placed on the platform and the body is fixed with straps. The methods of examination of patients include anoscopy. With it, you can examine the final section of the intestinal tube. An anoscope is required. This is a device that consists of an obturator, a tube and a light handle.

Before anoscopy, a digital rectal examination is often required. This is done in order to assess the patency of the intestine. If necessary, an anesthetic ointment is used. Thus, if intestinal pathology is suspected, an instrumental study is mandatory. It is impossible to make a diagnosis on the basis of a survey, examination and palpation.

For the first time, the idea of ​​imposing a hole that would communicate the intestinal cavity with the external environment in order to decompress it, received its practical implementation in the form of an enterostomy operation, which was performed on a patient with a strangulated hernia by the French surgeon Renaut in 1772. Washp in 1879 reported on the imposition of an unloading ileostomy on a patient with a stenosing tumor of the ascending colon. The outcome of the operation was unfavorable due to mercury poisoning, taken by the patient on the eve of the operation as a laxative. A favorable outcome after such an operation was first achieved by MausN in 1883. From that moment, enterostomy, as a method of treating intestinal obstruction, began to be used in medical institutions in Europe and America. In 1902, at the Congress of German Surgeons, Heidenhain reported on the use of enterostomy in six patients with paralytic obstruction, four of whom recovered. By 1910, Krogis had already experienced 107 such interventions. The term "ileostomy" was proposed in 1913 by Brown, who reported the successful treatment of 10 patients with ulcerative colitis and intestinal obstruction in this way. In Russia, the use of ileostomy in the treatment of peritonitis and intestinal obstruction was supported by A.A. Bobrov (1899) and V.M. Zykov (1900).

However, with the accumulation of clinical material, many surgeons began to treat such operations with restraint, which was associated with severe purulent-septic complications and high mortality after stomas. So, I.I. Grekov in 1912 recommended replacing enterostomy by emptying overstretched loops of the intestine by puncturing it, followed by suturing the puncture hole. By this time, the first reports of successful treatment of intestinal paresis with a probe inserted into the stomach and duodenum appear.

Already in 1910, Westermann summarized the experience of treating 15 patients with peritonitis using active gastric aspiration.

CHAPTER 2

Content and gave her high praise. At the suggestion of Kanavel (1916), a duodenal probe was used for this purpose. Wangensteen by 1913 had the experience of treating 32 patients with peritonitis and intestinal obstruction in a similar way. An important event in improving the methods of intestinal decompression should be considered the proposal of T.Miller et W.Abbott (1934) to use a probe with a rubber cuff at its end to drain the small intestine. Peristaltic waves, pushing the cuff inflated through a separate channel in the aboral direction, should have ensured the advancement of the zonades along the intestinal tube. In view of the fact that the probe often folded up in the stomach and did not pass into the duodenum and jejunum, it subsequently received a number of improvements. So ”MO Cantor in 1946 proposed replacing the cuff with a canister filled with mercury. Promotion of the probe along the gastrointestinal tract was carried out due to the fluidity of mercury. In 1948, G.A. Smith proposed a flexible stylet to control the tip of the Zand. The passage of the probe into the jejunum was carried out under x-ray control. D. L. Larson et al. (1962) invented an intestinal tube with a magnet at the end. The movement of the probe was carried out using a magnetic field. However, despite technical improvements in the Miller-Abbott probe, this method later turned out to be of little use for draining the small intestine in conditions of persistent paresis. It required lengthy and complex manipulations associated with the forced position of seriously ill patients, frequent control x-ray studies, and, in addition, the presence of peristaltic activity of the intestine was required. At the suggestion of G.A. Smith (1956) and J.C. Thurner et al. (1958) the Miller-Abbott probe began to be used for transnasal intubation of the small intestine during surgery.

Interest in enterostomy as a drainage operation resumed after the development of suspended enterostomy by Richardson (1927) with the insertion of a probe into the intestinal lumen to feed patients suffering from stomach tumors, as well as Heller's (1931) proposal to use a gastrostomy for the treatment of paralytic ileus. At the same time, F.Rankin (1931) proposed to form an ileostomy outside the laparotomy wound. In Russia, for the first time, suspension enterostomy for the treatment of peritonitis and intestinal obstruction was performed by B.A. Petrov in 1935. But a more significant contribution to the development and promotion of this method was made by S.S. Yudin. He outlined a detailed description of the imposition of a suspended enterostomy in the work “How to reduce postoperative mortality.”

1Guest at the wounded in the stomach”, published in 1943. This technique was widely used during the Great Patriotic War in the provision of surgical care to the wounded in the stomach.

According to A.A. Bocharov (1947) and S.I. Banaitis (1949), it was performed in at least 12.8% of operations for gunshot wounds of the abdomen with intestinal damage. In the postwar years, a gradual decline in interest in enterostomy according to S.S. Yudin began. Many authors have referred to the fact that in case of paralysis of the intestine, it leads to unloading of only that part of the intestine on which it is imposed. In addition, the formed high enteric fistulas often led to exhaustion and death of patients. The attitude to this issue changed after J.W.Baxer in 1959 suggested using long intestinal probes when applying a suspended enterostomy and intubating the entire small intestine.

In our country, the technique of decompression of the small intestine through a suspended ileostomy using long intestinal probes was developed in detail in the early sixties by Professor I.D. Zhitnyuk. Since then, it has been called "retrograde intubation of the small intestine according to I.D. Zhitnyuk" and has been successfully used in the treatment of peritonitis and intestinal obstruction for thirty years.

J.M. Farris et G.K. Smith in 1956 for the first time gave an in-depth analysis and substantiated the advantages of draining the small intestine through a gastrostomy. Among domestic surgeons, this method became widespread after the publication by Yu.M. Dederer in 1962 of the results of treatment with gastroenterostomy in patients with paralytic ileus.

I.S.Mgaloblishvili in 1959 proposed to use appendicostomy for intubation of the small intestine. However, the method of enterostomy through the cecostomy, proposed in 1965 by G.Scheide, has become more widespread.

With the advent of new designs of nasoenteric probes, many surgeons began to give preference to closed methods of intraoperative drainage of the small intestine. Even such proponents and pioneers of open drainage methods as O.H. Wangensteen and J.W. Baker began to use nasoenteric drainage in the treatment of peritonitis and intestinal obstruction.

Thus, in the late fifties - early sixties, surgeons were already armed with a number of ways to de-

Compression of the small intestine, and the intestinal probe, according to H.Hamelmann und H.Piechlmair (1961), has become the same indispensable tool in the operating kit, like a scalpel and tweezers

Despite the fact that sixty years have passed since one of the first reports on the use of drainage of the small intestine in the treatment of paralytic obstruction, this method has become widespread in the last two decades. This became possible due to a deep study of the therapeutic possibilities of drainage of the small intestine and intra-intestinal tube therapy, as well as the improvement of methods and techniques of intubation, the improvement of the design of enterostomy probes and the use of high-quality polymeric materials in their manufacture. It has been established that the therapeutic effect of drainage of the small intestine is not limited to the elimination of intra-intestinal hypertension and the removal of toxic substances from the intestine. It has been experimentally established and clinically confirmed that long-term drainage of the small intestine improves microcirculation and blood supply to the mucous membrane, reduces general intoxication and toxemia, helps to eliminate dystrophic changes in the intestinal wall, reduces extravasation of fluid into its lumen, restores motor activity and absorption capacity, prevents relapses of paralytic and adhesive intestinal obstruction.

There is a single emptying of the small intestine and its long-term drainage. A single emptying is performed during the operation.

Long-term drainage can be performed both non-operatively and surgically. Non-surgical methods include: drainage of the small intestine using Miller-Abbott probes, nasoenteric endoscopic intubation, and transrectal intubation of the colon and small intestine. In turn, surgical methods of drainage are divided into closed, which are carried out without opening the lumen of the gastrointestinal tract, and open, when drainage of the small intestine is associated with the formation of artificial fistulas of the stomach or intestines. In addition, drainage of the small intestine is divided into antegrade and retrograde. With antegrade drainage, intubation is carried out from the side of the upper parts of the digestive tract in the aboral (caudal) direction, with retrograde, the intestine is intubated from the bottom up. Closed surgical methods include nasoenteric drainage and transrectal intubation of the small intestine.

__________________ 69

operating - drainage of the small intestine, enterostomy and cecostomy, In a separate group, combined methods that presuppose separate drainage of the upper and lower parts of the tonsil - kshpkiGa also through drainage of the entire intestine. With "binned drainage, at the same time it can be AND open and closed, as well as antegrade and retrograde intubation of the intestine.

21 NON-OPERATIVE METHODS OF DRAINAGE OF THE SMALL INTESTINE

Non-surgical method of drainage of the small intestine using probes of the Miller-Abbott type. T.Msheer and W.Abbott in 1934 reported on the successful use of a special probe for decompression of the small intestine, which is a long (up to 3.5 m) soft rubber tube up to 1.5 cm in diameter with one or more side holes at the end . The end of the probe is equipped with a cuff that inflates as the probe moves through the gastrointestinal tract. The patient swallows the probe and lies on the right side. Constantly sucking the contents of the stomach and small intestine, the probe gradually, every 30-40 minutes moves forward by 5-7 cm. The position of the probe in the intestine is controlled by X-ray examination. Peristaltic waves, pushing the inflated cuff in the aboral direction, ensure the advancement of the probe to the desired level. The entire procedure for draining the small intestine takes three to four hours. The subsequent improvement of the probe by replacing the rubber cuff with a canister of mercury (Cantor's probe) contributed to its faster progress through the intestines.

According to Yu.M. Dederer et al. (1971), this method can be effective only in the presence of intestinal peristaltic activity. In addition, it requires lengthy and complex manipulations associated with a change in the position of seriously ill patients and frequent control x-ray studies, but at the same time, successful attempts to insert a probe into the jejunum do not exceed 60%. R.E. Brolin et al. (1987) consider that the use of a closed drainage method using a Miller-Abbott probe is indicated in the presence of partial patency. The distinction between obstruction and partial patency is based on the interpretation of abdominal radiographs.

The authors consider the definition of gas in the small and large intestines to be the main radiological sign. Complete obstruction is characterized by the presence of gas in the small intestine with fluid levels. bones and the absence of gas in the colon, while in cases of partial patency, along with swollen loops of the small intestine, there is gas in the colon. The effect of treatment after inserting the probe into the intestine is evaluated during the first 6-12 hours. Surgical intervention was required in 38 of 193 (19%) patients with partial patency and 125 of 149 (84%) patients with radiological signs of complete obstruction.

Good results from non-surgical decompression of the small intestine were obtained by F.G. Quatromoni et al. (1989) in 41 patients with postoperative small bowel obstruction. In 10 patients who were re-operated, a mechanical form of obstruction was diagnosed, in one - the cause of persistent paresis was an abdominal abscess.

There are reports of successful treatment with Miller-Abbott and Cantor probes in patients with adhesive intestinal obstruction (Norenberg-Charkviani A.E., 1969; Hofstter S.R., 1981; Wolfson P. et al., 1985).

The introduction of a rigid probe with an olive into the duodenum and jejunum is widely used for emergency probe enterography in the diagnosis of acute intestinal obstruction. The probe in such cases is supplied with a metal conductor, the end of which is located 10 cm proximal to the initial part of the probe. Promotion of the probe from the stomach into the duodenum is controlled fluoroscopically. The passage of the probe through the pylorus is facilitated by deep respiratory movements, as well as the position of the patient on the right side with a turn on the stomach. To eliminate the spasm of the pyloric sphincter, 1 ml of prozerin is injected subcutaneously. After the probe passes over the ligament of Treitz, the metal conductor is removed. From 500 to 1000 ml of 20% suspension of barium sulfate is injected into the intestinal lumen. As a rule, a 20-30-minute x-ray examination provides complete information about the nature of the obstruction (Eryukhin I.A., Zubarev P.N., 1980). If the picture is unclear, x-ray examination is repeated after two hours. According to K.D. Toskin and A.N. Pak (1988), the diagnostic efficiency of probe decompression enterography is 96.5%. Detection of traces or accumulation of barium suspension in the caecum, as well as the image of the relief of the mucous membrane of the colon on radiographs, reject acute obstruction. The probe in such cases you-

Removes the decompression function and is used to introduce b

In connection with the widespread introduction of fibroscopic technique in yaichny practice, the possibility of non-surgical azoenteric endoscopic drainage of the initial sections of the small intestine has appeared. To date, two methods have been developed for inserting a probe into the small intestine using a fiberscope: through the instrumental channel of the apparatus and in parallel with it under visual control.

In the first case, the introduction of the probe is carried out for enteral nutrition and through the tube intra-intestinal correction of metabolic disorders. The diameter of the probe lumen in this case is 0.2 cm, which is quite enough for infusion. The second method involves the introduction of a probe for decompression of the initial sections of the small intestine and requires the use of probes with a lumen diameter of 0.4 to 0.8 cm.

In both cases, manipulations are performed by an endoscopist. According to Yu.M.Pantsyrev and Yu.I.Gallinger (1984), the method of introducing the probe through the instrumental channel of the endoscope is more effective and safe compared to the method of passing the probe in parallel with the endoscope. Of the 111 observations, none of the authors observed any complications. The number of unsuccessful attempts does not exceed 1.3%.

Indications for passing the probe through the instrumental channel of the endoscope are organic or functional disorders of the patency of the gastroduodenal zone of the digestive tract (ulcerative or tumor stenosis, impaired passage through the gastroentero- or gastroduodenal anastomosis, gastric atony, postoperative pancreatitis, etc.).

Anesthesia of the pharyngeal mucosa and premedication are carried out in the amount usual for diagnostic gastroduodenoscopy. First, an examination of the mucous membrane of the stomach and duodenum is carried out, the cause of the obstruction is established. With a preserved duodenal passage, the tip of the endoscope reaches the lower-horizontal part of the duodenum, after which an intestinal probe is inserted through the instrumental canal. As the probe moves into the intestinal lumen, the endoscope is removed. In patients with gastroenteroanastomosis, the endoscope is inserted 40-50 cm into the outlet loop of the jejunum Distal to the anastomosis. If the endoscope cannot be passed through the narrowing area, then an attempt should be made to pass the probe through the visible hole. It should be noted that in patients after resection

The stomach with atony of the stump and edema of the anastomosis area is not difficult to find from the mouth. When inflated with air, it opens easily and is freely overcome by the endoscope. The same situation may arise during the formation of pyloroplasty with a two-row suture and postoperative pancreatitis. With the phenomena of anastomosis, the endoscope is carried out by carefully pushing the walls of the anastomosis. After removing the endoscope, the free end of the probe is passed through the nasal passage and fixed to the skin of the face with an adhesive plaster or sutured to the wing of the nose. An additional tube is inserted into the stomach. Before the introduction of nutrient mixtures and infusion solutions, the position of the probe and its patency are controlled radiologically using liquid radiopaque substances.

Endoscopic decompression drainage of the initial sections of the small intestine is carried out with confidence in the absence. the need for emergency surgery. According to R.E. Brolin et al. (1987), the main indication for its implementation is the need for urgent differential diagnosis between acute small bowel obstruction and other diseases that are accompanied by impaired passage through the small intestine. G. F. Gowen et al. (1987) and L. Stilianu et al. (1988) put broader indications for endoscopic drainage of the small intestine and recommend a decompression probe as a stage of preoperative preparation in most cases of intestinal obstruction. According to the authors, this makes it possible to avoid unnecessary laparotomies, secure endotracheal anesthesia, less traumatic revision of the abdominal organs, and thereby reduce the duration of surgical intervention. As evidenced by the data of T.P. Gurchumelidze et al. (1990), the greatest success with endoscopic intubation can be achieved in the treatment of patients with postoperative paresis or early adhesive small bowel obstruction. In 40 out of 54 patients, postoperative small bowel obstruction was resolved by the authors by endoscopic insertion of a probe into the proximal jejunum. The rest of the patients underwent surgery within 12 to 48 hours due to the lack of positive dynamics.

"tGya carrying out decompression probes should be used-

"Lisie and long gastrointestinal apparatuses (GIF-P3, *SqGIF-QW, GIF-D4 from Olympus, TX-7, TX-8 slim from ACM" or their analogues).

^ jq v. sinev et al. (1988) suggest pre-inserting the probe channel with a metal string that allows the probe tip to be manipulated. The stiffness of the probe is reduced by gradually withdrawing the string. Yu.M.Pantsyrev and K) I.Gallinger (1984) recommend stitching the probe with 5-6 silk ligatures in the initial part or applying ribbons, which are located at a distance of 4-5 cm from each other. They serve to capture them with biopsy forceps. Thus, it is easy to give the desired direction of the initial part of the probe, especially when passing it from the stomach through the bends of the duodenum.

Before starting endoscopic drainage, the stomach is emptied.

In the position on the left side through the nasal passage into the cardial part of the stomach, an intestinal probe with a diameter of 0.6-0.8 cm is passed.

A fiberscope is inserted into the stomach and, under visual control, the probe moves towards the pylorus.

An indispensable condition for the successful passage of the probe along the greater curvature to the pyloric canal is a good air expansion of the stomach. The presence of ligatures fixed to the probe makes it easier to move the probe into the duodenum. For this, the following approach is used. After detecting the initial end of the probe, the first ligature is captured with biopsy forceps, by pulling it up, the probe is pressed against the endoscope and in this position is passed into the duodenum. After removing the biopsy forceps from the ligature, the endoscope returns to the stomach, where the next ligature is captured. The manipulation is repeated until the probe reaches the lower horizontal part of the duodenum or passes beyond the ligament of Treitz. In the absence of ligatures fixed to the probe, the probe is grasped with forceps by the side holes.

After making sure that the probe is passed into the small intestine, the endoscope is removed. After removing the endoscope from the probe, the string is removed. The position of the probe and the condition of the intestine are monitored by X-ray examination. To facilitate the insertion of the probe, Yu.M. Pantsyrev and Yu.I. Gallinger (1984) developed an endoscopic technique of intubation along a metal guide. Endoscope under visual control as much as possible

Into the duodenum. Then through___ g #-""-"breathe

a long and rigid metal spiral probe with a twisted end is inserted into the lumen of the intestine - a wire "with a diameter of 0.2 cm. The endoscope is removed, and the intestinal probe is attached to a metal conductor and inserted through it into that intestine.

Drainage with a fiberscope is usually well tolerated by patients and takes a relatively short time - from 10 to 30 minutes. The greatest difficulties arise when the probe passes through the region of the ligament of Treitz. This manipulation can be facilitated by the use of a probe with an air balloon on its initial part (Gowen G.F. et al., 1987). The probe is inserted into the descending part of the duodenum. The balloon is inflated, and further advancement of the probe is carried out due to peristaltic waves that occur as the bowel is emptied. However, T.P. Gurchumelidze et al. (1990) consider intubation complete only when the tip of the probe is distal to the ligament of Treitz or at the level of the duodenojejunal fold. Their analysis of serial radiographs showed a gradual spontaneous migration of the probe in the diotal direction.

An obligatory condition after the end of drainage is active decompression of the intestine. For this purpose, B.G. Smolsky et al. (1980) and Yu.V. Sinev et al. (1988) suggested using a probe with two channels - perfusion and aspiration. Both channels open at different levels in the intestinal lumen, which makes it possible to carry out not only decompression, but also active intestinal dialysis or enterosorption.

With adequate decompression of the initial sections of the small intestine during the first day after intubation, the amount of aspiration content when creating a negative pressure of 30-40 mm of water. is at least 1500 ml, on the second day - about 1000 ml, on the third - 800 ml.

In addition, a double-lumen probe allows you to examine the digestive and suction function of the upper small intestine and, in accordance with the examination data, select media for enteral nutrition.

Non-surgical transrectal decompression of the colon and small intestine is most often used to resolve obstructive colonic obstruction or to eliminate volvulus of the sigmoid colon.

Complete obstruction of the intestine by a tumor is rare, but

“Permeability appears when the lumen narrows to its deo< 5 х0 д ИМ0 учитывать, что сужение кишки бывает & * 0 не только самой опухолью, но и воспалением окружа- о б уСЛ °тканей и отеком слизистой оболочки. Важное значение при г 0111 * еет функциональное состояние баугиниевой заслонки. В случаев она нормально функционирует даже при далеко за- формах толстокишечной непроходимости, а у 20% боль-^юдается ее функциональная несостоятельность, что ведет * savory colonic contents into the small intestine, its mechanical overstretching and the development of paresis. The colonic obstruction that has developed in this way enhances endogenous intoxication and toxemia and may be accompanied by the development of endotoxin shock.

Decompression of the colon with a rectoscope can only be performed with low-lying tumors of the rectum. After a cleansing enema, the patient undergoes sigmoidoscopy, and through the canal into the stenosing lumen of the tumor, a gastric tube richly moistened with vaseline oil with two or three side holes and a rounded end is passed. If the tumor is located above 30 cm from the anus, a fibrocolonoscope can be used to perform decompression. However, bowel lavage through the manipulation channel of the endoscope, as a rule, is ineffective. Most often, with the help of a fibrocoloscope, the place of narrowing is found and expanded, and then, under the control of vision, an enterostomy tube is passed through the visible gap of the channel above the place of the obstacle. In this case, you can use the same techniques as for endoscopic drainage of the initial sections of the small intestine. An endoscope can be passed through a stenotic tumor if it has exophytic growth, and the lumen is deformed due to polypoid growths on the surface of the tumor. To expand the lumen of the channel in the tumor, it is proposed to use electro- and laser photocoagulation (Mamikonov I.L. and Savvin Yu.N., 1980). However, it must be remembered that excessively violent manipulations can cause damage to the intestinal wall and intense bleeding from the tumor.

As the probe advances, the contents of the colon are evacuated with Janet's syringe or with the help of vacuum suction. In most cases, without the control of a fibrocolonoscope, it is not possible to pass the splenic or hepatic flexures of the colon with a probe. However, to decompress the colon and resolve the obstruction, emptying is often sufficient.

76__________________________________________ CHAPTER 2

dietary divisions. The probe is removed from the intestinal lumen on the second day.

Drainage of the small intestine by passing a probe through the Bauginian valve using a fibrocolonoscope is still considered only theoretically and is unlikely to find wide clinical application in the near future. According to Yu. V. Sinev et al. (1988) "introducing the probe in this way into the distal small intestine becomes possible only with careful emptying of the large intestine from the contents. At the same time, an eaterostomy probe with a lumen of no more than 0.3 cm can be passed through a biopsy channel with a diameter of 0.5 cm, which is not enough for full decompression.

2.2. SURGICAL METHODS OF DRAINAGE OF THE SMALL INTESTINE

2.2.1. Single methods of decompression of the small intestine

There are various ways to empty the small intestine once during surgery.

In some cases, decompression of the small intestine is carried out without opening its lumen by sequential extrusion (“milking”) of the contents retrogradely into the stomach or, more often, antegradely into the large intestine. Despite the fact that the majority of authors speak out against this method, considering it traumatic and ineffective, there are also its supporters. Thus, P.D. Rogal and A.A. Plyapuk (1977) in patients with intestinal obstruction recommend using a sparing technique of a single movement of the intestinal contents to the underlying sections.

GG consists in the fact that after the cause has been eliminated, the obstruction - the perforating surgeon with a wet gauze napkin holds 111 lu of the intestine between the first and the remaining fingers of the left hand, covering its lumen, and between the second and third fingers of the right ru "And stretches it, easily bringing it closer walls (Fig. 17). In this way, the contents of the intestine move to the underlying sections. At this time, the assistant intercepts the intestine freed from the contents every 15-20 cm.

In some cases, to free the intestine from its contents, it is punctured with a thick needle. However, in this way it is not always possible to free even a separate loop of the intestine from gases, and even more so from liquid contents. In order to achieve sufficient emptying of the intestine, it must be punctured in many places, which is ineffective and dangerous in relation to infection of the abdominal cavity. Therefore, this method is applied

fti ">

Glavd

Rice 19. Emptying the fine nozzle help electric pump,

very rarely. Much more often, a specially designed trocar with two side holes is used for this purpose (Dederer Yu.M., 1971). One of them with a wide lumen is connected to an electric suction, the second is smaller and serves to flush the tube if it is clogged with dense contents. The wall of the overstretched small intestine is pierced with a trocar stylet in the center of the previously applied purse-string suture. The stylet is raised to the upper position, and the sleeve moves along the intestinal lumen (Fig. 18). Intestinal contents are evacuated using an electric pump. To empty the nearby loops, the intestinal contents are either “chipped off” to the puncture site, or a probe is inserted into the intestine through the end opening of the trocar. After the evacuation of the intestinal contents, the trocar is removed, the purse-string suture is tightened, and two or three serous-muscular sutures are additionally applied.

Many surgeons perform an enterotomy to empty the small intestine. Between two threads-holders, an electric suction tip is inserted into the intestinal lumen and with its help, the nearest sections of the intestine are first released, and then other overstretched intestinal loops are strung on the suction tip (Fig. 19). N. Balsano and M. Reynolds (1970) suggested using a Foley catheter No. 22 for aspiration of contents from the small intestine.

Rns. 20. Single emptying knshkn with a Foley catheter.

the bosom of the catheter is filled with 3 ml of water, which ensures its free movement, prevents the mucous membrane from sticking to the probe opening and prevents leakage of small intestinal contents through the enterotomy opening in addition to the probe (Fig. 20). At the end of the procedure, the hole in the intestine is sutured in the transverse direction with a two-row suture.

Emptying the small intestine through one of the ends of its resected section is a fairly common method of single decompression. Removal of the contents of the intestine in this case is carried out using the tip of the electric suction or by passing a probe into the lumen of the intestine. After emptying the intestine, its continuity is restored or the proximal end is brought out in the form of an enterostomy.

Despite their apparent simplicity, these methods have a number of significant drawbacks. They are not aseptic and can lead to microbial contamination of the operating field. These methods can only empty the nearest intestinal loops. In addition, there is a danger of failure of the sutures placed on the altered intestinal wall. Therefore, recommendations to perform a single decompression of the small intestine by closed methods transnasally or transrectally are fully justified.

2.2.2. Nasoenteric drainage

The serial production of standard nasoenteric probes, the need for a special opening of the lumen of hollow o nov and the formation of external gastric or intestinal cheeks made it possible to recommend nasoenteric drainage as the method of choice for the prevention and treatment of enteral insufficiency.

For this purpose, probes are currently used, made of durable elastic material, resistant to the effects of gastric and intestinal contents, having thermal lability, radiopacity and not containing harmful chemical impurities. Their diameter does not exceed 1.2 cm, the channel lumen is 0.8 cm. in the form of an olive, which is made of the same material, has the same diameter and is dumbbell-shaped connected to the main part of the probe (Fig. 21). At a temperature of 37°C and above, the probe becomes soft and does not injure the intestinal wall. In the absence of a standard probe, nasoenteric drainage can be performed using a long (250-300 cm) rubber or silicone tube with a lumen of 0.4-0.8 cm. To give the probe elasticity, a stainless wire mandrel is inserted into its lumen. The initial part of the probe is closed with a plug cut out of rubber or silicone, which makes manipulations safe. The end of the mandrin should be made in the form of an olive-shaped thickening, which greatly reduces the injury to the mucous membrane when the probe is passed through the lumen of the esophagus, stomach and duodenum. For free sliding of the conductor, the inner surface of the probe is lubricated with vaseline oil or glycerin. As a conductor, biopsy forceps of a fibrogastroduodenoscope or a fluoroplastic catheter with a diameter of 0.2 to 0.3 cm can be used.

There are reports of drainage of the small intestine using a soluble probe made from synthetic protein (Jung D. et al. "1988). The dissolution of the probe in the intestinal lumen occurs on the 4th day from the moment of intubation. The authors used the probe in the treatment of 52 patients with adhesive intestinal obstruction. Complications associated with the stay of such a probe in the lumen of the intestine and stomach, as well as relapses of adhesive obstruction were not observed.

After deciding on nasoenteric drainage, the surgeon

Rice. 21. Single translucent nasoenteric probe.

examines the upper abdomen. Frees the subhepatic space from adhesions and adhesions. Palyshtorno assesses the condition of the abdominal esophagus, stomach and duodenum. Examines the area of ​​the duodenojejunal flexure.

During the adhesive process, the small intestine is secreted throughout. Deserated areas are sutured prior to intubation. In the presence of a tumor of the cardioesophageal zone, a chronic gastric or duodenal ulcer, a stenosing tumor of the gastric outlet, one should refuse to pass the probe through the stomach and intubate the small intestine using one of the retrograde methods.

Before inserting the intestinal tube into the esophagus, the anesthesiologist controls the stretching of the cuff of the endotracheal tube. Zon-Dom empties the stomach. Complete relaxation and depth of anesthesia are achieved. The olive of the intestinal probe is abundantly lubricated with vaseline oil, and its free end is connected to the electric suction system.

The anesthesiologist through the external opening of the nasal passage moves the probe into the esophagus. You can enter the probe through the mouth. However, in the postoperative period, this position of the probe can cause vomiting and disrupt the act of swallowing. Therefore, after the end of intubation, the free end of the probe is transferred to the nasal passage (Fig. 22).

mixing up the shields in the cartilage.

.

Rice. 22. Transfer of the nasoeutheral tube from the oral cavity to one of the vossial passages.

In 80% of cases, the probe is inserted into the esophagus without much effort. But sometimes there are difficulties during intubation due to the pressure of the intubated trachea on the anterior wall of the esophagus, insufficient or excessive elasticity of the probe, narrow nasal passage, curvature of the nasal septum,

To eliminate compression of the esophagus by an intubated trachea, upward displacement of the thyroid cartilage may be effective (Fig. 23). If there is no effect, you can use the following method. The index finger of the right hand is inserted into the oral cavity, the tip of the probe is groped and pressed against the back wall of the pharynx, and the probe is pushed into the esophagus (Fig. 24). Sometimes the passage of the probe is controlled using a laryngoscope (Fig. 25).

Yu.P. Svirgunenko et al. (1982) and B.K. Shurkalin et al. (1986) for the successful advancement of the probe through the esophagus proposed to intubate it with an endotracheal tube (Fig. 26). According to the authors, the endotracheal tube installed in the esophagus reliably performs the role of a conductor "facilitates the passage of the probe into the stomach and protects the mucosa of the nasopharynx and esophagus from

control

In addition, with the help of an inflatable cuff, the respirator - ^ gI are protected from getting into them the gastrointestinal

yaye

s pzhi mogo. For the same purpose, E.S. Babiev (1983) proposed to study a probe-conductor up to 100 cm long and 1.5 cm in diameter.

"th lumen is inserted the initial part of the intestinal probe, after which both probes move into the stomach. The guide probe is removed

after * the end of the testinal probe with side holes is in the duodenum. In G. Dorofeeev et al. (1986) successfully use a thick rubber gastric "tube" as a guide tube.

V.V.Izosimov and V.A.Borisenko (1984) recommend conducting a probe-guide along the entire length of the small intestine. A thin PVC tube is used as an intestinal probe. The probe guide is removed after the end of intubation. P.Yu. Plevokas (1989) improved the probe-conductor to a large extent by equipping it with metal rings. The rings create protrusions on the wall of the probe that are convenient for gripping, holding and holding the probe through the intestine. The length of the guide probe is 170-200 cm, the outer diameter is 1.2 cm. The inner tube, which is left in the intestinal lumen for its decompression, has a length of 300-350 cm, and a diameter of 0.5 cm.

As the probe advances, the surgeon from the side of the abdominal cavity directs it along the greater curvature of the stomach and fixes it with the right hand in the region of the exit section. With the left hand, the end of the probe is directed through the pylorus into the duodenal bulb. Often, a spasm of the pyloric sphincter interferes with the progress of the probe. The reason for this may be traumatic manipulations and the lack of coordinated actions of the surgeon and anesthesiologist. In such cases, the following technique may help manipulate the probe. With the right hand, through the anterior wall of the stomach at the border of its body and the antrum, the probe is captured at a distance of 2-3 cm from the olive. The pyloric pulp is fixed with two fingers of the left hand from the side of the duodenum. The ring of pyloric pulp under the control of the fingers of the left hand is "strung" on the olive of the probe (Fig. 27). As soon as the end of the probe is in the duodenal bulb, the surgeon with his right hand, synchronously with the movements of the anesthesiologist, advances the enterostomy tube in the distal direction. With the fingers of the left hand, he controls and directs its end down and backwards to the lower horizontal bend and further to the left towards the ligament of Treitz.

Forcing the movement of the probe through the intestine when feeling

________

CHAPTER 2

"

Rice. 27. Holding the probe in duodenum.

obstacles are unacceptable. In such cases, the duodenum is mobilized according to Kocher (Fig. 28).

When a probe appears in the initial section of the jejunum, it is grabbed by three fingers of the right hand and advanced 10-15 cm. In the stomach, the probe is placed along the lesser curvature.

An obstacle to the advancement of the probe in the area of ​​the duodenojejunal junction may be additional bends of the initial section of the jejunum, fixed by the ligamentous apparatus of the peritoneum or adhesions. In such cases, you should try to grab the olive of the probe and draw it in the distal direction with stringing movements (Fig. 29).

For the convenience of capturing the probe through the intestinal wall, recommending a number of devices. So, A.L. Prusov and N.S. Poshshdopulo (1983) proposed putting red rubber rings on the “working part” of the probe every 4 cm. Intubation is carried out through the mouth. After its completion, the probe is transferred to one of the nasal passages. AI Antukh (1991) uses gelatin to form thickenings of the esophagus. According to the author, gelatin sleeves dissolve on the third day under the action of intestinal juices and do not interfere with the extraction of the probe. For the same purpose, it was proposed to supply the initial part of the probe with one or more cuffs made of

Rice. 28. Carrying out the probe to the ligament Trend.

latex rubber (Miller-Abbott probe) (Nelson R.L., Nyhys L.M., 1979; Seidmon E.J. et al., 1984). The cuffs inflate in the stomach and thus create convenience when passing the probe through the bends of the duodenum.

To facilitate intubation of the intestine and prevent damage, some authors inflate it with oxygen or air (Prusov A.L., PapandopuloN.S., 1983; Weller D.G. et al., 1985). For this purpose, before intubation, a thin PVC tube with a diameter of 2-2.5 mm is inserted into the lumen of the probe with several lateral holes in its initial part, through which oxygen or air is supplied into the intubation time. With the help of this technique, D-G. Weller et al. (1985) was able to significantly reduce the trauma of the intestine, and the drainage procedure itself was performed within 30 minutes.

If the probe is folded in the stomach in the form of rings, then straighten 6141 It is possible by corrugating the initial section of the small intestine with

Rice. 29. Holding zonea to primary Department thin guts-

next pulling the probe in the distal direction. Less advantageous is the tightening of the probe by the anesthetist.

In the absence of intestinal paresis (Fig. 30), the probe advances due to the “stringing” of intestinal loops on it. Having corrugated 8-10 cm of the intestine, the surgeon simultaneously with the anesthetist pushes the ovary, straightening the intestine in the proximal direction. Bowel intubation in such cases can be accelerated* if the surgeon is manipulative.

Rns. thirty. Holding nasoenteric probe through the intestinal lumen.

to pool in the area of ​​the ligament of Treitz, and the assistant to direct the olive of the probe along the intestinal lumen.

Drainage of the small intestine by the transnasal method is carried out in most cases throughout its entire length (total nasoenteric drainage). However, there are reports (Gauens Ya.K. et al., 1985; Pashkevich I.F., Shestopalov A.E., 1989; Werner R. et al., 1984) about successful long-term decompression of the small intestine by draining only its initial section for 20-70 cm (proximal nasoenteric drainage). For these purposes, employees of the Moscow City Research Institute of Emergency Medicine named after. KV. Sklifosovsky developed a multi-channel multifunctional nasoenteric probe with several holes in its distal part. The probe is inserted during the operation for the ligament of Treitz by 50-70 cm.

However, to achieve adequate decompression in this way is possible only with moderate peritonitis and preserved HF1 peristalsis. In conditions of persistent intestinal paresis

	-

Rice. 81. The position of the nasoenteral probe in the digestive tract

intubation of the entire small intestine is required. In this regard, N.S. Uteshev et al. (1985) proposed to perform total intubation of the small intestine first, and after emptying it, insert a double-lumen probe 50 cm behind the ligament of Treitz.

It should also be noted that even in cases of total intubation of the intestine, soon after the restoration of its motility, the initial part of the probe is displaced in the proximal direction.

*rvm 24 hours after the operation, in the presence of peristaltic e o ^ti, the probe will be mixed by 15-20 cm, and by the fifth day, 2/3 of the small intestine remain intra-VV. To hold the probe in the *^ position M.Regent et al. (1974) and H.W. Waclawiczek ^iS?) consider it necessary to carry it out behind the Bauginian barrier-caecum. When using the Miller-Abbott? Kern probe (1980) and L. Nitzche et E. Hutter (1984), its fixation was carried out by inflating the cuff in the caecum. In this position, the authors left the probe for 7-8 days.

The impossibility of simultaneous separate drainage of the small intestine and stomach is the main disadvantage of standard nasoenteric probes. The difference in intraluminal pressure in the small intestine and stomach not only disrupts the drainage function of the probe, but also leads to stagnation of gastric and duodenal contents, which accumulates in the stomach as a result of intestinal paresis and impaired obturator function of the pyloric sphincter. Overfilling of the stomach increases the gag reflex and requires additional emptying.

Thus, out of 114 patients observed by us, in whom, for one reason or another, the lateral openings of the probe were left in the lumen of the stomach during transnasal intubation, in 67 (58%) the drainage function of the probe was possible only under the condition of active aspiration using a Janet syringe or vacuum suction . However, in 23 patients (20.8%), full decompression could not be obtained, and the evacuation of the contents of the stomach was carried out using an additional probe. In addition, it was impossible for these patients to produce a full-fledged intestinal therapy. Entered enterosorbents along the path of least resistance through the side holes first of all enter the stomach.

Vomiting during drainage with a single-lumen probe was noted in 36% of patients. At the same time, it occurred with the same frequency both in cases of leaving the side holes of the probe in the stomach, and without them. Among the postoperative complications in these patients, pneumonia and purulent tracheobronchitis are most often observed, the proportion of which is 21.1% and 12.7%, respectively (Table 22).

According to autopsy data, regurgitation of gastric contents during vomiting caused the death of 50 patients operated on for intestinal obstruction.

In this regard, when performing nasoenteric intubation

Table 22 The frequency of postoperative infectious-inflammatory

respiratory complications at transnasal drainage of the small intestine

91 34 57 , 249

35 21 11 5

Naeoenteral intubation with a single lumen probe:

Leaving holes

probe in the stomach

Without leaving a hole

probe in the stomach Separate drainage of the small intestine and stomach:

Separate probes

Double-lumen gastro-

enteral probe

Total:

Note. The probe in the lumen of the small intestine in the presented groups of patients was not younger than three days of the postoperative period.

insert an additional tube into the stomach. With its help, intestinal contents accumulating during intubation in the stomach are easily evacuated. It is technically more difficult to insert a probe into the stomach when nasoenteric intubation is performed. In such cases, a technique is used in which the probe is advanced into the esophagus with the index finger inserted into the oral cavity. To give the probe elasticity, a metal string is introduced into its lumen. The free ends of both probes are placed in one nasal passage and separately fixed to the wings of the nose.

In exceptional cases, an unloading gastrostomy is applied.

Separate drainage of the small intestine and stomach makes it possible not only to decompress the gastrointestinal tract, but also to carry out full-scale intra-gastrointestinal therapy. However, as experience has shown, drainage of the small intestine and stomach with separate probes has a number of disadvantages. Patients are more difficult to tolerate the presence of two probes in the throat and

At the same time, the emerging irresistible desire for nAoco*-^^^ does not stop even suturing them to the wings of the ulDVL. In particular, the presence of two probes in the esophagus and the esophagus is especially hard for patients of elderly and senile age, suffering from chronic diseases of the cardiovascular and dy-dj! 1 l noy systems. These patients are more likely to develop decubitus ulcers of the esophagus, and a violation of the closing function of the pdial sphincter, more often than with drainage with one probe, leads to reflux esophagitis and regurgitation of gastric contents. In this regard, various types of probes with separate drainage of the stomach and small intestine have been proposed in domestic and foreign literature (Gauens Y.K. et al., 1986; Tamazashvili T.Sh., 1986; Schmoz G, et al., 1983 ; Seidmon E.J. et al., 1984; Xaicala J. et al., 1985). However, most of them have a complex technical design and recommendations for reusable use, which is unacceptable for hospitals involved in emergency abdominal surgery. So, for the purpose of simultaneous and separate drainage of the stomach and small intestine, T.Sh. The valve passes the contents of the stomach and at the same time prevents the simultaneous flow of the intestinal. The probe proposed by E.J. Seidmon et al. (1984), in addition to two channels, it is equipped with cuffs, one of which, in order to prevent regurgitation of intestinal contents into the stomach, is inflated in the lumen of the duodenum. The stomach is drained through an additional channel of the probe.

It should be emphasized that the main disadvantage of the proposed multichannel probes is the small diameter of the channels intended for drainage of the intestine and stomach. As experimental and clinical studies have shown, the diameter of the lumen, which allows for adequate decompression of the gastrointestinal tract, must be at least 0.4 cm, which is currently technically acceptable in the manufacture of only two-lumen probes. The creation of three or more channels leads to an increase in the diameter of the probe, which makes it difficult to pass it through the nasal *ACs and the esophagus.

In this regard, we have developed a double-lumen nasogastro-enteral probe for simultaneous separate drainage of the dextrous intestine and stomach (priority certificate for the invention No. 4935940 dated May 12, 1991) (Fig. 32, Fig. 33). The probe is an elastic thermolabile and radiopaque polychlorinated

Rice. 33. General view of the gastroeutheral probe in serial production, Nil pipe with a plugged working end and a club-shaped guide part (A). The working part of the probe contains a channel (B) with 40-50 side holes located at a distance of 5 cm from each other, which serves for drainage of the small intestine, and a channel (C), in the initial part of which there are 3-4 holes for draining the stomach. The transition part (E) is a one-piece tube 30 cm long, which corresponds to the length of the duodenum. It is devoid of lateral openings and is a continuation of the intestinal canal. The gastric canal of the probe in the initial section of the transitional part is closed with a silicone sleeve, the diameter of which corresponds to 1/2 of the probe lumen. The length of the working part of the intestinal canal is from 1.6 m to 2 m. Diameter

k can be seen from the data presented in Table 22, in patients with a drained small intestine with a double-lumen gastroenteric probe, it decreased to 10.5% and was significantly less than in groups of patients who were drained with a single-lumen probe or with separate intestinal and gastric probes. The number of purulent tracheobron-hit decreased. This made it possible to expand the indications for transnasal intubation of the small intestine in elderly and senile patients.

ages.

In most cases, patients do not tolerate long-term presence of the probe in the nasopharynx and often remove it on their own already in the first hours after the operation. Therefore, it is necessary to securely fix the probe at the nasal passage. Most often, given the importance of long-term drainage of the intestine, the probe is fixed by suturing it to the wing of the nose. This is especially true for elderly and senile people, patients with unstable mentality, as well as with severe intoxication syndrome and delirium. G.-A.Sh. Kagan (1982), referring to the invasiveness of this method, suggested using a ligature previously held around the nasal septum to fix the probe. Patients in such cases, according to the author, experience less discomfort. E. J. Seidmon et al. (1984) proposed a special design that provides for the fixation of the probe in the nasal passages by inflating a cuff made of soft latex rubber. In addition, the probe can be fixed with bandage ribbons, the ends of which are held and tied around the head. R.Sh. Vakhtaigishvili and M.V. Belyaev (1983) propose to use a probe with a loop specially designed for holding a bandage bandage.

2.2.3. Transrectal intubation of the small intestine

(Doletsky S.Ya. et al., 1973; Topuzov V.C. et al., 1982; Ba^ G.A., Roshal L.M., 1991). This is due to the physiological and ash * tomo-topographic features of the child's intestines, as well as the difficulties in managing the postoperative period in this *■ category of patients with nasoenteral and transfistular drainage methods. In adults, the introduction of a probe through the large intestine into the small intestine is a more traumatic manipulation, especially when passing the probe through the splenic angle and Bauhin's valve. In addition, the tube, which has side holes in the lumen of the colon, is quickly clogged with feces and stops draining the intestine. Nevertheless, there are reports of the successful use of long-term transrectal intubation in the treatment of intestinal obstruction and peritonitis in adults (Zaitsev V.T. et al., 1977; Lyubenko LA. With et al., 1987; Griffen W., 1980). According to these authors, the proportion of transrectal drainage of the small intestine ranges from 9 to 11%.

There are many procedures for examining the intestines. This includes taking tests and examining “with your own eyes”. These are:

1. sigmoidoscopy;
2. colonoscopy;
3. irrigoscopy;

This article will discuss how colonoscopy is performed. Such a study is the introduction of a special probe into the patient's intestines through the anus. Colonoscopy allows you to establish the "big picture" of the colon, that is, to view on a special monitor the video received through the camera attached to the probe, all 130 - 150 cm of the colon. Special forceps built into the probe allow you to easily remove formations in the intestine - polyps - up to one millimeter in size and "take" them out with you for further research.

Just what the doctor ordered

Colonoscopy, like any other study, is not prescribed from the "bay of floundering." And for the appointment of this kind of medical intervention, the grounds must be very good. As a rule, a colonoscopy is prescribed in case of suspicion or detection of:

• bleeding of the gastrointestinal tract;
• polyps in the intestine;
• permanent intestinal obstruction;
• the initial stage of Crohn's disease;
• a complex of symptoms: low-grade fever of unclear etymology, anemia, weight loss;
• recurrent abdominal pain of unclear etymology;

Preparation for the procedure

no pills

So, you've been scheduled for a colonoscopy. Before conducting a colonoscopy, it is important to familiarize yourself with the procedure itself and, of course, the preparation for it. It is clear that when there are feces in the intestines, the examination is impossible, since, firstly, no one will see anything, and, secondly, the apparatus will obviously deteriorate.

Mandatory Diet

A colonoscopy diet is essential. She excludes from the diet foods that cause profuse stools and bloating. Such a diet should be started 2 to 3 days before the examination.

List of prohibited foods:

1. Black bread;
2. legumes;
3. Oatmeal, millet, barley porridge;
4. Greens (spinach, sorrel);
5. Apricots, apples, dates, oranges, bananas, peaches, grapes, tangerines, raisins;
6. Raspberry, gooseberry;
7. Beets, white cabbage, radishes, onions, radishes, turnips, garlic, carrots;
8. Carbonated drinks;
9. Milk;
10. Nuts;

1. Dairy products;
2. Broths from lean meats;
3. Unsavory cookies;
4. Wholemeal white bread;
5. Boiled beef, fish, poultry (low-fat varieties);

This diet will help to get rid of toxins and will not have time to get bored, as it is carried out only for 2-3 days before the colonoscopy.

On the eve of the procedure, the last meal should be no later than 12:00. Then you can drink tea, plain or mineral water, only tea is allowed for dinner. On the day of the examination, "meals" should consist only of tea or plain water.

Purgation

Even with a diet, there is a chance that feces will fall into the intestine at the time of the colonoscopy towards the probe. Let a small number, but they will be caught, since it is impossible to check “for sure” their absence or, conversely, their presence without, again, medical interventions. To 100% empty the intestines, you should resort to several methods of cleaning it.

Enema cleaning

Until recently, this method was the only one of its kind, therefore it is most often found among the people. To prepare the bowel for colonoscopy with an enema, repeat the procedure the night before and just before the examination.

In the evening, the intestines are cleaned twice - with an interval of 1 hour. Suitable times for cleaning are 20:00 and 21:00 or 19:00 and 20:00, respectively. The intestines should be washed to "clean" water. For one "approach" it is recommended to fill in one and a half liters of boiled water. That is, in the evening your intestines will “process” 3 liters of water. Evening cleaning can also be combined with taking laxatives.

In the morning, the intestines should also be washed twice: at 7:00 and at 8:00.

This method, despite its speed and convenience, has both a number of advantages and a number of disadvantages.

Medicines in progress

Bowel cleansing with Fortrans

The main advantage of this drug is that the drug is not absorbed in the gastrointestinal tract and leaves the body in the primary form. With the help of Fortrans, preparation for colonoscopy is extremely simple: the drug package must be diluted in 1 liter of water. The solution is taken in an amount at the rate of 1 liter per 20 kg of the patient's weight. On average, the volume of liquid drunk will be 3-4 liters.

Preparation for colonoscopy using Fortrans can be carried out in two ways:

This drug will not interfere with medical intervention, as it is specially designed for endoscopy procedures and X-ray examinations.

Dufalac as an option

Another tool that will help prepare your body and, in particular, the intestines, is Duphalac. This remedy is a mild and mild laxative and effectively prepares the intestines for intervention.

The drug should be taken the day before after a light lunch at 12:00 (later, as already mentioned, only liquids can be consumed). A 200 ml bottle should be diluted in 2 liters of water. Important: this solution should be consumed within 2-3 hours. After about an hour and a half, the patient will begin to defecate. The final emptying will follow three hours after the end of use.

Preparation with Flit

As for this drug, it appeared on the market quite recently, but is in great demand along with Duphalac and Fortrans.

The drug is taken on the eve of the examination 2 times. For the first time, Fleet in a volume of 45 ml should be diluted in 100 - 150 ml of cool water and drunk in one gulp immediately after breakfast. The second time, exactly the same dose of Fleet is taken in the evening after dinner. Before the examination, 2-3 hours before the examination, it is allowed to drink another dose of Fleet, prepared according to the already known "recipe" at 8:00 in the morning. If the interval between colonoscopy and medication is less than 2 hours, it should not be taken.

Preparation with Flit requires knowledge of some rules:

• For breakfast and dinner on the eve of the examination, there should be only water with a volume of at least 250 ml;
• For lunch, you should prepare meat broth, tea or juice, you can drink at least 750 ml of water;
• After each medication, you must drink at least 1 glass of cold water (the amount of liquid for drinking is not limited);
• The laxative effect occurs after about 30 minutes (may be longer, but not earlier), the maximum time after which the drug will act is 6 hours;

List of contraindications

Colonoscopy of the intestine is the cause of many complications, therefore, it is carried out in cases where there are simply no other, less traumatic, possibilities for checking.

Colonoscopy is contraindicated:

• pregnant*;
• with an exacerbation of Crohn's disease;
• with ulcerative colitis;
• during an attack of diverticulitis (during remission);

*- allowed in cases where only open bowel surgery is an alternative

In the process

A procedure such as a colonoscopy is carried out in special clinics. Before the colonoscopy, the patient is laid on his side. (mainly on the left). After the introduction of short-term anesthesia, when a person falls asleep, a colonoscope is inserted through the anus through the anus. Colonoscopy is carried out as follows: a special probe equipped with a camera and a flashlight is passed through the entire intestine, and the camera transmits the video to a special monitor.

The video is transmitted in HD format, and thanks to the video, the doctor can easily perform any actions without error. Live video also allows you to simultaneously conduct an examination and record readings on a card or outpatient sheet. When watching a video, the doctor, as a rule, immediately makes a diagnosis. The patient also has the opportunity, if not under anesthesia, to watch videos and examine his own intestines. Also, thanks to the video, the patient monitors the actions of the doctor.

It will not be possible to take the video with you even with a very strong desire. The colonoscope is also equipped with a set of instruments to remove a polyp, stop bleeding, and/or obtain intestinal tissue samples if needed. Colonoscopy is possible without anesthesia, and patients report only slight discomfort in the abdomen without any pain. The total duration of the study is about 30 minutes. For details on how a colonoscopy is performed, see the video.

And then what?

Colonoscopy is generally safe. However, like any medical intervention, it has a number of possible complications, such as:

You should immediately consult a doctor if, within a few days after the procedure:

• the temperature rose above 38 °;
• have pain in the abdomen;
• severe weakness is indicated, loss of consciousness occurs, dizziness is observed;
• there was vomiting, nausea;
• bleeding occurs from the rectum;
• diarrhea with blood appeared;

During a medical examination, almost every third patient reveals abnormalities in the digestive system. If the patient complains of pain in the abdomen and anorectal region, persistent constipation, bleeding from the rectum, he has weight loss, unfavorable blood counts (low hemoglobin, high ESR), then an experienced coloproctologist will definitely prescribe colonoscopy examination of the intestine.

Colonoscopy is a modern method of instrumental research used to diagnose pathological conditions of the colon and rectum. This procedure is carried out using a special device - a colonoscope, and allows you to visually assess the condition of the large intestine throughout its entire length (about 2 meters) in a matter of minutes.

The colonoscope is a flexible long probe, the end of which is equipped with a special illuminated eyepiece and a miniature video camera capable of transmitting an image to a monitor. The kit includes a tube for supplying air to the intestine and forceps designed for biopsy (taking histological material). Using a video camera, the device is able to photograph those parts of the intestine through which the probe passes, and display an enlarged image on the monitor screen.

This allows a specialist - a coloproctologist to examine the intestinal mucosa in detail and see the smallest pathological changes. Colonoscopy is indispensable for timely detection and this procedure has many possibilities, which is why experts prefer this study to other diagnostic methods.

Features of colonoscopy

What options does a colonoscopy examination provide?

The above features make the colonoscopy procedure the most informative diagnostic method. It is performed in many public and private medical institutions. According to the recommendation of the WHO (World Health Organization), as a preventive measure, it is desirable to undergo a colonoscopy once every five years for every patient after 40 years of age. If a person comes to the doctor with characteristic complaints, the study is prescribed without fail. What are the indications for this procedure?

Intestinal examination by colonoscopy is prescribed in the following cases:

In addition, colonoscopy is performed for suspected Crohn's disease, ulcerative colitis, and the presence of malignant tumors. The examination will help to identify manifestations of diseases (mucosal ulceration), and if a tumor is detected, take a piece of tissue for a biopsy.

Contraindications for the examination

There are some conditions in which a colonoscopy is undesirable, as the procedure can lead to serious complications. Colonoscopy is not done in the following cases:

In such conditions, the risk to the patient's health during the procedure is too high, so colonoscopy is replaced by other, alternative methods of examination.

How to prepare for the procedure?

In order for the procedure to pass without difficulties and complications, preliminary preparation is necessary. Preparation for colonoscopy of the intestine includes two important points:

1. adherence to a slag-free diet,
2. quality bowel cleansing.

Diet before colonoscopy of the intestine (correct menu)

It is clear that the procedure requires a thorough and complete cleaning of the digestive tract. This is necessary in order to free the intestinal walls from toxins and remove feces, which will create obstacles when advancing the diagnostic probe. Preparatory measures should begin 2-3 days before the procedure. In this case, you do not need to starve, you just need to follow the instructions of the doctor and adhere to a special diet.

From the diet should be excluded:

All these foods are hard to digest or cause excessive gas formation in the intestines.

• Wholemeal wheat bread
• Lean boiled meat (beef, poultry) or fish
• Diet broths
• Dry biscuits (biscuits)
• Sour-milk drinks (kefir, curdled milk, natural yogurt)

On the eve of the procedure, the last meal is allowed no later than 12.00 hours. Then during the day you can drink liquid (water, tea). The last meal should be 20 hours before the start of the examination. On the day of the examination, it is forbidden to eat food, you can drink only weak tea or drinking water.

Further preparation for a colonoscopy of the intestine is to cleanse it. To do this, you can use one of two methods:

Cleansing with an enema

In order for the preparation to be of high quality, on the eve of the procedure and twice immediately before the examination.

On the eve, it is better to clean the intestines in the evening, with an interval of one hour, for example at 20.00 and 21.00. For a cleansing enema, use 1.5 liters of distilled warm water. That is, in the evening, 3 liters of liquid are injected into the intestines and washed until “clean” water comes out. In the morning, the intestines are also cleansed with an enema twice, with an interval of one hour. Mild laxatives or castor oil can be used to facilitate cleansing the day before procedures.

Purification with modern preparations

In many cases, it is quite difficult and sometimes very painful to make a high-quality bowel cleansing with enemas on your own, especially or inflamed hemorrhoids. Special preparations come to the rescue, facilitating and stimulating bowel movements. They must be taken the day before the procedure. Bowel cleansing before colonoscopy can be done with Fortans, which was created specifically to prepare for diagnostic studies.

The dosage of Fortans will be individually calculated by the doctor, based on the patient's body weight. The calculation is made from the ratio: one bag per 20 kg of weight. So, if a patient weighs 80 kg, then for a complete bowel cleansing, he needs 4 sachets of Fortrans. For one package, you need to take one liter of warm boiled water. Dissolve all 4 packets in this way. Take the solution should begin two hours after the last meal.

The entire prepared solution must be drunk, but this does not mean that you need to take 4 liters of the solution at a time. It is recommended to pour the liquid with the dissolved drug into a glass and drink it in small sips, with breaks of 10-20 minutes. Thus, taking breaks between glasses with a solution, you should drink the entire volume of liquid in about 2-4 hours. It turns out that the intake rate will be approximately one hour per liter of solution.

If you cannot drink the entire volume of liquid, because a gag reflex may occur due to a not very pleasant taste, then you can divide it and drink 2 liters in the evening and two more liters in the morning. To facilitate the intake, doctors advise drinking the solution in small sips, without holding it in the mouth, so as not to feel the taste. Immediately after taking the next glass, you can take a sip of lemon juice or suck on a piece of lemon, this will eliminate nausea.

After the last dose of Fortrans, defecation can continue for another 2-3 hours. Therefore, the time of application should be correctly calculated, and if you drink the rest of the drug in the morning, then the last glass of the solution should be drunk 3-4 hours before the start of the colonoscopy procedure. The drug Fortans is not absorbed into the bloodstream and is excreted unchanged, so you should not be afraid of an overdose.

In some cases, when using Fortrans, adverse reactions occur in the form of flatulence, abdominal discomfort or allergic manifestations.

Another effective drug that can be used to cleanse the intestines before a colonoscopy - Lavacol. It is applied in the same way. The difference is that the sachet with the drug must be dissolved in a glass (200 ml) of boiled water. For complete cleansing, you need to drink 3 liters of the solution, one glass every 20 minutes. This drug is easier to tolerate and has a salty taste, so side effects such as nausea and vomiting are rare. Recommended reception hours - from 14.00 to 19.00 hours. Some abdominal discomfort may occur after the first doses of the drug.

These products are designed specifically to prepare for endoscopic examinations, they clean the intestines qualitatively and gently, delivering a minimum of inconvenience to the patient.

How is a colonoscopy procedure performed?

The technique of the procedure is simple. Let's talk about the main nuances so that the patient can imagine how an intestinal colonoscopy is done.

Thus, visually examine the large intestine throughout. If no serious pathologies are detected, then the procedure takes about 15 minutes, while diagnostic or therapeutic actions may take more time.

If a biopsy is necessary, local anesthetics are injected through a special channel of the endoscopic device, then a small piece of tissue is cut off and removed with special forceps.

During a colonoscopy, polyps or small benign formations can be removed, for which a special loop is used, which captures the outgrowths at the base, cuts them off and removes them from the intestine.

How painful is the procedure?

Many patients are concerned about the pain of the upcoming manipulations. Before starting the procedure, the doctor should explain how an intestinal colonoscopy is done and resolve the issue of pain relief. In many specialized clinics, the procedure is done without anesthesia, since usually the manipulation does not cause severe pain.

The patient may feel some discomfort when air is injected to straighten the folds of the large intestine or when the diagnostic probe passes through some anatomical bends of the intestine. These moments are usually easily tolerated, doctors recommend listening to your body and, if severe pain occurs, immediately inform the specialist performing the manipulation. This will help to avoid complications such as damage to the intestinal wall. Sometimes during the procedure, there may be an urge to defecate, at such moments, doctors recommend breathing correctly and deeply.

In special cases, when the patient has an adhesive disease or acute inflammatory processes in the rectum, severe pain during the procedure is possible. In such a situation, colonoscopy of the intestine is done under anesthesia. Usually, anesthesia is short-term, since the procedure itself does not take more than 30 minutes.

There are several alternative research methods, these are:

But this procedure is still in many ways inferior to the classical colonoscopy. It does not allow to identify pathological formations, the size of which is less than 10 mm. Therefore, in many cases, such an examination is preliminary and after it a classic colonoscopy procedure is necessary.

After the procedure: possible complications

During the examination, air is pumped into the intestinal cavity. When the procedure is over, it is removed by suction with a colonoscope. But in some cases, an unpleasant feeling of discomfort and bursting remains. To eliminate these sensations, the patient is recommended to drink activated charcoal, which is previously dissolved in a glass of water. The patient is allowed to eat and drink immediately after the end of the examination.

The procedure should be carried out in a specialized institution, by a competent and experienced specialist. If the manipulation is carried out according to all the rules, then this method is completely harmless and does not entail adverse consequences. However, as with any medical intervention, there is a risk of complications:

• Perforation of the intestinal wall. It is noted in about 1% of cases and most often occurs as a result of ulceration of the mucosa or purulent processes in the intestinal walls. In such cases, urgent surgical intervention is performed to restore the integrity of the damaged area.
• Bleeding in the intestines. This complication is quite rare and can occur both during the procedure and after it. Eliminated by cauterization or the introduction of adrenaline.
• Pain in the abdomen after the procedure. Most often appear after the removal of polyps, eliminated by analgesics.

The patient should immediately consult a doctor if, after the colonoscopy procedure, he has a fever, vomiting, nausea, dizziness, weakness. With the development of complications, there may be a loss of consciousness, the appearance of bleeding from the rectum or bloody diarrhea. All of these manifestations require immediate medical attention. But such complications are rare, usually the procedure is successful and does not entail adverse consequences.

Colonoscopy is recommended for regular colonoscopy for people over 50 years of age. This allows you to detect colorectal cancer in the early stages of development and gives a chance to defeat the disease.

Price

The cost of colonoscopy in Moscow depends on several factors: the level of the clinic or diagnostic center, modern equipment, and the qualifications of endoscopists.

The average price for the procedure is in the range of 4500-7500 rubles. In some elite clinics, the cost of the examination can reach up to 18,000 rubles. With the use of anesthesia, the procedure will cost more. In general, the price of the examination is quite acceptable and affordable for any patient.

The ultrasonic rectal probe consists of two concentric tubes - external and internal. The inner tube moves freely inside the outer (fixed). A sensor operating at a frequency of 3.5 MHz is mounted in the inner end of the movable tube. The depth of insertion of the probe into the rectum and the angle of inclination are mechanically adjusted in accordance with the conditions of the study. When moving the inner tube in the longitudinal direction, it is possible to register echo signals from the bladder at any level. Transverse echographic scans of the pelvic organs surrounding the rectum (prostate and seminal vesicles) can be obtained by radial scanning with automatic 360° rotation of the oscillator disk inside the transducer. The tip of the probe, previously lubricated with petroleum jelly, is slowly inserted into the rectum to a depth of 8-9 cm. The tightness of the probe to the mucous membrane of the rectum is achieved by filling a small rubber balloon at its top with water. It also serves to protect the rectal mucosa from unwanted ultrasonic influences. Regulation of the depth of the probe introduced into the rectum is carried out by scanning at intervals of 0.5 cm from the base of the bladder and seminal vesicles to the top. The ultrasonic rectal probe is connected to a gray scale scanner for fast echo recording and improved image quality on the display screen. Conducting transrectal echography using a manual probe expands the information content of the method due to the possibility of its introduction into the rectum to a greater depth, above the base of the prostate gland, which makes it possible to obtain an echographic image of the bottom of the bladder and seminal vesicles. At the same time, the height of ultrasound scanning on the Aloka chair is limited to 10 cm. The advantage of performing echography with a rectal probe mounted in the chair is the preservation of stable research conditions, which is important for evaluating the results of repeated echographs in the process of monitoring patients or their treatment. This is due to the fact that a change in the angle of insertion of the rectal probe in relation to the longitudinal axis of the prostate gland during repeated studies inevitably affects the echographic picture and affects the final result of determining the volume of the gland. In case of perineal biopsy of the prostate in connection with suspected prostate cancer under ultrasound control, it is preferable to use a manual rectal probe to determine the “zone of interest” in the gland. Its introduction in some cases may be accompanied by pain, especially with anal fissures or rectal diverticula. Difficulties in the introduction of a rectal probe occur when the prostate adenoma is large, with its predominant growth towards the rectum or when the prostate cancer spreads to the walls of the rectum. In such cases, local anesthesia of the rectal mucosa with lidocaine is performed before the study. It should be borne in mind that the introduction of a rectal probe can cause vegetative-vascular crises, and the rapid entry of lidocaine into the blood in some cases contributes to a decrease in blood pressure and the development of collapse. To prevent these complications, before transrectal echography, it is necessary to examine the patient's cardiovascular system and identify pathological changes in the rectum.