RU2199958C2 - Method for treating esophageal atresia - Google Patents

Abstract

FIELD: medicine, juvenile surgery. SUBSTANCE: The present method deals with treating esophageal atresia in neonatals. Gastrotomy should be carried out. Temporal occlusion of distal tracheo-esophageal fistula is conducted with the help of blocking agent through gastric lumen. As a blocking agent one should use elastic hollow tube with detachable obturator at its external end. Tube should be fixed by ligature around esophagus before developing strangulated groove both at the tube and esophagus. Gastrostoma should be formed. In postoperational period it is necessary to improve sanitary conditions in distal esophageal department by sucking off bronchial mucus through the mentioned elastic tube. The method enables to develop controlled occlusion of tracheo-esophageal anastomosis. EFFECT: higher efficiency of therapy. 1 ex

Description

 The invention relates to medicine, namely to pediatric surgery, and can be used to treat esophageal atresia in newborns.

 The problem is caused by the anatomical and topographic features of this category of patients (newborns 1-5 days of life), the presence of aspiration pneumonia in this disease and, as a consequence, high mortality in the postoperative period.

 There is a method of treating atresia of the esophagus by temporary occlusion of the lower tracheoesophageal fistula, which ensures that gastric contents do not enter the tracheobronchial tree to prevent aspiration pneumonia (B. J. Leininger, Silastic banding of esophageal atresia and tracheoesofageal fistula // J. Pediatr.- 1972 .-Vol. 5, N 7.-P. 404-407). With the help of a silastic choke, the stomach contents are further prevented from entering the tracheobronchial tree and air is discharged into the stomach, which improves the patient's condition and allows time for the spontaneous growth of the proximal and distal sections of the esophagus, so that an esophago-esophago anastomosis can be applied.

 The disadvantage of this method is the danger of impaired circulation of the esophagus wall and the known uncontrollability of the blocking mechanism, often leading to the occurrence of the functioning of the pathological anastomosis.

 Known methods for the treatment of esophageal atresia in temporary occlusion of the tracheoesophageal fistula are endobronchial blockage of the tracheoesophageal anastomosis (N. C. Filston, WR Jr. Chitwood, B. Schkolne et al.-The Fogarty ball cateter as an ait to management of the infant with esophageal atresia and traheoesophageal fistula complicated by severe RDS or pneumonia || J. Pediatr.-1982.-Vol.5, N17.-P.149-151), Fogerti bolon catheter (MR Salem, AY Wong, YH Lin et all.- Prevention of gastric distension during anesthesia for newborns || Anestesiology- 1973.-N. 38, -P. 82-83) by the endotracheal tube.

 A disadvantage of the known methods is the impossibility of creating a complete mechanical separation of the cavity of the stomach and the tracheobronchial tree, and subsequently the mismatch of the diameters of the occlusal tube and the growing esophagus, as well as the inability to control and reorganize the blocked esophageal sigment.

 The closest to the achieved positive result is a method of treating atresia of the esophagus (V.G. Bairov. Repeated operations in children with atresia of the esophagus // -Dis. Doct. Medical Sciences. -S-Pb., 1998, p. 85- 93), which consists in temporary occlusion of the distal section of the atreated esophagus with a foam rubber blocker inserted into the esophagus through the gastrostomy. The undoubted advantage of the known method is the conduct of the main operation in parallel with the application of a gatrostoma necessary for feeding a child. However, the disadvantage of this method is the lack of sufficient visualization of the procedure and the risk of dislocation of the obturator, which often leads to the resumption of the functioning of the pathological anastomosis with all the ensuing complications.

 The authors in this paper suggest an effective method of treating atresia of the esophagus, which helps to prevent aspiration complications and control the dynamics of restoration of patency of the distal esophagus, followed by a radical operation: creating a direct esophago-esophago anastomosis.

 A positive result of the claimed method is to increase the effectiveness of treatment of esophageal atresia due to the fact that a complete, reliable, controlled, easily performed occlusion of the tracheoesophageal anastomosis is created simultaneously with the application of a gastrostomy for nutrition.

 A positive result is achieved by the fact that a flexible hollow tube with a removable obturator at the outer end is used as a blocker, which is fixed in the cardiac section by a paesophageal silk ligature until a strangulation groove forms on the tube.

 The method is as follows: after assessing the condition of the newborn, conducting the necessary laboratory diagnostic measures, preoperative preparation (infusion, antibacterial, oxygen therapy), the patient is transferred to the operating room. The operation is performed under endotracheal anesthesia using high-frequency jet lung ventilation under ketamine-fentanyl anesthesia. The position of the patient on the back with a lumbar roller. An upper-median laparotomy is performed, the stomach and the mobilized cardiac esophagus are brought out into the wound. A gastrotomy is performed in the cardiac section, an elastic hollow tube with a removable obturator at the end, which is fixed with an external silk ligature around the esophagus with a force sufficient to form a strangulation groove on the tube, is passed through the lumen of the stomach into the distal esophagus with the diameter of the aboral end of the esophagus. A gastrostomy is formed for nutrition. At the end of the elastic tube after evacuation of bronchial sputum from the distal esophagus, an obturator is fixed, the abdominal cavity is sutured tightly.

 By the end of the third week, when the patient is ligated after the operation, the elastic esophageal tube mobility indicates the eruption of the fixative ligature and restoration of the esophagus walls, which makes it possible to carry out a radical operation, namely the application of a direct esophago anastomosis.

Clinical example
Patient M., born on September 18, 1999 (medical history 4491), was admitted to the clinic of pediatric surgery on 09/21/99 on the 3rd day after birth in a very serious condition: with severe respiratory failure amid aspiration pneumonia, with prematurity of the 3rd degree (body weight 1400 g), hemolytic anemia . The diagnosis of atresia of the esophagus with a lower tracheoesophageal fistula was established in the Central District Hospital on the third day after birth. When feeding a child, regurgitation of food through the nasopharynx and oropharynx was noted, the child was choking, chenille. When radiography - the oral end of the esophagus is located at the level of the first thoracic vertebra, in the gastrointestinal tract a large amount of gas, the phenomenon of severe pneumonia, i.e., shortness of breath up to 70 per minute, heart rate up to 180 per minute.

 After preoperative preparation for 12 hours (warming in the incubator, infusion therapy, sanitation of the tracheobronchial tree, antibacterial, hemostatic therapy, aspiration of mucus and sputum from the mouth, nasopharynx, oxygen therapy), the child underwent surgery. The patient's position on the back with a roller under the lower back. Endotracheal anesthesia using high-frequency ventilation of the lung under ketamine-fentanyl analgesia. An upper-median laparotomy was performed from the xiphoid process of the sternum to the navel. The stomach is withdrawn into the wound, the cardial part of the esophagus is mobilized around the perimeter (the latter has a diameter of 6 mm). A gastrotomy was performed in the cardial part of the stomach, an elastic hollow tube with a diameter of 0.5 cm with an obturator (plug) was inserted into the distal esophagus through the wound of the stomach at the outer end of the tube. Around the esophagus in its cardial section, silk ligature -4 was performed, tight fixation of the hollow tube to the wall of the esophagus with the formation of a strangulation groove on the esophagus and on the tube was provided. Two purse string sutures were put on the wound of the stomach, a gastrostomy according to Kader was formed through a separate puncture of the skin in the left hypochondrium. Nearby, the 2nd gastrostomy was formed according to Kader with a nutritional purpose, then the abdominal cavity was sewn tightly.

 The postoperative period was uneventful, feeding through the gastrostomy began in a day. The patient received antibiotic therapy, infusion therapy for 7 days. Sutures were removed on the 14th day - healing by first intention. The child's condition improved: the phenomena of pneumonia stopped (shortness of breath decreased to 40 per minute, heart rate 120-130 per minute, body weight 1780 g). The patient was sanitized by the distal esophagus by aspirating bronchial sputum through an elastic tube. On the 16th day after the operation, the mobility of the endotracheal tube located in the distal esophagus is noted, the tube is removed, silk ligature is noted on its wall.

 The patient had an x-ray of the esophagus with contrast: the oral end of the esophagus is at the level of the 3rd thoracic vertebra, the phenomena of aspiration pneumonia are stopped. The operation was performed - the application of a direct anastomosis through the posterolateral extrapleural torocotomic access in the 4th intercostal space. It was found intraoperatively that the diameter of the distal esophagus is 12 mm, the proximal esophagus is 15 mm. After the elimination of the three-esophageal fistula and mobilization of the ends of the esophagus, a single-row end-to-end anastomosis was applied - end-to-end, with a continuous suture using a monolithic absorbable suture thread RDS 5-0 on a fluoroplast catheter. A drainage tube with a diameter of 5 mm with lateral openings was brought to the line of sutures of the esophagus, it was brought out through the 6th intercostal space along the posterior axillary line. The surgical wound is stitched tightly.

 In the postoperative period, which went smoothly, the patient received parenteral nutrition for 7 days, feeding through the gastrostomy was performed from 8 days. Sutures were removed on the 10th day, the probe from the esophagus was removed on the 3rd day. After the control contrast radiography of the esophagus on the 14th day after the operation (anastomosis patency is good), feeding through the mouth was started. Discharged from the hospital on the 45th day in a satisfactory condition with recovery. The body weight at discharge 3260 g, the gastrotomy opening closed spontaneously after removing the gastrotomy tube.

 High efficiency of the method is ensured by the fact that in the claimed method for temporary occlusion of the tracheoesophageal fistula, an elastic tube of appropriate diameter is inserted through the gastrotomy into the distal esophagus. The tube is fixed with silk ligature, carried out around the cardiac section of the esophagus with the force necessary to form a strangulation fixative groove on the tube, which gives time (2-3 weeks) to prepare the patient for the radical stage of treatment. The presence of a removable obturator at the outlet end of the tube allows, if necessary, the accumulation of accumulated bronchial sputum in the distal esophagus, and the strangulation fixative ligature in the cardiac esophagus does not prevent its spontaneous growth. The appearance of full mobility of the tube in the 2nd - 3rd week after surgery, during observation of the patient during dressings, indicates recanalization of the lumen of the esophagus due to eruption of the ligature and simultaneous restoration of its walls, which allows the operation to create a direct anastomosis (between oral and the aboral ends of the esophagus) in conditions of arrested pneumonia and an improvement in the general condition of the child, as well as with reduced diastasis (between the ends of the atresiated esophagus) due to the growth of its oral end. It is known that the distal esophagus, in contrast to the oral, grows in diameter, and not in length, which at the time of radical surgery ensures proportionality of the diameters of the stitched ends of the esophagus. During this period, there is an extension of the oral and expansion of the distal end of the esophagus, relief of pneumonia, improvement of the general condition of the patient, which ultimately increases the effectiveness of the treatment of such patients and allows you to create a direct anastomosis.

Claims (1)

 A method of treating atresia of the esophagus, including gastrotomy, temporary occlusion of the distal tracheoesophageal fistula with a blocker through the lumen of the stomach, characterized in that an elastic hollow tube with a removable obturator at the outer end is used as a blocker, which is fixed with a silk ligature around the esophagus until a strangulation groove forms on the tube and esophagus , form a gastrostomy, in the postoperative period sanitize the distal esophagus, sucking bronchial sputum through an elastic tube.