RU2255676C1 - Endosurgical method for removing benign submucous esophagus tumors - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves introducing dumbbell-shaped balloon into esophagus lumen. The balloon is blown-up to make tumor bulge out.

EFFECT: enhanced effectiveness of treatment; rapid and reliable tumor boundary detection.

Description

The present invention relates to medicine, in particular to endosurgical methods for removing submucosal tumors of the esophagus.

A known method of removing a benign intramural tumor of the esophagus, when they carry out a wide thoracotomy in the 5 intercostal space on the right. Then, the location of the tumor in the wall of the esophagus is determined by palpation. An incision is made over the palpable changed part of the esophagus. The musculature of the esophagus is longitudinally dissected and the tumor encapsulated in the wall of the esophagus is bluntly exfoliated. An incision in the muscular wall of the esophagus is sutured with separate interrupted sutures (Operative Surgery. Edited by Prof. I. Littmann. Publishing House of the Hungarian Academy of Sciences, Budapest, 1985).

The disadvantage of this method is the high invasiveness of the operation associated with a wide opening of the chest cavity and the intersection of the muscles of the anterior chest wall, forced apart of the ribs.

In addition, the operation is fraught with the risk of large blood loss both during the intervention and in the postoperative period. It also cannot be ignored that the postoperative period and subsequent rehabilitation of patients is extremely difficult.

In the last decade, with the development of endosurgical technologies, it became possible to perform thoracoscopic operations, including the removal of benign submucosal tumors of the esophagus.

Thoracoscopy is performed, then using the instrumental “palpation” they find the location of the tumor. Using endoscopic instruments, they cut the wall of the esophagus above the tumor. Under video control, enucleation of education is carried out. After this, the esophageal wall defect is sutured with a continuous suture (A. Nakamura, S. Ito, S. Ide, K. Kashima, H. Nakatani, T. Tagawa “Thoracoscopic removal of benign tumor of the esophagus with use of a suture clip”. Surgical Endoscopy, Vol. 12, N5, May 1998, p. 696).

Such an intervention is less traumatic, while the time of postoperative rehabilitation of patients is significantly reduced, and a good cosmetic effect is noted.

The disadvantages of the method are the difficulty of retaining the detected tumor in the field of view without fixation by clamps, which can lead to “splitting” of the formation into several fragments, as well as difficulties in determining the boundaries of the tumor in relation to the mucosa of the esophagus, which can lead to perforation of the latter.

The objective of the invention is a method that allows to improve the results of treatment due to faster and more reliable detection of the boundaries of the tumor and its atraumatic fixation.

The problem is solved by the method consisting in the fact that previously a dumbbell-shaped balloon is introduced into the lumen of the esophagus, which is brought to the tumor and inflated until the tumor bulges out.

The method is as follows.

A 10 mm probe is inserted into the esophagus, at the end of which there is a dumbbell-shaped balloon. At the location of the tumor, determined before the operation by X-ray and endoscopic methods, the balloon is inflated with liquid, which leads to a protrusion of the esophagus wall with the tumor. There is an improvement in the visualization of the boundaries of the tumor and its atraumatic fixation. An esophagus wall is dissected above the tumor with an electrosurgical hook. The operation is almost bloodless, since a 20-fold increase on the monitor screen allows you to differentiate small vessels. Tupfer, dissector and hook perform tumor husking. The boundaries of the tumor are easily determined, since it is located between two dumbbell-like extensions of the balloon. And the border between the tumor and the mucous membrane is also easy to catch, because the mucous membrane is spread on the wall of the balloon, and the tumor is easily differentiated with instrumental “palpation”. The husked tumor is immersed in an endoscopic container. Then, using an endoscopic suturing instrument (EndoStich device or needle holders and atraumatic absorbable suture material), the defect in the muscular membrane of the esophagus is sutured with a continuous suture. Control hemostasis. The drainage of the pleural cavity is carried out through one of the thoracoports. The injection site of the thoracoport is expanded to the size necessary to extract the endocontainer with the removed tumor.

The method is applicable both to solitary and multiple benign tumors of the esophagus, regardless of their size.

Clinical example.

Patient D., 68 years old, from 11.02.2003 to 7.03.2003 was examined and treated in the surgical thoracic department with a diagnosis of leiomyoma of the lower third of the esophagus. Hypertension II Art.

Complaints at admission: a burning sensation and dull pain in the epigastric region that occurs 2-3 hours after eating. The pains are stopped by taking no-shpa, maalox.

From the anamnesis: in 1995, when examining gastritis with endoscopy, a submucosal tumor of the esophagus (leiomyoma) 1.5 cm in diameter was detected. It was under dynamic observation (once a year they performed endoscopy and radiography). Slow tumor growth was noted. By December 2002, education had increased in size to 3 cm. There was no dysphagia. Was admitted to the clinic for examination and treatment.

Upon admission: satisfactory condition. Integuments of usual coloring and humidity. The vesicular breathing, no wheezing. The borders of the heart are not expanded, the tones are not changed. Heart rate 72 per minute. HELL 130/90 mm Hg The abdomen is soft, moderately painful in the epigastric region. The liver is not enlarged. Pasternatsky’s symptom is negative on both sides.

Blood and urine tests without significant deviations from normal values. RW, HBSAg, HCVAb neg. No antibodies to HIV were detected. The coagulogram is within normal limits. Blood type: A (II), Rh positive.

X-ray examination of the chest organs: lungs without fresh focal and infiltrative changes.

Ultrasound examination of the abdominal organs: the liver is not enlarged, with smooth contours, the parenchyma is homogeneous, increased echogenicity. The bile ducts are not dilated. The gall bladder is irregular in shape, the walls are somewhat denser, with multiple parietal structures up to 4 mm. The pancreas is not enlarged, increased echogenicity. Spleen, kidneys are not changed.

CONCLUSION: cholesterosis of the gallbladder.

ECG: sinus rhythm. Focal changes were not detected.

Endoscopic endoscopy: in the esophagus, at the border of the middle and lower third, the submucosal tumor (leiomyoma) is up to 3 cm, the mucous membrane above it is not changed. The cardia closes. The stomach has fluid, mucus. Mucous elastic, unevenly hyperemic, with areas of atrophy. The angle is flat, not deformed. The gatekeeper is round in shape. The bulb is smooth, passable, mucous with moderate focal hyperemia. Postbulbar department without features.

Computed tomography of the chest: the lumen of the esophagus in the upper third of the chest is widened. In the lower third of the esophagus wall is thickened over 25 mm, the lumen is not visible. The contours of the esophagus are even, clear.

On February 26, 2003, an operation was performed - thoracoscopic removal of leiomyoma of the lower third of the esophagus, drainage of the right pleural cavity.

Endotracheal anesthesia with a 2-lumen tube with a shutdown of the right lung. The position of the patient on the stomach. A thoracoscope was inserted in the 8th intercostal space along the posterior axillary line on the right. In the 7th, 8th and 9th intercostal spaces, one 10 mm and two 5 mm trocars, respectively, were introduced along the scapular line. Crossed the lower pulmonary ligament. The mediastinal pleura was opened. After introducing a probe into the lumen of the esophagus with a dumbbell balloon on the distal part and inflating the balloon with air, it was found that in the lower third of the esophagus there is a round-shaped tumor on the right wall with clear contours 3.5 × 3 cm in size.The tumor is fixed on the balloon.

Intraoperative diagnosis: leiomyoma of the lower third of the esophagus. The muscular membrane of the esophagus is dissected. Using an ultrasonic dissector, the tumor was removed without damaging the mucous membrane of the esophagus. Suturing of the muscle membrane with a continuous suture apparatus “Endostich”. Mediastinal pleura is sutured with separate sutures. The tumor is immersed in a container and removed through a 2.5 cm incision. Control of hemostasis. The pleural cavity is drained by 2 drains. The patient was transferred to the supine position; intraoperative endoscopic endoscopy was performed, in which it was established that there was no defect in the esophagus mucosa. A probe for enteral nutrition was left in the duodenum.

Macrodrug: a gray-white tumor of soft elastic consistency.

Drainages removed after 24 hours. Smooth postoperative course. Enteral nutrition through a probe for 4 days after surgery. The sutures were removed on the 9th day, the wounds healed by primary intention.

Histological examination of a macrodrug: leiomyoma with proliferation sites.

In satisfactory condition on the 9th day after the operation, the patient was discharged home under the supervision of a surgeon at the place of residence.

The method according to the invention increases the safety of treatment by protruding the tumor in the field of view and atraumatic fixation of the balloon.

Claims (1)

A method for endosurgical removal of benign submucosal tumors of the esophagus, characterized in that a dumbbell-shaped balloon is first introduced into the lumen of the esophagus and inflated until the tumor bulges out.