RU2262311C1 - Method for postponed vocal prosthetics - Google Patents

Abstract

FIELD: medicine, surgery, ORL-oncology.

SUBSTANCE: it is necessary to perform laryngopharyngectomy and substitute the developed defect with jejunal segment upon microvascular anastomoses. On restoring the function of swallowing one should install vocal prosthesis in fistula between trachea and jejunal segment. Moreover, to apply prosthesis conductors through the mouth one should introduce a siliconized polychlorovinyl tube. The innovation suggested enables to perform vocal prosthetics after resecting a larynx, a pharynx and cervical esophageal department.

EFFECT: higher efficiency.

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Description

The invention relates to medicine, in particular to methods for surgical treatment of ENT - cancer patients.

A known method of delayed voice prosthetics after laryngectomy (complete removal of the larynx), in which a metal esophagoscope is inserted into the esophagus, puncture of the posterior wall of the trachea and the anterior wall of the esophagus. A thin catheter is inserted through the resulting fistula. After 10-12 days (after the formation of the lumen of the fistula) using a special conductor, a prosthesis is installed in the lumen of the fistula from the side of the tracheostomy (US Patent No. 5300119, CL 623/9 of 04/05/94).

This method requires complex devices for the introduction of the prosthesis and has limited use, since it is applicable only to those cases when the pharyngeal-esophageal segment participating in phonation is preserved during the operation.

There is a method of delayed prosthetics at various times after a laryngectomy, in which a rigid metal esophagoscope is inserted into the esophagus under anesthesia. The end of the esophagoscope is placed at the level of the tracheostomy with the open part anteriorly, controlling its position during palpation through the posterior wall of the trachea and the anterior wall of the esophagus. After that, with the help of a trocar, puncture of these walls is performed, departing from the upper edge of the tracheostomy by 0.5 cm. A flexible conductor is inserted into the fistula, which is advanced into the lumen of the esophagoscope, and then brought out through the oral cavity. A voice prosthesis is fixed at its end. When pulling the conductor in the opposite direction, the prosthesis is installed in the lumen of the fistula (US Patent No. 5314470, CL 623/9 from 05.24.94).

The disadvantages of this method are that the introduction of a hard esophagoscope is very difficult and dangerous with severe osteochondrosis and other pathological conditions of the spine. This requires total relaxation of the patient, achieved only with the use of endotracheal anesthesia. Great difficulties for using this method arise with trismus of the masticatory muscles and defects in the oral cavity, which cause narrowing and difficulty in opening it. When a rigid esophagoscope is inserted into the esophagus, especially if the surgeon does not have sufficient experience, trauma to the esophagus is possible. The restoration of sonorous speech in this method, as well as in the previous case, is carried out with the participation of fluctuations in the folds of the mucous membrane of the esophagus, which are formed at the level of its first narrowing.

The closest is a method of delayed voice prosthetics after removal of the larynx, including the introduction through the mouth into the lumen of the esophagus of an intubation tube curved in the form of an arc, the distal end of which is bent at an angle of 30 ° to its longitudinal geometric axis, and the end of the distal end of the endotracheal tube is made at an angle of 35 ° to the longitudinal geometric axis of the tube and has smooth edges, the distal end of the endotracheal tube is fixed in position with an anterior section at the level of the tracheostomy, palpation is determined in the tracheostomy the puncture site of the posterior wall of the trachea and the anterior wall of the tubular organ, these organs are punctured, a flexible conductor is inserted through the formed fistula, it is brought out through the oral cavity, a voice prosthesis is fixed at the end of the conductor, and a voice prosthesis is installed in the fistula when pulling the conductor (Patent of the Russian Federation No. 2197902, IPC A 61 B 17/00; A 61 F 2/20 from 2001).

In 20% of patients suffering from cancer of the larynxopharynx at stage IV, the process spreads to the mouth of the esophagus. With surgical treatment in this case, the larynx, pharynx, cervical esophagus is removed laryngopharyngectomy. The resulting defect is usually replaced by a segment of the jejunum on microvascular anastamoses or a stalk cut from the greater curvature of the stomach. After performing the operation of such a volume, it is possible to restore the gastrointestinal tract in the patient, as a result of which he is able to freely eat through the mouth. However, having lost his larynx, the patient loses the opportunity to communicate with others through sonorous speech. Since speech is part of the personality, a way of expressing thoughts and feelings, voice loss is hard to perceive not only by the patient himself, but also by his relatives. In 40% of patients after removal of the larynx, mental disorders and depressive states form.

The technical result to which the invention is directed is to develop a method of surgical treatment and prosthetics of ENT - oncological patients, which allows them to return speechlessness after removal of the pharynx, larynx and cervical esophagus - laryngopharyngectomy.

The specified technical result is achieved in that in the method of delayed voice prosthetics after removal of the larynx, including the introduction through the mouth into the lumen of the esophagus of an endotracheal curved in the form of an arc, the distal end of which is bent at an angle of 30 ° to its longitudinal geometric axis, and the end of the distal end of the endotracheal tube made at an angle of 35 ° to the longitudinal geometric axis of the endotracheal tube and has smooth edges, the distal end of the endotracheal tube is fixed in the front end position at the level of trachea ostomy, palpation in the tracheostomy, determines the place of puncture of the posterior wall of the trachea and the anterior wall of the tubular organ, performs the puncture of these organs, introduces a flexible conductor through the fistula, leads it out through the oral cavity, secures a voice prosthesis to the end of the conductor, sets up a voice prosthesis in the fistula, in the case of the spread of the cancer, the larynx, larynx, and esophagus remove these organs, the resulting defect is replaced by a segment of the jejunum per m of vascular anastomoses, prosthetics are performed after restoration of swallowing function, while the endotracheal tube is inserted into the lumen of the jejunum with the butt end anteriorly, the posterior wall of the trachea and the anterior wall of the jejunum are punctured, a flexible conductor is inserted through the fistula into the lumen of the jejunum, pharynx and oral cavity , its end is brought out, the voice prosthesis is fixed on it and, stretching the flexible conductor in the opposite direction, the prosthesis is installed in the fistula.

The invention is illustrated by drawings, where:

- figure 1 shows the region of the tracheostomy of the patient in section with an endotracheal tube inserted into the lumen of the jejunum and a rigid conductor inserted into the lumen of the endotracheal tube;

- figure 2 shows the region of the tracheostomy of the patient at the time of palpation of the puncture site of the posterior wall of the trachea and the anterior wall of the jejunum;

- figure 3 shows the region of the tracheostomy of the patient at the time of puncture of the posterior wall of the trachea and the anterior wall of the jejunum;

- figure 4 shows the region of the patient’s tracheostomy in section with a rigid conductor inserted into the fistula formed after the puncture, and with mylar thread tied to its club-shaped tip;

- figure 5 shows the region of the patient’s tracheostomy in a section with a voice prosthesis installed in the fistula.

After laryngopharyngectomy (after at least 4 months, when the swallowing function has fully recovered and scars have formed on the neck), an endotracheal tube No. 8-9 (item 1 in Figure 1) is used from siliconized polyvinyl chloride, at which the ends are bent at an angle of 30 °, and the distal end 2 is cut off so that its end 3 is positioned at an angle of 35 ° to the longitudinal axis of the endotracheal tube 1. The distal end 2 of the endotracheal tube 1 is passed through the mouth (not shown in the drawing) into the jejunum segment 10 and placed at the level tracheostomy. As a rule, due to scars, it is rather difficult to palpate the end face 3 of the distal end 2 of the endotracheal tube 1. For this, a rigid conductor 4 is inserted into the lumen of the endotracheal tube 1, the end of which is palpated with finger 5 in the tracheostomy. After that, with the help of a scalpel 6, the posterior wall 7 of the trachea 8 and the anterior wall 9 of the jejunum segment 10 are punctured. Puncture without a hard conductor 4 is dangerous, given the elasticity of the tissue of the jejunum segment 10. The distal end 11 of the hard conductor 4 is brought into the hole formed, tied to it the club-shaped tip 12 is a flexible conductor 13, which is a dacron thread No. 5, and is pulled into the oral cavity. The second end of the flexible conductor 13 is left in the area of the tracheostomy. At the elongated end of the flexible conductor 13, the edge of the voice prosthesis 14 is fixed and, when it is pulled back, the voice prosthesis is installed in the fistula 15. In this case, the endotracheal tube 1 acts as a “tunnel” and does not allow the voice prosthesis 14 fixed on the flexible conductor 13 to become entangled in the folds of the segment mucosa jejunum 10. Then the endotracheal tube 1 is removed.

Clinical example

Patient S. 62 years old was admitted 10.05.01 to the Department of Head and Neck Tumors of the Moscow City Clinical Hospital No. 62 (hereinafter referred to as Moscow City Clinical Hospital No. 62) with a diagnosis of laryngopharynx with passage to the esophagus stage IV-B, metastases (MTS) to the neck nodes on the right . Dysphagia. When examining data for distant metastasis was not revealed.

As the only possible method of care, 05/17/01 the patient underwent surgery - laryngopharyngectomy (removal of the larynx and pharynx) with resection of the cervical esophagus, plastic defect with a segment of the jejunum on microvascular anastomoses. Crail operation on the right. Histology No. 1247-87 / 03 - squamous keratinizing cancer, MTS in the lymph nodes. The postoperative period was uneventful. The wound healed by primary intention.

Given the prevalence of the tumor process, in the second stage of the combined treatment, remote gamma therapy (DHT) was performed with a total focal dose (SOD) of 40 Gray in the regions of regional metastasis.

Loss of voice was hard on the patient and his relatives. In order to rehabilitate speech function, the patient tried to engage with a speech therapist, but could not master the esophageal voice.

In July 2003, he appealed to the Moscow City Clinical Hospital No. 62 with an insistent request to try to restore his voice using a voice prosthesis. When examining data for relapse and metastases were not revealed. When conducting an insusculation test, it was determined that air freely passes through the intestinal transplant. In this regard, it was decided to perform a delayed voice prosthetics.

Under intravenous anesthesia, an endotracheal tube No. 9 was inserted through the mouth into the lumen of the jejunum transplanted onto the neck. Its ends were bent at an angle of 30 °, and the distal end was cut off at an angle of 35 °. The distal end of the tube was installed at the level of the tracheostomy, which was determined visually and by palpation. Puncture of the posterior wall of the trachea and the anterior wall of the transplanted segment of the jejunum was performed using a scalpel to form the tracheoesophageal fistula. From the side of the trachea, a flexible conductor was inserted through the fistula into the intestinal lumen and its end was brought out through the mouth. A Provox prosthesis was fixed at the end of the conductor, and when the conductor was pulled back, the prosthesis was installed in the fistula.

The next day after prosthetics, the patient began to pronounce the first sounds and words, and after 5-7 days, the speech acquired sufficient volume. However, it should be noted that the quality of the patient’s voice was worse than that of ordinary patients who had prosthetics after removal of the larynx: it was lower in timbre and speech was slower. Despite this, the patient can freely communicate with others, talk on the phone, his voice is satisfied.

Claims (1)

A method of voice prosthetics for laryngopharyngectomy, in which a defect is replaced by a segment of the jejunum on microvascular anastomoses, and after restoration of swallowing function, a voice prosthesis is installed in the fistula between the trachea and the intestinal segment, while siliconeized polyvinyl chloride pipe is introduced into the intestine to conduct the prosthesis conductors through the mouth.

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