RU2343871C1 - Method of endosurgical excision of innocent submucosal esophagus tumours - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: enter probe into esophagus. Device for visualisation of borders of tumour is fixed on the probe extremity. Fan the device using liquid before tumour detection. Dissect esophagus walls over a tumour from mucous an esophagus. Enucleate the tumour. Take in defect. Thus the device is executed in the form of a cuff in width of 7 cm, in the length of 8 cm. At cuff inflating its diameter makes 4 cm. The wire thread is placed on all area of the cuff, between its anterior and posterior walls through each 0.5 cm. In the cuff centre is executed the aperture 2-4 cm in diameter.

EFFECT: method is simple, provides reduction of traumatic effects of interventions at expense of exception of thoracoscopic manipulations, damage of muscular wall of esophagus, excludes punching of esophagus at the expense of reliable bracing of tumour.

1 dwg, 1 ex

Description

The invention relates to medicine, namely to endoscopic surgery and can be used to treat benign submucosal tumors of the esophagus.

A known method of removing a benign intramural tumor of the esophagus, when carry out a wide thoracotomy in the 5th 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 (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" 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). 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 prototype is a method for removing tumors of the esophagus using a dumbbell-shaped balloon (Patent RU No. 2255676, 2005), the essence of which 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 by 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. 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 disadvantage of this method is that the thoracoscopy itself is traumatic, during its application when several manipulators are inserted into the cavity, there is a risk of injury to the pleural cavity, and the installation of drains in the pleural cavity causes infection of the cavity due to contact with the drains, which affects the duration of the postoperative period and its complications. In addition, when the tumor is husked, the muscular wall of the esophagus is damaged, as a result of which hemorrhagic serous fluid accumulates in the pleural cavity with insufficient hemostasis, which, in turn, causes an unfavorable environment. With the introduction of a dumbbell-shaped balloon with a recess in which the tumor is fixed, when it is inflated, its extrusion becomes insufficient, due to the fact that the tumor is in the recess. Also, when the tumor is husked out, the balloon is able to soften, due to its soft structure, to migrate and become unfixed, due to which trauma and perforation of the esophagus wall with instruments is possible. Due to the fact that the tumor can be of different sizes, the use of a dumbbell-shaped balloon is not always effective for extruding the tumor, this leads to the migration of the tumor in different directions and complicates the technique of surgical intervention.

The technical result is the simplification and reduction of the invasiveness of the method, the exclusion of thoracoscopic manipulations.

The specified technical result is achieved in that in a method comprising introducing a probe at the working end of which there is a device for visualizing the boundaries of the tumor, inflating the device with liquid until a tumor is detected, dissection of the esophagus wall above the tumor, husking of the tumor, suturing of the defect, device for visualizing the boundaries of the tumor is made in the form of a cuff 7 cm wide, 8 cm long, the diameter of which, when inflated, is 4 cm, while over the entire area of the cuff, between its front and back walls, every 0.5 cm the wire thread is placed, a hole with a diameter of 2-4 cm is made in the center of the cuff, and the defect is dissected from the side of the esophagus mucosa.

The invention is illustrated in the drawing.

The method is as follows. A 5 mm probe 2 is inserted into the esophagus 1, at the end of which a cuff 3 is fixed with a width of 7 cm, a length of 8 cm. When the cuff is inflated, its diameter is 4 cm. Moreover, over the entire area of the cuff, between its front and back walls every 0.5 see placed wire thread 4 for rigid fixation of the cuff in the esophagus. A hole 5 with a diameter of 2-4 cm was made in the center of the cuff for the tumor 6 to enter and reveal its borders. The diameter of the hole depends on the size of the tumor. At the location of the tumor, determined before the operation by X-ray and endoscopic methods, the cuff is inflated with liquid, which leads to the formation of a cylindrical shape in the esophagus, larger in diameter of the esophagus. Due to the fact that the cuff swells up to 4 cm in diameter, the esophagus wall is tensioned, the tumor is extruded and flows into the cuff opening, good visualization of the tumor borders and its non-invasive fixation. In this case, a lumen is formed inside the cuff, tightening the walls of the esophagus in the area of tumor localization. Above the tumor from the mucous membrane, the esophagus wall is dissected with an endoscopic instrument. The operation is less traumatic and almost bloodless. Endoscopic instruments perform tumor husking. The boundaries of the tumor are easily determined, since it is located in the opening of the cuff. And the border between the tumor and the mucous membrane is also easy to catch, because the mucous membrane is slightly stretched in the opening of the cuff, and the tumor is easily differentiated with instrumental "palpation". The husked tumor is evacuated. Then, using an endoscopic instrument, the defect in the mucous membrane of the esophagus wall is sutured (drawing).

Clinical example. Patient M., 55 years old, medical history No. 5757/07 was admitted with complaints of 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 was detected 2.5 cm in diameter. 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. 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.

The patient was operated on. Under general anesthesia, a 5 mm probe was inserted into the esophagus, at the end of which there is a cuff 7 cm wide, 8 cm long, which when inflated becomes 4 cm in diameter. In this case, over the entire cuff area, between the front and back walls of the cuff every 0.5 see, laid wire thread for rigid fixation of the cuff in the esophagus. A hole with a diameter of 3 cm was cut out in the center of the cuff to enter and reveal the borders of the tumor. The cuff was inserted into the esophagus, folded into a tube. At the location of the tumor, determined before the operation by X-ray and endoscopic methods, the cuff is inflated with liquid, which leads to the formation in the esophagus of a cylindrical shape larger in diameter than the esophagus. Due to the fact that the cuff inflates up to 4 cm in diameter, the esophagus wall is tensioned, the tumor is squeezed out into the cuff opening, good visualization of the tumor borders and its non-invasive fixation. In this case, a lumen is formed inside the cuff, tightening the walls of the esophagus in the area of tumor localization. Above the tumor from the mucous membrane, the esophagus wall is dissected with an endoscopic instrument. Endoscopic instruments perform tumor husking. The boundaries of the tumor are easily determined, since it is located in the opening of the cuff. And the border between the tumor and the mucous membrane is also easy to catch, because the mucous membrane is slightly stretched in the opening of the cuff, and the tumor is easily differentiated with instrumental "palpation". The husked tumor is evacuated. Then, with the help of an endoscopic instrument, the defect in the mucous membrane of the esophagus wall is sutured. The operation is less traumatic and almost bloodless. The postoperative period went smoothly. Enteral nutrition through a probe for 4 days after surgery. Sutures were removed on the 7th day, the wound without rough scarring. In satisfactory condition on the 7th day after the operation, the patient was discharged home under the supervision of a surgeon at the place of residence.

The proposed method for the removal of benign tumors of the esophagus we used in the clinic in 20 patients. The tumor was reliably held in the cuff opening without migration in different directions due to the detection of boundaries and its rigid fixation. The wall of the esophagus underwent the least trauma, and due to the fact that thoracoscopy and drainage of the pleural cavity were not used, the risk of postoperative complications decreased. No complications associated with the use of the method were noted. Thus, the proposed method increases the safety of treatment due to the entry of the tumor into the hole without migration in different directions, the detection of boundaries and its rigid fixation, as a result of which the esophagus wall undergoes the least injury.

Claims (1)

A method for endosurgical removal of benign submucosal tumors of the esophagus, including the introduction of a probe, on the working end of which there is a device for visualizing the borders of the tumor, inflating the device with liquid until the tumor is detected, dissecting the esophagus wall above the tumor, husking the tumor, suturing the defect, characterized in that the device for visualizing the borders the tumor is made in the form of a cuff 7 cm wide, 8 cm long, the diameter of which when inflated is 4 cm, while over the entire area of the cuff, between its Independent user and rear walls every 0.5 cm wire filament arranged in the center of the cuff formed with a diameter of 2-4 cm hole cut a defect produced by the mucosa of the esophagus.

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