RU2377957C2 - Method of treating tracheoesophageal fistulas in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used in treating children with tracheoesophageal fistulas. That is ensured by inserting a fibroesophagoscope into oesophagus. Then a fistula is electrocoagulated with using an endoscopic electrode and coagulated with 96% ethyl alcohol through an endoscopic catheter. Thereafter from oesophagus, a Tachocomb filling is delivered to fill the fistula entrance followed by clipping with endoscopic fasteners.

EFFECT: method allows effectively eliminating tracheoesophageal fistulas by endoscopic technique without thoracotomy, herewith reducing perioperative injuries and rehabilitation time.

7 dwg, 3 ex

Description

The invention relates to pediatric surgery, in particular to thoracic surgery and endoscopy, and is aimed at eliminating tracheoesophageal fistula by closing their mouths in the lumen of the esophagus.

Surgical treatment of tracheoesophageal fistulas with right-sided cervical access is already known, during which mobilization, ligation and intersection of the anastomosis are performed. [Yu.F. Isakov, E. A. Stepanov, V. A. Michelson and others. Surgical diseases in children. Publishing House "Medicine", 1998, p.127.]

It is also known that in the treatment of fistulas, a posterolateral thoracotomy is used, in which a fistula is isolated, ligated and crossed. [Ashcraft K.U., Holder T.M. Children's surgery. Hardford Publishing House, 1996, Volume 1, Page 288.]

However, the disadvantage of this method is that it is an open traumatic operation on the chest organs, which carries an increased risk of purulent postoperative complications, with a long postoperative and recovery period, as well as cosmetic defects of the chest remaining after the operation are of no small importance.

The aim of the invention is the elimination of tracheoesophageal fistula without resorting to thoracotomy, which is an open traumatic operation, and as a result, there is a significant reduction in the time of surgery and anesthesia, the postoperative and rehabilitation period, the absence of complications inherent in thoracotomy, as well as the complete absence of cosmetic defects.

This goal is achieved by the fact that at one stage during fibroesophagoscopy, the lumen of the tracheoesophageal fistula is first electrocoagulated with an endoscopic electrode, then through the endoscopic catheter, the lumen of the fistula is chemocoagulated with 96% ethanol, then a fill from the tachocomb is performed and the mouth of the fistula is sealed by the gullet from the esophagus, endoscopic staples.

Figure 1 presents the x-ray of the esophagus with a contrast agent: the contrast of the tracheoesophageal fistula is determined. Figure 2 presents an endoscopic picture of the lumen of the esophagus: the mouth of the tracheoesophageal fistula is indicated by an arrow. Figure 3 presents an endoscopic picture of the lumen of the esophagus: previously, 0.8 ml of a staining substance (methylene blue) was introduced into the mouth of the tracheoesophageal fistula opening in the lumen of the trachea, after which the staining of the mouth of the tracheoesophageal fistula is determined (indicated by an arrow). Figure 4 - filling the mouth of the tracheoesophageal fistula with a tachocomb, previously the mouth of the fistula was subsequently subjected to electrocoagulation and chemocoagulation (96% ethyl alcohol). Figure 5 - clipping of the sealed mouth of the fistula. Figure 6 - control esophagoscopy performed 3 months after surgery: in the lumen of the esophagus in the area of the mouth of the tracheoesophageal fistula two clips are determined. In Fig.7 - control radiograph after endoscopic treatment (after 3 months): in the area of the tracheoesophageal fistula, a slight filling defect is indicated (indicated by an arrow), the tracheoesophageal fistula is not contrasted.

The method is illustrated by the following clinical examples.

Example 1

Patient M., 6 years old, with a congenital tracheoesophageal fistula, was previously examined and treated at the place of residence without satisfactory results (this diagnosis was not established at the place of residence). Received for further examination and treatment.

Upon receipt complained of choking during meals.

An examination revealed a tracheoesophageal fistula:

on fluoroscopy with a contrast agent, a tracheoesophageal fistula is determined at the T-1 level along the right wall of the esophagus up to 0.3 cm, 0.3 cm long. The contrast gets into the trachea, is completely evacuated when coughing;

fibroesophagoscopy - 16 cm from the edge of the teeth along the right wall of the esophagus is determined by a fistula, the mouth with a diameter of 0.3 cm;

fibrobronchoscopy - at a distance of 4 cm from the bifurcation of the trachea, a fistula with a diameter of 0.4 cm is located on the back wall.

The child underwent dissection of the tracheoesophageal fistula using right-sided cervical access.

At the follow-up examination after 6 months, the child remained complaining of choking while eating. After a routine examination, a relapse of the tracheoesophageal fistula was noted. The patient decided to perform endoscopic removal of the fistula according to the proposed technique.

At the follow-up examination after 7 months, the child was in satisfactory condition, no complaints.

On fluoroscopy with a contrast agent, fibroesophagoscopy, the tracheoesophageal fistula is not determined, on fibrobronchoscopy the complete closure of the mouth of the fistula is also determined.

The performed operation completely eliminated the tracheoesophageal fistula, while the time of manipulation and anesthesia was significantly reduced, and the time of the postoperative rehabilitation period was also reduced in comparison with the traumatic abdominal operation.

Example 2

Patient Z., 15 l. As a result of a traffic accident, a child has a brain contusion, a subdural hematoma on the left. Operated at the place of residence: craniotomy, evacuation of hematoma. I was on mechanical ventilation for 10 days, after which tracheal stenosis was formed, a tracheoesophageal fistula was formed above the tracheal stenosis.

Translated for further treatment.

According to the survey:

fibroesophagoscopy - in the middle third of the esophagus along the front wall is determined by the mouth of the tracheoesophageal fistula, with a diameter of 0.2 cm. 1.2 ml of a coloring substance is introduced into the mouth of the fistula (methylene blue solution);

fibrobronchoscopy - in the middle third of the trachea, cicatricial stenosis of the trachea with a diameter of 0.3 cm is determined. Above the stenosis of the trachea, the mouth of the tracheoesophageal fistula with a diameter of 0.2 cm is determined, from the mouth of the fistula, the stain is determined.

To eliminate tracheal stenosis, the patient decided to form a tracheofissure with subsequent tracheal intubation with a T-shaped tube. At the same time, through the formed tracheofissure, an attempt was made to close the mouth of the tracheoesophageal fistula by suturing the latter.

In a second examination, after 14 days, the mouth of the fistula with a diameter of 0.2 cm was determined in the esophagus, and a point mouth was determined on the membranous part of the trachea.

The patient was decided to perform endoscopic dissection of the tracheoesophageal fistula according to the proposed technique.

According to the control examination performed 12 days after the operation, the child has complete closure of the tracheoesophageal fistula.

On a survey radiograph of the chest organs in the area of the mouth of the tracheoesophageal fistula, two clips are determined. When fluoroscopy with a contrast agent, the latter is not detected in the trachea.

On fibroesophagoscopy in the area of the mouth of the tracheoesophageal fistula, a slight deformation of the lumen of the esophagus with moderate convergence of the folds is determined, and two clips are also determined on the front wall.

At subsequent hospitalizations, recurrence of the tracheoesophageal fistula was not observed.

Thus, the performed operation according to the proposed methodology led to a significant improvement in the condition of the child.

Subsequently, the patient was transferred to an adult health care network. According to long-term results, he has a persistent remission.

Example 3

Patient P., 2 years. The child was operated on the second day of life for atresia of the esophagus. It has been observed in the clinic since the age of six months, when the child developed postoperative esophageal stenosis. On this occasion, esophageal bougienage was performed.

On the control examination on the x-ray revealed a tracheoesophageal fistula.

On fibroesophagoscopy on the anterior wall of the esophagus, the mouth of the tracheoesophageal fistula is determined up to 0.2 cm in size.

On fibrobronchoscopy, the mouth of the tracheoesophageal fistula is not determined.

It was immediately suggested that endoscopic removal of the tracheoesophageal fistula was proposed according to the proposed method: at one stage during fibroesophagoscopy, the lumen of the tracheoesophageal fistula is first electrocoagulated with an endoscopic electrode, then through the endoscopic catheter, the lumen of the fistula is chemocoagulated with ethyl alcohol, and then the osseous duct is filled with the fillings. then the seal is clipped by applying endoscopic clips.

The postoperative period was uneventful.

On examination after 12 days and on control examination after one year, the complete closure of the mouth of the tracheoesophageal fistula is determined.

Thus, the performed endoscopic removal of the tracheoesophageal fistula according to the proposed technique led to the complete clinical recovery of the child. In this case, a traumatic abdominal operation was not performed, there was a minimum manipulation time and anesthesia time. The rehabilitation and recovery period was practically absent, the stay of the child in the hospital was significantly reduced.

In our clinic, 17 children of various age groups were operated on.

There are long-term results: in 10 children, control studies showed persistent remission, a complete absence of clinical complaints. Two children transferred to an adult health care network.

When x-ray examinations noted the absence of signs of tracheoesophageal fistula.

With fibroesophagoscopy in the area of the mouth of the fistula, a slight deformation of the lumen is determined, in three cases moderate convergence of the folds of the esophagus is noted.

With fibrotracheoscopy, the mouth of the tracheoesophageal fistula is not determined.

The remaining children have not yet passed the control examination.

Despite its apparent simplicity, a method for endoscopic treatment of tracheoesophageal fistulas has not yet been proposed, and none of the specialists in this field have previously performed such operations. We first proposed a method for the treatment of tracheoesophageal fistulas in children, which consists in the fact that during a fibroesophagoscopy one-stage, the lumen of the tracheoesophageal fistula is first electrocoagulated with an endoscopic electrode, then through the endoscopic catheter, the lumen of the fistula is chemocoagulated with 96% ethanol, and then the tube is filled with from the esophagus, then the seal is clipped by applying endoscopic clips. Since this method does not open the lumen of the chest, there is a significant reduction in the time of surgery and anesthesia, the postoperative and rehabilitation period, the absence of complications inherent in thoracotomy, as well as the complete absence of cosmetic defects.

Claims (1)

A method for the treatment of tracheoesophageal fistulas, based on uncoupling of their mouths, characterized in that during the fibroesophagoscopy one-stage, the lumen of the tracheoesophageal fistula is first electrocoagulated with an endoscopic electrode, then the lumen of the fistula is chemocoagulated with ethyl alcohol and then filled with 96% ethyl alcohol and then filled the mouth of the fistula from the esophagus, then the seal is clipped by applying endoscopic clips.

Images