RU2445014C1 - Method of surgical treatment of larynx - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to otolaryngology and can be applied in surgery of larynx cancer, including the case with complications of preceding radiotherapy. Essence of method lies in application of tracheostoma, realising access, isolation of thyroid cartilage and carrying out thyreofissure in it, ablation of locally spread tumour, plasty of formed defect and formation of neolarynx with application of nickelide titanium frame, layer-by-layer suturing of the wound. Access is realised by transverse semilunar incision on lower neck fold. Skin-fatty flap on pedicle is separated with bringing aside. Flap of subcutaneous neck muscle on pedicle is separated with bringing aside. As neolarynx frame used is flap of nickelide titanium tissue. Flap is formed by topography of thyroid cartilage and size of formed defect. After that, toughening dublicature is formed on the centre and perimetre of flap. Plasty of formed defect and formation of neolarynx is performed by successive layer-by-layer covering of formed defect with flap on pedicle of subcutaneous neck muscle, neolarynx frame and skin-fatty flap on pedicle. Neolarynx frame is fixed to periosteum of hyoid bone, cricoid cartilage and edge tissues of formed defect.

EFFECT: application of claimed invention makes it possible to increase operation quality, preserve larynx functions, including phonic.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used for functionally safe surgical treatment of laryngeal cancer, including with negative consequences of previous radiation therapy.

The larynx is an anatomically and morphologically complex organ that combines the functions of the commutator of the food and respiratory tracts, the perfect speech and the most harmonious musical apparatus in nature. Thus, its normal functioning ensures the main physiological processes of the body, the social integration of man, his spiritual life. These circumstances prescribe a special delicacy of the surgeon's actions and the use of advanced technological means for the maximum preservation of the functions of the larynx.

The creation of the proposed method is preceded by a long history of solving the problem of adequate replacement of the strength element of the larynx after extensive resection for tumors.

A number of organ-preserving methods for surgical treatment of laryngeal cancer with a variety of implants, prosthetic formative structures of the larynx, actions and techniques of plastic surgery of the defect formed are known. In the method [Bystenin VA, Bely O.N. To the question of laryngeal-tracheal prostheses / Bulletin of otolaryngology. 1981, No. 3, pp. 81-84] use a T-shaped tube made of rubber, plastic or biological tissue. Primitivism of the prosthesis, low biocompatibility of materials lead to the disadvantages of the method from the point of view of the surgeon (complexity of the operation) and the patient (low quality of life), to the low viability of the treatment.

More reliable methods using polymer implants to replace the removed cartilage [Olshansky V.O., Bityutsky P.T., Daryalova S.L. The current state of treatment of cancer of the larynx / Questions of Oncology, T. XXXIII, 1989, pp. 41-47]. The methods allow to maintain the volumetric anatomy of the larynx, to rehabilitate the respiratory and acoustic functions of the larynx. However, the low biocompatibility of polymers leads to inflammatory consequences, cicatricial stenosis, necrosis and rejection of implants.

An opportunity according to the biocompatibility criterion is provided by a new class of medical materials - titanium nickelide alloys. Plastic surgery using nickel-titanium implants is more affluent.

A known method for the surgical treatment of laryngeal cancer using a plate implant made of permeable-porous titanium nickelide [RF Patent No. 2160564] as a prosthesis for a fragment of the thyroid cartilage.

The gaping thyroid cartilage defect resulting from the removal of a locally advanced tumor is closed, firstly, with an implant of this material, properly molded according to the anatomy of the thyroid cartilage and the size of the defect, and paragortan tissue - on top. The method for the prior art is highly consistent and efficient. The disadvantages of the method are due to the porous surface of the implant, which is open to the internal environment of the larynx, which serves as a sorbent of the bacterial inflammatory flora for a long period of re-epithelization.

In the known method [RF Patent No. 2359621], the aforementioned drawback is moderate by laying the implant on the inside with an auto-tissue to isolate and accelerate re-capitalization. The method is as follows.

After a tracheostomy, access, mobilization of the thyroid cartilage and its dissection in the area of the outer margin of the projection of the tumor on its surface are performed. The upper perichondrium of the thyroid cartilage is separated on the leg and taken to the opposite site of the outer margin of the tumor. Locally distributed tumor is removed along with the adjacent fragment of the thyroid cartilage. Shelter of the formed gaping defect in compliance with the volumetric dimensions and the anatomical shape of the larynx (formation of the neo-larynx) is started with a separated upper perichondrium over which a molded permeable-porous titanium nickelide implant is mounted based on the defect edges. The implant is fixed due to the natural adhesion of the rough surface of the material to the soft tissues of the wound edges (Velcro effect). The operation is completed with regular actions of drainage and suturing of the wound. Increased, in comparison with the previous analogue, the viability of the operation leaves the need for further improvement of the method.

By the greatest similarity, this analogue is selected as a prototype.

The technical result of the invention is to increase the viability of the operation in the treatment of cancer of the larynx in complicated conditions of hyperemia and edema of paragortan tissue.

The specified technical result is achieved by the fact that in the method of surgical treatment of cancer of the larynx, including the application of a tracheostomy, access, isolation of the thyroid cartilage and thyroid fissure, removal of a locally spread tumor, plastic repair of the defect and the formation of neo-throat using a nickel-titanium skeleton, layered wound closure , access is carried out by a transverse crescent incision along the lower cervical fold, separated with a skin-fat flap allotted upward, separated with lateral abduction of a flap of the subcutaneous muscle of the neck on the leg.

A flap of a nickelide-titanium tissue formed by the topography of the thyroid cartilage and the size of the defect formed is used as a neogortic scaffold. The plasticity of the formed defect and the formation of the neoglarynx are performed by sequential layer-by-layer covering of the defect with a flap on the leg from the subcutaneous muscle of the neck, the neogortic skeleton and the skin-fat flap on the leg, the neogastric frame being fixed to the periosteum of the hyoid bone, cricoid cartilage and marginal tissues of the formed defect.

Achievability of the technical result is mainly due to the use of a different, compared with the prototype, material of the neogortic carcass, its different location and individual actions associated with the implementation of the method.

Nickel-titanium fabric, like porous casting, refers to materials with through permeability. Possessing high biocompatibility, these materials energetically, reliably and, to a large extent, organically integrate with living tissues. The tissue structure of the implant used also has an elastic and soft deformation ability. This property makes it possible to technologically easily (especially important, intraoperatively) and functionally correctly produce objects of an irregular and complex shape, like a fragment of the thyroid cartilage. The soft structure of the material provides less conflict with compatible auto-fabrics in the supporting and difficult-to-match areas. This reduces the possibility of postoperative complications, implant rejection, and reduces convalescence time.

Studies of the authors of the proposal show the actual possibility of highly efficient integration of nickel-titanium material with hyperemic laryngeal tissues undergoing preoperative radiation therapy.

The success of the implant integration and the overall repair process depending on this is facilitated by the selected structure of the layered shelter formed after the removal of the tumor of the gaping laryngeal defect. The inner surface of the first subcutaneous muscle layer is lighter than other parahortan tissues, re-epitalized, thereby ensuring the normal functioning of the larynx in its aforementioned combined function. The outer surface of this flap is in contact with the tissue of the implant and through its gaps - with the fat layer of the next skin-fat flap. Thus, the implant, in addition to the formative role of the neogortic scaffold, due to its high and universal biocompatibility, serves as a connecting and, in the long term, reinforcing element of the formed layered tissue block. Increasing the viability of the operation is also a constructive technique - performing duplicate around the perimeter and center of the flap of a nickel-titanium fabric, which, forming ribs, further stabilizes the given shape, improving the frame function of the implant.

The combination of these positive properties leads to a technical result. They also correspond to the material structure, which is more convenient for the surgeon and less traumatic for the patient to access the surgical field through a crescent incision along the lower cervical fold. Reception of fixation of the implant to the periosteum of the hyoid bone and cricoid cartilage is the most reliable and safe for the vocal cords.

A new set of technical means and surgical operations during operations, the non-obviousness of the logical connections of signs with the technical result indicate the compliance of the proposal with the criterion of "inventive step".

The illustrations show:

Figure 1. Appearance of the neo-laryngeal framework. 1 - textile fabric made of nickel-titanium thread, 2 - duplicate of the central section.

Figure 2. A fragment of the operation. Autopsy of the surgical field. 3 - skin-fat flap, 4 - flap of the subcutaneous muscle of the neck, 5 - thyroid fissure of the thyroid cartilage, 6 - tracheostomy.

Figure 3. A fragment of the operation. Installation of the neo-laryngeal framework.

Figure 4. The appearance of the wound after suturing.

Figure 5. The appearance of the patient after surgery.

The attainability of the technical result is confirmed by specific clinical examples of the treatment of laryngeal cancer at the Oncology Research Institute of the Siberian Branch of the Russian Academy of Medical Sciences (Tomsk).

Example 1. Patient M., 53 years old. Diagnosis of the disease: moderately differentiated, non-keratinizing squamous cell carcinoma of the larynx T1NOMO. The state of continued growth after remote gamma-therapy SOD 60 Gy.

The tumor occupies the left vocal fold with spreading to the anterior commissure.

The patient underwent surgical treatment according to the method of the proposed method, which is carried out as follows.

According to preliminary measurements of the volume of the forthcoming resection, the implant (Fig. 1) was made of nickel-titanium fabric for frame reinforcement of the neogortic complex. The central portion 1 of the implant, in accordance with the anatomy of the thyroid cartilage, is bent at an angle of about 100 °. The stiffness of this area and the peripheral areas around the perimeter is reinforced by duplicate tissue. The thickness of the nickel-titanium fabric thread is 300 microns; The fabric texture is textile, slightly sparse.

Under local anesthesia, tracheostomy 6 is applied (Fig. 3). Access is made by a horizontal semilunar incision along the lower cervical fold. The skin-fat flap 3 from the site of the projection of the tumor on the surface is separated on the intact leg and laid up with the release of the thyroid cartilage, the flap of the subcutaneous muscle 4 is separated and laid to the side. The resection of the thyroid cartilage in a single unit with the tumor was performed within the following boundaries: on the left, 1 cm from the posterior edge, on the right, 1.5 cm from the angle of the thyroid cartilage, above the thyroid ligament, closer to the hyoid bone, below the conical ligament, closer to the cricoid cartilage. During resection, fixation of the pharyngeal constrictors to the posterior parts of the thyroid cartilage was preserved. Intraoperative cytological control was performed along the line of resection. A thorough hemostasis was performed. An obturator is installed in the laryngeal cavity. The gaping defect is covered layer by layer with a flap of the subcutaneous muscle with suture fixation to the edges of the wound, then with a fabricated and sterilized implant (Fig. 1) and a repaired skin-fat flap. In this case, suture fixation of the implant was made by nickel-titanium thread to the periosteum of the hyoid bone, cricoid cartilage and soft tissues of the edges of the formed defect. The postoperative wound is sutured tightly (figure 4).

Wound healing in the postoperative period was carried out by primary intention (figure 5). Intensive antibacterial therapy and reorganization of the neo-laryngeal cavity were performed through obstruction, which was subsequently removed on the 14th day. The decanulation was carried out after 4 weeks. According to subjective assessments and instrumental examination data, on the 14th and 30th days, repair processes were accelerated. Towards the end of the observation period, the surface of the neo-larynx was covered with a pink mucous membrane. The lumen of the neo-larynx is wide enough, the phonic function is preserved.

Example 2. Patient M., 48 years old, was admitted for treatment at the Oncology Research Institute of Tomsk after complex, including radiation therapy, in the Trans-Baikal CODE (Chita) with a verified diagnosis of the disease: squamous cell carcinoma of moderate differentiation (histology number 47728-29 ) with objective data: hyperemia scooped-epiglottis folds and epiglottis. The first vocal fold is filled with a small tuberous tumor with spread to the laryngeal ventricle. The first commissure is intact. The mobility of the right vocal fold during phonation is limited.

The patient underwent surgical treatment according to the method of the proposed method with a variation of actions associated with the localization of the tumor. The results of treatment, according to the patient's condition and the data of control examinations, upon discharge from the clinic indicate the success of the operation and the attainability of the technical result of the proposed method.

The technical readiness and methodological refinement of the method at the moment meets the criteria of the invention of "industrial applicability".

Claims (1)

A method for surgical treatment of laryngeal cancer, including applying a tracheostomy, accessing, isolating the thyroid cartilage and performing thyroid fissure, removing a locally spread tumor, plasticizing the defect and forming a neo-throat using a nickel-titanium framework, layerwise wound closure, characterized in that the access is transverse a crescent incision along the lower cervical fold, otseparevat with abduction upward the skin-fat flap on the leg, otseparovat with abduction laterally of the cutaneous muscle of the neck on the leg, a nickelide-titanium tissue flap formed according to the topography of the thyroid cartilage and the size of the defect with the formation of a tightening duplicate along its center and perimeter is used as the neogastric scaffold, the plasticity of the defect formed and the formation of the neoglottis are performed by sequential layering of the formed defect the leg of the subcutaneous muscle of the neck, the neogastric frame and the skin-fat flap on the leg, and the neogortic frame is fixed to the periosteum of the hyoid bone, cricoid cartilage and marginal tissues of the formed defect.

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