RU2565836C1 - Method for microsurgical repair of pharynx and cervical oesophagus with colo-omental autograft in oncology patient - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: pharynx and cervical oesophagus are repaired by means of a colo-omental autograft with a long vascular pedicle. The autograft is formed of a transverse colon with an adjoining strand of a greater omentum, a descending colon and an adjoining portion of a mesocolon. A common vascular pedicle includes a left colic artery and a vein. After reduction excision, the formed autograft is transferred into a defect and fixed with retention sutures. End-to-end anastomoses are formed between inner thoracic vessels and autograft vessels. After the blood flow starts, two digestive end-to-end anastomoses are formed on the autograft neck with an orostoma and oesophagostoma. The anastomotic area is covered with the strand of the greater omentum. The neck wound skin defect is repaired by autodermoplasty.

EFFECT: method enables the vocal rehabilitation following the tracheooesophageal by-pass, recovery of the integrity and volume of the oesophagus if observing extensive defects.

1 ex, 13 dwg

Description

The invention relates to medicine and reconstructive surgery in particular.

A known method of microsurgical reconstruction of the pharynx with a colic-omental autograft. The method consists in the fact that pharyngoplasty is performed using the free segment of the transverse colon with the adjacent lock of the greater omentum, the blood supply to the middle colon vessels, while the autograft is revascularized with the vessels of the neck (Town Hall MV “Microsurgical reconstruction of the tissues of the oral cavity and pharynx colonic omental autograft in cancer patients "(clinical and anatomical study), diss. candidate of medical sciences, Moscow, 2007, P. 45).

However, in the known method there are disadvantages:

- in cases of pronounced cicatricial and radiation changes in soft tissues on the neck, there are no reliable sources of autograft revascularization;

- the insufficient length of the vascular pedicle of the autograft (6-8 cm) does not allow revascularization of the autograft with distant sources of blood circulation (internal chest vessels) and this is why delayed microsurgical reconstruction of the pharynx is extremely difficult.

The closest method we have adopted as a prototype is the method of microsurgical repair of combined pharyngeal defects in cancer patients. In conditions of pronounced cicatricial and radiation changes in soft tissues on the neck, a gastro-omental flap with a long vascular pedicle is used. Revascularization of the autograft is carried out far from the defect by anastomosis of the right gastro-omental vessels and internal chest vessels (RU 2098027 C1).

The disadvantages of this method include:

- after restoration of the digestive function, there is no possibility of further vocal rehabilitation by tracheoesophageal bypass surgery and installation of a vocal prosthesis, since with a prosthesis, aspiration of gastric juice from the pharynx into the lower respiratory tract with the subsequent development of fatal complications is possible;

- technical difficulties encountered in the formation of the graft after a previously formed gastrostomy.

The objective of the invention is to restore the integrity, volume of the pharynx and cervical esophagus with extensive defects in cancer patients.

This task is achieved in that the autograft is formed from the transverse colon with the adjacent strand of the greater omentum, the descending colon and the adjacent part of the mesentery of the colon, with nutrition on a single vascular pedicle - the left colon artery and vein, which forms the vascular arch of Riolan, after the formation of autotransplant reduction resection of the descending colon and the left half of the transverse colon with the preservation of the mesenteric portion of the autograft, vascular pedicle of the autograft tata are crossed, the formed autograft is transferred to the defect area and fixed with provisional sutures, the vascular pedicle of the autograft is guided to the internal thoracic vessels, anastomoses are formed between the internal thoracic vessels and the autograft vessels, end-to-end type, after the start of blood flow, restoration of autograft reconstruction is recorded and by the formation of two digestive anastomoses on the neck between the edges of the colonic fragment of the autograft with an orostoma and esoph a guest of the end-to-end type, the area of digestive anastomoses is covered with a lock of a large omentum, then the neck wound skin defect is restored by autodermoplasty.

The invention is illustrated by a detailed description, clinical example and illustrations, which depict:

FIG. 1 is a diagram of the formation of colonic omental autograft.

FIG. 2 is a diagram of pharyngoplasty with a colic-omental autograft.

FIG. 3 - photo of patient P. before reconstruction of the pharynx.

FIG. 4 - access markup is shown.

FIG. 5 - allocation of the right internal chest vessels.

FIG. 6 - stage of formation of colonic omental autograft.

FIG. 7 - reduction resection of the descending colon and the left half of the transverse colon with the preservation of the mesenteric portion with the supply vessels in the same volume.

FIG. 8 - the photo shows a colonic-omental autograft with an elongated vascular pedicle.

FIG. 9 - stage of formation of digestive anastomoses on the neck.

FIG. 10 - tamponade of a neck wound with an omental fragment of an autograft.

FIG. 11 - autodermoplasty of the neck wound.

FIG. 12 - a fluoroscopic image shows the passage of barium along the throat.

FIG. 13 - photo of patient P. 1 year after surgery.

The method is as follows.

Under endotracheal anesthesia, parasternal mediastinotomy is performed on the right with resection of the cartilage of the II and III ribs. The internal thoracic vascular bundle is mobilized and crossed at the upper edge of the cartilage of the 4th rib without damage to the parietal pleura. A recipient wound on the neck is prepared for the plastic phase of the operation, the edges of the orostomy and esophagostomy are mobilized, and scar tissue is excised. At the same time, laparotomy is performed. A free microsurgical autograft is formed from the transverse colon with the adjacent lock of the greater omentum, the descending colon and the adjacent part of the mesentery of the colon, with nutrition on a single vascular pedicle - the left colon artery and vein, which forms the vascular arch of Riolan. The length of the intestinal portion of the autograft can reach 65 cm. After the formation of the autograft, a reduction resection of the descending colon and the left half of the transverse colon is performed, while the mesenteric portion of the autograft is preserved in the same volume (Fig. 1), thereby extending the vascular leg of the autograft to 20-25 and the intestinal portion of the autograft is reduced to 10-15 cm. The vascular leg of the autograft is crossed. The formed autograft is transferred to the defect area and fixed with provisional sutures. The vascular leg of the autograft is carried out to the internal thoracic vessels. Under optical enlargement, anastomoses are formed between the internal thoracic and left colon vessels (one arterial and one venous) of the end-to-end type using microsurgical technique. After the start of blood flow, restoration of autograft viability is recorded and pharynx reconstruction is started by forming two digestive anastomoses on the neck between the edges of the colonic fragment of the autograft with orostomy and esophagostoma of the end-to-end type (Fig. 2). The zone of digestive anastomoses is covered with a lock of a large omentum. The skin is restored by autodermoplasty. The wound in the mediastinum is sutured tightly, leaving passive drains. An anastomosis is formed in the abdominal cavity between the transverse colon and the sigmoid colon in a side-to-side manner. The laparotomic wound is sutured tightly leaving a control drainage. Apply aseptic dressings.

Thus, the use of this plastic material allows you to delay the restoration of the integrity and lumen of the pharynx, and reliably cover the intestinal wall and the line of organ anastomoses with a lock of a large omentum.

The method was used in the clinic for the treatment and rehabilitation of 4 cancer patients with tumors of the larynx. At the 1st stage of surgical treatment, all patients underwent laryngectomy with circular resection of the larynopharynx and cervical esophagus and bilateral cervical lymphatic dissection. After the end of the rehabilitation period, all patients underwent a delayed microsurgical reconstruction of an extensive defect of the pharynx and cervical esophagus with a colic-omental autograft. In the early postoperative period, there were no complications from the abdominal organs. In the long term, dyspeptic syndrome or other functional disorders were not observed. Adequate nutrition by mouth, weight gain was noted. Subsequently, voice rehabilitation was performed by installing a voice prosthesis.

A clinical example of the method.

Patient P., 33 years old, was admitted with a diagnosis of primary multiple metachronic cancer: 1. Cancer of the larynxopharynx IVa art. T2N2M0. Condition after polychemotherapy in 2011. Continued tumor growth with metastases in the lymph nodes of the neck on the right. Condition after surgical treatment in 2011-2012. Orostomy, esophagostoma, tracheostomy. No relapse and metastases. 2. Cancer of the thyroid gland I tbsp. T1NOMO. Condition after surgical treatment in 2011. No relapse and metastases.

Morphological study

1) No. F 4327-53: in the mucous membrane of the larynxopharynx, a site of acanthosis with pronounced dysplasia of the epithelium to carcinoma in situ with a micro focus of invasive squamous cell carcinoma with a weak tendency to keratinization is determined: on a subepithelial basis, pronounced lymphoplasmocytic infiltration with small lymphoid follicular follicles , the presence of single complexes (separately lying) of squamous cell carcinoma with severe dystrophic changes (therapeutic pathomorphism of the III degree). In the surrounding mucous membrane of the larynopharynx - pronounced parakeratosis, focal papillomatous and acanthotic growths of the squamous epithelium with foci of dysplasia (including the edges of the pharyngeal resection). In the mucous membrane of the larynx there are foci of squamous metaplasia and mild dysplasia of the epithelium. The edges of the resection are intact. In the resected area of the thyroid gland, against the background of an adenomatous goiter, a micro focus (less than 1 mm) of papillary thyroid cancer of a typical structure is determined. In three lymph nodes - metastases of squamous cell carcinoma with partial and complete replacement of lymphoid tissue, focal invasion per capsule of nodes, signs of therapeutic pathomorphism of 3 degrees.

2) No. Ф 26171-90 / OP: in seven lymph nodes metastases of squamous cell carcinoma with a tendency to keratinization, pronounced dystrophy of tumor cells, areas of fibrosis (signs of therapeutic pathomorphism of 1 degree), mainly with partial and subtotal replacement of preexisting tissue, without going beyond the capsule nodes.

From the anamnesis: considers herself a patient since 12.2010, when she noted the appearance of sore throat. I went to the ENT doctor at the place of residence where pharyngitis was diagnosed. Anti-inflammatory therapy was performed. In March 2011, she noted the appearance of an enlarged lymph node on the right neck. I applied to the Russian Scientific Center for Radiology, where I diagnosed laryngopharyngeal cancer with metastases to the lymph nodes of the neck on both sides. In June 2011, 1 course of chemotherapy was carried out (toxater, carboplatin). Then she was sent to the Moscow Oncology Center No. 1, where from 18.07.11 to 18.10.11 polychemotherapy was carried out with drugs: Erbitux, oxaliplatin and fluorouracil.

For further treatment, she independently applied to the Moscow Scientific Research Institute for Medical Sciences. P.A. Herzen, where after the examination, continued growth of the larynopharynx tumor and metastases in the lymph nodes of the neck on both sides was diagnosed. Surgical treatment proposed at the consultation. At the 1st stage in December 2011, an operation was performed: laryngectomy with circular resection of the larynopharynx and cervical esophagus, hemithyroidectomy on the right, lymphadenectomy on the neck on the right, orostomy, esophagostomy and tracheostomy. At the 2nd stage in March 2012, an operation was performed: lymphadenectomy on the left neck. Subsequently, dynamic observation was carried out. The patient fed through a nasogastric tube, daily changing the bandages on the neck and changing the tracheostomy tube. In February 2013, during the follow-up examination, data for relapse and tumor metastases were not obtained.

The patient is re-hospitalized at Moscow P.A. Herzen for reconstruction of the pharynx and cervical esophagus. At admission: the patient's condition is relatively satisfactory. Breathing through the tracheostomy is free. Food through a nasogastric tube in sufficient volume. Locally: larynx and larynxopharynx removed. There are multiple old postoperative scars on the neck. Orostomy, esophagostoma and tracheostomy are formed satisfactorily (Fig. 3). Pronounced cicatricial process in the soft tissues of the neck. There are no signs of local tumor recurrence. According to a comprehensive examination of tumor metastases, no tumors were detected. According to ultrasound doppler location data, blood flow in the facial arteries on both sides and in the right upper thyroid artery is not determined, blood flow in the left upper thyroid artery is sharply reduced, the lumen of the internal jugular veins is narrowed, blood flow in the right internal thoracic artery is satisfactory. An X-ray examination of the large intestine revealed no pathology. After preoperative preparation in February 2013, an operation was performed: delayed microsurgical pharyngoplasty with colonic-omental flap, autodermoplasty.

On the operation: under endotracheal anesthesia, access markings were made on the neck, chest wall and abdominal wall (Fig. 4). A parasternal mediastinotomy on the right was performed with resection of the cartilage of the II and III ribs. The internal thoracic vascular bundle was mobilized (Fig. 5) and crossed at the upper edge of the cartilage of the 4th rib. A vascular clip is superimposed on the inner thoracic vessels. The incision on the chest wall is extended upward to the neck. The edges of the orostomy and esophagostomy are mobilized on the neck, and scar tissue is excised. At the same time, a laparotomy was performed. When revising the abdominal cavity, no pathology was detected. The left half of the colon is mobilized. Colon angioarchitectonics examined. The middle colon vessels and the descending branch of the left colon vessels are isolated, crossed and bandaged. A large omentum was mobilized and crossed, leaving its strand of 10 × 15 cm in size on the transverse colon. Using the apparatus for applying lateral gastrointestinal anastomoses, the colon was suppressed at the level of the middle third of the transverse colon and at the border of the descending colon into the sigmoid colon (Fig. 6). The length of the intestinal portion of the autograft is 60 cm. Nutrition of the autograft due to the left colon vessels is sufficient. Then, in the autograft, a reduction resection of the descending colon and the left half of the transverse colon was performed, while maintaining the mesenteric portion with the supply vessels in the same volume (Fig. 7). After reduction, the length of the vascular pedicle of the autograft was 15 cm, the intestinal portion of the autograft was reduced to 16 cm. The size of the omental portion of the autograft remained the same (Fig. 8). A vascular clip is superimposed on the vascular leg of the autograft. The colonic-omental autograft is cut off and moved to the neck, where it is fixed with provisional sutures. The vascular leg of the autograft is carried out in the right parasternal region. Under optical magnification, two microvascular anastomoses were formed between: the internal thoracic and left colon veins of the end-end type and the internal thoracic and left colon veins of the end-end type. The start of blood flow. Autograft viability restored. Next, pharyngoplasty was performed by forming an esophageal-intestinal anastomosis of the end-end type and an oro-intestinal anastomosis of the end-end type (Fig. 9). A nasogastric tube is installed through the formed pharynx. The area of intestinal anastomoses on the neck and the area of microvascular anastamoses in the parasternal region are plugged with an omentum strand (Fig. 10). The wound of the parasternal region is drained by a latex graduate and sutured tightly. The neck wound is drained by latex graduates and partially sutured. The defect of the skin of the wound of the neck was restored by free dermis from the right thigh (Fig. 11). In parallel, in the abdominal cavity, sigmo-transversoanastomosis of the intestines was formed by the type of side-by-side. The mesentery of the colon is sutured with separate interrupted sutures. The wound of the abdominal wall is sutured in layers tightly, leaving drainage in the small pelvis. Alcohol dressings are applied to the wounds.

The postoperative period is smooth. The wound healed by primary intention. An autograft is viable, adapted, with no signs of impaired blood supply. In the early postoperative period, nutrition was administered through a nasogastric tube. From the 14th day, nutrition began by mouth (Fig. 12), the nasogastric tube was removed. On the 16th day, the patient is decanulated. In satisfactory condition, the patient was discharged from the hospital. During follow-up examinations, there are no signs of disease progression. The patient eats through the mouth in full, there is no dyspeptic syndrome. I gained weight.

One year after reconstruction of the pharynx (Fig. 13), voice function was restored by forming a tracheoesophageal shunt and installing a voice prosthesis. Currently, the patient is socially adapted, returned to work.

The use of the proposed method in MNII them. P.A. Herzen made it possible to achieve several advantages: topographic and anatomical stability of the autograft revascularization source located outside the zone of radiation damage and cicatricial process on the neck; due to the length of the vascular pedicle of the autograft, it became possible to revascularize the graft with the internal thoracic vessels; the use of the formed autograft allowed us to recreate the integrity and volume of the pharynx and cervical esophagus with extensive defects, and its mucous secretion does not have an aggressive effect, which made it possible to further conduct voice rehabilitation by means of a tracheoesophageal bypass grafting and installation of a voice prosthesis.

Claims (1)

A method of microsurgical reconstruction of the pharynx and cervical esophagus with a colic-omental autograft in an oncological patient, comprising the use of an autograft with a long vascular pedicle, characterized in that the autograft is formed from the transverse colon with the adjacent strand of the greater omentum, descending colon of the colon and colon with food on a single vascular pedicle - the left colon artery and vein forming the vascular arch of Riolan, after the formation of a of the autograft, a reduction resection of the descending colon and the left half of the transverse colon is performed, while the mesenteric portion of the autograft is preserved, the vascular pedicle of the autograft is transected, the formed autograft is transferred to the defect area and fixed with provisional sutures, the vascular catheter is inserted between the grafts and the vessel with autograft vessels of the end-to-end type, after starting the blood flow, restoration is fixed viability of the autograft, they begin reconstruction of the pharynx by forming two digestive anastomoses on the neck between the edges of the colonic fragment of the autograft with orostomy and esophagostoma of the end-to-end type, cover the zone of digestive anastomoses with a lock of the greater omentum, and then restore the neck with a skin defect.

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