RU2637824C1 - Method for treatment of damage to lower third of cicatrically stenotic esophagus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: gastrotomy is performed. In the lumen of the stomach two ends of the U-shaped tube are directed. One end of the Y-shaped tube is retrograde to the esophagus above the zone of injury and stenosis. The esophagus wound is sutured on the tube, as in a thick (Ch/Fr-32) probe. The other end of the Y-shaped tube is placed in the antegrade direction into the stomach as a gastrostomy. After surgery, gastric decompression and enteral feeding through the withdrawn tube are performed. The Y-shaped tube in the area of the esophageal wound is located before the full maturing of the connective tissue scar.

EFFECT: reliable closure of the lower third of the esophagus, restenosis prevention in the postoperative period.

1 dwg, 1 ex

Description

The invention relates to medicine, namely to thoracic surgery.

Known methods for treating injuries of the lower third of the esophagus, in most cases, referring to perforation of the scar-narrowed esophagus, involving the use of various techniques in relation to the perforation and enteral feeding of the patient.

A known method (see Adyshirin-Zade E.E., Gabbazov A.G., Andreev I.S., Yurchenko I.N. Surgical treatment of iatrogenic lesions of the esophagus // Traumatology and orthopedics of the XXI century. Collection of abstracts of the VIII Congress of Orthopedic Traumatologists Russia. - Samara, 2006. - P. 1108 (Coaut. Adyshirin-Zade E.E., Gabbazov A.G., Yurchenko I.N.).

The disadvantages of this method are: trauma, since there is a need for the formation of both laparotomy and thoracotomy access during surgery, the possibility of casting gastric contents into the mediastinum with the development of mediastinitis, as well as a high risk of cicatricial narrowing of the esophagus.

The known method (see RU No. 2468758 from 12/27/2010, A61B 17/00). The essence of the method lies in the fact that laparotomy, diaphragmotomy, isolation of the abdominal esophagus, ligation of the esophageal tube below the defect closer to the stomach are performed. At the same time, the anterior wall of the esophagus is flashed without trapping the mucous membrane. Then both ends of the thread are carried around the esophagus tube and tightened with a knot until the esophagus is completely eliminated. The thread is used from vikril material.

The disadvantages of this method are: healing of the wound of the esophagus by secondary intention at a later date with the formation of scar tissue and the possible development of stenosis, the need for long-term nutrition of the patient through the gastrostomy.

The closest analogue to the technical solution is the method with the application of a purse string suture below the site of damage, which is tied around a nasoesophagogastric tube. The authors describe this technique: before suturing the wounds of the lower third of the esophagus from the inside, a purse string suture is applied to the mucous membrane of the esophagus below the wound using an absorbable suture material that is tied around a nasoesophagogastric tube (RU No. 2274422 dated 05/21/2004, A61B 17/00) - prototype.

The disadvantages of the prototype: with a long stay nasoesophagogastric tube develop complications such as pressure sores of the mucous membrane of the nasal passages and rhinopharynx, while difficulty breathing can lead to the development of pneumonia. In addition, when the probe is removed after 10-14 days, along with a decrease in the risk of esophageal suture failure, the development of stenosis in the suture zone is not excluded, which is due to the maturation of connective scar tissue. This is most relevant if the operation was performed against the background of already existing cicatricial narrowing of the esophagus in the suture area or when the cicatricial-narrowed esophagus ruptured during bougienage, which leads to repeated cicatricial narrowing (restenosis). It should be noted that in the presence of cicatricial narrowing of the esophagus, due to degenerative changes in the mucous membrane, the application of a purse string suture can be not only problematic, but also impossible in principle.

The objective of the invention is the reliable closure of damage to the lower third of the esophagus and the prevention of the development of repeated cicatricial narrowing of the esophagus (restenosis) in the postoperative period.

This object is achieved in that in a method of treating injuries of the lower third of the scar-narrowed esophagus, including suturing the wound of the esophagus on the tube, a gastrotomy is performed through which two ends of the U-shaped tube are passed into the lumen of the stomach, while one end is carried out retrograde from the stomach to the lower a third of the esophagus is above the rupture zone and stenosis, and the wound of the esophagus is sutured on it, and the other is placed in the antegrade direction in the stomach like a gastrostomy, and in the postoperative period, the stomach is decompressed and enteral nutrition, while the U-shaped tube is used for a time sufficient to mature the connective tissue of the wound of the esophagus (from 3 to 4 weeks). It is possible to leave the tube for a longer time (up to 6-8 months) if necessary, but it is more rational to limit it to an interval of 3-4 weeks with the condition of subsequent dynamic monitoring of the patient, since this is sufficient for the connective tissue to mature in the area of damage, more comfortable conditions are created for the patient in the postoperative period and other complications are excluded.

In FIG. 1 shows a General view of the proposed method, where:

1 - gastrostomy

2 - the lumen of the stomach

3 - esophagus lumen

4 - U-shaped tube

5 - the gastric part of the U-shaped tube

6 - esophageal part of the U-shaped tube

7 - damage to the lower third of the esophagus

8 - scar-narrowed part of the esophagus

9 - angle formed by two parts of the U-shaped tube

The method is as follows (see Fig. 1).

A laparotomy is performed, followed by a gastrotomy 1, through which the two ends of the U-shaped tube 4 are passed into the lumen of the stomach 2. After that, one end of the U-shaped tube 6 is carried out in a retrograde direction into the esophagus 3 above the lesion and stenosis zone. The wound of the esophagus is sutured on the tube 7, as on a thick (size according to Ch / Fr - 32) probe. The other end of the U-shaped tube 5 is installed in the antegrade direction into the stomach according to the type of gastrostomy, and after the operation, decompression of the stomach and enteral nutrition are performed on it. In this case, the U-shaped tube in the stomach and in the area of the wound of the esophagus can be stored for a long time, up to the full maturation of the connective tissue scar in the area of the wound of the esophagus.

EFFECT: reliable closure of damage to the lower third of the esophagus and prevention of the development of repeated cicatricial narrowing of the esophagus (restenosis) in the postoperative period.

There is a specific example of the invention. Patient A. was in the department of thoracic surgery for decompensated cicatricial narrowing of the lower third of the esophagus (he drank battery fluid six months ago), in connection with which he underwent esophageal boughening up to bougie number 32. In the early postoperative period, there were complaints: chest pain, in the upper abdomen, shortness of breath, general weakness, swelling of the face, neck and upper chest. Examination according to multispiral computed tomography of the chest organs with water-soluble contrast revealed: hydropneumothorax on the left, damage to the lower third of the esophagus, pneumomediastinum. In an emergency, the patient underwent surgery - laparotomy, gastrotomy, suturing of the esophagus defect along the esophagus end of the U-shaped tube, installing the gastric end of the U-shaped tube as a gastrostomy, mediastinal debridement, drainage of the left pleural cavity and mediastinum. In the postoperative period, the patient was in the intensive care unit and intensive care unit, where he received the necessary medical support, enteral nutrition and decompression of the stomach were carried out according to the type of gastrostomy installed in the stomach, part of the tube. A month later, on the control review x-ray of the chest organs with a water-soluble contrast - no streaks of contrast over the contour of the esophagus were revealed. After removal of the U-shaped probe in satisfactory condition, is discharged for treatment at the place of residence.

The proposed method allows to obtain the following result: preventing the development of restenosis in the area of the associated wound of the esophagus, eliminating the development of complications such as pneumonia and bedsores of the mucous membrane of the nasal passages and rhinopharynx, providing favorable conditions for reparative processes in the wall of the esophagus.

Thus, the proposed method for treating injuries of the lower third of the scar-narrowed esophagus, due to the retrograde installation of one end of the U-shaped tube in the esophagus and suturing of the esophagus on it, provides for the prevention of suture failure in the early postoperative period, and prolonged exposure of the tube to the esophagus prevents the development of restenosis , the finding of the second end of the U-shaped tube in the lumen of the stomach allows for full enteral nutrition and the necessary decompression of the organ. The proposed method during its practical application in our clinic (Department of Hospital Surgery IMO NovGu) was used in 5 patients, 4 against the background of existing stenosis of the lower third of the esophagus, in all 5 cases of postoperative complications.

Claims (1)

A method for treating injuries of the lower third of the scar-narrowed esophagus, including suturing the wound of the esophagus on the tube, characterized in that they perform a gastrotomy through which two ends of the U-shaped tube are passed into the lumen of the stomach, while one end is carried out retrograde from the stomach to the lower third of the esophagus above zones of rupture and stenosis, and on it the wound of the esophagus is sutured, and the other is installed in the antegrade direction in the stomach as a gastrostomy, and in the postoperative period, decompression of the stomach and enteral nutrition are performed through it When this U-shaped tube is used for a time sufficient for the maturation of the connective tissue of the esophagus sewn wounds.

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