RU2668473C2 - Method for restoration of voice function in cancer patients after laryngectomy - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, to oncology and reconstructive microsurgery, namely to the restoration of the voice function in patients after laryngectomy. In the method, a large intestine iliac autograft is used from a fragment of the distal ileum 15 cm long, cecum with an appendix, a fragment of the right half of the large intestine with blood supply on a single vascular pedicle, including the iliac-colonic artery and vein. Then, a tracheal-pharyngeal shunt is formed using the fragment of the small intestine. At the same time, the fragment of the ascending colon that is cut along its antiplatelet edge is arranged isoperistaltically. Plastic repair of the anterior-lateral walls of the pharynx is performed using a fragment of the ileum and a tracheal-pharyngeal shunt is formed with the aid of the iliac-tracheal anastomosis of the end-end type.EFFECT: method allows to reduce the level of disability, to prevent the aspiration of saliva and food into the trachea, which is achieved through the implementation of the above methods of the invention.1 cl, 11 dwg, 1 ex

Description

The invention relates to medicine, oncology and reconstructive microsurgery, namely to restore voice function in patients after laryngectomy.

A known method of restoring voice function in patients undergoing laryngectomy using a voice prosthesis. Tracheo-esophageal bypass surgery is performed for patients with distant larynx, followed by the installation of a vocal prosthesis. (N.F. Nijdam, A.A. Annyas, N.K. Schutte, and N. Leever. A New Prosthesis for Voice Rehabilitation After Laryngectomy. Arch Otorhinolaryngol (1982) 237: 27-33).

The disadvantages of this method include:

- The need to replace a voice prosthesis every 6 months, sometimes more often. Only with careful use and sufficient hygiene is an annual replacement possible.

- Replacing a voice prosthesis requires hospitalization and observation in a hospital. The use of a one-day hospital is allowed.

- Regular replacement of a voice prosthesis requires high economic costs.

- Daily hygiene of the voice prosthesis is required, including sanitation after each meal.

Performing subsequent surgical interventions (myotomy) aimed at restoring the mobility of the pharynx, which is necessary to improve voice formation.

The closest method that we have adopted as a prototype is a method of restoring voice function in patients after laryngectomy with circular resection of the larynx and pharynx using microsurgical reconstruction of the upper sections of the aero digestive tract using a free colic-iliac autograft. In this method, the pharynx is restored by the part of the autograft, including the cecum and the fragment of the ascending colon in the form of a tube, to form the orocecal and ascendo-esophageal anastomoses, and the tracheopharyngeal shunt is formed by the part of the autograft, including the fragment of the small intestine. Revascularization of the autograft is performed by anastomosis of the colonic-iliac vessels and neck vessels (New Options for AerodigestiveTract Replacement After Extended. Laryngoscope 110: October 2000. P. 1750-1755).

The technical result of the invention is to restore voice function in cancer patients after laryngectomy, to prevent aspiration of saliva and food into the trachea through the tracheo-iliac shunt, to shorten the rehabilitation time and reduce the level of patient disability.

The specified technical result in the implementation of the invention is achieved due to the fact that, as well as in the known method, a colonic-iliac autograft is used, a tracheopharyngeal shunt is formed with a fragment of the small intestine.

A feature of the claimed invention lies in the fact that an ascending colon is used for plasty of the anterior-lateral pharyngeal wall, dissected along the antimesenteric edge, placed isoperistaltically, and a tracheopharyngeal shunt is formed using a ileo-tracheal anastomosis of the end-to-end type.

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

FIG. 1 - Marking the surgical field.

FIG. 2 - Type of macrodrug.

FIG. 3 - Type of neck vessels prepared for anastomosis.

FIG. 4 - Scheme of the formation of colonic-ileal autograft: 1 - transverse colon; 2 - intersection (a.et v.colica dextra); 3 - ileum; 4 - vascular pedicle of colonic-iliac autograft (a.et v.ileocolica); 5 - resected dome of the cecum with the appendix; 6 - the cecum; 7 - colonic iliac autograft; 8 - the ascending colon; 9 - the intersection of the right branch of a.et v.colica media.

FIG. 5 - An autograft comprising: a fragment of the distal ileum, a cecum with an appendix, and a fragment of the right half of the ascending colon, with blood supply to a single vascular pedicle, including the ileo-colonic artery and vein.

FIG. 6 (a, b) - diagram and photo: dissection of the large intestine fragment of the autograft along the mesenteric edge.

FIG. 7 - Plastic surgery of the anterior-lateral walls of the pharynx with the application of separate nodal sutures between the mucous membrane of the pharynx and the edges of the large intestinal fragment of the flap (the entrance to the ileocecal valve is indicated with forceps).

FIG. 8 - The formation of the ileo-tracheal anastomosis according to the type of "end-end".

FIG. 9 - Scheme of using the ileocecal segment with a bauginium damper for holo-transforming operations in oncology: 10 - tracheotomy opening; 11 - trachea; 3 - plot of the ileum; 4 - a.et v. ileocolica; 8 - wall of the cecum and parts of the ascending colon (Questions of reconstructive and plastic surgery No. 3 (38) September 2011, p. 41. I. B. Kazantsev, A. A. Sotnikov).

FIG. 10 - View of the wound before autodermoplasty.

FIG. 11 The final view of the wound, covered with a split dermal flap. The method is as follows.

At the first stage, under endotracheal anesthesia, a "T" -shaped skin incision is made in the skin of the anterior surface of the neck (Fig. 1). The edges of the wound mobilize and breed. The front muscles of the neck cross with the leaving of the latter on the larynx. The isthmus of the thyroid gland is crossed, thyroid lobes are mobilized and taken to the sides. Laryngeal neurovascular bundles are isolated, transected and ligated from both sides. The hyoid bone horns are resected. Make a circular intersection of the trachea between the cricoid cartilage and the first half ring of the trachea. Perform sublingual pharyngotomy. A tissue block is formed, including the larynx with cricoid cartilage. Next, the drug is removed in a single block (Fig. 2). Perform thorough hemostasis. The neck vessels (artery and vein) are mobilized and prepared for anastomosis (Fig. 3). A transverse skin incision is made 2.5 cm below the lower skin edge of the resection. The front muscles of the neck are mobilized and bred. The anterior wall of the trachea is selected, which is opened between 4 and 5 half rings, forming the final tracheostomy by applying separate nodal sutures between the half rings of the trachea and the skin edges of the wound. Re-intubation is performed by installing an endotracheal tube into the trachea through the tracheostomy.

At the same time produce a laparotomy. An autograft is formed from a fragment of the distal ileum 15 cm long, the cecum with the appendix and a fragment of the right half of the colon, with blood supply to a single vascular pedicle, including the ileo-colonic artery and vein (Fig. 4). The vascular pedicle is clipped and transected with ligation of the ileo-colonic stump (Fig. 5). The graft is transferred to a pharyngeal defect.

Further, microvascular anastomoses are formed under optical magnification: between the artery and vein of the neck with autograft vessels. Start the blood flow, evaluate the viability of the autograft and establish a naso-gastric tube for feeding. The dome of the cecum with the appendix is resected. A fragment of the ascending colon is dissected lengthwise along the mesenteric margin, positioning isoperistaltically (Fig. 6). Plastic surgery of the anterior-lateral walls of the pharynx is made by applying separate nodal sutures between the mucous membrane of the pharynx and the edges of the large intestine fragment of the autograft (Fig. 7). An ileo-tracheal anastomosis of the end-to-end type is formed (Fig. 8, 9). The mesenteric portion covers the areas of microvascular anastomoses and pharyngeal sutures (Fig. 10). The wound is partially sutured leaving rubber graduates left and right. A split dermal flap from the right thigh is placed on a fragment of a flap that is not covered by skin flaps of the neck (Fig. 11).

In the abdominal cavity, an ileo-colonic anastomosis is formed using a linear stapler isoperistaltically in a “side-by-side” manner. Silicone drainage is installed in the right lateral canal of the abdominal cavity. Laparotomy wounds are sutured in layers, aseptic dressings are applied. Re-intubated onto the tracheostomy tube.

Example. Patient M., 52 years old, diagnosis: Laryngeal sarcoma, Art. II G3. Morphological study: low-grade polymorphic cell sarcoma (G3).

From the anamnesis: since June 2016 notes hoarseness of voice. Not treated. He independently applied to the Moscow Scientific and Research Institute for them. P.A. Herzen for examination and treatment. After the examination, the present diagnosis is established. Treatment tactics were discussed at an interdisciplinary consultation, surgical treatment was recommended.

At admission: the patient's condition is relatively satisfactory. Karnowski index - 70, ECOG-WHO-2 scale. On palpation of the tumor pathology is not determined. Crepitation of the larynx is preserved. Lymph nodes of the neck are not enlarged. With indirect laryngoscopy: the supraplastic and vestibular sections of the larynx are not changed. At the level of the middle section, the mucosa of both vocal folds is smooth, with no signs of infiltration. Both halves of the larynx are mobile. In the area of the anterior commissure, tuberous tumor infiltration of a bright red color is defined, extending to the subcladding section along the anterior wall and the anterior 1/3 of both side walls. The total extent of tumor infiltration is up to 3 cm. The lumen of the glottis and subclavian section is narrowed.

After preoperative preparation, an operation was performed: laryngectomy with simultaneous microsurgical plastic surgery of ileo-colonic autograft.

On the operation: Under the ETN, a skin incision was made that borders the tracheostomy, then a "T" -shaped skin incision of the anterior neck surface (Fig. 1). The edges of the wound are mobilized, divorced. The front muscles of the neck are crossed. The isthmus of the thyroid gland was crossed, the thyroid lobes were mobilized, laid aside. The laryngeal neurovascular bundles on both sides were isolated, crossed, and bandaged. The hyoid bone horns are resected. Performed sublingual pharyngotomy. During the audit, the laryngeal cavity is occupied by an exophytic coarse tuberous tumor with a length of 8 cm, fixed in the region of the anterior commissure in an area of 1 cm. A tissue block is formed, including a larynx with cricoid cartilage. The drug is removed in a single block (Fig. 2). Hemostasis. The superior thyroid artery on the right and the facial vein on the right are mobilized, prepared for anastomosis, (Fig. 3). A transverse skin incision was made 2.5 cm below the level of the first half-ring of the trachea, the edges of the wound were mobilized. The front muscles of the neck are mobilized and divorced. The anterior wall of the trachea is highlighted. The trachea is opened between 4 and 5 half rings. The final tracheostomy was formed by applying separate nodal sutures between the semicircles of the trachea and the skin edges of the wound. Reintubation.

An upper median laparotomy was performed. During the audit in the examined areas without tumor pathology. An autograft was formed from a fragment of the distal ileum of 15 cm long, the cecum with the appendix, a fragment of the right half of the colon, with blood supply to a single vascular pedicle, including the ileo-colonic artery and vein (Fig. 4). The vascular pedicle is clipped and crossed with ligation of the ileo-colonic stump (Fig. 5). The graft is transferred to the neck.

Microvascular anastomoses are formed under optical enlargement: between the superior thyroid artery on the right and the ileo-colonic artery of the flap of the end-to-end type and between the facial vein on the right and the iliac-colonic vein of the end-to-end type. The start of blood flow. Flap viability has been restored. A naso-gastric tube for feeding was installed.

The dome of the cecum with the appendix is resected. A fragment of the ascending colon is dissected along the mesenteric margin, located isoperistaltically (Fig. 6 a, b). Plastic of the anterior-lateral walls of the pharynx was made with the application of separate nodal sutures between the mucous membrane of the pharynx and the edges of the colonic fragment of the flap (Fig. 7). Next, an ileo-tracheal anastomosis of the end-to-end type was formed (Fig. 8 a, b). The mesenteric portion covers the areas of microvascular anastomoses and pharyngeal sutures. The wound is partially sutured leaving rubber graduates left and right. On a fragment of the autograft that is not covered by skin flaps of the neck (Fig. 10), a split dermal flap from the right thigh is laid (Fig. 11).

An ileo-colonic anastomosis was applied in the abdominal cavity using an NTLC 75 linear apparatus and 2 SR 75 cassettes isoperistaltically in a side-by-side manner. Silicone drainage is installed in the right lateral canal of the abdominal cavity. Laparotomy wounds were sutured in layers, aseptic dressings were applied. Re-intubation on tracheostomy tube No. 8.

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 carried out through a nasogastric tube, which was removed on the 14th day after surgery and oral nutrition was restored. 1 month after the operation, training of the vocal function was started, while the tracheostomy opening was blocked with the thumb after inhaling, and on the exhalation, air was passed through the tracheopharyngeal shunt into the oral cavity. A distinct speech was noted. During dynamic observation - the patient eats through the mouth in full, there is no dyspeptic syndrome. He gained weight. Currently, the patient is socially adapted.

The use of the proposed method in clinical practice made it possible to achieve the following technical results:

- simultaneously and fully restore voice function after laryngectomy;

- the ileocecal valve, which is part of the combined autograft, prevents aspiration of saliva and food into the trachea through the tracheo-iliac shunt;

- the mucous secretion of the autograft does not have an aggressive effect on the mucous membrane of the trachea, which allows you to implement a plan for voice rehabilitation;

- there is no functional and aesthetic damage in the donor zone after the formation of the flap;

- significantly reduces the time of rehabilitation, and also reduces the level of disability of the patient;

- the use of autotissue does not require large financial costs compared with the installation and constant replacement of the voice prosthesis.

Claims (1)

A method of restoring vocal function in cancer patients after laryngectomy, including the use of a colonic-ileal autograft and the formation of a tracheopharyngeal shunt with a fragment of the small intestine, characterized in that the ascending colon is used to plastic the anterior-lateral walls of the pharynx, the incision is made along its length and the incisor is inserted a ileal fragment forms a tracheopharyngeal shunt using an ileo-tracheal anastomosis of the end-to-end type.

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