RU2750908C1 - Method for closing the pharyngeal defect in patients after laryngectomy - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology; oncology.

SUBSTANCE: in the lower part of the pharyngeal defect, a needle is injected and threaded into the serous-muscular layer of the esophagus in a horizontal direction. Next, an injection is made into the serous-muscular layer without injecting the mucous membrane from the pharynx and the needle and thread are threaded through the thickness of this layer for 2-3 cm. Then the same needle is used to inject and thread the serous-muscular layer of the tongue root in the medial area in the horizontal direction. After that, the edges of the defect are pulled together with a thread and a fixing knot is performed, dividing the pharyngeal defect into two equal parts. Then, in one of the obtained parts, a needle is injected into the serous-muscular layer of the esophagus in the lower part of the defect, with the mucosa being captured on the needle and sutured to the mucosal-muscular layer of the tongue root, tightening the captured edges. The next suture is done similarly, continuing the suturing, moving from the medial part of the defect to its lateral edge. After suturing the lateral defect with a serous-muscular suture, a second row of continuous entwining suture is formed with the capture of the constrictors of the pharynx and the muscles of the tongue root in the opposite direction with respect to the first suture. Next, the thread is fixed to the central knot. Similarly, suturing is performed on the other side. Then, in the lower part of the defect, the membranous part of the trachea is mobilized and separated from the esophagus for 1.5-2 cm. From the sternum, the medial bundles of the sternocleidomastoid muscles are cut off on both sides. It is moved to the formed bed between the membranous part of the trachea and the anterior wall of the esophagus and fixed with a U-shaped suture to the esophagus and the membranous part of the trachea. Active aspiration drainage is installed through the counterincision in the supraclavicular area. Layer-by-layer subcutaneous-fat tissue and skin are sutured.

EFFECT: method allows creating favorable conditions for the primary wound healing after laryngectomy and reducing the risk of postoperative complications.

1 cl, 6 dwg, 2 ex

Description

The field of technology.

The invention relates to medicine, namely to otorhinolaryngology and oncology of ENT organs and is intended to close the pharyngeal defect in patients after laryngectomy.

State of the art.

Among the malignant neoplasms of the ENT organs, the most common cancer is the larynx. In 2018, the incidence rate of laryngeal cancer in the Russian Federation was 6.69 per 100 thousand of the population among men and 0.33 per 100 thousand of the population among women. In total, 6896 cases of malignant neoplasms of the larynx were detected, of which 58.5% were detected at stages III-IV of the disease.

One of the stages of combined or complex treatment, which is carried out for patients with stage III-IV laryngeal cancer, is surgical in the amount of laryngectomy. The most common local complications in the postoperative period include the failure of the pharyngeal suture, which leads to the formation of a pharyngeal fistula and pharyngostomy. According to various authors, similar complications develop up to 30% of cases.

It is believed that the successful closure of the pharyngeal defect largely depends on the technique of forming the pharyngeal-esophageal anastomosis. Many methods have been proposed for suturing the pharyngeal defect after laryngectomy, but none of them provides 100% healing of the postoperative wound by primary intention. It is impossible to exclude the negative impact on the course of the wound process of excessive tension of the edges of the postoperative wound in the pharyngeal region, which occurs when the patient's head is tilted and turned, as well as an involuntary cough when changing the tracheotomy tube.

Known technique for the formation of the pharyngeal-esophageal anastomosis after extended laryngectomy [patent for invention No. 2331375 from 17.01.2007, V.E. Romanishchev et al.]. The essence of the invention is as follows - using tweezers and a needle holder, the first row of a continuous suture is applied with an atraumatic needle, stepping back from the edges of the wound by 5 mm. Through piercing of the pharyngeal wall from the inside to the outside, one submucosal outer stitch with synthetic thread 4/0 is produced parallel to the edge of the wound. Then the wall of the opposite side is pierced from the inside to the outside with a submucosal outer stitch. The second row is applied with interrupted catgut sutures on the submucosa, and in the area of the tongue root is stitched twice. The third row of interrupted catgut sutures is applied to the remaining pharyngeal constrictors. At the end, the pharyngeal-esophageal anastomosis is covered with interrupted catgut sutures stitched together by the sternocleidomastoid muscles with long-term aspiration drainage.

The disadvantages of this method are:

1. Through piercing of the pharyngeal wall from the inside to the outside provides high permeability to microflora and increases the risk of wound infection.

2. The second and third row is formed by interrupted sutures, which contributes to the deterioration of microcirculation in the surrounding tissues, due to crushing between the sutures.

3. Covering the pharyngeal-esophageal anastomosis with sternocleidomastoid muscles stitched together without their mobilization and cutting off from the attachment site causes additional stress in the suture area when the head is turned.

The closest analogue of the claimed invention is a method of pharyngeal reconstruction [Patent for invention No. 244739 dated 12.02.2012, Trofimov E.I. et al.]. The essence of the method consists in the reconstruction of the pharynx by imposing a purse-string submucosal suture along the perimeter of the resected pharynx, tightening it until the edges come into full contact and then imposing a submerged Z-shaped suture. In this case, an adaptive lambda-shaped submucosal-submucosal suture is applied to the edges of the pharyngeal defect. The suture is turned with its apex to the edge of the pharyngeal mucosa. Then the edges of the defect are pulled together. The pharyngostoma is finally eliminated by the imposition of two semi-celiac submucosal sutures.

The disadvantages of this method are:

1. Excessive tension of the edges of the defect of the resected pharynx, which contributes to impaired blood circulation in the area of the formed suture, and also leads to diastasis of the edges of the postoperative wound.

2. There is no additional fixation of the pharyngeal suture by muscles.

3. The risk of developing gross cicatricial deformities in the neoglottic region.

4. Additional pressure on the pharyngeal suture when throwing back and turning the head.

The objective of the invention is to develop a method for closing a pharyngeal defect in patients after laryngectomy, which makes it possible to create the most favorable conditions for the primary healing of a surgical wound.

To solve this problem, a method was developed for closing the pharyngeal defect in patients after laryngectomy, which consists in the fact that in the lower part of the defect, an injection is made and a needle is inserted into the serous-muscular layer of the esophagus in a horizontal direction, then an injection is made into the serous-muscular layer without piercing the mucosa the membranes from the side of the pharynx and threading the needle and thread in the thickness of this layer for 2-3 cm, then with the same needle, inject and threading the thread into the serous-muscular layer of the root of the tongue in the medial region in the horizontal direction, after which the edges of the defect are pulled together with a thread and a fixing knot is performed, dividing the pharyngeal defect into two equal parts, located laterally from the fixing knot, then in one of the obtained parts, a needle is inserted into the serous-muscular layer of the esophagus in the lower part of the defect, with the capture of the mucous membrane on the needle and sutured to the mucous membrane. the muscle layer of the root of the tongue, pulling together the grasped edges, the next stitch is done in the same way, Continuing hemming, moving from the medial part of the defect to its lateral edge, after suturing the lateral defect with a serous-muscular suture, form the second row of a continuous twisted suture with the capture of the constrictors of the pharynx and the muscles of the tongue root in the opposite direction to the first suture, then the thread is fixed to the central node , similarly, suturing is carried out on the other side, then in the lower part of the defect the membranous part of the trachea is mobilized and separated from the esophagus for 1.5-2 cm, the medial bundles of the sternocleidomastoid muscles are cut off from both sides from the sternum, and moved to the formed bed between with the membranous part of the trachea and the anterior wall of the esophagus and fixed with a U-shaped suture to the esophagus and the membranous part of the trachea, establish active aspiration drainage through the counter-opening in the supraclavicular region, suture the subcutaneous fat and skin layer by layer.

The technical result of the claimed invention is as follows. The surgical techniques developed by us create the most favorable conditions for the primary wound healing after laryngectomy and, therefore, reduce the number of postoperative complications.

The advantages of our proposed method:

1. Reduction of tension on the pharyngeal suture when the head is thrown back;

2. Continuous suture without additional fixing nodes on the mucous membrane allows to exclude crushing of tissues and does not worsen trophism;

3. Suturing of mobilized medial bundles of the sternocleidomastoid muscles between the membranous part of the trachea and the anterior wall of the esophagus provides a constant size of the tracheotomy opening and allows cannula-free management of patients.

The method is carried out as follows.

Surgical intervention takes place under conditions of general anesthesia.

After laryngectomy in the medial region of the lower part of the defect, a needle is injected using an atraumatic monofilament suture 4.0 horizontally into the serous-muscular layer of the esophagus, then the needle is passed through the thickness of the serous-muscular layer without piercing the mucous membrane from the pharynx for 2-3 cm and threading a needle with a thread is carried out. Then, with the same needle and thread, an injection and threading into the mucous-muscular layer of the root of the tongue is made for 0.5-1 cm, in the medial region in the horizontal direction. After that, the edges of the defect are pulled together with a thread and a fixing knot is made. As a result of this manipulation, the pharyngeal defect is divided into two equal parts, located laterally from the fixing node.

Next, the same thread is used to suture one of the two defects located laterally from the fixing node. To do this, a needle is injected into the serous-muscular layer of the esophagus in the lower part of the defect, with the capture of a part of the serous-muscular membrane on the needle and sutured to the mucous-muscular layer of the tongue root, forming a stitch. Then, a part of the serous-muscular membrane in the lower part of the defect lateral to the formed stitch is captured with a needle and sutured to the mucous-muscular layer of the tongue root lateral to the formed stitch. Suturing begins in the medial part of the defect, moving towards its lateral edge. The suture step in the lower part of the defect is 2-3 times larger than in the upper one and depends on the surplus of the esophageal mucosa. After suturing the lateral defect with a serous-muscular suture, a second row of continuous twisted suture is formed with the capture of the constrictors of the pharynx and the muscles of the root of the tongue, in the opposite direction with respect to the first suture. Next, the thread is fixed to the central knot. Similarly, two rows of seams are superimposed on the other side.

At the next stage, the membranous part of the trachea is mobilized and separated from the esophagus for 1.5-2 cm. From the sternum, the medial bundles of the sternocleidomastoid muscles are cut off from both sides and move into the formed bed between the membranous part of the trachea and the anterior wall of the esophagus and are fixed by P- shaped suture to the esophagus and the membranous part of the trachea. An active aspiration drainage is established through the counteropening in the supraclavicular region. Subcutaneous fat and skin are sutured in layers.

The method is illustrated by the following figures:

FIG. 1 - Injection of a needle into the serous-muscular layer of the esophagus parallel to the edge of the defect.

FIG. 2 - Formation of the fixing knot.

FIG. 3 - Suturing of one of the two defects located laterally from the fixation knot.

FIG. 4 - Formation of the second row with a continuous twisted suture towards the fixing knot with the capture of the constrictors of the pharynx and the muscles of the root of the tongue.

FIG. 5 - Suturing of the second of the two defects located laterally from the fixation knot.

FIG. 6 - View of the postoperative wound after fixation of the medial bundles of the sternocleidomastoid muscles with a U-shaped suture to the esophagus and the membranous part of the trachea.

An example of the implementation of the claimed method No. 1.

Patient P., 36 years old, was admitted to the department of the FGBU NKTSO FMBA of Russia with complaints of hoarseness. From the anamnesis it is known that a larynx neoplasm was detected at the place of residence. A biopsy was performed, and a histological examination revealed squamous cell carcinoma. After further examination, the diagnosis was made: laryngeal cancer T3N0M0 II clinical group. An oncological consultation was held, combined treatment was recommended. Was admitted for the surgical stage of treatment.

On examination, the anterior surface of the neck is not changed, the zones of regional lymph drainage are palpable free.

With indirect laryngoscopy: the entrance to the larynx is free, the epiglottis is not changed, mobile. The tumor is infiltrative growth, occupies the right vocal and vestibular folds. During phonation, the mobility of the right half of the larynx is limited.

Performed laryngectomy with closure of the pharyngeal defect according to the stated method. The needle is injected parallel to the edge of the esophageal defect in its middle part into the serous-muscular layer, then the serous-muscular layer is placed on the piercing part of the needle without piercing the mucous membrane from the pharynx for 2 cm. After that, the needle is removed and the injection is made into the mucous membrane. the muscular layer of the root of the tongue and threading the needle for 0.5 cm into the serous-muscular layer of the root of the tongue, pulling the edges of the defect - a fixing knot is performed. As a result of this manipulation, the pharyngeal defect is divided into two equal parts, located laterally from the fixing node.

Next, the same thread is used to suture one of the two defects located laterally from the fixing node. To do this, a needle is injected into the serous-muscular layer of the esophagus, with stringing of excess mucous membrane onto the needle and stitching it to the root of the tongue. The step of the suture in the lower part of the defect is 2 cm, in the upper part - 1 cm.After the elimination of the lateral defect with the serous-muscular suture, the second row of a continuous twisted suture is formed, with the capture of the constrictors of the pharynx and the muscles of the tongue root, in the opposite direction, to the fixing suture. Next, the thread is fixed to the central knot, and the seam continues in the same way on the other side.

At the next stage, the membranous part of the trachea is mobilized and separated from the esophagus for 1.5 cm.From the sternum, they are cut off on both sides and moved to the formed bed, between the membranous part of the trachea and the anterior wall of the esophagus, the medial bundles of the sternocleidomastoid muscles are fixed U-shaped suture to the esophagus and membranous trachea. An active aspiration drainage is established through the counteropening in the supraclavicular region. Subcutaneous fat and skin are sutured in layers.

The postoperative period was uneventful, the wound healed by primary intention, the sutures were removed on the 10th day, tissue crush was not observed, the nasogastric tube was removed on the 14th day. The conclusion of the postoperative histological examination is squamous cell carcinoma.

The condition at discharge is satisfactory. When viewed on the anterior surface of the neck, a tracheostomy, into which a tracheotomy tube No. 6 is installed. With fibrolaryngoscopy, the pharyngeal-esophageal funnel is formed correctly, has a constant size, the mucous membrane is pink, moist. Free breathing through the tracheostomy, It is carried out in all parts of the lungs.

An example of the implementation of the claimed method No. 2.

Patient C, 54 years old, was admitted to the department of the FGBU NKTSO FMBA of Russia with complaints of hoarseness, difficulty breathing through natural routes, cough with sputum from a tracheostomy. The above complaints have been bothering about 8 months, have not been treated. An emergency tracheotomy was performed at the place of residence 1 month ago. A biopsy was performed at the NCCO; histological examination revealed non-keratinized squamous cell carcinoma. After further examination, the diagnosis was made: laryngeal cancer T4aN0M0 II clinical group. An oncological consultation was held, combined treatment was recommended. Was admitted for the surgical stage of treatment.

On examination, the anterior surface of the neck of the tracheostomy in a typical location is sufficient for breathing.

With indirect laryngoscopy: the entrance to the larynx is free, the epiglottis is not changed, mobile. A tumor of a mixed, predominantly infiltrative form of growth, occupies the left parts of the larynx, the glottis is narrowed, with phonation the mobility of the larynx is absent.

Performed laryngectomy with closure of the pharyngeal defect according to the stated method.

The needle is injected parallel to the edge of the esophageal defect in its middle part into the serous-muscular layer, then the serous-muscular layer is inserted onto the piercing part of the needle without piercing the mucous membrane from the pharynx for 3 cm. After that, the needle is removed and an injection is made into the serous the muscle layer of the tongue root, tightening the edges of the defect - a fixing knot is performed. As a result of this manipulation, the pharyngeal defect is divided into two equal parts, located laterally from the fixing node.

Next, the same thread is used to suture one of the two defects located laterally from the fixing node. To do this, a needle is injected into the serous-muscular layer of the esophagus, with stringing of excess mucous membrane onto the needle and stitching it to the root of the tongue. The suture pitch in the lower part of the defect is 1.5 cm, in the upper part - 0.5 cm.After the elimination of the lateral defect with a serous-muscular suture, the second row of a continuous twisted suture is formed, with the capture of the constrictors of the pharynx and muscles of the tongue root, in the opposite direction, to fixing suture. Next, the thread is fixed to the central knot, and the seam continues in the same way on the other side.

At the next stage, the membranous part of the trachea is mobilized and separated from the esophagus for 2 cm.From the sternum, they are cut off on both sides and moved to the formed bed, between the membranous part of the trachea and the anterior wall of the esophagus, the medial bundles of the sternocleidomastoid muscles are fixed with a U-shaped suture to esophagus and membranous trachea. An active aspiration drainage is established through the counteropening in the supraclavicular region. Subcutaneous fat and skin are sutured in layers.

The postoperative period was uneventful, the wound healed by primary intention, the sutures were removed on the 10th day, crushing of the tissues in the suture area was not observed, the nasogastric tube was removed on the 14th day. The conclusion of the postoperative histological examination is squamous cell non-keratinizing cancer.

The proposed method has been treated for several years in 18 patients with laryngeal cancer stage III-IV. In the postoperative period, healing occurred by primary intention. The formed constant size of the tracheotomy opening subsequently allowed for cannula-free management of patients.

Claims (1)

A method of closing a pharyngeal defect in patients after laryngectomy, which consists in the fact that in the lower part of the defect, an injection is made and a needle is inserted into the serous-muscular layer of the esophagus in the horizontal direction, then an injection is made into the serous-muscular layer without piercing the mucous membrane from the pharynx and threading a needle and thread through the thickness of this layer for 2-3 cm, then with the same needle, an injection and threading into the serous-muscular layer of the tongue root in the medial region in the horizontal direction is made, after which the edges of the defect are pulled together with a thread and a fixing knot is performed, dividing the defect of the pharynx into two equal parts, located laterally from the fixing node, then in one of the parts obtained, a needle is inserted into the serous-muscular layer of the esophagus in the lower part of the defect with the capture of the mucous membrane on the needle and suturing it to the mucous-muscular layer of the tongue root, pulling the captured edges, the next stitch is done in the same way, continuing the hem, moving forward from the media the flax part of the defect to its lateral edge, after suturing the lateral defect with a serous-muscular suture, a second row of continuous twisted suture is formed with the capture of the constrictors of the pharynx and the muscles of the root of the tongue in the opposite direction to the first suture, then the thread is fixed to the central node, similarly suturing is carried out with on the other hand, then in the lower part of the defect, the membranous part of the trachea is mobilized and separated from the esophagus for 1.5-2 cm, the medial bundles of the sternocleidomastoid muscles are cut off from both sides from the sternum, and moved into the formed bed between the membranous part of the trachea and the anterior the wall of the esophagus and fixed with a U-shaped suture to the esophagus and the membranous part of the trachea, establish active aspiration drainage through the counterperture in the supraclavicular region, suture the subcutaneous fat and skin layer by layer.

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