RU2791388C1 - Method for reconstruction of anterolateral larynx and cervical trachea in patients with extended laryngotracheal obliteration of the lumen - Google Patents

Abstract

FIELD: medicine; surgery; otorhinolaryngology.

SUBSTANCE: before the operation, the required number of allografts from demineralized bone tissue is kept in saline for 10 minutes. Then they are given a rectangular shape with rounded edges. In this case, the size of allografts is selected individually depending on the extent of the defect. Finished allografts are perforated with through holes. Then, during the operation, after excision of the scar tissue, a new lumen of the larynx and trachea is formed. In the area of stenosis, form the inner lining of the anterior wall of the trachea. Muscular-fascial pockets are formed paratracheally, where the required number of allografts is placed and set in a vertical position. They are fixed to the surrounding tissues with vicryl 3.0, covered in layers with muscles, fascia, subcutaneous fat and skin. Then carry out prosthetics on a T-shaped tracheostomy tube from 3 to 6 months. The control period is carried out without a tracheostomy tube with a hermetically sealed laryngotracheostomy opening. With a favorable course of the control period: maintaining the supporting function of the walls of the laryngotracheal complex with allografts, in case of absence of a rejection reaction and material migration, absence of prolapse of allografts into the lumen of the respiratory tract, the laryngotracheostomy defect is sutured and the laryngotracheostomy is closed.

EFFECT: increasing the efficiency of treatment, reduction of the stages of reconstructive operations in the treatment of patients with extended laryngeal-tracheal obliteration, reduction of the probability of postoperative complications, preventing restenosis of the laryngeal-tracheal complex, elimination of the need for repeated surgical interventions, reduction of the duration of inpatient treatment and terms of rehabilitation of patients.

4 cl, 2 ex, 6 dwg

Description

The invention relates to medicine, namely to surgery and otorhinolaryngology, and can be used in the complex treatment of patients with extended cicatricial stenosis of the larynx and trachea during reconstructive plastic surgery.

Cicatricial stenosis of the larynx and trachea is a pathological process, the consequence of which is the replacement of the normal structures of the larynx and trachea with coarse fibrous connective tissue, the destruction of cartilage tissue with a violation of their frame function and leading to a narrowing of the lumen of the larynx-tracheal complex with partial or complete obliteration of the lumen.

The most common causes of cicatricial stenosis of the larynx and trachea are: tracheal intubation with artificial lung ventilation (ALV); emergency and planned tracheostomy; damage to the larynx in systemic diseases of the blood and connective tissue; traumatic damage to the larynx and trachea; thermoinhalation trauma; surgical treatment of the larynx and cervical trachea in history.

Artificial ventilation of the lungs (ALV), non-compliance with the tracheostomy technique can contribute to the formation of ischemic damage and erosion with the subsequent formation of stenosis of the larynx-tracheal complex of varying severity due to the replacement of normal structures with scar tissue with the outcome in a circular narrowing, or complete atresia of the lumen of the larynx and trachea [4 ,5, 6].

Morphological changes in the formation of cicatricial stenosis go through successive stages in the form of erosive-ulcerative tracheitis, proliferation of granulation tissue with lymphocytic infiltration and subsequent squamous metaplasia of the epithelial lining with destruction of cartilage elements and their focal ossification, which leads at the final stages to the formation of chronic cicatricial stenosis of the larynx and cervical trachea [7, 8].

The search for new solutions, the improvement of existing methods of treatment and the development of new approaches to the treatment of patients with extensive cicatricial obliteration of the lumen of the larynx and cervical trachea is an urgent and demanded task.

There is a known method of circular resection of the trachea with restoration of the integrity of the respiratory tract using end-to-end laryngeal-tracheal anastomosis, in which all parts of the larynx and trachea affected by the pathological process are completely removed, stitching, as a rule, unchanged tissues [10].

To obtain satisfactory results of surgical treatment with circular resection of the trachea, it is necessary to have breathing through the natural respiratory tract in cannula carriers, a small length of stenosis (less than 4 cm), the absence of severe concomitant pathology from other organs and systems, which limits the possibilities of surgical treatment and reduces the number of patients which may be recommended circular resection [11].

In addition, there is a high probability of an unfavorable outcome in the presence of a functioning tracheostomy, which is a focus of chronic infection and supports the inflammatory process in the larynx and trachea of varying severity. The zone of inflammation in the altered wall of the larynx and trachea may be histologically more visible and determined by computed tomography. In the case of an insufficiently resected fragment of the trachea with preservation of the affected area, there is a high probability of anastomosis failure. With extended resection of the laryngotracheal region, there is also a possibility of anastomosis divergence and ineffectiveness of surgical treatment with the development of complications up to death [10].

Staged laryngotracheoplasty is a method of surgical treatment of chronic cicatricial stenosis of the larynx and trachea with external access and consists in excising the scar tissue of the larynx and trachea throughout its entire length and forming a new airway lumen. In most cases, extended cicatricial stenoses are accompanied by a partial or complete absence of cartilaginous tissue at the level of the lesion, which requires the use of various implant materials to restore the supporting function of the upper respiratory tract and maintain an adequate lumen of the larynx and trachea in the absence of its own cartilaginous structures. The tendency to postoperative recurrence of scar tissue makes the treatment multi-stage, lengthy and difficult. Long-term prosthetics with silicone T-shaped tracheostomy tubes are the most common [6, 12].

The main purpose of scaffold materials is to maintain a stable airway lumen and counteract mechanical stress, including during coughing and during forced breathing, as well as to prevent the respiratory tract from falling during inspiration [13].

There are various options for plasty of the laryngotracheal defect and reconstruction of the lower respiratory tract using autologous tissues. However, musculoskeletal plastic surgery of the larynx and trachea is characterized by low functional results, which is associated with complications in the form of flotation of the walls of the larynx and trachea and, as a result, the absence of a frame function. The implementation of a one-time sampling of autologous tissues and their implantation in the required area is often difficult and may not be sufficient to achieve the result due to the limited amount of material. In addition, there is a risk of significant trauma to the donor area, which limits the use of automaterials [14].

The disadvantages of using autocartilage are the need for additional surgical intervention associated with the collection of implant material and its subsequent manufacture of the required size and shape. There is a risk of anatomical, functional and cosmetic defects in the donor area, which may necessitate their plastic restoration and additional surgical intervention in the donor area. In patients with extensive cicatricial changes and sluggish septic processes of the surrounding tissues, the use of microsurgical techniques necessary for the formation of prefabricated revascularized musculocutaneous and musculoskeletal autografts is impossible [15].

Known studies using a synthetic material in the form of a grid of marlex as an implant material.

Yagudin R.K. et al. a fringing incision of the skin around the tracheostomy was performed, the skin was sutured over the tracheostomy with the epidermis into the lumen. The anterior muscles of the neck were sutured with the second layer. A mesh of polypropylene monofilament produced by Esfil or Prolen was placed on the muscles with the third layer. To evacuate the wound discharge above the implanted mesh, 2 vacuum drainages were left. The tracheostomy opening was finally closed by moving two triangular skin flaps, which were cut out on the sides of the tracheostomy (fourth layer)
In 3 patients (all with four-layer plasty), an early recurrence of stenosis occurred in the period from 1 to 27 days after the operation, associated with balloting of the side walls of the trachea [16].

When using Marlex, patients often present with pain in the area of implantation, suppuration of the wound with the formation of fistulas and sequestration of the prosthesis, extrusion of the mesh in the late postoperative period through the skin or into the lumen of the respiratory tract with the development of stenosis and arrosive bleeding from large vessels are not excluded.

Histological data obtained during the study of prostheses removed for various reasons at different time intervals after implantation show that a persistent inflammatory reaction persists between the polymer fibers and the tissues of the recipient. In addition, the material is encapsulated by a thick capsule without fixation and germination by its connective tissue, which contributes to the migration of the implant into the surrounding tissues [17].

A known method of plasty of the lateral wall of the larynx and trachea (RU 2615272, A61B 17/00 published 04/04/2017), which consists in the installation of xenomaterial based on polytetrafluoroethylene in the soft tissues adjacent to the laryngotracheostomy hole. A skin incision is made at a distance of 2 cm from the edge of the laryngotracheostomy, a full-thickness skin-subcutaneous-platysmal flap is formed and a bed for xenomaterial based on polytetrafluoroethylene is created in the thickness of the medial pedicle of the sternocleidomastoid muscle, followed by its fixation to the side wall with a laryngotracheostoma [18].

The prototype of the present invention is a method of plastic defect of the anterior wall of the trachea. (RU 2295923 A61B17/24 published on 03/27/2007). Elimination of the tracheal defect in the area of the anterior wall is carried out using a strip of allochondral graft, which is placed in the transverse direction in the area of the tracheal defect. The graft is covered with an arterialized musculofascial flap of the sternocleidomastoid muscles and a fascial restrictor to prevent lysis of the allochondral tissue [19]. However, this invention is mainly used for limited defects in the anterior wall of the trachea and is not applicable for extended combined defects in the anterior-lateral walls of the airways. In case of laryngotracheomalacia, when there are no supporting viable structures and conditions are created for pathological flotation of the supporting frame of the larynx and trachea with the subsequent development of airway stenosis, it is also necessary to strengthen the side walls of the larynx and trachea, which cannot be ensured by the use of the above method.

The above methods of surgical treatment of cicatricial stenosis of the larynx and trachea are used in the presence of preserved lateral fragments of the cartilaginous semi-rings of the trachea and the cartilaginous skeleton of the larynx, which perform the main frame function, which limits their use in patients with extensive extended cicatricial stenosis with an existing deficit of supporting viable tissues in the narrowing zone, extensive destruction of cartilaginous elements in combination with chondromalacia or complete absence of supporting cartilaginous structures in the area of reconstruction of the laryngotracheal defect, which have a key function to maintain a stable airway lumen.

Thus, there remains a need for an effective method for plastic surgery of extended cicatricial stenoses of the larynx and trachea in patients with a significant deficit of supporting viable cartilaginous structures of the laryngotracheal segment, devoid of the above disadvantages.

The purpose of the invention is to increase the efficiency of surgical treatment of patients with extended laryngotracheal cicatricial deformity with complete or partial obliteration of the lumen by improving the method of plasty of the laryngeal tracheal defect.

We have proposed a method for plastic surgery of the anterolateral walls of the larynx and cervical trachea with an extended (2-5 cm) laryngeal-tracheal cicatricial deformity of the lumen using allografts from demineralized bone tissue .

The density of the bone allograft tissue helps to maintain the required shape and resistance to mechanical stress, including forced breathing and coughing. Preliminary demineralization and lyophilization gives the necessary compliance to achieve elasticity and flexibility while in the tissues of the recipient. Through holes along the perimeter of the allograft contribute to the germination of surrounding tissues into the implant material with reliable fixation in the surrounding tissues. When using allografts from demineralized bone tissue, there is no risk of graft rejection, hyperreactivity of surrounding tissues and encapsulation with subsequent migration into surrounding tissues.

Demineralized bone allografts are available in unlimited quantities and are relatively versatile for different patients. When using allografts, individual modeling of the shape and size required by a particular patient is possible.

In the manufacture of an allograft, the bone tissue first undergoes chemical modification, namely, it is washed in a hydrogen peroxide solution, then it undergoes a stage of dehydration and degreasing in alcohol solutions. Demineralization of bone tissue is carried out with acid solutions and saline solutions. The final step before packaging and sterilization is the lyophilization of allogeneic bone grafts. The material has been widely tested and there are data on its use in traumatology, neurosurgery, thoracic surgery, and dentistry [20].

Achievable technical result from the claimed method is to increase the effectiveness of treatment, reduce the stages of reconstructive operations in the treatment of patients with extended laryngeal tracheal obliteration, reduce the likelihood of postoperative complications, prevent restenosis of the laryngeal tracheal complex and eliminate the need for repeated surgical interventions, which reduces the duration of inpatient treatment, rehabilitation time patients.

The technical result is achieved through the use of allografts from demineralized bone tissue, which allows you to simultaneously form a supporting frame of the larynx and trachea and make a partial reduction in the size of the laryngotracheostomy hole by about 2/3 of the original one.

The invention is supported by illustrations.

Figure 1. Allograft from demineralized bone tissue, previously placed in a physiological solution of 0.9% NaCl.

Figure 2. Schematic representation of the prepared allograft with through holes, 1 - through holes.

Figure 3. Formation of the muscular-fascial pocket paratracheally, 2 - muscular-fascial pocket.

Figure 4. Modeled allograft, ready for implantation in the previously formed musculo-fascial pocket.

Figure 5. Implantation of the allograft in the previously formed muscle-fascial pocket.

Figure 6. Layered closure of the allograft by the surrounding muscles, fascia, subcutaneous fat and skin.

Implementation of the invention.

Allografts from demineralized bone tissue are removed from sterile packaging and placed for 10 minutes in saline 0.9% NaCl (Fig. 1). Then, with a scalpel, immediately before the operation, the required number of allografts, mainly rectangular in shape with rounded edges, is modeled. The size of allografts is selected individually depending on the extent of the defect. Using a microdrill, the grafts are perforated along the entire perimeter with through holes, preferably with a diameter of 1 mm in increments of 5 mm (Fig. 2). Additional sterilization is not required.

Next, the anterolateral larynx and cervical trachea are reconstructed in patients with extended laryngotracheal obliteration of the lumen. The operation is performed under general anesthesia. The scar tissue obliterating the lumen of the larynx and trachea is excised, a new lumen of the larynx and trachea is formed. In the absence of supporting cartilaginous structures in the stenosis zone, the inner lining of the anterior wall of the trachea is formed and muscular-fascial pockets are formed paratracheally (Fig. 3). The simulated allografts are placed in the muscular-fascial pockets paratracheally in the area of the side walls, and, if necessary, in the area of the pre-formed inner lining of the anterior wall, and set in a vertical position (Fig. 4, 5). The allografts are fixed to the surrounding tissues with 3.0 vicryl and covered in layers with muscles, fascia, subcutaneous fat, and skin (Fig. 6). In the future, prosthetics are carried out on a T-shaped tracheostomy tube from 3 to 6 months. Subsequently, a control period is carried out without a tracheostomy tube with a hermetically sealed laryngotracheostomy opening. With a favorable course of the control period - maintaining the supporting function of the walls of the laryngotracheal complex with allografts in the control period, the absence of a rejection reaction and material migration, the absence of prolapse of allografts into the lumen of the respiratory tract, the laryngotracheostomy defect is sutured and the laryngotracheostomy is closed.

In NIKIO them. 10 patients with combined cicatricial stenosis of the larynx and trachea with extended laryngotracheal obliteration of the lumen were operated on at L.I. Sverzhevsky DZM. 10 patients underwent reconstructive plastic surgery using allografts from demineralized bone tissue. The postoperative follow-up period was 6 months.

When using an allograft from demineralized bone tissue, easy modeling in the form of a bone allograft, the absence of a rejection reaction in the early and late postoperative periods, and resistance to pathogenic flora persisting in the area of the laryngotracheostomy defect were noted. Resorption of the allograft from demineralized bone tissue in the late postoperative period was not observed, which was confirmed by the results of computed tomography of the larynx and cervical trachea. Gradual partial replacement of it with coarse-fibered fibrous tissue was noted, which performs a supporting function, capable of maintaining an adequate lumen of the respiratory tract and preventing the walls of the larynx and trachea from floating during breathing and coughing.

Clinical example 1.

Patient M., 25 years old, was admitted with complaints of breathing through a tracheostomy tube.

From the patient's anamnesis, it is known that six months ago she was on a long-term intubation in the intensive care unit due to the manifestation of type 1 diabetes mellitus. When trying to remove the endotracheal tube, the phenomena of acute respiratory failure of the 3rd degree were revealed, in connection with which a median tracheostomy was performed.

At the outpatient stage, the examination of the patient revealed an extended laryngotracheal obliteration of the lumen above the tracheostomy tube with a length of 5 cm according to computed tomography of the larynx and cervical trachea.

The patient underwent reconstructive plastic surgery on the larynx and cervical trachea with excision of scar tissue throughout. A significant lysis of cartilaginous supporting components in the area of the lateral walls of the trachea was found, as a result of which there was a high risk of flotation and retraction of the airways with repeated stenosis of the lumen.According to the extent of the defect of the side walls, 2 allografts were formed intraoperatively from demineralized bone tissue of a rectangular shape with rounded edges, each measuring 32 mm in length and 16 mm in width. Thanks to pre-soaking in a physiological solution of 0.9% NaCl, the grafts became pliable and it became possible to give them the necessary shape for the subsequent performance of the supporting function. Muscular-fascial pockets were formed paratracheally. Allografts from demineralized bone tissue are perforated around the entire perimeter, as indicated in the method, to facilitate the germination of the graft by local tissues. The simulated allografts were implanted vertically into the musculofascial pockets in the area of the side walls, with secure fixation to the surrounding tissues with vicryl 3.0 and layer-by-layer covering of the allografts with muscles, fascia, subcutaneous fat, and skin. Formed anterolateral walls of the trachea, capable of performing an adequate support function. The size of the laryngotracheostomy opening was reduced by 2/3 of the original.

In the postoperative period at the outpatient stage, the patient underwent antibacterial, decongestant, and inhalation therapy. Prosthetics of the laryngeal-tracheal complex is carried out on a T-shaped tracheostomy tube, followed by a control period without a tracheostomy tube with a hermetically sealed tracheostomy opening.

In the postoperative period, complications in the form of graft rejection, purulent-septic processes, exposure of its structures, graft migration were not observed. The postoperative wound healed by primary intention, the formed airway lumen remained stable. The long-term results of the operation with the use of a graft from demineralized bone tissue observed by us for 6 months indicate stable preservation of the newly formed lumen of the larynx and cervical trachea. The control period is carried out without a T-shaped tracheostomy tube, with a hermetically sealed tracheostomy hole using an aseptic bandage. With control fibrolaringotracheoscopy, the lumen of the larynx and trachea is wide and free. The patient is scheduled for the next stage of reconstructive plastic surgery with complete closure of the laryngotracheal defect.

Clinical example 2.

Patient M., 32 years old, was admitted with complaints of breathing through a tracheostomy tube.

From the patient's anamnesis it is known that 8 months ago he was on a long-term intubation in intensive care after a traffic accident with a severe closed craniocerebral injury. The patient underwent a median tracheostomy due to a long stay in the intensive care unit and airway instability. After stabilization of the general somatic status of the patient and restoration of consciousness and spontaneous breathing, decannulation was not possible due to the phenomena of acutely increasing respiratory failure when the tracheostomy tube was removed.

At the outpatient stage, the examination of the patient revealed an extended laryngotracheal obliteration of the lumen above the tracheostomy tube with a length of 5.4 cm according to computed tomography of the larynx and cervical trachea.

The patient underwent reconstructive plastic surgery on the larynx and cervical trachea with excision of scar tissue throughout. A significant lysis of the cartilaginous supporting components in the area of the lateral and anterior walls of the trachea was found, as a result of which there was a high risk of flotation and retraction of the airways with repeated stenosis of the lumen.According to the length of the defect, 3 allografts were formed intraoperatively from demineralized bone tissue of a rectangular shape with rounded edges measuring 38 mm in length and 16 mm in width (2 pcs for implantation in the area of the side walls) and measuring 20 mm in length and 14 mm in width ( 1 pieces for implantation in the area of the anterior wall). Thanks to pre-soaking in a physiological solution of 0.9% NaCl, the grafts became pliable and it became possible to give them the necessary shape for the subsequent performance of the support function. Muscular-fascial pockets were formed paratracheally. Allografts from demineralized bone tissue are perforated around the entire perimeter, as indicated in the method, to facilitate the germination of the graft by local tissues. Modeled allografts in the amount of two were implanted vertically into the side walls in the muscular-fascial pockets, with reliable fixation to the surrounding tissues with vicryl 3.0 and layer-by-layer covering of the allografts with muscles, fascia, subcutaneous fat and skin. Formed anterolateral walls of the trachea, capable of performing an adequate support function. Then, at the same time, the next stage of surgical treatment was the formation of the inner lining of the anterior wall of the trachea. To exclude floating and retraction of the anterior wall of the trachea due to a lack of supporting viable structures, the third bone allograft, perforated along the entire perimeter, was implanted in the region of the anterior wall on a previously formed inner lining, with reliable fixation to the surrounding tissues with vicryl 3.0 and layer-by-layer covering of the allograft with muscles, fascia, subcutaneous fat and skin. The size of the laryngotracheostomy opening was reduced by 2/3 of the original.

In the postoperative period at the outpatient stage, the patient underwent antibacterial, decongestant, and inhalation therapy. Prosthetics of the laryngeal-tracheal complex is carried out on a T-shaped tracheostomy tube, followed by a control period without a tracheostomy tube with a hermetically sealed tracheostomy opening.

In the postoperative period, complications in the form of graft rejection, purulent-septic processes, exposure of its structures, graft migration were not observed. The postoperative wound healed by primary intention, the formed airway lumen remained stable. The long-term results of the operation with the use of a graft from demineralized bone tissue observed by us for 6 months indicate stable preservation of the newly formed lumen of the larynx and cervical trachea. The control period is carried out without a T-shaped tracheostomy tube, with a hermetically sealed tracheostomy hole using an aseptic bandage. With control fibrolaringotracheoscopy, the lumen of the larynx and trachea is wide and free. The patient is scheduled for the next stage of reconstructive plastic surgery with complete closure of the laryngotracheal defect.

Thus, the proposed method allows to increase the efficiency and reduce the morbidity of the treatment of patients with an extended deficit of supporting viable structures in the area of the anterolateral walls of the larynx and trachea due to a certain sequence of surgical procedures with the implantation of a demineralized bone graft individually modeled during the operation, as well as to reduce the frequency of postoperative complications.The use of bone demineralized graft in the proposed method allows you to restore the supporting skeleton of the larynx and trachea, does not cause rejection. The use of bioinert, lyophilized demineralized alloplastic material from bone tissue in reconstructive surgery allows for the earliest possible social and labor rehabilitation of patients.

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Claims (4)

1. A method for reconstructing the anterolateral parts of the larynx and the cervical part of the trachea in patients with extended laryngotracheal obliteration of the lumen, characterized in that before the operation, the required number of allografts from demineralized bone tissue, which were previously kept in saline for 10 minutes, are given a rectangular shape with rounded edges, with In this case, the size of the allografts is selected individually depending on the length of the defect, the finished allografts are perforated with through holes, then during the operation, after excision of the scar tissue, a new lumen of the larynx and trachea is formed, the inner lining of the anterior wall of the trachea is formed in the stenosis zone, and muscular-fascial pockets are formed paratracheally, where the required number of allografts is placed and placed in a vertical position, fixed to the surrounding tissues with 3.0 vicryl, covered in layers with muscles, fascia, subcutaneous fat and skin, the prosthesis is made tracheostomy tube from 3 to 6 months, a control period is carried out without a tracheostomy tube with a hermetically sealed laryngotracheostomy opening and, if the control period is favorable, the support function of the walls of the laryngotracheal complex is maintained by allografts, there is no rejection reaction and material migration, and there is no prolapse of allografts in airway lumen - the laryngotracheostomy defect is sutured and the laryngotracheostomy is closed. 2. The method of reconstruction according to claim 1, characterized in that at least two allografts are placed in the region of the side walls. 3. The method of reconstruction according to claim 1, characterized in that at least two allografts are placed in the region of the side walls and one allograft is placed in the region of the anterior wall. 4. Reconstruction method according to claim 1, characterized in that the allografts are perforated with through holes using a microdrill, with a hole diameter of 1 mm, a step of 5 mm.

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