RU2795088C1 - Method for reconstruction of tracheostomy with simultaneous plasty of a tracheoesophageal fistula and formation of anatomical and physiological conditions for esophageal speech - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology.

SUBSTANCE: make incision in the mucous membrane of the trachea posterior wall in the form of inverted drop, bordering the tracheoesophageal fistula. Suture the mucous membrane of the trachea around mouth of fistula. After that, make skin incision with M-shape in the upper part. Then form skin-subcutaneous-platysmal V-shaped flap along the contour of the skin incision upper part. Make incision in mucous membrane of the trachea membranous part along the midline up to drop-shaped incision. Dissected fragments are parted to the sides to form V-shaped bed for previously made V-shaped skin-subcutaneous-platysmal flap from the anterior surface of the neck. Place the flap over the sutured mouth of fistula on the prepared bed, matching the apex with the lower point of the drop-shaped incision. Suture the flap to the trachea membranous part with interrupted sutures. Pull up the mobilized trachea anteriorly and re-form, tracheostome. Suture trachea to the skin along the lower and lateral edges with interrupted sutures.

EFFECT: method allows to eliminate a fistulous defect between the trachea and esophagus with simultaneous repair of the stenosed tracheostome end section, reduce the incidence of tracheoesophageal fistula recurrence, and also form the optimal shape of the pharyngeal-esophageal segment, which does not interfere with swallowing and contributes to the development of the esophageal speech.

1 cl, 1 dwg, 1 ex

Description

Technical field

FIELD: medicine.

State of the art

Patients after laryngectomy often develop cicatricial stenosis of the terminal section of the tracheostomy. The frequency of this postoperative complication in laryngectomized patients varies significantly - from 4 to 43% of cases, and according to some literary sources it reaches 55%, and averages 28.4% (Topolnitsky E.B., Tsydenova A.N. Treatment of cicatricial stenosis of the trachea after laryngectomy Siberian Medical Review 2022;(3):113-116 DOI: 10.20333/25000136-2022-3-113-116).

Tracheoesophageal shunting (TES) with voice prosthesis is one of the three main methods of voice rehabilitation after laryngectomy and is currently considered the “gold standard” for voice restoration in this group of patients. This method is performed by creating an opening between the posterior wall of the tracheostomy and the adjacent esophagus, into which a valved silicone voice prosthesis is inserted. Despite the high efficiency of the method, in 12% of cases it is not possible to achieve a positive result, and the patient cannot reproduce a substitute voice using a voice prosthesis, in 7.3% of cases patients refuse to use a voice prosthesis on their own some time after the operation. In these cases, the patient is shown the removal of the voice prosthesis and the suturing of the fistulous opening. There are many ways of surgical treatment of tracheoesophageal fistulas, which indicates the unresolved problem and the need to develop new effective methods for their radical surgical treatment. Plastic surgery of the tracheoesophageal fistula often leads to a decrease in the lumen of the trachea and cicatricial deformities of the end section of the tracheostomy.

Tracheoesophageal fistulas in combination with cicatricial stenosis of the trachea and a functioning tracheostomy require special surgical tactics aimed at the simultaneous restoration of the tracheal lumen and plasty of the tracheoesophageal fistula.

A widely used method is to eliminate cicatricial narrowing of the tracheostomy by dissecting the trachea section longitudinally, excising scar tissue in the region of the lower edge of the tracheostomy, redressing the lumen of the trachea to an adequate size, followed by suturing the skin to the mucosa with separate sutures (M.I. Svetlakov. Cancer tumors of the larynx. L .: "Medicine", 1964). The disadvantage of this method is the significant likelihood of restenosis due to insufficient compensation of the frame function of the trachea and limiting the possibility of increasing the diameter of the tracheostomy due to anatomical features.

A known method of reconstructing a tracheostomy (RU 2266060 C1 Kozhanov, 2004) after laryngectomy in patients with tracheoesophageal bypass with voice prosthesis. After excision of scar tissues, redressing of the lumen of the larynx and suturing the edges of the skin to the mucous membrane of the trachea, two triangular fragments are excised from the membranous part of the posterior wall of the tracheostomy with the base outward with the apex in the area of the tracheoesophageal shunt. Then the back wall of the trachea is deflected towards the esophagus to a vertical position, after which the skin is sutured to the edges of the resulting defects in the tracheal mucosa. An endoprosthesis is placed in the formed hole of the tracheoesophageal shunt to restore the function of voice formation. The method allows to optimize the passage of the air flow into the lumen of the pharynx to form a pseudo-voice and is aimed at solving the problem of stable fixation of the voice prosthesis in the tracheoesophageal shunt.

The disadvantages of this method are:

- Technical difficulties in performing an incision of a complex configuration on the mucosa of the membranous part of the trachea.

- The impossibility of its use for plastic surgery of the tracheoesophageal fistula after the removal of the voice prosthesis.

- Difficulty in the passage of food (during swallowing) and air (during the formation of the esophageal voice) through the pharyngeal-esophageal segment due to an increase in the thickness of the tissues between the trachea and the esophagus during the formation of folds of the mucous membrane of the posterior wall of the trachea.

The closest analogue of the invention is a method for forming a flap for a tracheoesophageal fistula, made of fasciocutaneous tissue on a leg and separating the suture line, described in patent RU 27470 (13) U1. A left or anterior collotomy is performed, then the trachea is mobilized in the area of the tracheoesophageal fistula. The fistula is tied up and excised, the hole in the trachea is sutured according to a known technique. Then, with a skin-fascial flap, cut out from the edges of the stab wound, plastic surgery of the esophageal wall is performed. Then 3 rows of sutures are applied to fix the flap.

The disadvantages of this method include:

- The need to use a T-shaped tracheostomy tube in the postoperative period, which is not feasible in patients after laryngectomy.

- A musculocutaneous flap reinforcing the suture line on the esophagus leads to compression of the pharyngeal-esophageal anastomosis and may cause swallowing problems in patients after laryngectomy.

The objective of our invention is to improve the functional results of the treatment of tracheoesophageal fistulas, reduce the number of postoperative complications and form a high rehabilitation potential.

To solve this problem, we propose a method for the reconstruction of a tracheostomy with simultaneous plasty of the tracheoesophageal fistula, which consists in the fact that under endotracheal anesthesia with intubation through the tracheostomy with the cuff of the endotracheal tube below the level of the tracheoesophageal fistula, an inverted drop-shaped incision of the mucous membrane of the posterior wall of the trachea is made around the tracheoesophageal fistula , departing 0.3-0.4 cm from the fistula opening, the tracheal mucosa around the fistula opening is mobilized, rotated inward and sutured with a purse-string suture, after which a skin incision is made, bordering the lower and lateral edges of the tracheostomy from 9 to 3 hours, with an indent of 0 .5-1 cm from the edge of the tracheostomy opening, then the skin incisions on both sides of the tracheostomy are continued along straight lines upwards parallel to the midline of the body at a distance of 1.5-2 cm from the upper edge of the tracheostomy opening, then the skin incision on each side is continued with a turn to 135° medially to the middle of the upper edge of the tracheostomy opening, where both incisions converge at one point, forming an M-shaped skin incision in the upper part, after performing the specified skin incision, a skin-subcutaneous-platysmal V-shaped flap is formed along the contour of the upper part of the skin incision, the resulting flap is mobilized in all directions at a distance of 2-3 cm, then, along the contour of the skin incision, the tissues around the tracheostomy are excised in layers with the inclusion of scarred skin, subcutaneous fat and 1-2 half-rings of the trachea in the block of removed tissues, then the trachea is mobilized caudally at a distance of up to 2 half rings, its membranous part is mobilized from the esophagus at a distance of 2 cm, after which the mucous membrane of the mobilized membranous part of the trachea is incised along the midline for the entire length of the mobilized part, until it joins with the drop-shaped incision made earlier, dissected fragments bred to the sides, forming a V-shaped bed for the previously formed V-shaped skin-subcutaneous-platysmal flap from the anterior surface of the neck, the V-shaped skin-subcutaneous-platysmal flap is placed over the sutured fistulous opening on the prepared bed, matching the top with the lower point of the drop-shaped incision, and sutured to the membranous part of the trachea with interrupted sutures, the mobilized trachea is pulled up and anteriorly, the tracheostomy is re-formed, and the trachea is sutured to the skin along the lower and lateral edges with interrupted sutures.

The technical result of the invention is as follows.

By increasing the circumference of the tracheostomy opening by creating a V-shaped flap, the risk of recurrence of cicatricial stenosis of the end section of the tracheostomy is reduced. Separation of the suture lines prevents the formation of secondary tracheoesophageal fistulas. The proposed technique for suturing the tracheoesophageal fistula with simultaneous reconstruction of the tracheostomy makes it possible to form the optimal shape of the pharyngeal-esophageal segment, which does not interfere with swallowing and contributes to the development of the esophageal voice, by minimizing the thickness of the tissues between the posterior wall of the trachea and the esophagus.

Implementation of the invention.

The invention is carried out as follows.

Under endotracheal anesthesia with intubation through a tracheostomy, with the cuff of the endotracheal tube below the level of the tracheoesophageal fistula, an incision of the mucous membrane of the posterior wall of the trachea in the form of an inverted drop is made, bordering the tracheoesophageal fistula, in the form of an inverted drop, retreating 0.3-0.4 cm from the fistula opening. The mucous membrane of the trachea around the fistula opening is mobilized, rotated inward and sutured with a purse-string suture.

Then proceed to the excision of scar tissue around the tracheostomy. To do this, a skin incision is made, bordering the lower and lateral edges of the tracheostomy from 9 to 3 hours, with an indentation of 0.5-1 cm from the edge of the tracheostomy opening, depending on the prevalence of cicatricial changes in the skin. Further, skin incisions on both sides of the tracheostomy continue along straight lines upwards parallel to the midline of the body at a distance of 1.5-2 cm from the upper edge of the tracheostomy opening, then the skin incision on each side continues with a 135° turn medially to the middle of the upper edge of the tracheostomy opening, where both cuts converge at one point. Thus, a skin incision is formed, having an M-shape in the upper part (Fig. 1).

After performing the specified skin incision, a skin-subcutaneous-platysmal V-shaped flap is formed along the contour of the upper part of the skin incision. The resulting flap is mobilized in all directions at a distance of 2-3 cm, to give it mobility.

Further, along the contour of the skin incision made, the tissues around the tracheostomy are excised in layers with the inclusion of cicatricial skin, subcutaneous fat and 1-2 tracheal half-rings in the block of removed tissues, depending on the degree of their involvement in the cicatricial process.

The trachea is mobilized caudally at a distance of up to 2 half rings, its membranous part is mobilized from the esophagus at a distance of 2 cm. holes. The dissected fragments are bred to the sides, forming a V-shaped bed for the previously formed V-shaped skin-subcutaneous-platysmal flap from the anterior surface of the neck.

A V-shaped skin-subcutaneous-platysmal flap is placed over the sutured fistula opening on the prepared bed, matching the apex with the lower point of the drop-shaped incision, and sutured to the membranous part of the trachea with interrupted sutures. The mobilized trachea is pulled up and anteriorly, the tracheostomy is re-formed, and the trachea is sutured to the skin along the lower and lateral edges with interrupted sutures.

Brief description of explanatory materials.

Fig. 1 is a schematic representation of the formation of an M-shaped cut and teardrop cut. The color shows the places of comparison of the V-shaped flap with its bed in the membranous part of the trachea.

An example of the implementation of the claimed method.

As an example, we present the following observation. Patient M., 68 years old, was admitted to the Department of Oncology of the ENT Organs of the Federal State Budgetary Institution NMICO FMBA of Russia on March 28, 2022 with complaints of a tracheoesophageal fistula and a nasogastric tube. It is known from the anamnesis that on February 19, 2021, the patient underwent extended laryngectomy. In October 2022, tracheoesophageal bypass with voice prosthesis was performed. In the postoperative period, there were difficulties with the reproduction of the pseudo-voice. Conservative therapy and sessions with a speech therapist for 3 months did not show a positive effect, it was decided to remove the voice prosthesis and repair the tracheoesophageal fistula. On January 13, 2022, the tracheoesophageal shunt was removed, and the esophageal fistula was repaired with local tissues. A nasogastric tube was placed. On the 15th day after the operation, a divergence of the sutures, a recurrence of the tracheoesophageal fistula, the flow of saliva and fluid into the trachea through the fistula opening were revealed.

On February 26, 2022, the patient underwent reconstruction of the tracheostomy with simultaneous plasty of the tracheoesophageal fistula according to the developed technique. The operation was performed under endotracheal anesthesia with intubation through the tracheostomy, with the cuff of the endotracheal tube below the level of the tracheoesophageal fistula. A contact diode laser made a cut of the mucous membrane of the posterior wall of the trachea fringing the tracheoesophageal fistula in the form of an inverted drop, retreating 0.4 cm from the fistulous opening. The mucosa of the trachea around the fistula was mobilized, rotated inside and sutured with a purse-string suture with a synthetic absorbable monofilament suture material PDS-II 4-0.

Next, a skin incision was made with a scalpel, bordering the lower and lateral edges of the tracheostomy from 9 to 3 hours, with an indentation of 1 cm from the edge of the tracheostomy opening. Skin incisions on both sides of the tracheostomy were extended along straight lines upwards parallel to the midline of the body at a distance of 1.7 cm from the upper edge of the tracheostomy opening, then the skin incision on each side was extended downward and medially with a 135° turn to the middle of the upper edge of the tracheostomy opening, forming M-shaped section configuration. Formed skin-subcutaneous-platysmal V-shaped flap along the contour of the upper part of the produced skin incision. The resulting flap is mobilized in all directions at a distance of 2 cm to give it mobility. Tissues around the tracheostomy were excised in layers along the contour of the skin incision, with cicatricial skin, subcutaneous fat and 2 half-rings of the trachea included in the block of removed tissues. Capillary bleeding was stopped with a bipolar electrocoagulator. The trachea was mobilized caudally at a distance of up to 2 semicircles, its membranous part was mobilized from the esophagus at a distance of 2 cm. The mucosa of the mobilized membranous part of the trachea was cut along the midline along the midline for the entire length of the mobilized part, until it was connected to the drop-shaped incision made earlier for suturing the fistula opening. The dissected fragments are separated to the sides, forming a V-shaped bed with the apex at the lower point of the drop-shaped incision for the previously formed V-shaped skin-subcutaneous-platysmal flap from the anterior surface of the neck. A V-shaped skin-subcutaneous-platysmal flap is placed over the sutured fistula opening on the prepared bed and sutured to the membranous part of the trachea with VICRYL 4-0 synthetic absorbable suture material with interrupted sutures. The mobilized trachea was pulled up and anteriorly, the tracheostomy was re-formed, the trachea was sutured to the skin along the lower and lateral edges with VICRYL 4-0 suture material with interrupted sutures.

In the postoperative period, the patient received a course of antibacterial (Ceftriaxone 1 g 2 r/day, IV, 7 days), anti-inflammatory (Ketoprofen 2.0 IM 2 r/day for 7 days) therapy, nutrition was carried out through a nasogastric tube. The patient was discharged on the 10th day after the operation in a satisfactory condition, with a nasogastric tube. There were no signs of recurrence of the tracheoesophageal fistula.

The patient was examined on an outpatient basis 3 weeks after the operation: no recurrence of the tracheoesophageal fistula was detected, the nasogastric tube was removed, during external examination the postoperative wound healed by primary intention, a postoperative scar is determined. Breathing through the tracheostomy is free, sufficient, carried out in all parts of the lungs. The diameter of the tracheostomy hole is 22 mm, retraction of the tracheostomy with narrowing of the tracheostomy hole was not detected at rest and during exercise, incl. inducing the erection reflex. With fibrolaryngoscopy, the entrance to the larynx is free, the pharyngeal-esophageal funnel is cicatricially changed, the mucous membrane is pink, moist. Endoscopic examination of the act of swallowing showed a decrease in the time of the pharyngeal phase, the absence of fluid retention in the pharyngeal-esophageal funnel and repeated swallowing, when the erection reflex was induced, the appearance of air bubbles from the pharyngeal-esophageal funnel was noted, which indicates an improvement in the patency of the pharyngeal-esophageal segment both in the antegrade direction (when swallowing), and in retrograde (with an erection reflex to stimulate the esophageal voice).

The claimed method operated on 10 patients with recurrent tracheoesophageal fistulas and stenosis of the terminal section of the tracheostomy. In the postoperative period, no recurrences of tracheoesophageal fistulas were detected in patients, and restenosis of the end section of the tracheostomy was not observed. Also, in all cases, there was an improvement in swallowing and an erection reflex for the formation of an esophageal voice.

Claims (1)

A method for reconstructing a tracheostomy with simultaneous plasty of a tracheoesophageal fistula, which consists in the fact that under endotracheal anesthesia with intubation through a tracheostomy with a cuff of the endotracheal tube below the level of the tracheoesophageal fistula, an incision of the mucous membrane of the posterior wall of the trachea in the form of an inverted drop is made, bordering the tracheoesophageal fistula, retreating 0.3- 0.4 cm from the fistulous opening, the mucosa of the trachea around the fistulous opening is mobilized, rotated inward and sutured with a purse-string suture, after which a skin incision is made, bordering the lower and lateral edges of the tracheostomy from 9 to 3 hours, with an indentation of 0.5-1 cm from edges of the tracheostomy opening, then the skin incisions on both sides of the tracheostomy are continued along straight lines upwards parallel to the midline of the body at a distance of 1.5-2 cm from the upper edge of the tracheostomy opening, then the skin incision on each side is continued with a turn of 135 ° medially to the middle of the upper the edges of the tracheostomy opening, where both incisions converge at one point, forming an M-shaped skin incision in the upper part, after performing the specified skin incision, a skin-subcutaneous-platysmal V-shaped flap is formed along the contour of the upper part of the skin incision, the resulting flap mobilize in all directions at a distance of 2-3 cm, then the tissues around the tracheostomy are excised in layers along the contour of the skin incision with the inclusion of cicatricial skin, subcutaneous fat and 1-2 half-rings of the trachea into the block of removed tissues, then the trachea is mobilized caudally at a distance up to 2 semicircles, the membranous part of it is mobilized from the esophagus at a distance of 2 cm, after which the mucous membrane of the mobilized membranous part of the trachea is cut along the midline for the entire length of the mobilized part, until it joins with the drop-shaped incision made earlier, the dissected fragments are parted to the sides, forming a V -shaped bed for the previously formed V-shaped skin-subcutaneous-platysmal flap from the anterior surface of the neck, the V-shaped skin-subcutaneous-platysmal flap is placed over the sutured fistula opening on the prepared bed, matching the top with the lower point of the teardrop-shaped incision, and sutured to the membranous parts of the trachea with interrupted sutures, the mobilized trachea is pulled up and anteriorly, the tracheostomy is re-formed, along the lower and lateral edges the trachea is sutured to the skin with interrupted sutures.

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