RU2421161C1 - Method of surgical treatment of tracheoesophageal fistulas of non-tumour genesis - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to field of medicine, namely to surgery and can be used in treatment of tracheoesophageal fistulas of non-tumour genesis. Essence of method lies in isolation and dissection of fistula tract, separate sewing and covering with autotransplant of trachea and esophagus holes, installation of drainage tube to area of intervention. Tracheoesophageal fistula is isolated, as covering autotransplant used is flap of fatty tissue from anterior mediastenum or greater omentum on feeding pedicle with free U-shaped edge, which is brought by means of traction ligatures to area of fistula. Fistula tract is covered and fatty flap is fixed by tying ligatures to each other. For fistula dissection onto fatty flap in projection of fistula tract applied is compression clip from titanim nickelide with effect of shape memory and superelastisity, made in form of two parallel wire branches, fixed with distal end to traction thread, whose loose end id passed outside through drainage tube lumen. Clip is removed 8-10 days after surgical intervention by thread traction. ^ EFFECT: application of claimed invention makes it possible to simplify surgeon's work and reduce duration of operation, increase its consistency. ^ 2 ex, 5 dwg

Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of tracheoesophageal fistula of non-tumor origin.

A known method of surgical treatment of acquired tracheoesophageal fistula, including the allocation of the trachea and esophagus, dissection and circular excision of the mucous membrane of the esophagus in the fistula, suturing the wall of the trachea and esophagus from an additional incision on the opposite wall of the esophagus [1]. The disadvantages of the method are associated with a high risk of inconsistency of the sutures and the development of relapse of the fistula due to the intimate location of the sutures of the trachea and esophagus, as well as the penetrating nature of the suture, which violates the protective barrier of the mucous membrane, which leads to the formation of ligature messages through which microorganisms spread from the lumen into the wall of the trachea and esophagus. Tissue infection and suture leads to severe inflammation and teething.

Closest to the proposed (prototype) is a method of radical surgery for the fistula of the esophagus and respiratory tract, including the isolation, excision or dissection of the fistulous passage, separate suturing of the holes of the trachea and esophagus [2]. The disadvantages of the method are associated with the risk of failure of the sutures on the esophagus and trachea in the early stages after surgery with the development of mediastinitis or relapse of the fistula. This predisposes to the inevitable infection of the intervention area as a result of opening the lumen of the trachea and esophagus, a violation of the blood supply to the separated trachea and esophagus, the technical complexity of suturing the formed defects, as well as uneven compression of the tissues along the suture line, penetration of sutures through the mucous membrane into the lumen of the trachea and esophagus, which violates biological tightness of the seam and conditions for primary healing. In addition, due to severe inflammatory changes in the suture, there is a risk of developing tracheal and esophageal stenosis in the long term. In order to prevent the inconsistency of the sutures on the trachea and esophagus, in addition to the method, it is recommended to disconnect the suture line of these organs by rotating the esophagus around its axis or to cover the sutures with an auto-, xeno- or allograft and stitching them along the suture line and around them. As a plastic covering material, a muscle flap on the feeding leg is used (a sternum-thyroid, sternum-hyoid flap, pectoralis major, intercostal, sternocleidomastoid muscle, diaphragm flap, etc.) [2, 3, 4], bovine pericardium, polytetrafluoroethylene ("Gore-Tech") [5].

A new technical task is to simplify the actions of the surgeon and reduce the duration of the operation, increase its viability.

To solve the problem in a method of surgical treatment of tracheoesophageal fistulas of non-tumor origin, including isolation and dissection of the fistulous passage, separate suturing and covering with the autograft holes of the trachea and esophagus, installing a drainage tube to the intervention area, a tracheoesophageal fistula is isolated, it is used as a covering transcutaneous fat transplant the mediastinum or the greater omentum on the supply leg with a free edge of a U-shape, which is brought down by means of a traction ligatures to the fistula area, cover the fistulous passage and fix the fat flap, linking the ligatures to each other, to dissect the fistula on the fat flap in the projection of the fistula, apply a compression clip of titanium nickelide with shape memory and superelasticity effect, made in the form of two parallel wire branches, attached by the distal end to the traction thread, the free end of which is carried out through the lumen of the drainage tube, then the clips are removed 8-10 days after surgery chiy for a thread.

The technical result is achievable due to the whole set of interrelated essential features, the determining ones being the preliminary covering of the fistula area with a fat flap on the feeding leg with a free U-shaped edge, followed by the application of a compression clip made of superelastic titanium nickelide to separate the tracheoesophageal fistula. The flap of adipose tissue of the anterior mediastinum or greater omentum on the feeding leg is highly flexible and easily formed, has good adhesion and angiogenesis, has stable blood supply and powerful potential for immunological reactivity, is resistant to infection and accelerates the healing of adjacent tissues. The free edge of the U-shaped flap technically just allows you to circularly cover the fistulous passage, reliably disconnect the sutures of the trachea and esophagus, and it does not require excessive mobilization of the flap. After installation and heating of the clip from the surrounding tissue under the action of thermomechanical restoration of the original, closed shape (shape memory effect), the fistula is clamped while the fat flap is firmly fixed at the required level, which does not require additional flap suturing to the trachea and esophagus. In the indicated sequence of technical solutions, the duration of the stage of uncoupling of the fistula and the covering of the suture line is greatly simplified and significantly reduced, and, as a result, the time of the entire operation. Due to the property of superelasticity and dosed compression, the clip does not simultaneously dissect the fistula tissue according to the guillotine principle, but provides an elastic preload for the entire period of time, which leads to atrophy and necrosis of the area under the clip, scarring of tissues nearby for 8-10 days. Using a traction thread fixed to the clip and brought out through the drainage tube, the surgeon is able to freely and atraumatically remove the clip from the body. After removing the clip, the mouth of the fistula on the trachea and esophagus remains completely covered by its own tissues. Removing the clip from the area of intervention, as a foreign body, indicates the advantage of the method compared to the prototype, where the suture material remains in the wound and can sustain inflammation for a long time. In addition, as a result of the separation of the tracheoesophageal fistula with the indicated technique, a compression suture is formed in the area of the mouth of the fistula of the trachea and esophagus, which provides the necessary physical (mechanical) and biological integrity of the formed anastomosis. Clips made of titanium nickelide allow you to create a metered compression on living tissue, which improves the tightness of the created anastomosis and reduces the inflammatory response. This reduces the risk of postoperative complications, increases the strength of the connection and provides anatomical and physiological restoration of this area.

The absence in the world literature and in patent information sources of solutions with a similar set of essential features testifies to the correspondence of the proposal by the authors with the criteria of “novelty” and “inventive step”. The invention is illustrated by schemes for performing specific techniques and examples of individual operations in the experiment.

The illustrations show:

Figure 1. Formation and movement of a large omentum flap on the feeding leg into the chest cavity: 1 - large omentum flap with a free U-shaped edge, 2 - traction ligatures, 3 - trachea, 4 - esophagus, 5 - diaphragm.

Figure 2. Bringing with the help of two ligatures of the fat flap on the feeding leg with a free edge of a U-shaped to the fistula: 2 - traction ligatures, 6 - tracheoesophageal fistula.

Figure 3. Fixation by ligatures of a fatty flap at the level of the fistula. The scheme of the cross section at the level of the fistula.

Figure 4. Installing a compression clip (7). The scheme of the cross section at the level of the fistula.

Figure 5. Type of clip covered with a fatty flap of the tracheoesophageal fistula, drainage: 7 - clips jaws, 8 - drainage tube.

The method is as follows. Depending on the level of the location of the fistula, a left-sided cervical, cervico-sternotomic or right-sided thoracotomy access is performed, intraoperatively visualize the fistula with fibroesophagoscopy, and separate the trachea and esophagus at the level of the fistula, highlighting the fistula. A flap is formed from the fat tissue of the anterior mediastinum on the feeding leg with a free edge of a U-shape, and if it is not expressed or the surgeon prefers it, a similar flap is formed from a large omentum (Fig. 1). To do this, laparotomy is additionally performed, a defect is formed in the anterior diaphragm, a large omentum is mobilized, a flap is created on it on the supply leg with a free U-shaped edge. After the formation of the fat flap of the required length, it is flashed over the free edges with two twisting ligatures and a traction is inserted for the flap into the lateral space between the trachea and esophagus at the level of the tracheoesophageal fistula (Fig. 2), they cover the fistulous passage and fix the fat flap, linking the ligatures to each other, the free ends of the ligatures are cut off (figure 3). The branches of pre-chilled titanium nickelide clips with shape memory and superelasticity effect, made in the form of two parallel wire branches, attached with the distal end to the traction thread, are bred and a clip is placed on the fat flap in the projection of the fistulous course (Fig. 4). After heating from the surrounding tissues and closing the jaw of the clip, the fistula is clamped and the fat flap is finally fixed. The free end of the traction thread is carried out through the lumen of the drainage tube (figure 5). Install a drainage tube to the area of intervention. The surgical wound is sutured tightly. Clips are removed 8-10 days after surgery by traction over the thread. The drainage tube is removed no earlier than one day after removing the clip.

A verification test of the attainability of the technical result is the experimental testing of the proposed method for the surgical treatment of tracheoesophageal fistulas of non-tumor origin, modeled on 8 outbred dogs weighing 10-16 kg. Animal experiments were performed in the experimental surgery department of the Central Research Laboratory of SibGMU. The study was carried out according to the ethical principles set forth in the "European Convention for the Protection of Vertebrate Animals Used for Experimental and Other Scientific Purposes", all manipulations and removal of animals from the experiments were carried out under general anesthesia. In the postoperative period, clinical observation, x-ray, endoscopic control, histological examination of the preparations was carried out.

Example 1 (a mongrel dog weighing 16 kg with a pre-formed tracheoesophageal fistula at the neck level). After treating the surgical field with iodine and alcohol under general anesthesia with controlled breathing, a cervicotomy was performed, access to the formed tracheoesophageal fistula was made, the trachea and esophagus were separated at the level of the fistula, the fistula was isolated, and the anterior mediastinal adipose tissue flap was formed on the feeding leg with a free U-margin forms. After the formation of the flap of the required length, it was stitched for the free edges with two twisting ligatures and a traction for them brought the flap into the lateral space between the trachea and esophagus at the level of the tracheoesophageal fistula (Fig. 2), carried out the shelter of the fistulous passage and fixation of the flap, linking the ligatures to each other (Fig. .3), the free ends of the ligatures were cut off. The branches of pre-chilled titanium nickelide clips with shape memory and superelasticity effect were made in the form of a two-turn elongated wire spiral closed along the entire length, with a symmetrical arrangement of the free ends of the wire at the first end of the spiral, with both branches of each spiral turn over the prevailing length to the side the second end of the spiral is straightened and brought together until they touch each other to form linear branches [5] attached to the traction thread by the distal end and a clip is mounted on the fat flap in the projection fistulous (Figure 4). After heating from the surrounding tissues and closing the jaw of the clip, a fistula was clamped and a fatty tissue flap was fixed. The free end of the traction thread was carried out through the lumen of the drainage tube (figure 5). A drainage tube was installed to the intervention area and brought out through a separate incision to the neck. The surgical wound was sutured in layers. The clips were removed 8 days after surgery by traction over the thread. The drainage tube was removed one day after removing the clip.

Example 2 (a purebred dog weighing 14 kg with a preformed tracheoesophageal fistula at the neck level). After treating the surgical field with iodine and alcohol, cervicotomy was performed under general anesthesia with controlled breathing, access to the formed tracheoesophageal fistula, the trachea and esophagus were separated at the level of the fistula, and the fistula was isolated. Laparotomy was performed, a defect was formed in the diaphragm and a flap of the greater omentum on the supply leg with a free edge of a U-shape (Fig. 1). After the formation of the flap of the required length, it was stitched for the free edges with two winding ligatures and traction for them through the formed hole in the diaphragm, moved to the anterior mediastinum and further to the neck, the flap was placed in the lateral space between the trachea and esophagus at the level of the tracheoesophageal fistula (Fig. 2) , carried out the shelter of the fistulous passage and fixation of the flap, linking the ligatures to each other (figure 3), the free ends of the ligatures were cut off. The branches of pre-chilled titanium nickelide clips with shape memory and superelasticity effect were made in the form of a two-turn elongated wire spiral closed along the entire length, with a symmetrical arrangement of the free ends of the wire at the first end of the spiral, with both branches of each spiral turn over the prevailing length to the side the second end of the spiral is straightened and brought together until they touch each other to form linear branches [5] attached to the traction thread by the distal end and a clip is mounted on the flap adipose tissue in the projection of the fistulous course (figure 4). After heating from the surrounding tissues and closing the jaw of the clip, a fistula was clamped and a fatty tissue flap was fixed. The free end of the traction thread was carried out through the lumen of the drainage tube (figure 5). A drainage tube was installed to the intervention area and brought out through a separate incision to the neck. Surgical wounds were sutured in layers. The clips were removed 10 days after surgery by traction over the thread. The drainage tube was removed one day after removing the clip.

The results of experimental testing confirm the efficiency of the proposed method and the attainability of the technical result. The readiness of the operation for clinical use indicates the compliance of the proposal with the criterion of "industrially applicable".

Thus, the proposed method allows to simplify and reduce the duration of the operation, to increase its viability.

Information sources

1. Pat. 2202961, IPC ⁷ А61В 17/00. A method of surgical treatment of acquired tracheoesophageal fistula / M.B. Skvortsov, E.V. Nechaev, V.V.Drokov. No. 2000116538; Declared June 21, 2000; Publ. 04/27/2003, Bull. No. 18, Priority 06/21/2000 (Russia). 6 sec

2. Tracheo-bronchial surgery / B. V. Petrovsky, M. I. Perelman, N. S. Koroleva. M .: 1978. - S.254-257.

3. Sokolov V.V., Bagirov M.M. Reconstructive surgery for combined tracheoesophageal injuries and their sequelae // Eur. J. Cardiothorac. Surg. 2001; 20: 1025-1029.

4. Bardini R., Radicchi V., Parimbelli P. et al. Repair of a recurrent bening tracheoesophageal fistula with a Gore-tex membrane // Ann. Thorac. Surg. 2003; 76: 304-6.

5. Pat. 2285468, IPC ⁷ A61B 17/11, A61B 17/122. Clip for anastomosis of hollow organs / G.Ts. Dambaev, V.E. Gunter, M.M.Soloviev and others No. 2005103056; Announced on 02/07/2005; Publ. 10/20/2006, Bull. No. 29, Priority 02/07/2005 (Russia). 8 sec

Claims (1)

A method for the surgical treatment of tracheoesophageal fistulas of non-tumor origin, including isolation and dissection of the fistulous passage, separate suturing and covering with the autograft of the tracheal and esophagus openings, installing a drainage tube to the intervention area, characterized in that the tracheoesophageal fistula is isolated, which is used as a covering autograft transplant or a large omentum on the supply leg, with a free edge of a U-shape, which is let down using traction ligatures areas of the fistula, cover the fistulous passage and fix the fat flap, linking the ligatures with each other, to dissect the fistula on the fat flap in the projection of the fistula, apply a compression clip of titanium nickelide with shape memory and superelasticity effect, made in the form of two parallel wire branches attached to the distal end to the traction thread, the free end of which is carried out through the lumen of the drainage tube, then the clips are removed 8-10 days after surgery by traction for the thread.

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