Method for setting stent in performing laryngoplastic repair operation in children cases

FIELD: medicine.

SUBSTANCE: method involves forming larynx lumen using stent. Silicon stent is set into larynx lumen in a way that upper end of the stent is 0.3-0.5 cm higher than the vocal cords and the lower one is 0.5 cm below stenosis area. The stent is sutured with a through U-shaped suture using long-term resorption material through larynx walls. External diameter of the stent is 1-2 mm greater than age lumen of the larynx. Tracheostomic cannula is arranged below the stent without its fixation being done.

EFFECT: enhanced effectiveness in repairing larynx lumen.

3 dwg, 1 tbl

 

The present invention relates to medicine, namely to pediatric surgery and pediatric otorhinolaryngology, in particular to laryngoplasty using autogenous rib cartilage.

Stenting of plastic surgery on the throat it is used for fixation of the graft and the formation of the lumen of the larynx, particularly when laryngoplasty using autogenous rib cartilage.

There is a method of stenting in laryngoplasty when fixation of the graft and the formation of the lumen of the larynx is applied prolonged endotracheal intubation [Cotton RT, Seid AB. // Ann. Otol. Rhinol. Laryngol. - 1980. - Vol.89. - P.508-511.]. The disadvantage of this method stenting is the need for endotracheal intubation in the postoperative period, the possibility of serious complications associated with occlusion of the endotracheal tube.

There is also known a method of stenting with the use of stent type “protector” to form the lumen of the larynx and fixation of the graft. Type stent protector is made of endotracheal tube. The proximal end of the tube sealed, and is fixed to the distal tracheostomy tube [Flowers E.A. Reconstructive surgery of the larynx and cervical trachea when cicatricial stenosis in children. // The Diss. Prof. L. - 1990. - 270 S.]. This method of stenting of Sopra the Yong difficulties in the postoperative period (the need for removal of the stent when replacing the tracheostomy cannula), complications (offset stent).

The aim of the invention is to improve the results of surgical treatment of children with laryngeal stenosis of various etiologies.

This objective is achieved in that the stent is made of silicone set into the lumen of the larynx so that the upper end of the stent was located 0.3-0.5 cm above the vocal folds, the bottom 0.5 cm below the area of stenosis, stitch through U-shaped suture through the wall of the larynx, long-absorbable material, and the outer diameter of the stent should not exceed the age of the lumen of the larynx 1-2 mm, and tracheostomy cannula is located below the stent without committing to it.

The position of the stent is controlled endoscopically and after healing of the wound surface, the stent is removed or independently coughs patient in 1.5-2 months.

Figure 1 shows the first stage of the operation - dissection of the thyroid and cricoid cartilages;

figure 2 - the scheme of silicone stent is the second stage of the operation;

figure 3 the interposition graft (made of cartilage 5th ribs) - the last phase of the operation.

The invention is illustrated in the following examples.

Example 1.

Patient M., 7 months. Child 1 month operated on for inguinal hernia repair. Due to complications during anesthesia was indubious. After the operation is transferred to the intensive care unit. Attempts extubation ineffective in connection with symptoms of severe respiratory failure. Was on endotracheal intubation within 15 days. Due to the inability of extubation was imposed by tracheostomy.

On admission the child carrier tracheostomy cannula. Performed direct laryngoscopy. Optics Storz 4 mm In the area of the cricoid cartilage rough cicatricial stenosis eccentric shape up to 2 mm in diameter. Stenosis razbortirovav with difficulty, the underlying divisions of the trachea is not changed. The child postintubation cicatricial stenosis of the larynx.

Given the presence of cicatricial process in the larynx, the child decided to perform plastic surgery of larynx. On the middle line 3 (figure 1) cut the cricoid 2, and part of the thyroid cartilage 1. The stent 1 (2) of the silicone is installed in the lumen of the larynx so that the upper end of the stent was located 0.5 cm above the vocal folds, the bottom 0.5 cm below the area of the stenosis. The stent is sewn end-to-end U-shaped suture through the wall of the larynx long-absorbable material (PDS II 1/0). moreover, the outer diameter of the stent should not exceed the age of the lumen of the larynx 1-2 mm.

The cartilage of the 5th rib 1 (3) cut in the frontal plane so that the front cut edges together with nadgradnja could be taken as an autograft. Cartilage is modeled in the form of defect 1 (figure 3) in Horta and and sewn as spacers by nadgradnja into the lumen of the larynx 2,3 (figure 3). Layer-by-layer wound closure.

The postoperative period was uneventful, with no complications. Performed control laryngoscope. In the lumen of the larynx is visualized stent. The child was discharged after 2 weeks.

Re-hospitalization within 3 months. Performed direct laryngoscopy. Optics Storz 3 mm Voice folds in position partial cultivation, the lumen of the larynx satisfactory. In the lumen has 2 granuloma - immediately below the vocal cords 1×1 mm on the side wall 1×3 mm removed. The stent is not defined (coughed 1.5 months after surgery). The child was decannulated. Breathing through the mouth and nose free.

The patient was discharged home in good condition.

Example 2.

Patient Century. 8 months. In the neonatal period was in the ICU on a ventilator for about aspiration pneumonia. Due to the ineffectiveness of extubation at the age of 1 month performed the tracheotomy.

Upon receipt of the executed laryngoscope: revealed stenosis of the larynx in the area of the cricoid cartilage, a diameter of less than 3 mm, razbortirovav. Polarisavenue membranous part over to the tracheostomy tube.

The child is made of plastic larynx, as described in example 1.

Re-hospitalization within 2 months. During laryngoscopy: a tube 5 mm of the Stent is not defined (from allal 1.5 months after surgery). The lumen of the larynx is not less than 5 mm, there is a granuloma in the area of the cricoid cartilage, the latter is removed. Stenosis of the larynx removed. Child decanulation and was discharged home in good condition.

Example 3.

Patient P. 13 years. In 2 years by place of residence in connection with laryngotracheitis and pneumonia was imposed by tracheostomy. Repeatedly attempts decanulation - unsuccessfully. Against this background, the child is to date very frequently suffered from bronchitis and pneumonia, suffered destructive pneumonia.

Admission: child carrier tracheostomy. From tracheostomy saniyede a large number of sputum. When direct laryngoscopy:

cicatricial stenosis of the larynx immediately below the vocal folds. The tracheostomy hole is located high in the thyroid-thyroid membrane. The child cicatricial stenosis of the larynx due to extended wear tracheostomy cannula placed highly on the level of the thyroid-thyroid membrane.

The child is made of plastic larynx, so that when the dissection of the cricoid and partially thyroid cartilage hole tracheostomy isecheno. The further course of the operation as described above. After completion of plastics larynx formed a new tracheostomy level 2-3rd tracheal rings 2 (figure 2). Decannulate 3 months after surgery and the patient goes home in udovletvoritelno condition.

To date, the clinic at the Children's City Clinical Hospital n.a. Noffilative No. 13, the Moscow Department of thoracic surgery plastic larynx using a stent made from silicone 20 patients.

The table presents the results of surgical treatment of patients with robovie stenosis of the larynx.

 Result 
The operation name Number
 Chorus.Satisfied.Bad. 
Laryngoplasty one84315
transplant    
Laryngoplasty two11-2
grafts    
Resection of the larynx11-3
Only106320

The average age of the patients was 3.5 years. Positive re the query result in surgical treatment of cicatricial stenosis of the larynx was 80% (16 patients).

Good result, we believe the full restoration of the lumen of the larynx and the disappearance of all symptoms of respiratory failure after the first surgical intervention.

In the group with satisfactory assessment of included patients in whom after laryngoplasty there were phenomena recensione decreased with time or eliminated by using additional treatment (dilations, endoscopic removal of granulations), as well as patients who remained deformation of the lumen with a significant decrease in symptoms of symptoms of respiratory distress.

Poor result, we believe it is pronounced or full restenosis with which you cannot cope, and patients need a second operation. 3 patients required reoperation due to phenomena expressed restenosis. Made 2 re laryngoplasty using rib cartilage and wedge resection of the trachea.

The main criterion for the effectiveness of the treatment of laryngeal stenosis is decannulate patient and complete restoration of breathing through the natural Airways. Terms of decannulation our patients ranged from 20 days to 2 years. 70% of patients were decanulation in the first 4 months after starting treatment. Longer periods of decannulation explained, in our opinion, incomplete what regularium cartilage graft, secondary healing with formation of scar tissue, as well as existing severe comorbidity. Currently, all patients decanulation.

The present invention not obvious to a person skilled operating in this field.

The invention is of great socio-economic impact, as it allows to achieve a one-step model of treatment, reduction of terms of treatment of patients with robovie stenosis of the larynx, ease of care of a tracheostomy cannula, more rapid socio-psychological rehabilitation of the patient after applying the silicone stenting stent at plastic surgery of the larynx costal cartilage.

The method of stenting in laryngoplasty in children using autologous costal cartilage, including the fixation of the graft and the formation of the lumen of the larynx using a stent from a polymer material, wherein the stent is made of silicone set into the lumen of the larynx so that the upper end of the stent was located 0.3-0.5 cm above the vocal folds, the bottom 0.5 cm below the area of stenosis, stitch through U-shaped suture through the wall of the larynx long-absorbable material, and the outer diameter of the stent should not exceed the age of the lumen of the larynx 1-2 mm, and tracheostomy cannula is located below the stent without committing to it is.



 

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