Method for treating esophageal diseases

FIELD: medicine, surgery.

SUBSTANCE: before operation one should detect the type of patient's constitution. Patient should be put onto his/her left side, in case of dolichomorphous type of constitution at the angle of 70°. In case of mesomorphous type - at the angle of 60°. And at brachymorphous type - at the angle of 50° against horizontal plane of operation table, moreover, the angle is open to anterior surface of patient's body. Then one should introduce trocars for desired manipulations, perform videothoracoscopic esophageal extirpation or resection. The innovation suggested enables to improve objective criteria for accessibility of the organ under removal.

EFFECT: higher efficiency of therapy.

3 dwg, 3 ex

 

The invention relates to medicine, namely to surgery, and can be used in the treatment of diseases of the esophagus by his video thoracoscopic of removing or resection of right-sided access with separate lung intubation in the position of the patient on the left side.

Esophagus diseases (cancer, scar contraction, neuromuscular disease) are among the most complex, requiring surgical treatment. Subtotal resection and removing the esophagus are the operations of choice in cancer, cicatricial strictures, achalasia of the esophagus and kardiospazm IV senior Surgical intervention performed from transthoracic access, are traumatic and are accompanied by a number of complications and deaths. Itself thoracotomy is very traumatic and can cause severe disorders of hemodynamics and gas exchange, contributes to the development of postoperative pneumonia, atelectasis, pleural effusion, empiem. Operations of abdomino-cervical access, less traumatic, but the execution by them of adequate lymph node dissection difficult. Transhiatal removal of esophagus difficult to mobilise due to developed in the tissue of mediastinum cicatricial process or tumor. The selection of the esophagus under the video thoracoscopic control combines the more low invasiveness and good visualization of the esophagus, to reduce the risk of intra - and postoperative complications.

A study of patent and scientific and medical literature revealed the following methods of treatment of diseases of the esophagus by resection or removing at different location of the patient on the operating table and places the introduction of trocars to perform videoendosurgical operations.

The known method the position of the patient on the operating table for removing the esophagus, first described by A. Cushieri et al. (1994), on his stomach. The trocars are introduced in the following points: I - in the second intercostal space on the posterior axillary line, II - III intercostal space in the mid-axillary line, III - IV intercostal space on the posterior axillary line, IV - V intercostal space at the anterior axillary line, V - in the sixth intercostal space on the posterior axillary line.

The disadvantages of the method for positioning the patient on his stomach are the deterioration of the function of the respiratory system, which hinders artificial lung ventilation, a high probability of displacement of the endotracheal tube, the possibility of lung atelectasis, a sharp decrease in lung compliance, residual capacity and total respiratory movements, the inconvenience of manipulating the neck and the inability to perform in this position for abdominal access to complete the reconstructive phase of the operation.

what rotation invention as the most similar set of features of the claimed method the next method of removing the esophagus while the patient positioning on the operating table on the left side (So Akaishi et al., 1996). Patient is placed on the left side at an angle of 90 degrees, in the right pleural cavity is entered 6 thoracoport: I - in the second intercostal space at the anterior axillary line, II - III intercostal space on the posterior axillary line, III - IV intercostal space in the middle clavicle line IV - IV intercostal space in the mid-axillary line V - V intercostal space on the posterior axillary line VI - VI intercostal space in the mid-axillary line.

The way to perform extirpate and resection of the esophagus in the statement of the authors of the modification has the following disadvantages:

1. The position of all the patients operated on its side at an angle of 90° without taking into account body type hinders the access to the esophagus hanging light degrades the objective criteria of access, which requires additional manipulation by retraction of the lung.

2. More trocars (5-6 prototype) makes it difficult manipulation in confined space posterior mediastinum and pleural cavity, increases the invasiveness of access unlike the proposed method, which is laying the patient depending on the body type angle 70, 60 or 50 degrees, which reduces the number of input ports to 3-4.

3. The contralateral ventilated lung is in the left half of the chest, the most compressed under the weight of the body of the patient, which makes it the ventilation.

The task of the claimed invention is to reduce negative. effects of the location of the patient on the operating table and the improvement of objective criteria availability of the removed organ.

This object is achieved in that before the operation to determine the index of the body type of the patient, and when dolichoderine the type of patient planiruut angle 70°when the mesomorphic type of patient planiruut at an angle of 60°and when brachymeria the type of patient planiruut angle of 50° to the horizontal plane of the operating table.

The method is as follows. Before the operation, determine the index of the body type of the patient according to the formula: (the girth of the chest/height)×100 (Beks B., 1988). If the index is less than 51, the body type of the patient is defined as dolichoderinae, when the index 51-56 as mesomorphic and if the index is more than 56 as brachymorphic.

The patient is administered anesthesia and produce separate bronchus intubation. Then lay the patient on his left side, bronirovannyi angle 70 (1), 60 (2) or 50 (3) degrees, depending on body type, open to the front surface of the patient's body, the roller is not in use. The position of the surgeon - face to the front surface of the patient's body, the position of the monitor in front of the operator, that is, from the rear surface of the patient's body. Treasurywala in the following points: I - 10 mm trocar in the fourth intercostal space at the anterior axillary line for thoracoscope 30°, II - 10 mm in the fifth intercostal space in the mid-axillary line III - 5 mm in the third intercostal space on the posterior axillary line. If necessary, under the control of thoracoscope introduce additional trocar in the sixth intercostal space at the anterior axillary line.

After the introduction of trocars cut lung-phrenic ligament mode electrocautery, easy release of adhesions and brought to the front. First cut through the mediastinal pleura over the lower third of the esophagus up to the arc azygos vein, and then above. The wall of the esophagus capture clip of Babcock and, by traction of the esophagus to the right and to the left, to mobilize its all over, freeing it from the fascial spurs front and rear. The selection of the esophagus in cancer of the esophagus is done with the removal of mediastinal lymph nodes in the amount of F2. After mobilization of the esophagus above and below the arc azygos vein esophagus capture below the arc and by traction in the cranio-caudal direction, cut fascial spurs connecting the shell arc azygos vein and esophagus. The selection of the esophagus at the intersection of its arc azygos vein is the most critical phase of the operation. In some cases (when the location of the tumor in the middle third of the thoracic esophagus, the presence of chronic the CSOs sclerosing mediastinitis due periesophageal when cicatricial strictures of the esophagus) arc azygos vein it is necessary to cross after the preliminary intracorporeal ligation and blending the two series tantalum staples, for this purpose can be used as a linear stapling device.

Removal of the esophagus as possible through an incision in the neck, and through the abdominal access. A transplant from the stomach or colon is carried out in the posterior mediastinum in the box remote esophagus under the control of videothoracoscopy. If the transplant is used a colon, then make the imposition of the anastomosis between the graft and the stomach, as well as restore the continuity of the intestine.

The pleural cavity drain in the seventh and eighth intercostal space, be sure to make the drainage of the abdominal cavity and neck wounds. Remove trocars, surgical wound is sutured.

The method was tested in 14 patients in the Rostov state medical University.

Examples of specific implementation method.

Example 1. Patient-co., 43 years history No. 8524/167, he enrolled in the Department of thoracic surgical Rostov state medical University 14.11.2003 year with complaints of shortness of passage of solid food through the esophagus. On the basis of objective and instrumental methods of examination diagnosed with cancer of the lower third of the thoracic esophagus stage III. Index body type of the patient is calculated by the formula: (the girth of the chest/height)×100 equal 49,4 - dolichoderinae type telelog the deposits (89/180)× 100.

After preoperative preparation 27.11.2003 year performed the operation. The patient was put in anaesthesia and made a separate bronchus intubation. Performed laparotomy, made the dissection, resection of the gastric cardia and the cutting of the graft from the stomach. Then produced by laying the patient on his left side, bronirovannyi angle 70°, open to the front surface of the patient's body, the roller was not used. The position of the surgeon - face to the front surface of the patient's body, the position of the monitor in front of the operator, that is, from the rear surface of the patient's body. The trocars introduced in the following points: I - 10 mm trocar in the fourth intercostal space at the anterior axillary line for thoracoscope 30°, II - 10 mm in the fifth intercostal space in the mid-axillary line III - 5 mm in the third intercostal space on the posterior axillary line. Under the control of thoracoscope introduced an additional trocar in the sixth intercostal space at the anterior axillary line.

When the audit is determined by the tumor size of 7×6×5 cm thick consistency, starting at 3 cm above the esophago-gastric junction and extending to the middle third of the thoracic esophagus (not reaching 2 cm below the level of the junction of the esophagus arch of the azygos vein). Dissected pulmonary-phrenic ligament, easy release of adhesions and retracted anteriorly. First cut IU actinella pleura over the lower third of the esophagus up to the arc azygos vein, and then above. The wall of the esophagus captured clip babcoke and, by traction of the esophagus to the right and to the left, the esophagus is mobilized throughout. Uninstalled the targeted-environmental wall of the lymph nodes in the amount of F2. After mobilization of the esophagus above and below the arc azygos vein esophagus captured below the arc cut fascial spurs connecting the shell arc azygos vein and esophagus. Arc azygos vein is crossed after the preliminary intracorporeal ligation and blending the two series of tantalum clips. The esophagus in the chest cavity mobilized throughout. The esophagus is removed through an incision on the neck. A transplant from the greater curvature of the stomach conducted in the posterior mediastinum in the box remote esophagus imposed anastomosis in the neck. The pleural cavity is drained in the sixth intercostal space, also drained the abdominal cavity and the cervical wound. The trocars removed, surgical wounds sutured.

At the control examination after 4 months the patient was in good condition, no complaints. Continues to work in the specialty.

Example 2. Patient K., 46 years old, medical history, No. 4626/82 was admitted to the Department of surgery №1 12.05.02 with complaints of shortness of passage of food through the esophagus, weakness, progressive weight loss. From the anamnesis it is known that by mistake he took a gulp of alkali. On the basis of objective data and the tool is Talnah methods diagnosed extended cicatricial stricture of the esophagus. Index body type of the patient (98/179)×100 equal 54,7 (mesomorphic body type).

After preoperative preparation 19.05.2002 year performed the operation. The patient was put in anaesthesia and made a separate bronchus intubation. Then produced by laying the patient on his left side, bronirovannyi at an angle of 60°, open to the front surface of the patient's body, the roller was not used. The position of the surgeon - face to the front surface of the patient's body, the position of the monitor in front of the operator, that is, from the rear surface of the patient's body. The trocars introduced in the following points: I - 10 mm trocar in the fourth intercostal space at the anterior axillary line for thoracoscope 30°, II - 10 mm in the fifth intercostal space in the mid-axillary line III - 5 mm in the third intercostal space on the posterior axillary line.

Dissected pulmonary-phrenic ligament, easy release of adhesions and retracted anteriorly. First dissected mediastinal pleura over the lower third of the esophagus up to the arc azygos vein, and then above. The wall of the esophagus captured clip babcoke and, by traction of the esophagus to the right and to the left, the esophagus is mobilized throughout. After mobilization of the esophagus above and below the arc azygos vein esophagus captured below the arc cut fascial spurs connecting the shell arc azygos vein and esophagus. Arc azygos vein is crossed after the seat reservation intracorporeal ligation and blending the two series of tantalum clips. The esophagus in the chest cavity mobilized all over, crossed at the level of the esophago-gastric junction using a linear surgical stapling apparatus. The graft from the right half of the colon conducted in the posterior mediastinum in the box remote esophagus imposed anastomosis in the neck. The pleural cavity is drained in the seventh intercostal space, drained the cervical wound. The trocars removed, surgical wounds sutured.

At follow-up after 8 months the patient's condition is satisfactory, no complaints, the passage of food through the esophagus satisfactory.

Example 3. Patient s., 57 years history No. 4156/272, was admitted to the Department of surgery №1 Rostov state medical University 23.05.2001 year with complaints of shortness of passage of solid food through the esophagus, weight loss in 6 months. 10 kg, General weakness. On the basis of objective and instrumental methods of examination diagnosed with cancer of the middle third of the thoracic esophagus stage III. Index body type of the patient (101/170)×100 equal to 59.4 (brachymorphic body type).

After preoperative preparation 08.06.2001 year performed the operation. The patient was put in anaesthesia and made a separate bronchus intubation. Performed laparotomy, made the dissection, resection of the gastric cardia and Wickramasekara from the stomach. Then produced by laying the patient on his left side, bronirovannyi angle of 50°, open to the front surface of the patient's body, the roller was not used. The position of the surgeon - face to the front surface of the body of the patient. The trocars introduced in the following points: I - 10 mm trocar in the fourth intercostal space at the anterior axillary line for thoracoscope 30°, II - 10 mm in the fifth intercostal space in the mid-axillary line III - 5 mm in the third intercostal space on the posterior axillary line. Additional trocar is installed in the sixth intercostal space at the anterior axillary line.

When the audit is determined by the tumor size 5×4×4 cm thick consistency, starting at the level of the middle third of the thoracic esophagus, just below the arc azygos vein. Dissected pulmonary-phrenic ligament, easy release of adhesions and retracted anteriorly. First dissected mediastinal pleura over the lower third of the esophagus up to the arc azygos vein, and then above the arc azygos vein. The wall of the esophagus captured clip babcoke, the esophagus is mobilized throughout. Produced by removal of mediastinal lymph nodes in the amount of F2. Arc azygos vein is crossed after the preliminary intracorporeal ligation and blending the two series of tantalum clips. The esophagus in the chest cavity mobilized throughout. The esophagus is removed through an incision on the neck. Trance is Lancet from the greater curvature of the stomach conducted in the posterior mediastinum in the box remote esophagus, imposed anastomosis in the neck. The pleural cavity is drained in the sixth intercostal space, also drained the abdominal cavity and the cervical wound. The trocars removed, surgical wounds sutured.

During examination after 6 months the patient had no complaints.

Application of the proposed method for the treatment of diseases of the esophagus allows you to differentiate between performing thoracoscopic access depending on the body type of the patient and conduct operations in more comfortable conditions in connection with the increase of range of the angle of operative steps, the angle of inclination of the axis of the operational steps, which reduces the risk of intraoperative complications. This way in the absence of an underlying cushion and additional measures retraction of the lung contributes to the reduction in the postoperative period in the number of postoperative complications respiratory system.

References

1. Beks B. Individual anatomical variability of organs, systems and body shape of the person. Kiev: Health, 1988. - 223 C.

2. Akaishi T., Kaneda I., N. Higuchi et al. Thoracoscopic en bloc total esophagectomy with radical mediastinal lymphadenectomy. J. Thorac. Cardiovasc. Surg. 1996; 112:1533-1540.

3. Cushieri A. Thoracoscopic subtotal oesophagectomy. Endosc. Surg. Allied. Technol. 1994; 2:21-25.

The method of treatment of diseases of the esophagus by laying the patient on his left side, the introduction of trocars for manipulation and made the I video thoracoscopic of removing or esophageal resection characterized in that before the operation to determine the index of the body type of the patient, and when dolichoderine type of patient is placed under an angle of 70°when the mesomorphic type of patient is at an angle of 60°and when brachymeria the type of patient - angle of 50° to the horizontal plane of the operating table, when this angle is open toward the front surface of the body of the patient.



 

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