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Eshonhodjaev Otabek Djuraevich, Republican Specialized Center of Surgery named after academician V. Vahidov, Doctor of philosophy
E-mail: dr.otabek@mail.ru Khudaybergenov Shukhrat Nurmatovich, Republican Specialized Center of Surgery named after academician V. Vahidov, Doctor of medical sciences Kayumhodjaev Abdurashit Abdusalamovich, Republican Specialized Center of Surgery named after academician V. Vahidov, Doctor of medical sciences Mustafaev Azizjon Toshmuhammadovich, Tashkent Medical Academy, Master of thoracic surgery E-mail: aziztm25@gmail.com
Plastic surgery of persistent and extensive defects of the anterior wall of the trachea and neck soft tissues after laryngo-tracheostomy
Abstract: Clinical experience in the treatment of neck defects after laringotraheostomy. Using of the autocartilage in plastic surgery of extensive neck defects.
Keywords: neck defects, microsurgery, delta-pectoral flap, cartilage-fascial flap.
Introduction
In order to restore airway patency during critical and decompensated stenosis of the larynx and trachea in some patients using tracheostomy with the introduction of the cannula into the lumen of the trachea below the level of the stenosis. In some cases, at surgical correction of stenosis we perform laryngo-tracheostomy with wide excision of tissue around the area of stenosis, followed by the introduction into the lumen of the tubular airway dilators for a specified duration. Subsequently, after the formation of persistent laryngotra-cheitis raises the question of closing the defect without violating patency and restenosis without trachea. Often posttraumatic stenosis complicated by festering wound in the neck, combined with tracheal wall defect [2; 6; 9]. Proposed large number of possible fabrics and materials, as well as variants of operations aimed at eliminating defects in this area [1; 3; 5; 7]. The main requirements to them clearly formed: they must be of sufficient size to provide a carcass function and the possibility of a secret evacuation, as well as being resistant to infection [4; 5; 8]. Despite this, the problem of the closure of large defects of laryngo-trachea is relevant and continues to be the subject of research and microsurgery discussions, otolaryngologists and thoracic surgeons [3; 10; 12].
Material and methods
In the Department of Surgery of the lungs and mediastinum RSCS named after academician V. Vahidov in the period from 2008 to 2015, was hospitalized 26 patients with defects of the anterior wall of the upper third of the trachea, subglottic larynx and soft tissue of the neck after laryngotracheostomy or tracheostomy. Among these 8 patients were referred from other medical institutions of the republic, 18 patients were admitted to the final stage of the combination of staged treatment of cicatricial post-trache-ostomy and post-intubation tracheal stenosis. Previously it in our department has been carried out stages of endoscopic coagulation, bougienage tracheal stenosis, followed by plastics tracheal lumen with the formation on the T-shaped stent. After routine examination including endoscopy (bronchofiberscope, esopha-gogastroduodenoscopy), MSCT of the chest with the seizure of the neck area and clinical patient diagnostic methods carried out surgical treatment.
Thus in patients with persistent defects extensive anterior tracheal wall and soft tissues of the neck, with the defect size not exceeding 2 cm. in width and 4 cm. in height was performed three layer plastic skin and muscle with simultaneous elimination of local tissue defect.
6 patients had extensive defects in the anterior-lateral wall of the cervical trachea and subglottic larynx, and also had a deficit of soft tissues of the neck around the stoma. The dimensions of the defect in one case amounted to 3 x 5 cm., in the second case — 3.5 x 5.5 cm. see also the presence of large defects after laryngotracheostomy complicated breach the vertical axis of the lumen of the respiratory tract, and the posterior tracheal wall came forward in the defect area. The complexity of the plastic was the lack of soft tissues around the defect, large defects due to lack of cartilage and skin-muscular frame and bend the vertical tracheal axis in the an-teroposterior direction, which required the creation of the graft on the hard frame of sufficient size, with the mucous lining of the inside with the possibility of creating a hermetic lumen.
Results and discussion
Patients (n = 22) with anterior tracheal wall posttracheostomy defects and soft tissue defects with sizes from 1.0 cm. to 2.0 cm. wide and 2.0 cm. to 4.0 cm. in height (Fig. 1) when the defect depth of 8 mm., i. e. anterior-posterior size of the tracheal lumen and the lumen formed persistent airway narrowing in the plastic zone without a tread (T-shaped stent or tracheostomy cannula) made the local three-layer or four-layer skin and muscle plastic defect.
The technique is to perform a defect section bordering scar-altered skin some distance from the edges of 0.6-0.8 cm. and a depth in average of 0.8-1.0 cm., depending on the size of the defect is eliminated. Thus, on the one hand the release of skin grafts, i. e. their mobilization must be sufficient so far as is necessary to prevent the tension generated first layer. On the other hand excessive mobilization of a cut flap can cause flotation of bound edges, which is fraught with a lack of framing the respiratory tract in the area after the plastics during respiration, phonation and cough.
Created the first layer, stitched atraumatic absorbable thread (Vicryl 3/0) turns into the epidermis. This point is mandatory holding submucosal sutures, which excludes further adhesion of
bronchial secretions to the filament due to the absence of the suture in the lumen of the trachea. The second layer sutured adjacent muscles (m. sternocleidomastoideus, m. Sternothyroideus, m. Ster-nohyoideus) by means of the capture in the seam and convergence on the first layer. The third layer — the skin, the nodal atraumatic thread tightening the skin and eliminate the defect formed by leaving a rubber graduates.
When applying each subsequent weld seam in the wall of the underlying captured to further strengthen the wall layers in the flotation exclude cough shock, as well as to prevent the formation of cavities between the layers.
After the defect plasty was performed intraoperative fibro-bronchoscopy through an endotracheal tube with a tightening in her throat infraglottic department for visual assessment sutured the defect area. Thus investigated leaks formed front wall in the form of cutaneous inserts, layer mapping, the presence or absence of deformation and/or constriction of the trachea in the plastic zone.
Control bronchoscopic examinations were performed in patients on the 5th day after the operation. Then, after 1 month, 3 months, 6 months and one year after the operation. Two patients had a point failure joints skin and muscle plasticity to form a skin-tracheal fistula size of 2-3 mm., which closed on their own without surgery by conservative treatment with the imposition ofaseptic dressings ointment.
Six patients with extensive defects in the anterior-lateral walls of the trachea and the distal part of the larynx, produced complex reconstructive surgery using microsurgical techniques.
In one case, the patient was operated with the diagnosis: Extensive defect of soft tissues of the neck and the front-side walls of the cervical trachea and the distal part of the larynx. Posttracheostomy and postoperative cicatricial stenosis of the trachea. Condition after circular tracheal resection. Cicatricial-paralytic laryngeal stenosis. Full extended cicatricial obliteration of the distal larynx and cervical trachea. Condition after laser recanalization tracheal stenosis. Condition after laryngotracheoplasty at T-tube stent.
Fig. 1. Extensive defect anterior-lateral walls of the trachea and the soft tissues of the neck
Due to the extensive defect of the front wall of the trachea and soft tissue front of the neck is made of plastic microsurgical prefabricated delta-pectoral autorib flap with autodermaplasty. Defect size was 3 cm. in width and 5 cm. in height, the depth of the lumen was 1.2 cm. The axis of the respiratory tract has been broken, the distal
larynx and trachea into the upper third of the defect projections have forward direction behind the axis in the sagittal direction, and the average third of the trachea in the retrosternal area had front to back direction of the axis in the sagittal direction.
Plastic extensive defects of the cervical trachea suggests the recovery is not only soft tissue defect, but also the restoration of the mucous lining of the trachea and framing functions. To restore tracheal defects requires an adequate supply of high-grade, skin devoid of hair in the area of reconstruction. The absence of such sites in the neighborhood (or sharp dystrophic scarring) requires the use of tissue from skin taken from other areas of the patient's body (Filatov stem formation, moving skin-fascial flap on a vascular pedicle, autotransplantation complex flaps on microvascular anastomosis).
We have perfected a method of forming prefabricated flap. As the supporting tissue used in this case implanted graft autorib cartilage. Depending on the tracheal defect parameters carried fence part in cartilage compounds VI and VII ribs, by the usual method in plastic surgery. Subsequently formed cartilaginous carcass implanted into the distal portion of the delta-pectoral graft under fascial.
Procedural steps:
Stage 1. Formation ofprefabricated delta-pectoral flap implantation autorib cartilaginous carcass in the distal flapO (Fig. 2).
Fig. 2. Formation delta-pectoral flap with implantation of cartilaginous skeleton (delta-pectoral0skin and cartilage-fascial flap)
Stage 2. Raising prefabricated flap to form a round stem. Substitution tracheal defect with the restoration of the mucous lining (due to skin flaps) and cartilage carcass (due to the implanted autorib cartilage). Closing of the donor area and part of the fascial flap with split skin.
Stage 3. Trimming of the flap leg and final plastic tracheal defect (Figure 3).
Fig. 3. Long-term results of extensive plastic defect cervical trachea
As a result of the reconstruction achieved phonation recovery and patency of the trachea (Figure 4).
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Fig. 4. The final result. MSCT of the neck organs. 10 months after the plastic tracheal defect prefabricated delta-pectoral flap, cross-section
In 4 cases, the patients underwent extensive plastic defect prefabricated autorib cartilage.
The technique is a two-stage closure of the tracheal defect extensive anterolateral wall of the trachea. At the first stage the fence autorib cartilage without opening the pleural cavity. Then, from autocartilage were cut out two identical forms of implant
sizes more than in length by 1.5 cm. length of the defect (Fig. 5). Then the two cuts made parallel to the vertical axis of the defect in the formed bed intermuscular laid cartilage implants. Harboring them absorbable stitching thread soft tissue over the implant. Sutured skin incisions leaving rubber graduates with the imposition of aseptic dressings.
Fig. 5. A — Patient T., 20 years old. A. Marking cartilage implantation zone; B — cut to form cartilage ready for implantation into the soft tissue of the neck
The second phase was carried out in 40 days, with the aim of healing implants (autorib cartilage) to generate around the case. Assessment of the viability autorib cartilage was performed by palpation. In the dynamics after the surgery remained stiff and elasticity autocartilage implanted on the side walls of the stoma, which confirmed the absence of lysis of the latter and the suitability to carry out the final stage of plastic extensive tracheal defect.
Under general endotracheal anesthesia, an incision on the right and left parallel to the walls of the stoma, mobilized implanted early cartilage autocartilage retaining legs (the bottom wall formed by the case), to rotate the cartilage with the movement in the projection of the defect and fixed with implants absorbable atraumatic suture material (Vicryl 4.0 or Biosyn 4.0). Separated lateral flap of skin with subcutaneous fat sheltered surface rotate autocartilage leaving rubber graduates (Fig. 6).
Fig. 6. The final form of the hermetic closure of the defect
Two patients after skin-grafting and muscle in 1 case after au-torib plastics in the early postoperative period, there was a partial failure of seams from the air intake of the zone created by skin-muscular front wall without differences external seams. In both cases, conservative methods achieved the elimination of signs of insolvency seams with the termination of air intake and phonation when coughing with a hermetic closure of the defect. In all other cases obtained good immediate and long-term results. The control broncho spectroscopy determined defect plastics sheltered area of the skin insertion, without disturbing the terrain and without narrowing the lumen of the trachea.
Thus, the selection process plastics or tracheal reconstruction of the defect is determined in each case individually. Local skin-muscle flaps, as well as complicated skin and musculoskeletal grafts from adjacent the neck and different parts of the thorax may be used. The indication for this operation is the presence of a defect and persistent tracheal lumen formed at this level, with no signs of restenosis of the respiratory tract, the absence of inflammation
and infection of the tissues around the stoma. When the size of the tracheal defect to 2 x 4 cm., sufficient depth corresponding to the lumen of the lumen of the trachea below and above the stoma, the single axis of the trachea and larynx without distal displacement and deformation of the lumen is a skin-muscle plastic defect replacement with local fabrics.
Conclusions
1. The large number of donor zones hinged flap near the neck defects allows to use them widely for plastics extensive and persistent tissue defects. Using an improved method of forming prefabricated flap, it allows to produce plastic large tracheal defects with the restoration of the cartilaginous skeleton.
2. Formation of rotational flaps, in particular autocartilage and delta-pectoral flap for reconstruction of extensive persistent tracheal defects and soft tissues of the neck is technically simple, requires no additional microsurgical benefits to create a framing the front wall without violating the patency of the respiratory tract, without constriction and deformation lumen.
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Yuldasheva Nasiba Alisherovna, Tashkent State Stomatology Institute, Department of Orthopedical stomatology E-mail: bonusha-uz@list.ru
Prognosis of the individual risk of periodontal disease development in the pregnant women
Abstract: The pregnant women have one of the highest risks of the occurrence of stomatological diseases. We observed 847 pregnant women at the age of18 to 36 years. The research showed, that development of the prognostic coefficients by the most important and characteristic for pregnant women risk factors, particularly where there is danger of the occurrence of the periodontal pathology, present the opportunity for physician-stomatologists and obstetrician-gynecologists.
Keywords: pregnancy, parodontitis, risk factors, reproductive health.
