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УДК 617-089
Surgery of tracheal stenosis
Eshmuratov T., Shirtaev B., Batyrhanov М., Pyurova L,Sundetov M, Zharylkapov N, Zhunisov N, Eleusizov A, Akimniyazova B, Kasenbaev R.
National Scientific Center of Surgery. Almaty, Republic of Kazakhstan
Аннотация
Хирургия стенозов трахеи
Ешмуратов Т.Ш., Ширтаев Б.К., Сундетов М.М., Батырханов М.М., Жарылкапов Н.С., Жунисов Н.А., Елеусизов А.М., Акимниязова Б. Б., Касенбаев Р.Ж.
Национальный научный центр хирургии им. А.Н. Сызганова
г. Алматы
В статье представлены итоги диагностики и хирургического лечения 72 пациентов со стенозами трахеи в ННЦХ им. А.Н. Сызганова. Показан опыт проведения восстановительных операций при рубцовых стенозах трахеи, методы диагностики и отдаленные результаты хирургического лечения.
Ключевые слова: трахея, рубцовый стеноз, хирургическое лечение, бронхоскопия.
One of the actual problems of the respiratory organs surgery remains qualified early diagnosis and treatment of cicatricial stenosis of the trachea.
With the growth of road traffic injuries, natural and technological disasters increased the number of patients requiring tracheal intubation. Prolonged intubation and tracheostomy are most often the cause of stenosis of the trachea.
From a review of the scientific literature revealed limited use of clinical and functional methods of research and dynamic endoscopic surveillance for patients with stenosis of the upper respiratory tract at all subsequent stages of development and correction of cicatricial processes. Not clarified the criteria for recovery in relation to different groups of patients with stenotic disease of the trachea and assessment methods.
Radical surgical treatment of cicatricial stenosis of the trachea has a long history, and the development of operative methods is carried out in two directions:
a) one-stage operation - circular resection of the stenotic segment with anastomosis "end to end";
b) stage plastic surgery with the formation of the lumen of the trachea using a temporary prosthesis (stent-protectors). [1, 2, 3, 4, 5,6].
Own observations
The study is based on the experience of diagnosis and treatment of patients with tracheal stenosis.
The aim of the study
is to improve ways to treat scar strictures of the trachea that will lead to the restoration of patency and prevent secondary stenosis.
Methods
Laboratory and clinical, bacteriological, functional, X-ray, computed tomography, endoscopic.
Over the past 5 years, were examined 72 patients with cicatricial stenosis of the trachea. Among them were 30 women and 42 men aged from 9 to 65 years. Tracheal stenosis were associated with prolonged intubation, tracheostomy or have resulted from household and traffic injuries.
Surgical removal of scar strictures of the trachea was performed by two accesses: through the natural way -endotracheally and open method with tracheotomy or sternotomy.
Planning stages of rehabilitation treatment, their sequence, anesthetic management of instrumental studies and surgical interventions based on an assessment of the identified structural and physiological changes in the etiological and pathogenetic basis. At scar strictures of the trachea is mainly performed multistage reconstructive plastic surgery.
Surveyed patients complained of shortness of breath at rest, cough, hemoptysis. Progressed signs of intoxication: a sharp fatigue, nervous disorders, headaches, decreased intelligence. All this points to the severity of the functional disorders associated with obstruction of the air passage.
All the patients underwent radiographic studies, and in some cases, computed and magnetic resonance imaging of the larynx and cervical trachea.
To determine the infection of the tracheobronchial tree was performed bacteriological examination. Took a smear of tracheostomy with sowing to determine the microbial flora and its sensitivity to antibiotics. Were found in different proportions: Escherichia coli, Staphylococcus aureus and epidermidis and Pseudomonas aeruginosa. Most often identified associations at the same time several microorganisms (gram-negative microorganisms, together with Gram-positive). In these cases, antibiotic sensitivity was very selective and only broad-spectrum preparations.
Analysis of the result set of the functional assessment of patients showed that the most informative in assessing ventilation disorders were fast respiration parameters, especially the maximum peak velocity loop "flow-volume" and direct measurements of airway resistance inspiratory and expiratory.
For the diagnosis of stenosis laryngotracheal area preference for endoscopy under local anesthesia, as it is a low-traumatic, has a large diagnostic and treatment capabilities. In this regard, have been developed broad indications laryngotracheoscopy with tracheal stenosis scarring. However, in patients with severe stridor and the threat of asphyxiation tracheoscopy rendered impossible due to the sharp stenosis. In this situation, performed rigid tracheoscopy under anesthesia with mechanical ventilation.
Important endoscopic signs that reflect the severity of changes in the area of stenosis were:
- intraluminal anatomical changes, the channel configuration of stenosis and the degree of constriction;
- extensibility of walls stenotic site by endoscopic
Журнал Национального научного центра хирургии им. А.Н. Сызганова
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instruments and the availability of inspection of the channel stenosis;
- the nature of the inflammatory process in the mucosa of the stenotic site;
Was operated on 67 patients with endoscopic intervention as an independent method of treatment of cicatricial stenosis of the upper respiratory tract were used in 15 cases. Endoscopic removal from airway scar tissue, granulation was performed by endoscopic electrosurgical instruments. Contraindication to endoscopic attempts of manipulation of cicatricial stenosis of the trachea was an indication of bleeding in the respiratory tract, and choking during meals, as well as the presence of very dense scar formed. These patients needed a radical correction of cicatricial stenosis of the trachea.
In 52 patients were performed radical surgery on the trachea external access. Conducted in this group of patients with active pre-and post-operative endoscopic treatment using endoscopic surgical techniques has allowed to improve their performance, and in some cases reduce the amount of surgery.
Among the methods of surgical correction of stenosis middle and lower third of the trachea in a certain place sternotomy received circular resection of the lesion with the anastomosis "end to end". This operation was conducted three patients. But such an operation, especially in the presence of purulent tracheobronchitis or hondroperihondritis is technically difficult and dangerous. When forming an anastomosis between the larynx and the trachea considerable difficulties arise because of the imbalance between the loose-ends.
Open cervical access operations was performed tracheostomy at the level of earlier detected stenosis with the optimal surgical procedures and possible complications with. Recanalization of the trachea was carried out by electrosurgical scarring and stricture diathermocoagulation granulation tissue or soft tissue overlying the lumen. Taken into account the anatomical structure of the respiratory tract in order to improve the follow-epithelialization of the tracheal mucosa and restore physiological properties. To achieve sustainable restoration and preservation of the lumen of the trachea was performed tracheal stenting for long term. For endoprosthesis used T-shaped silicone tube with an outer diameter of 7-13mm. Flexible stents with appropriate size inserted through the available tracheostomy hole, which was supplemented by tracheofissure for easy change of the prosthesis on the future planned stages of observation. The distal segment of the T-shaped tube was carried out in the lower sections of the trachea.
Regulation establishes the the tube was monitored visually using a fibreoptic bronchoscope, then conducted through its lumen. Horizontal level of the upper branch of the tube was covered with a rubber obturator to prevent the development of granulation.
Three patients achieved tracheal prosthesis installation by tracheal stent. During endoprosthetic replacement were used tracheal and bronchial stents of Micro-Tech (Nanjing) Co., Ltd.
After obtaining sufficient lumen of the trachea, as well as the complete cessation of growth of granulation and removal of temporary prosthesis used important point is to eliminate the defect. Closure of the defect of the front wall of the trachea was performed by two methods. Selection of ways to restore the integrity of the trachea was dependent on the size of traheofissure, as well as the lumen of the trachea. The first method of tracheoplastic consists in suturing defect anterior tracheal wall with local fabrics, skin-muscle flap, this method is used in 14 patients, in order to eliminate large defects and
the creation of a cosmetic effect three patients underwent closure of the defect using microsurgical equipment involving microsurgery, by transplanting skin -Muscular flap pedicled.
The second way defect closure of the front wall of the trachea - used in 26 patients - two-step, which used a reference tissue, as the last applied auto-or homo cartilage. The first stage was carried out grafting cartilage in the subcutaneous tissue at one edge of the tracheofissure. Three months after the procedure was performed tracheal defect closure by moving the skin flap with cartilage.
Risks and complications
Operational bronchoscopic intervention - a real surgical operation, fraught with complications and adverse effects. One of the most real and dangerous - bleeding into the lumen of the airway. The reason it can be mechanical damage of tumor vessels by bronchoscope or instrument. However, when using electrocoagulation and laser loop insufficient coagulation of vessels can be complicated by bleeding. The most dangerous bleeding during the operation under local anesthesia using bronchofiberscope or videoscope. Blood instantly blocking the lens and visibility disappears completely, and through a narrow instrument channel can not be removed rapidly and offer the blood clots. In case of bleeding, which was able to cope, do not forget the importance of careful aspiration from small bronchi extravasated blood in them, which before extubation must perform sanation bronchofibroscopy and washing of the bronchi of both lungs.
Another complication, which can meet physician, is a perforation of the wall of the trachea or bronchus. Most actual occurrence of this complication during recanalization of the trachea in its cicatricial stenosis or tumor. The most dangerous perforation wall in areas where directly to the trachea or bronchi adjacent esophagus or a large blood vessel. Perforating wound in this place can be complicated by the development of tracheoesophageal fistula or fatal bleeding. Even a small gap of a wall of large bronchus may be complicated by mediastinal emphysema or pneumothorax. They contribute to the development of mechanical ventilation and cough during awakening from anesthesia and in the postoperative period. Typically, this involves a subcutaneous emphysema in the neck and anterior chest wall revealed on characteristic crepitation.
Of the complications encountered in our practice during surgical manipulation, it is necessary to note the damage with a surgical blade back of the throat. Primary obstruction of the trachea in this patient was caused by the coalescence of adjacent walls of the laryngeal-pharyngeal. In place of the injured were fragments of cartilage arytenoid processes. The patient was able to recanalized lumen of the trachea, install a T-shaped prosthesis to achieve a stable recovery of the airways, and for further plastic laryngeal-pharyngeal he was sent to the ENT Center of the Russian Federation.
One patient died on the operating table in an extended open tracheotomy because of massive bleeding due to violation of the integrity of the large vessels, scar-welded to the walls of the trachea.
Rapid death as a result of asphyxia by hemorrhagic masses occurred in patients with postintubation stenosis of the upper third of the trachea during endoscopic excision of scar and granulation tissue. Retrospective analysis of death case showed the necessity the timely implementation of a tracheostomy to ensure adequate ventilation and aspiration at the time of operative procedures.
One patient with post-traumatic cicatricial stenosis of the lower third of the trachea during endoscopic recanalization of the lumen of the trachea using electroexcision, in connection with the development of decompensated stenosis and the development of severe deformation of the walls of the trachea, perforation occurred posterior-lateral wall of the trachea with the development of pneumothorax, which was eliminated by draining pleural cavity.
In the early postoperative period were the following complications: marginal necrosis of the skin with the development of insolvency and the eruption of the seams on the musculocutaneous flap in 3 patients, resorption of homocartilage in subcutaneous tissue in 2 patients.
Effectiveness of corrective interventions in stenotic trachea processes assessed by the degree of reduction of anatomical patency of the airway and respiratory function in the next six months after surgery.
In 59 operated patients, clinical recovery occurred, they returned to the socially active life and socially useful work. They have not only disappeared clinical manifestations of diseases, but also in the control studies in the dynamics (endoscopic, radiological, functional) confirmed the almost complete restoration of the anatomical structure and function of the trachea.
Conclusion. In most patients the stage tracheo-plastic is the only possible and relatively safe method of treatment, and the right selected variant of plastics and sequence of medical actions in patients with stenosis of the trachea allows for recovery.
To carry out reconstructive-plastic surgery of the trachea requires considerable personal experience of thoracic surgeon, bronchologist and coordinated work of all the staff, highly qualified anesthetic management, high-quality and well-functioning equipment. Such operations can be performed only in specialized thoracic surgical departments with sufficient experience in open surgery on the trachea and lungs at a constant readiness for emergency surgery in the event of complications.
Literature
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Summary
SURGERY OF TRACHEAL STENOSIS
Esmuratov T., Shirtaev B, Sundetov M, Batyrhanov М, Zharylkapov N, Zhunisov N, Eleusizov A, Akimniyazova B, Kasenbaev R.
National Scientific Center of Surgery
Almaty, Kazakhstan
The article presents the results of the diagnosis and surgical treatment of 72 patients with stenosis of the trachea in National Scientific Center of Surgery. Shown the experience of recovery operations at cicatricial stenosis of the trachea, methods of diagnosis and long-term results of surgical treatment.
Keywords: trachea, cicatricial stenosis, surgical treatment, bronchoscopy.
Тужырым
Кен/рдк стеноздарынын хирургиясы
Ешмуратов Т.Ш., Ширтаев Б.К., Сундетов М.М., Батырханов М.М., Жарылкапов Н.С., Жунисов Н.А., Елеусизов А. М., Акимниязова Б. Б., Касенбаев Р.Ж.
А.Н.Сызганов атындагы ¥лттыц хирургиялыц гылыми орталыгы. Алматы
Мацалада А.Н.Сызганов атындагы ¥ГХО-да 72 науцаста кенрдек стенозымен царалгандардын диагностикамен хирургиялыц ем нэтижелер1 кврсетiлген. Сонымен цатар кенрдектщ тыртыцтыц стеноздарында жасалатын цалпына келт/'рет/'н оталар жалалынды, диагностикалыц эдстерi мен хирургиялыц емнн алыстаган нэтижелер1 бар.
1здеуге арналган свздер: кец'рдек тыртыцтыц стеноз хирургиялыц ем бронхоскопия.
