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Lecture notes, cheat sheets
Pediatric surgery. Malformations of the esophagus. Esophageal obstruction (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE № 4. Malformations of the esophagus. Obstruction of the esophagus Various diseases of the esophagus occur in children of all age groups. Most often, the need for urgent surgical intervention arises in connection with congenital malformations and injuries of the esophagus. Somewhat less often, indications for emergency care are due to bleeding from the dilated veins of the esophagus with portal hypertension. Malformations of the esophagus are among the diseases that often cause the death of children in the first days of life or the occurrence of serious complications in them that disrupt further development. Among the numerous congenital defects of the esophagus for emergency surgery, those types that are incompatible with the life of a child without urgent surgical correction are of interest: congenital obstruction (atresia) and esophageal-tracheal fistulas. Obstruction of the esophagus Congenital obstruction of the esophagus is due to its atresia. This complex malformation is formed in the early stages of intrauterine life of the fetus and, according to studies, occurs relatively often (for every 3500 children, 1 is born with esophageal pathology). In atresia, in most cases, the upper end of the esophagus ends blindly, and the lower part communicates with the trachea, forming a tracheoesophageal fistula (90-95%). Amniotic fluid and fluid that the baby swallows after birth cannot enter the stomach and accumulate along with mucus in the upper blind sac of the esophagus, then regurgitate and aspirate. The presence of a fistula in the upper segment of the esophagus accelerates aspiration - after swallowing, the liquid partially or completely enters the trachea. The child quickly develops aspiration pneumonia, which is aggravated by the throwing of stomach contents into the trachea through the esophageal-tracheal fistula of the lower segment. A few days after birth, death occurs from aspiration pneumonia. Such children can only be saved by urgent surgical correction of the defect. A successful outcome of the treatment of congenital obstruction of the esophagus depends on many reasons, but above all - on the timely detection of atresia. Early initiation of special treatment reduces the possibility of aspiration. A diagnosis made in the first hours of a child's life (before the first feeding) will prevent or greatly alleviate the course of aspiration pneumonia. clinical picture The first earliest and most consistent sign that suggests esophageal atresia in a newborn is a large amount of frothy discharge from the mouth and nose. Suspicion of esophageal atresia should be increased if, after the usual suction of mucus, the latter continues to accumulate rapidly in large quantities. Mucus at times has a yellow color, which depends on the throwing of bile into the trachea through the fistula of the distal segment of the esophagus. In all children with obstruction of the esophagus, by the end of the 1st day after birth, quite distinct respiratory disorders (arrhythmia, shortness of breath) and cyanosis can be detected. Auscultation in the lungs is determined by an abundant amount of moist rales of various sizes. When the upper esophagus communicates with the trachea, aspiration pneumonia is diagnosed immediately after birth. Abdominal distension indicates an existing fistula between the distal esophagus and the airways. If the first indirect signs of atresia were detected in the maternity hospital, the diagnosis should be confirmed or rejected by probing the esophagus. With atresia, a freely pushed catheter is delayed at the level of the top of the bag of the proximal segment of the esophagus (10-12 cm from the edge of the gums). If the esophagus is not changed, then the catheter easily passes for a greater distance. It must be remembered that in some cases the catheter can develop, and then a false impression is created about the patency of the esophagus. To clarify the diagnosis, the catheter is carried to a depth of more than 24 cm, and then its end (if there is atresia) is inevitably found in the child's mouth. At the first feeding obstruction of a gullet comes to light quite definitely. All drunk liquid (1-2 sips) immediately pours back. Feeding is accompanied by a sharp violation of breathing: the newborn turns blue, breathing becomes superficial, arrhythmic, it stops. These phenomena occur during each feeding. Gradually increasing cyanosis. When auscultating the lungs, an abundant amount of different-sized moist rales is revealed, more on the right. The general condition of the child progressively worsens. With exhaustive completeness and reliability, the diagnosis is made on the basis of an X-ray examination of the esophagus using a contrast agent, which is carried out only in a surgical hospital. The data obtained are a necessary part of the preoperative examination and serve as a guideline for choosing the method of surgical intervention. X-ray examination of children with suspected esophageal atresia begins with a plain chest x-ray (it is very important to carefully assess the condition of the lungs). Then, a rubber catheter is passed into the upper segment of the esophagus and the mucus is sucked off, after which 1 ml of iodolipol is injected through the same catheter into the esophagus with a syringe. The introduction of a large amount of iodized oil can lead to an undesirable complication - overflow of the blind upper segment of the esophagus and aspiration with filling of the bronchial tree with a contrast agent. Pictures are taken in the vertical position of the child in two projections. The contrast agent after X-ray examination is carefully sucked off. The use of barium sulfate as a contrast agent for examination of the esophagus in newborns with any form of atresia is contraindicated, since its entry into the lungs, which is possible during this study, causes atelectatic pneumonia. In the general serious condition of the child (late admission, prematurity III-IV degree), you can not undertake examinations with a contrast agent, but limit yourself to the introduction of a thin rubber catheter into the esophagus (under the control of an X-ray screen), which will allow you to fairly accurately determine the presence and level of atresia. It should be remembered that with the rough introduction of a low-elastic thick catheter, the pliable film of the blind oral segment of the esophagus can be displaced, and then a false impression is created about the low location of the obstruction. A characteristic radiological symptom of esophageal atresia when examined with a contrast agent is a moderately dilated and blindly ending upper segment of the esophagus. The level of atresia is more accurately determined on lateral radiographs. The presence of air in the gastrointestinal tract indicates an anastomosis between the lower esophagus and the respiratory tract. The visible upper cecum and the absence of gas in the gastrointestinal tract suggest atresia without a fistula between the distal esophagus and the trachea. However, this radiographic finding does not always completely rule out a fistula between the distal esophagus and the airways. The narrow lumen of the fistula is clogged with a mucous plug, which serves as an obstacle to the passage of air into the stomach. The presence of a fistula between the upper segment of the esophagus and the trachea can be detected radiologically by throwing a contrast agent through the fistula into the respiratory tract. This examination does not always help to detect a fistula, which in such cases is found only during surgery. Differential diagnosis Differential diagnosis must be made with asphyxial conditions of the newborn caused by birth trauma and aspiration pneumonia, as well as isolated tracheoesophageal fistula and “asphyxial strangulation” of the diaphragmatic hernia. In such cases, esophageal atresia is excluded by probing. Treatment The success of surgical intervention depends on the early diagnosis of the defect, and hence the timely start of preoperative preparation, the rational choice of the method of operation and the correct postoperative treatment. Many combined defects have a significant impact on the prognosis. It is extremely difficult to treat premature babies; newborns of this group have rapidly developing pneumonia, reduced resistance, and a peculiar reaction to surgical intervention. Preoperative preparation. Preparation for the operation begins from the moment the diagnosis is established in the maternity hospital. The child is continuously given humidified oxygen, antibiotics and vitamin K. The mucus secreted in large quantities is carefully aspirated through a soft rubber catheter inserted into the nasopharynx at least every 10-15 minutes. Feeding by mouth is absolutely contraindicated. Transportation of the patient to the surgical department is carried out according to the rules provided for newborns with the obligatory continuous supply of oxygen to the child and periodic suction of mucus from the nasopharynx. Further preparation for the operation is continued in the surgical department, striving mainly to eliminate the phenomena of pneumonia. The duration of preparation depends on the age and general condition of the child, as well as the nature of pathological changes in the lungs. Children admitted in the first 12 hours after birth do not require long-term preoperative preparation (1,5-2 hours is enough). At this time, the newborn is placed in a heated incubator, humidified oxygen is constantly given, and mucus is sucked out of the mouth and nasopharynx every 10-15 minutes. Antibiotics, heart medications, and vitamin K are administered. Children admitted later after birth with symptoms of aspiration pneumonia are prepared for surgery 6-24 hours after birth. The child is placed in an elevated position in a heated incubator with a constant supply of humidified oxygen. Every 10-15 minutes, mucus is suctioned from the mouth and nasopharynx (the child needs an individual nursing post). With long-term preparation, every 6-8 hours, mucus is aspirated from the trachea and bronchi through a respiratory bronchoscope or by direct laryngoscopy. Antibiotics, cardiac agents are administered, an aerosol with alkaline solutions and antibiotics is prescribed. Late admission shows parenteral nutrition. Preoperative preparation is stopped with a noticeable improvement in the general condition of the child and a decrease in the clinical manifestations of pneumonia. If during the first 6 hours the preoperative preparation does not have a noticeable success, the presence of a fistulous tract between the upper segment and the trachea, in which mucus inevitably enters the respiratory tract, should be suspected. Continuation of preoperative preparation in such cases will be useless, it is necessary to proceed to surgical intervention. Surgery for esophageal atresia is performed under endotracheal anesthesia. The operation of choice should be the creation of a direct anastomosis. However, the latter is possible only in cases where the diastasis between the segments of the esophagus does not exceed 1,5 cm (if the upper segment is located high, anastomosis can only be created with a special stapler). The imposition of anastomosis with a high tension of the tissues of the esophageal segments does not justify itself due to technical difficulties and the possible eruption of sutures in the postoperative period. In newborns weighing less than 1500 g, multi-stage, "atypical" operations are performed: delayed anastomosis with preliminary ligation of the esophageal-tracheal fistula. On the basis of clinical and radiological data, it is almost impossible to establish the true distance between the segments. Finally, this issue is resolved only during surgery. If during thoracotomy a significant diastasis (more than 1,5 cm) between the segments or a thin lower segment (up to 0,5 cm) is detected, then the first part of the two-stage operation is performed - the esophageal-tracheal fistula of the lower segment is eliminated and the upper end of the esophagus is brought to the neck. These measures prevent the development of aspiration pneumonia, thereby saving the life of the patient. Created lower esophagostomy serves to feed the child until the second stage of the operation - the formation of an artificial esophagus from the colon. The operation of creating an anastomosis of the esophagus Technique of extrapleural access. The position of the child on the left side. The right hand is fixed in a raised and retracted anterior position. A diaper rolled up in the form of a roller is placed under the chest. The incision is made from the nipple line to the angle of the scapula along the V rib. Bleeding vessels are carefully ligated. The muscles are carefully dissected in the fourth intercostal space. The pleura is slowly peeled off (first with a finger, then with a damp small tuff) along the incision up and down 3-4 ribs. Using a special small-sized screw retractor, the hooks of which are wrapped in damp gauze, the edges of the chest cavity wound are spread apart, after which the pleura-covered lung is retracted anteriorly with a Buyalsky spatula (also wrapped in gauze). The mediastinal pleura is peeled off above the esophagus up to the dome and down to the diaphragm. Measure the true length of diastasis between the segments. If the anatomical relationship allows you to create a direct anastomosis, then proceed to the mobilization of the segments of the esophagus. Technique of mobilization of segments of the esophagus. Find the lower segment of the esophagus. The reference point is the typical location of the vagus nerve. The latter is removed inside, the esophagus is relatively easily isolated from the surrounding tissues and taken on a holder (rubber strip). The lower segment of the esophagus is mobilized over a short distance (2-2,5 cm), since its significant exposure can lead to impaired blood supply. Directly at the point of communication with the trachea, the esophagus is tied up with thin ligatures and crossed between them. Stumps are treated with tincture of iodine. The ends of the thread on the short stump of the esophagus (near the trachea) are cut off. Additional suturing of the tracheal fistula is usually not required. Only a wide lumen (more than 7 mm) is an indication for applying one row of continuous suture to the stump. The second thread at the free lower end of the esophagus is temporarily used as a "holder". The upper segment of the esophagus is found by the catheter inserted into it before the start of the operation through the nose. A suture is applied to the top of the blind sac, for which it is pulled up, exfoliating the mediastinal pleura, and carefully isolated upward with a wet tupfer. The oral segment has a good blood supply, which allows it to be mobilized as high as possible. Tight adhesions to the posterior wall of the trachea are carefully dissected with scissors. If there is a fistula between the upper segment and the trachea, the latter is crossed, and the holes formed in the trachea and esophagus are sutured with a double-row continuous marginal suture with atraumatic needles. The mobilized segments of the esophagus are pulled towards each other by the threads. If their ends freely go behind each other (which is possible with diastasis up to 1,5 cm, in premature babies - 1 cm), then they begin to create an anastomosis. Anastomosis technique. Creating an anastomosis is the most difficult part of the operation. Difficulties arise not only in connection with diastasis between the segments of the esophagus, but also depend on the width of the lumen of the distal segment. The narrower its lumen, the more difficult it is to suture, the greater the likelihood of their eruption and the occurrence of narrowing of the anastomosis site in the postoperative period. Due to the variety of anatomical options for esophageal atresia, various methods of creating an anastomosis are used. Atraumatic needles are used for suturing. Anastomosis by connecting segments of the esophagus in an end-to-end fashion. The first row of separate silk sutures is applied through all layers of the lower end of the esophagus and the mucosa of the upper segment. The second row of sutures is passed through the muscle layer of both segments of the esophagus. The greatest difficulty of this method lies in the imposition of the first row of sutures on extremely thin and delicate tissues, which cut through with the slightest tension. Anastomosis is used for small diastasis between the segments of the esophagus and the wide lower segment. To connect the ends of the esophagus, you can use special seams such as wrapping. Four pairs of such threads, superimposed symmetrically on both segments of the esophagus, first serve as holders, for which the ends of the esophagus are pulled up. After approaching their edges, the corresponding threads are tied. When tying the sutures, the edges of the esophagus are screwed inward. The anastomosis is strengthened with a second row of separate silk sutures. Such sutures make it possible to impose an anastomosis with some tension without fear of cutting through the delicate tissues of the organ with threads. The technique of oblique anastomosis of the esophagus significantly reduces the possibility of stricture formation at the suturing site. Double esophagostomy according to G. A. Bairov is the first stage of a two-stage operation and consists of the elimination of esophageal-tracheal fistulas, removal of the oral segment of the esophagus to the neck and the creation of a fistula from its distal segment for feeding the child in the postoperative period. The milk entering through the lower esophagostomy opening does not flow out after feeding, since during this operation the cardiac sphincter remains preserved. Technique of the operation of the lower esophagostomy. After making sure that the creation of a direct anastomosis is impossible, proceed to the mobilization of the segments of the esophagus. First, the upper segment is isolated for as long as possible. In the presence of a tracheal fistula, the latter is crossed, and the resulting hole in the esophagus and trachea is sutured with a continuous marginal suture. Then the lower segment is mobilized, tied up at the trachea and crossed between two ligatures. Several separate silk sutures are applied to the short stump at the trachea. The vagus nerve is removed inside, the esophagus is carefully isolated to the diaphragm. In a blunt way (opening the inserted Billroth clamp), the esophageal opening is expanded, the stomach is pulled up and the peritoneum is dissected around the cardial section (attention should be paid to the close location of the vagus nerve). After that, the child is turned on his back and an upper laparotomy is performed with a right paramedian incision. The mobilized distal segment is passed into the abdominal cavity through the dilated esophagus. In the epigastric region to the left of the midline, a transverse incision (1 cm) is made through all layers of the abdominal wall. A mobilized esophagus is passed into the formed hole in such a way that it rises above the skin by at least 1 cm. Its wall is fixed from the inside with several sutures to the peritoneum, and sutured to the skin from the outside. A thin tube is inserted into the stomach through the withdrawn esophagus, which is fixed with a silk thread tied around the protruding part of the esophagus. Wounds of the abdominal wall and chest are sewn up tightly. The operation ends with the removal of the upper segment of the esophagus. postoperative treatment. The success of the operation largely depends on the correct conduct of the postoperative period. For more thorough care and careful observation in the first days after surgery, the child needs an individual nursing post and constant medical supervision. The child is placed in a heated incubator, giving the body an elevated position, constantly giving humidified oxygen. Continue the introduction of antibiotics, vitamins K, C, B, prescribe UHF currents on the chest. 24 hours after the operation, a control radiograph of the chest cavity is performed. The detection of atelectasis on the side of the operation is an indication for sanitation of the tracheobronchial tree. In the first hours after surgery, the child may progressively develop respiratory failure, which requires urgent intubation and assisted breathing (after suction of mucus from the trachea). After a few hours, the child's condition usually improves, and the tube can be removed from the trachea. Re-intubation after anastomosis should be done with great care and only by a clinician experienced in neonatal re-intubation. The erroneous introduction of the tube instead of the trachea into the esophagus threatens to rupture the sutures of the anastomosis. Oxygenobarotherapy gives a positive effect. In the postoperative period after the simultaneous restoration of the continuity of the esophagus, children receive 1-2 days of parenteral nutrition. The correct calculation of the amount of fluid required for parenteral administration to a child is very important. A single amount of liquid on the first day of feeding should not exceed 5-7 ml. In the following days, breast milk and glucose are gradually added (5-10 ml each), bringing the daily volume of fluid to the age norm by the end of the week after the operation. Feeding through a probe is carried out with the child in an upright position, which prevents fluid regurgitation through a functionally defective cardiac sphincter in a newborn. With an uncomplicated course, the probe is removed on the 8-9th day. The patency of the esophagus and the condition of the anastomosis are monitored after 9-10 days by X-ray examination with iodolipol. The absence of signs of anastomotic leakage allows you to start feeding by mouth from a bottle or from a spoon. At the first feeding, the child is given 10-20 ml of 5% glucose. and then - breast milk in half the dose of the amount that the newborn received when feeding through a tube. In the following days, the amount of milk is increased daily by 10-15 ml for each feeding, gradually bringing it to the norm for age and body weight. Fluid deficiency is compensated parenterally by fractional daily administration of a 10% solution of glucose, plasma, blood or albumin. This avoids a noticeable drop in body weight in the newborn. On the 10-14th day, the child is applied to the chest for 5 minutes first and a control weighing is carried out. Feeding the child from the horn. During this period, the required amount of food is calculated based on the body weight of the child: it should fluctuate between 1/5 and 1/6 of the body weight of the newborn. Gradually increase the time of attachment to the breast and at the beginning of the 4th week they switch to 7 meals a day. Postoperative management of a child who underwent the first part of a two-stage esophageal plasty has some differences due to the possibility of feeding through the esophagostomy opening. The small size of the stomach of a newborn, a violation of its motor function due to trauma during the creation of a fistula, requires fractional feeding with a gradual increase in the amount of fluid administered. From the 7th day after the operation, the volume of the stomach increases so much that up to 40-50 ml of liquid can be slowly injected through the esophagostomy opening (3/4 of the total amount of liquid is replenished with breast milk and 10% glucose solution). From the 10th day they switch to 7 meals a day with normal dosages. In the first days after the intervention, careful care of fistulas on the neck and anterior abdominal wall is necessary. The latter especially needs frequent dressing changes, skin treatment with antiseptic pastes, and exposure to ultraviolet rays. A thin rubber drainage inserted into the stomach is not removed for 10-12 days until the lower esophageal fistula is completely formed. Then the probe is inserted only at the time of feeding. The sutures are removed on the 10-12th day after the operation. Children are discharged from the hospital (with an uncomplicated course) after a stable weight gain is established (week 5-6). If a newborn has had a double esophagostomy, the child's mother should be taught proper fistula care and feeding techniques. Further monitoring of the child is carried out on an outpatient basis by a surgeon together with a pediatrician. Preventive examinations should be carried out every month before the child is sent to the second stage of the operation - the creation of an artificial esophagus. Surgical complications in the postoperative period occur mainly in newborns who have undergone simultaneous esophageal plastic surgery. The most severe complication should be considered the failure of the anastomotic sutures, which, according to the literature, is observed in 10-20% of operated patients. The resulting mediastinitis and pleurisy are usually fatal, despite the creation of gastrostoma, drainage of the mediastinum and pleural cavity. With early recognition of the divergence of the anastomotic sutures, an urgent rethoracotomy and the creation of a double esophagostomy are necessary. In some cases, after the creation of a direct anastomosis, recanalization of the tracheoesophageal fistula occurs, which is manifested by sharp bouts of coughing with each attempt to feed through the mouth. The complication is recognized when examining the esophagus with a contrast agent (iodolipol flows into the trachea), and the final diagnosis becomes by subanesthetic tracheobronchoscopy. Treatment is carried out by creating a gastrostomy and draining the mediastinum (with an increase in the phenomena of mediastinitis). After the subsidence of inflammatory changes and the final formation of the fistulous tract, a second operation is indicated. Sometimes recanalization is combined with stenosis in the anastomosis area. After the simultaneous creation of an anastomosis of the esophagus, all children are subject to dispensary observation for at least 2 years, since late complications may occur during this period. In some children, 1-2 months after the operation, a rough cough appears, which is associated with the formation of adhesions and scars in the area of the anastomosis and trachea. Carrying out physiotherapeutic measures helps to get rid of this late complication, which is usually eliminated at the age of 5-6 months. In the period up to 1-2 years after surgery, an isolated narrowing of the esophagus in the area of the anastomosis may occur. The treatment of this complication usually does not cause difficulties: several sessions of bougienage (under the control of esophagoscopy) lead to recovery. In rare cases, conservative measures are unsuccessful, which is an indication for repeated thoracotomy and plastic surgery of the narrowed esophagus. Authors: Drozdov A.A., Drozdova M.V. << Back: Acute diseases of the lungs and pleura (Lung malformations. Lobar emphysema. Complicated congenital lung cysts) >> Forward: Esophageal-tracheal fistulas. Damage to the esophagus. Perforation of the esophagus (Esophageal-tracheal fistulas. Damage to the esophagus. Chemical burns. Perforation of the esophagus)
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