LECTURE No. 5. Esophageal-tracheal fistulas. Damage to the esophagus. Esophageal perforation

1. Esophageal-tracheal fistulas

The presence of a congenital anastomosis between the esophagus and the trachea without other anomalies of these organs is rare.

There are three main variants of the defect, among which there is mainly a short and wide fistulous course. The fistula is usually located high, at the level of the first thoracic vertebrae.

The presence of a fistulous tract between the esophagus and trachea leads to the rapid development of pneumonia due to the aspiration of fluid swallowed by the child. An unrecognized and untreated fistula usually causes the death of a child. Only a narrow anastomosis sometimes proceeds with mild symptoms, and in such cases, patients can live for a long time.

clinical picture

Clinical symptoms of esophageal-tracheal fistula appear in most cases after the first feeding of the child, but their intensity depends on the variant of the malformation.

A narrow and long fistulous tract, as a rule, is not detected in the neonatal period.

These babies occasionally have severe coughing spells while feeding. Parents do not attach importance to them, since feeding in a certain position of the child saves him from seizures. The child often suffers from pneumonia.

In cases of a wide and short fistula, feeding a newborn is almost always accompanied by a fit of coughing, cyanosis, and frothy discharge from the mouth. These children quickly develop aspiration pneumonia.

After eating, the number of wet coarse rales in the lungs increases. Feeding the child in an upright position reduces the possibility of milk flowing through the fistulous tract into the trachea, and coughing occurs less often, without being accompanied by cyanosis.

A large fistula, in which both organs at some distance are represented as if by one common tube, appears at the first feeding.

Each sip of the liquid triggers a coughing fit. Respiratory failure is prolonged, accompanied by severe cyanosis.

The general condition progressively worsens due to severe pneumonia and extensive atelectasis of the lungs.

X-ray examination is of some importance for the diagnosis of esophageal-tracheal fistula. Survey pictures reveal the nature of pathological changes in the lungs.

If aspiration pneumonia is clinically and radiographically determined, special studies are postponed until the process subsides in the lungs (treatment of pneumonia is part of the preoperative preparation).

In older children, the fistulous tract can be detected radiologically when examining the esophagus with a liquid contrast agent.

The child is placed under the screen on the x-ray table in a horizontal position.

The contrast medium is given from a spoon or injected through a catheter placed in the initial part of the esophagus. It is generally accepted that partial or complete filling of the bronchial tree with a contrast agent indicates the presence of an anastomosis. The latter is usually not determined on the radiograph, since the yodolipol cannot linger in a wide and short fistulous course.

By carefully observing through the screen the passage of the contrast agent through the esophagus, one can sometimes catch the moment of its passage through the fistula into the trachea.

Clinical and radiological data on the presence of an esophageal-tracheal fistula can be confirmed by esophagoscopy. When an esophagoscope is inserted and the esophagus is examined, the fistulous tract becomes noticeable by small air bubbles emerging from it in time with breathing. A narrow fistula is usually not visible during esophagoscopy, it is masked by mucosal folds.

A clearly fistulous course is determined only with tracheobronchoscopy, which is performed under anesthesia for all children with suspected esophageal-tracheal fistula.

With the introduction of a bronchoscope to a depth of 8-12 cm, usually 1-2 cm higher than the bifurcation of the trachea, a slit-like defect (fistula) located along the cartilage ring is visible on its posterior right surface.

Identification of the fistula is facilitated by the introduction of a 1% solution of methylene blue into the esophagus, which, penetrating into the trachea through the fistula, emphasizes its contours.

Differential diagnosis

Differential diagnosis is difficult in children of the neonatal period, when it is necessary to exclude an esophageal-tracheal fistula if the child has a birth injury, accompanied by a violation of the act of swallowing or paresis of the soft palate.

When feeding, such newborns periodically experience coughing fits, respiratory rhythm disturbance, and pneumonia increases.

X-ray examination of the esophagus with iodolipol in these cases does not clarify the diagnosis, since in both diseases, throwing (aspiration) of the contrast agent into the respiratory tract (bronchography) can occur. For differential diagnosis, the child begins feeding only through a probe inserted into the stomach. After subsiding aspiration pneumonia, tracheobronchoscopy is performed, which allows you to make or cancel the diagnosis of esophageal-tracheal fistula.

Treatment

Elimination of congenital esophageal-tracheal fistula is possible only by surgery. Surgical intervention is carried out after the diagnosis is established.

Preoperative preparation. Preoperative preparation begins immediately after the detection of clinical symptoms of the esophageal-tracheal fistula.

The child is completely excluded from feeding through the mouth - all the necessary amount of liquid is injected into the stomach through a tube, which is removed after each feeding. From the first day, active antipneumonic treatment begins: antibiotics. oxygen therapy, UHF currents on the chest, alkaline aerosol with antibiotics, mustard wrap, intravenous administration of blood plasma, vitamins.

The child is in a heated incubator with high humidity. Several sessions of oxygen barotherapy are performed. The duration of preoperative preparation varies: 7-10 days (until the elimination or noticeable reduction of pneumonia).

The operation for congenital esophageal-tracheal fistula is performed under endotracheal anesthesia and with blood transfusion. The position of the child is on the left side.

Operation technique. The most convenient access in infants is extrapleural. On the fourth intercostal space on the right (with a high fistula, access is recommended through a cut on the neck).

The lung covered with pleura is retracted forward and inward, the mediastinal pleura is exfoliated above the esophagus. The esophagus is mobilized for 1,5-2 cm up and down from the place of its communication with the trachea.

In the presence of a long fistulous passage, the latter is isolated, tied up with two silk ligatures, crossed between them, and the stumps are treated with an iodine solution.

Over the crossed fistula tract, one row of submersible silk sutures is applied to the esophagus and trachea with an atraumatic needle.

With a wide and short fistula, the esophagus is carefully cut off with scissors from the trachea, and the resulting holes are closed with a two-row continuous suture with atraumatic needles. To prevent postoperative narrowing of the esophagus, the latter is sutured in the transverse direction (over the catheter inserted before the operation).

The most difficult to eliminate is a large esophageal-tracheal fistula, in which both organs have common walls for some length (0,7-1 cm).

In such cases, the esophagus is transected above and below the junction with the trachea. The holes formed on the trachea are sutured with two rows of sutures, then the continuity of the esophagus is restored by creating an end-to-end anastomosis.

A thin polyethylene tube is inserted into the stomach to feed the baby. With extrapleural access to the mediastinal space, a thin (3-4 mm) polyethylene tube is brought to the area of ​​the sutures of the esophagus (through a separate puncture in the sixth intercostal space) for 2-3 days. The chest cavity is closed tightly.

With transpleural access, the mediastinal pleura is sutured. The air remaining after suturing the chest wall in the pleural cavity (detected on control radiographs) is sucked off with a syringe during puncture.

postoperative treatment. In the postoperative period, the child continues to receive active antipneumonic therapy, since usually the operation causes an exacerbation of the process in the lungs.

An elevated position is created for the patient, an aerosol is prescribed, humidified oxygen is constantly given, antibiotics, cardiac agents are administered.

On the first day after the operation, mustard plasters are placed on the chest on the left, and from the next day, an UHF electric field is assigned to the lung area. According to indications, bronchoscopy and suction of mucus are performed.

On the first day, the child needs parenteral nutrition, then feeding is carried out in fractional doses every 3 hours through a thin tube left during the operation. The amount of fluid is calculated depending on the age and body weight of the child.

Within 2-3 days, 1/3 of the volume of liquid is injected through a probe, the rest is intravenous drip. The probe is removed on the 5th-6th day (when creating an end-to-end anastomosis, feeding through the probe is continued for 9-10 days). By the 6-8th day, the child should receive the usual age norm of breast milk. Older children are prescribed liquid food from the 7-8th day after the operation.

The patient is discharged home on the 20-25th day when the phenomena of pneumonia are eliminated (in infants, in addition, a stable weight gain should be established).

Before discharge, a control X-ray examination of the esophagus with a contrast mass is performed. In cases where narrowing is detected in the area of ​​the former fistula, a course of bougienage should be carried out, which begins no earlier than a month after the operation.

2. Damage to the esophagus. Chemical burns

In children, damage to the esophagus is relatively rare, occurring mainly due to chemical burns or perforation of the organ wall (foreign bodies, instruments).

The severity of the burn of the esophagus and the degree of its pathological changes depend on the amount and nature of the chemical swallowed by the child.

When exposed to acids, the depth of damage to the esophageal wall is less than when exposed to alkalis. This is due to the fact that acids, neutralizing the alkalis of tissues, coagulate the protein of the cells and at the same time take away water from them.

As a result, a dry scab is formed, which prevents the penetration of acids into the depths. The impact of alkalis on tissues is accompanied by colliquat necrosis. The absence of a scab leads to a deep penetration of the caustic substance into the tissues and damage them. There are three degrees of burns of the esophagus: mild, moderate and severe.

Mild degree is characterized by damage to the mucous membrane such as desquamative esophagitis. In this case, hyperemia, edema and areas of superficial necrosis are noted. The inflammatory process subsides and epithelization occurs within 7-10 days. The resulting superficial scars are elastic, do not narrow the lumen of the esophagus and do not affect its function.

With an average degree, the lesions are deeper. Necrosis extends to all layers of the organ. After 3-6 weeks (as necrotic tissue is rejected), the wound surface becomes covered with granulations and then scars. The depth and prevalence of scar changes depend on the severity of damage to the esophageal wall.

Severe degree is characterized by deep and extensive damage to the esophagus with necrosis of all layers of its wall. The burn is accompanied by mediastinitis.

clinical picture

The clinical picture of a burn of the esophagus depends on the nature of the substance that caused the burn and the degree of damage to the esophagus. From the first hours after the burn, the condition of children is severe due to the developing phenomena of shock, swelling of the larynx and lungs, as well as intoxication and exsicosis.

As a result of rapidly growing inflammation, profuse salivation is noted, often repeated and painful vomiting. From the moment of contact with a caustic substance, there is a burning pain in the mouth, in the pharynx, behind the sternum and in the epigastric region. It intensifies with swallowing, coughing and vomiting movements, so all children stubbornly refuse to eat and drink.

The inflammatory process is accompanied by an increase in temperature to high numbers. Dysphagia can be explained by both pain and swelling of the esophageal mucosa.

Three periods are distinguished in the clinical course of the disease. The first period is characterized by acute inflammation of the mucous membrane of the mouth, pharynx and esophagus, and in the coming hours the swelling and pain increase, the child refuses to eat, there is a high fever.

This condition often lasts up to 10 days, and then improves, pain disappears, swelling decreases, temperature normalizes, esophageal patency is restored - children begin to eat any food. The acute stage gradually passes into the asymptomatic period. The apparent well-being sometimes lasts up to 4 weeks.

3-6 weeks after the burn, a period of scarring begins. Gradually, the phenomena of obstruction of the esophagus increase. In children, vomiting occurs, retrosternal pains join.

X-ray examination with a contrast agent during the scarring period reveals the nature, degree and extent of the pathological process.

Treatment

A child who has received a chemical burn of the esophagus requires emergency hospitalization. In the acute stage of the disease, measures are taken to remove the state of shock and vigorous detoxification therapy aimed at preventing or reducing the local and general effects of the poison. For this purpose, painkillers and cardiac drugs are administered to the victim, the stomach is washed through the tube. Depending on the nature of the caustic substance, washing is done either with a 0,1% solution of hydrochloric acid (with an alkali burn), or with a 2-3% solution of bicarbonate of soda (with an acid burn) in a volume of 2-3 liters. As a rule, there are no complications from the introduction of a gastric tube.

The complex of anti-shock measures, in addition to the introduction of cardiac agents and oinopon, includes intravenous infusions of plasma, glucose solution, vagosympathetic cervical novocaine blockade.

To prevent pulmonary complications, it is advisable to constantly supply the patient with humidified oxygen and an elevated position.

The possibility of layering a secondary infection dictates the early use of antibiotic therapy (broad-spectrum antibiotics).

Gastric lavage is used not only in emergency care, but also 12-24 hours after the burn. This removes the remaining chemicals in the stomach.

An important therapeutic factor is the use of vitamin therapy hormones and the appointment of a balanced diet. In severe cases, when children refuse to drink and water, protein preparations and liquid are administered intravenously for 2-4 days to relieve intoxication and for the purpose of parenteral nutrition. To improve the general condition, the patient is prescribed oral feeding with high-calorie, chilled food, first liquid (broth , milk), and then well-mashed (vegetable soups, cottage cheese, cereals).

From the first days after the injury, children should receive one dessert spoon of vegetable or vaseline oil through their mouths, it has a softening effect and improves the passage of the lump through the esophagus.

Until recent years, bougienage has been considered the main method of treating burns of the esophagus. Distinguish between early, or preventive, bougienage and later, therapeutic - with cicatricial stenosis of the esophagus. The tactics of treatment is determined by the degree of burns of the oral cavity, pharynx and esophagus. To identify and assess the nature of the lesion and its prevalence, diagnostic esophagoscopy is performed.

Early bougienage prevents the formation of cicatricial stenosis of the esophagus. Bougienage is started from the 5-8th day after the burn.

Only special soft bougie are used. By this time, acute inflammatory changes in the wall of the esophagus subside, granulations appear, the general condition of the child improves, and the temperature returns to normal.

Bougienage is carried out without anesthesia three times a week for 1,5-2 months. During this period, the child is in the hospital.

Then he is discharged for outpatient treatment, having prescribed bougienage once a week for 2-3 months, and in the next six months - 1-2 times a month.

In rare cases, with severe and widespread burns, accompanied by mediastinitis, the child cannot eat. To prevent exhaustion, they resort to the creation of a gastrostomy, which is also necessary for complete rest of the organ.

This favorably affects the course of inflammation and promotes regeneration. Only after the child is taken out of a serious condition, they decide on the method of further treatment.

Usually, from the 5-7th week, attempts at direct bougienage with the help of an esophagoscope begin. The presence of a gastrostomy allows the use of "bougienage by thread".

With timely and correct treatment of chemical burns of the esophagus in children, good long-term results are obtained in almost 90% of cases. The cicatricial obstruction of the esophagus that occurred after the burn is an indication for plastic surgery of the esophagus with an intestinal graft.

3. Perforation of the esophagus

Perforation of the esophagus in children occurs mainly during bougienage due to cicatricial stenosis, damage by a sharp foreign body, or during instrumental examination. Up to 80% of these complications occur in medical institutions. which creates favorable conditions for their early recognition and provision of the necessary medical assistance. However, due to the fact that damage to the esophagus is more common in children of the first years of life, timely diagnosis of complications can be extremely difficult.

Usually, the attending physician thinks of perforation of the esophagus arises in connection with the development of signs of mediastinitis. Most surgeons explain the extremely severe course and prognosis of this complication in children by the anatomical features of the structure of the mediastinum.

clinical picture

The clinical picture of acute purulent mediastinitis in children, especially young children, is variable and largely depends on the nature of the damage to the esophagus.

With the slow formation of perforation observed in connection with a decubitus of the esophageal wall by a foreign body (coin, bone), the surrounding tissues are gradually involved in the process, which react with inflammatory demarcation.

This leads to some delimitation of the process, and it is extremely difficult to catch the moment of damage to the esophagus. A complication in such cases is diagnosed by a combination of rapidly developing general symptoms, physical and radiological data.

One of the first symptoms of acute purulent mediastinitis is chest pain. It is difficult to find out localization, and only in older children can it be clarified that it is retrosternal and intensifies when swallowing.

The child's resistance to examination usually excludes the possibility of using "pain" symptoms for diagnosis - the appearance of pain when the head is thrown back or the trachea is passively displaced.

The child becomes inactive, any change in position in bed causes anxiety due to increasing pain. The general condition of the patient is rapidly deteriorating. Shortness of breath appears. The disease is often accompanied by persistent cough Body temperature rises to 39-40 °C.

Physical examination reveals moist rales, in some cases shortening of percussion sound in the interscapular space.

When examining blood, there is a sharp increase in the number of leukocytes, neutrophils with a shift to the left.

The X-ray method of research, as a rule, confirms the presumptive diagnosis. Widening of the mediastinal shadow, the presence of emphysema, and examination with a contrast medium usually allow you to determine the level of damage to the esophagus.

Esophagoscopy in acute purulent mediastinitis in children is usually not performed, since additional trauma to the organ can worsen the already serious condition of the patient.

Mediastinitis that occurs in children with perforation of the esophagus by sharp foreign bodies is diagnosed with less difficulty.

The very fact of the presence of a sharp body in the esophagus allows us to think about damage to the wall of the organ. If the instrumental removal of the foreign body turned out to be impossible and the patient experienced a sharp deterioration in his general condition, chest pain appeared, body temperature increased, there is no need to doubt the diagnosis.

Recognition of mediastinitis is helped by X-ray data (stationary position of a foreign body, expansion of the shadow of the mediastinum, and sometimes the presence of gas in it). In such cases, immediate surgical removal of the foreign body is indicated.

Perforation of the esophagus with instruments usually occurs during bougienage for cicatricial narrowing or during esophagoscopy. Diagnosis is usually not difficult due to the appearance of sharp pain at the time of damage to the esophageal wall.

Perforation is accompanied by phenomena of shock: the child turns pale, the filling of the pulse becomes weak, and blood pressure noticeably decreases. After removing the bougie and conducting special therapy (painkillers, intravenous infusion of calcium chloride, blood, anti-shock fluid), the patient's condition improves somewhat, but chest pain continues to bother the child.

The general symptoms of mediastinitis develop rapidly: the temperature rises, pneumonia appears, shortness of breath, the blood picture changes, and the state of health deteriorates sharply.

If the esophagus is damaged and inflammation is localized in the lower mediastinum, pain under the xiphoid process and symptoms of peritoneal irritation are noted. Subcutaneous emphysema is often found.

X-ray examination plays a leading role in establishing the diagnosis of esophageal perforations. Direct radiological symptoms are: the presence of air in the soft tissues of the mediastinum and neck, as well as the leakage of the contrast mass beyond the contours of the esophagus.

Treatment

Surgical treatment begins with the creation of a gastrostomy. Further surgical tactics depend on the nature of the damage to the esophagus and the extent of mediastinitis.

The presence of an acute foreign body in the esophagus, which led to perforation and the development of mediastinitis, is an indication for urgent mediastinotomy. The operation in such cases has a dual purpose - the removal of a foreign body and drainage of the mediastinum. Delay in surgical intervention worsens the course of the postoperative period.

With the slow formation of a perforation (pressure sore) associated with a long stay of a foreign body in the esophagus, drainage of the mediastinum is indicated. The nature of the operative access depends on the level of inflammation: the upper sections are drained by cervical mediastinotomy according to Razumovsky, the middle and posterior ones - by extrapleural access according to Nasilov. Regardless of the methods of drainage during intervention, it is necessary to spare the adhesions formed in the mediastinum, which to a certain extent prevent the spread of the purulent process.

In cases where the complication is diagnosed relatively late and the child has a formed delimited abscess, mediastinal drainage surgery is also necessary and often effective.

Damage to the esophagus and the rapid spread of a purulent process in the mediastinum usually lead to a breakthrough of the abscess into the pleural cavity. In such cases, urgent thoracotomy with pleural drainage is indicated. Often we have to deal with extremely severe damage to the esophagus requiring resection.

Postoperative treatment of children with esophageal perforation and mediastinitis requires persistence and great attention in identifying the entire range of therapeutic measures.

After the operation, the child is placed in an elevated position, constantly humidified oxygen is prescribed. Painkillers are administered after 4-6 hours. Drip intravenous infusion continues for 2-3 days. Transfusion of blood and protein preparations (plasma, albumin) is performed daily in the first week, then after 1-2 days. The child is prescribed broad-spectrum antibiotics (according to sensitivity), replacing them after 6-7 days. Tampons are tightened after 2-3 days, then removed. Drainage in the mediastinum is left until the purulent discharge stops. An esophageal fistula usually closes on its own. The child is undergoing physiotherapy (for example, UHF). If there is a communication of the mediastinal abscess with the pleural cavity and the latter has been drained, then a minimum negative pressure of 5-7 cm of water should be created in the active aspiration system. Art. (490-686 Pa, or 0,490-0,686 kPa). The tube from the pleural cavity is removed after the elimination of the esophageal fistula and pleurisy.

The child is fed through a gastrostomy with high-calorie food. After elimination of mediastinitis and healing of the wound of the esophagus, feeding through the mouth is started (if there is no stenosis). Plastic surgery on the esophagus (intestinal transplantation, resection) is possible after at least 2 years after complete recovery from mediastinitis.

Authors: Drozdov A.A., Drozdova M.V.

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