Pediatric surgery. Treatment of esophageal perforation (most important)

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Pediatric surgery. Treatment of esophageal perforation (most important)

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21. Treatment of esophageal perforation

Operative therapy start 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 - removal of the 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 lower sections are drained 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 the purulent process in the mediastinum usually lead to the breakthrough of the abscess into the pleural cavity. In such cases, urgent thoracotomy with pleural drainage is indicated.

Postoperative treatment in children with esophageal perforation and mediastinitis requires perseverance 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. The tube from the pleural cavity is removed after the elimination of the esophageal fistula and pleurisy.

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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