ESOPHAGOTOMY

From Big Medical Encyclopedia

EZOFAGOTOMYYa (Greek oisophagos a gullet - | - tome a section, a section) — operation of a section of a wall of a gullet for opening of its gleam or penetration from a gleam of a gullet into periesophagal cellulose. AA. can be independent operation or one of stages more from false intervention.

AA. make for the purpose of removal from a gullet of foreign bodys at impossibility of their extraction via the esophagoscope; for creation of an esophageal ostomy (see the Gullet, the Gullet artificial, Esophagostomy); for chresiishchevodny opening of periesophagal abscesses.

Distinguish longitudinal and cross 0. The last more preferably can also be partial or full, napr, during creation of an ezofagostoma. Longitudinal E. provides broad opening of a gleam of a gullet, but demands in the subsequent sewing up on a thick drainage in lengthwise direction. At its sewing up in transverse direction danger of insolvency of seams increases. Depending on access to a gullet E. can be outside (cervical), intrathoracic extra pleural, intrathoracic transpleural, transabdominal (chrezdiafragmalny) and internal (transesophageal).

Cervical E. offered Verduc in 1611, for the first time executed in 1738 Mr. of Goursaud, and in Russia in 1881 — Lisenko. As the indication served the foreign bodys restrained in a gullet. In 1862 J. G. F. Maisonneuve carried out «blindly» transesophageal E. at cicatricial and cancer stenoses of a gullet. In 1925 A. Seiffert suggested to see off transesophageal E. via the esophagoscope for opening of periesophagal phlegmons and abscesses. In 1888 I. I. Nasilov developed vnutrigrudvgy vneplev-ralny E., to-ruyu for the first time with success E. Enderlen in 1901 executed in clinic. Intrathoracic transpleural E. D. Dobromyslov offered in '1900.

Outside (cervical) E. make at position of the patient on spin, the head at the same time is turned in the party, opposite to the place of operation, and cast a little away back. AA. it is necessary to carry out under an endotracheal anesthesia (see. Inhalation anesthesia). As a rule, use left-side access. Right-hand access is shown when are available rentgenol. data on perforation of the right wall of a gullet or on localization on the right inflammatory process. The skin section is carried out on a first line grudino - a clavicular and mastoidal muscle. After a section of a superficial fascia and a hypodermic muscle of a neck at all length of a skin section open a front wall in la of hectare of l looking for grudino - a clavicular and mastoidal muscle closer to medial edge. The muscle is taken away lateral-but, cut a back wall of her vagina and delay knaruzh together with a neurovascular bunch. The thyroid gland with grudinopodjyazychny and grudinoshchitovidny muscles is delayed by knutr, cross a scapular and hypoglossal muscle. Tie up and cut the lower thyroid artery, preserving a recurrent nerve against damage. Tup-ferom move apart cellulose and bare the sidewall of a gullet noticeable by reddish coloring and lengthwise direction of muscle fibers. After a section throughout 1 cm of muscular layers of a gullet make cuts a mucous membrane between threads handles in transverse direction, expanding the opening is farther in the stupid way. Handles serve also for the subsequent cultivation of edges of a wound. At a perforation of a gullet it is better to expand the available opening and through it it is careful by means of a clip to remove a foreign body. After extraction of cross standing foreign body it is necessary to examine attentively an opposite wall of a gullet not to miss its possible perforation; survey sometimes requires additional mobilization of walls of a gullet.

Defect of a wall of a gullet is taken in in transverse direction a two-row noose suture on an atraumatic needle: an internal row — noose catgut or vikrilovy sutures with nodes in a gleam on a mucous membrane; outside — noose silk or mylar sutures on muscular layers and an adventitia. The line of seams for increase in reliability is covered with surrounding fabrics, fixing them rare seams on a circle of the taken-in ezo-fagotomichesky opening. It is important not to allow hard tightening of seams, a cut can lead to eruption of a wall of a gullet. Inflammatory process in periesophagal cellulose does not exclude mending of an esophageal wound on condition of sufficient outside drainage, topical administration of antibiotics, temporary switching off of a gullet by an establishment of gastric fistula (see the Gastrostomy) and carrying out transnazalno the probe in a stomach (see Sounding of a stomach).

A contraindication to suture are the expressed destructive changes of edges of a wound of a gullet (decubituses, purulent fusion) connected with long stay in it of foreign bodys.

Neck wound after E. it is necessary to leave open, having brought a rubber drainage to a gullet (it is better two-pro-svetny). In the presence in periesophagal cellulose of inflammatory process continuous or flowing and fractional irrigation of a wound by solutions of antibiotics, hlorgeksi-dyne, a furagina, etc. is shown (see Wounds, wounds). AA. finish with carrying out the thin transnasal probe in a stomach. In the first 6 — 8 days after operation in the absence of complications food of the patient is carried out via this probe (see artificial nutrition). At abscesses and phlegmons of a neck after E. and drainage of purulent cavities of the patient stack on a bed, the head end the cut is lowered.

At considerable changes in a wall of a gullet and in surrounding cellulose for food of the patient it is better to impose a gastrostomy (see the Gastrostomy). About a wound repair of a gullet judge by data rentgenol. researches using the water-soluble radiopaque substance or solution tinted by indigo carmine or methylene blue to-ry allow to drink to the patient.

If patol. process or a foreign body are localized in intrathoracic or abdominal departments of a gullet, resort to intrathoracic transpleural E. Vnut-rigrudnuyu extra pleural E. in a crust, time do not apply that is caused, on the one hand, by its injury and limitation of a surgery field, and on the other hand, development of anesthesiology (see) and resuscitation (see), allowed to perform successfully operations and to nurse patients after opening of pleural cavities. For performance E. in upper and average thirds of a gullet resort to a right-hand thoracotomy in the V mezhreberye, and in the lower third and abdominal department — to a left-side thoracotomy in VI or VII mezhreberye or to an upper median laparotomy with a diaphragmotomy (transabdominal, chrezdiafragmal-ny E.).

For creation of broader operational access at intrathoracic transpleural E. make a resection of a juxtaspinal part underlying, in relation to an intercostal space, in Krom the thoracotomy, edges throughout 2 cm is made. After a section in lengthwise direction of a parietal pleura (at right-hand access, besides, tie up and cross an unpaired vein) the gullet is stupidly allocated on the small site and bring under it a rubber or gauze handle. Then continue to allocate walls of a gullet from an aorta and a rachis in the stupid way, crossing connective tissue tyazh only after their bandaging.

Equipment intrathoracic E. and the subsequent mending of a wound of a gullet generally the same, as at sew-howl E. Odnako special value get careful suture on a wound of a gullet and good drainage (see). Upon termination of gullet operation enter a rubber drainage into a wound of a mediastinum, fixing it one catgut seam to a mediastinal pleura so that the end of a drainage approached the sewn-up wound of a gullet, but did not adjoin to the line of seams. The free end of a drainage tube is removed through an additional opening in an adjacent mezhreberye. After Irrigation of a pleural cavity layer-by-layer sew up with solution of antibiotics a wound of a thorax and delete the remains of air from a pleural cavity. Switching off of a gullet from the act of swallowing for the period of a wound repair is obligatory. The pleural cavity is drained separate drenazhy.

In the next postoperative period at insolvency of seams of a gullet development of a mediastinitis (see) and empyemas of a pleura, in the remote period — emergence of cicatricial strictures of a gullet is possible.

Bibliography: See bibliogr. to St. Esophagostomy. E. N. Popov.

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