GULLET ARTIFICIAL — the body (or a part it) used for creation by plastic surgery (oesophagoplasty) of a new way of passing of food from a throat to underlying departments of a digestive tract.
Indications to P.'s creation and.: 1) burn strictures in the absence of effect of conservative treatment, including bougieurage; 2) two-stage cancer therapy of a gullet — after Dobromyslov's operation — Toreka (see. Gullet ); 3) seldom peptic strictures of a gullet arising because of an incompetence of cardia.
the Patients needing oesophagoplasty, as a rule, are exhausted owing to impossibility of normal food. Therefore at a preparation for surgery normalization of proteinaceous and water and electrolytic balance is necessary. For this purpose in the preoperative period appoint parenteral food (see), a cut at a number of patients can be full. At impossibility to carry out parenteral food or its inefficiencies it is shown gastrostomy (see). Apply antibiotics of a broad spectrum of activity to preparation for oesophagoplasty.
Methods of oesophagoplasty
the Beginning of creation of an artificial gullet at cicatricial impassability and cancer of a gullet was necessary Birkhe-rom (H. Bircher, 1894) which suggested to create a gullet of the skin rag found in a breast. This operation was not widely adopted because of emergence of round ulcers of again formed gullet, heavy dermatitis, multiple fistulas, malignant new growths, etc.
L. Wullstein in 1904 for creation of an artificial gullet suggested to use a small bowel in combination with skin plastics.
Ts. Ra (1906) for the first time was created at the person by an artificial gullet from a small bowel, having excreted a transplant of such length that it was moved under skin to the handle of a breast. The neostomy of a transplant with a gullet was the second stage of this operation. P. A. Herzen made oesophagoplasty in three stages: mobilization of a gut, a neostomy of a gut with a stomach and an anastomosis of a gut with a gullet. S. S. Yudin, improved a technique and technology of mobilization of a transplant, offered special tools for creation of the hypodermic channel. It did not include in a passage a stomach for prevention of development of round ulcers of a jejunum and anastomosed a small bowel only with a gullet (fig. 1, a). This type of oesophagoplasty is called method of Ru — Herzen — Yudina. J. H. Garlock, B. V. Petrovsky, H. R. Sweet, Ohshawa, etc. applied an intrathoracic apa-stomozirovaniye of P. with a stomach after a resection
P. Beck (S. of Beck) in 1905, I. O. Gal-pern and to A. Jianu in 1912. Offered D. Gavriliu in 1957 a method of oesophagoplasty by the rag created from big curvature of a stomach (fig. 1,6). At this method an abdominal cavity open with a slanting section in left hypochondrium. From big curvature of a stomach find a pedicellate sleeve which is moved under skin of a breast on a neck. In several days the transplant is anastomosed with cervical department of a gullet.
Kirchner (1920) (fig. 1, c) after crossing of the cardia moved with Kirschner all stomach under skin on a neck and anastomosed it with a gullet. It connected the cardia which remained in an abdominal cavity to a jejunum with an additional enteroenteroanastomoz across Ru. Principle: Kirchner's operations with success were used by the Japanese surgeon Nakaya-ma (To. Nakayama, 1954), and in the Soviet Union — A. A. Rusanov, etc.
Kelling (G. Kelling, 1911) applied oesophagoplasty from a poperechnoobodochny gut. However the transplant from a cross colon seldom manages to be brought to the level of cervical department of a gullet in this connection the additional skin plastics often is required. Royt (Roith, 1923) the Shouting ~ sleepyheads and to Tupa (R. of Orsoni, R. Toupet, 1950) — the left half of a colon (fig. 1,5), and P. Lafargue et al. (1951) — the right half of a colon with a terminal piece ileal used for oesophagoplasty the right half of a colon (blind, ascending and a part of cross and colonic) (fig. 1, d). At mobilization of blind and ileal guts apply B. A. Petrov and G. R. Hundadze's technique consisting in flaking of a root of a mesentery of a small bowel from retroperitoneal cellulose and movement up of all small bowel together with a mesentery. Such reception allows to move a transplant up in addition on 15 — 20 cm.
The greatest distribution to a wedge, practice methods of creation of P. received and. from a small bowel on - to Yudin and from the right half of a colon.
Oesophagoplasty according to Yudin consists of the following stages. Carry out an upper median laparotomy. Allocation of a gut and section of a mesentery of a small bowel begin 8 — 10 cm below than Treytts's team, tying up and crossing 3 — 5 radial vessels. Cross a gut, it sew up the distal end and peritonize. Recover a continuity of intestines by means of imposing of an enteroenteroanastomoz on type the end sideways. The allocated part of a gut is brought out of an abdominal cavity and will see predgru-dinno via the hypodermic tunnel created by means of special tools to the level of a thyroid cartilage or a corner of a mandible where fix to skin. La-parotomnuyu the wound is sewn up. In 5 — 6 days, having convinced of viability of the carried-out gut, anastomose it with cervical department of a gullet.
Oesophagoplasty by the right half of a colon includes the following stages. Carry out an upper median laparotomy, bypassing a navel on the right and below it on 6 — 8 cm. Cut a parietal peritoneum over a caecum and on the outer edge of the ascending colon; cut a big epiploon from a cross colon, cross the right phrenic and colonic sheaf. Study features of a structure ileal and colonic, right colonic and average colonic arteries and veins then find a transplant which length depends on the place of its arrangement. Cross an ileal gut in 10 — 15 cm from a caecum, make appendectomy, cross a cross colon at the level of branching of an average colonic artery. Take in the distal end of a cross colon.
Through an opening in an omentulum carry out the mobilized gut behind a stomach. The lower end of a transplant is anastomosed with antral department of a stomach. Create an anastomosis between an ileal gut and distal department of a large intestine. The transplant is carried out on a neck and isoperistaltically anastomosed with a gullet.
Prior to the beginning of the fiftieth years all surgeons newly created P. and. carried out on a neck antetorakalno, later along with it began to use an intrathoracic way of carrying out a transplant. A. G. Savinykh by means of a sagittal diaphragmotomy carried out an enteric transplant on a neck through a postmediastinum.
N. I. Yeremeyev, Robertson and Sardzhent (R. Robertson, T. R. Sarjeant, 1950 — 1951) described a technique of a retrosternal esophagoplasty.
Intrapleural oesophagoplasty was carried out by S. S. Yudin (1947), Rinkhoff (W. F. Rien-hoff, 1946).
The question of the choice of this or that way of oesophagoplasty and way of carrying out a transplant shall be solved especially individually depending on the general condition of the patient, anatomic features of abdominal organs, and also character of very tectonics of vessels of intestines. So, it is antetorakalno because at such retrosternal is complicated by emergence more often more rational to carry out oesophagoplasty after an extirpation of a gullet concerning cancer.
At a cicatricial stricture of a gullet the location of a transplant is chosen depending on the level of a stricture. At its low arrangement the most rationally intrapleural arrangement of a transplant as at use before - or retrosternal oesophagoplasty in the remaining cul-de-sac of a gullet, strictures are higher, development of an inflammation, cancer and other complications is possible.
In case of an extended stricture in an average third of chest department of a gullet when above and below a stricture the gleam of a gullet is kept, the segmented plastics is shown. The solution of a question of expediency of use of segmented plastics requires a research of a distal piece of a gullet what apply a retrograde ezofagoskopiya and an ezofagografiya to. Enter the rigid endoscope into a gastrostomy (e.g., rektoskop). During the inflating of a stomach into the cardia enter a tube of the endoscope and examine a mucous membrane of a gullet. Then through a tube enter a gastric tube and force a Janet's syringe a suspension of barium sulfate. At the same time sick give a drink of a contrast agent through a mouth and do x-ray films. Such technique allows to contrast a gullet above and lower than a stricture, having accurately determined the extent of narrowing. For segmented plastics use a small or large intestine which segment is carried out to a chest cavity and anastomose with a gullet above and lower than a stricture (fig. 2).
If the stricture extends to the cardia of a stomach, then the lower anastomosis is imposed with a stomach.
In case of a stricture or cancer of cervical department of a gullet make a resection it with the subsequent oesophagoplasty by a free segment of a small bowel which blood supply is provided by means of an anastomosis between vessels of a transplant and branches of cervical vessels.
Alloplastichesky substitution of a gullet did not receive use in clinical practice.
In the first two days food of patients is carried out in the parenteral way. On 3 — the 4th days after operation begin additional feeding through a gastrostomy. It is necessary to watch viability of a transplant. In case of an arrangement of a transplant under skin overseeing by it is facilitated. Usually on second day after operation at easy effleurage by fingers in the field of an arrangement of a transplant it is possible to see its peristaltics or tonic contraction that indicates its viability. At a necrosis of a gut there is inflation of a transplant throughout, then erubescence over a gut and symptoms of intoxication appear. In doubtful cases it is necessary to bare a small section of skin the upper site of a transplant for the purpose of control of its viability. At an arrangement of a transplant in an afterbreast or in a pleural cavity the only objective way of control is survey of a transplant on a neck. In case of detection of a necrosis it is necessary to remove all transplant or its part. After removal of a nekrotizirovanny gut the mediastinum should be drained from a neck and an abdominal cavity.
After oesophagoplasty such diseases as a reflux esophagitis can develop (see. Esophagitis ), connected with lack of the cardia or disturbance of its sphincteric and valve function; disturbance of passability of an artificial gullet as a result of cicatricial changes in area of an anastomosis or on the soil a reflux esophagitis; diverticulums of an artificial gullet; ulcers of a transplant; fistulas, polyposes and seldom cancer of an artificial gullet.
Pathological anatomy of an artificial gullet
Macroscopic changes of an artificial gullet depend on its arrangement and body from which it is created. At antetorakalny oesophagoplasty around a transplant there is a large number of the commissures sometimes squeezing a gleam of a hypodermic gullet. At long existence of a transplant hypodermic cellulose around it is sharply condensed. P.'s gleam and. it is unevenly narrowed at single or multiple papillomatous growths on its inner surface or extensive cicatricial process around a transplant (fig. 3, 4). Loops antetorakalno of the located transplant from a small bowel have identical width, thickness of its walls can increase due to surrounding commissures (fig. 5). The relief of a mucous membrane of a transplant remains even at its long-term existence.
In the functioning intestinal transplants in the next months after oesophagoplasty on a mucosal surface of a cover slime due to proliferation of scyphoid cells collects and gradually the gleam of crypts of a mucous membrane extends. At long-term existence of a transplant the atrophy vorsin a mucous membrane of a gut which get various size develops, but in them proliferation of scyphoid cells (fig. 6, 7) remains. Reorganization of walls of vessels of a submucosal layer of a gut comes to light a hypertrophy of muscle and elastic fibers. The hypertrophy of muscle fibers of a wall of a gut develops slowly and is expressed more sharply in an enteric transplant. In two-three decades of functioning of an enteric transplant muscle fibers of a wall of a gut atrophy that is not observed in a transplant from a large intestine. Differences in structural changes of P. and. from the right or left half of a colon it is not observed.
In the stomach used for oesophagoplasty in early terms the inflammatory changes of a mucous membrane which are gradually replaced for the first year of existence by its atrophy come to light.
Changes of a stomach at oesophagoplasty are defined by a type of a transplant and participation of a stomach in digestion. Near a skin and gastric anastomosis often there is ulcer dermatitis owing to a pelting in a gleam of a skin transplant of gastric contents. Scarring of an ulcer of an anastomosis leads to a stenosis of an anastomosis — to one of frequent late complications of oesophagoplasty. In the stomach which is disconnected from digestion the mucosal atrophy and a muscular layer of a wall against the background of which in several decades typical stomach ulcers or a duodenum and even a carcinoma of the stomach can develop develops. Inclusion of a stomach, even undergone an atrophy, in process of digestion at thinly - and colic oesophagoplasty in several years can lead to formation of round ulcers of an enterogastric anastomosis (in 2 — 5% of cases). Round ulcers of an anastomosis differ in the small sizes, usually are located in the regions or near an anastomosis. In day of such ulcers under a layer of granulations there are large arteries which erosion can lead to profuse gastric bleeding (fig. 8). Around an anastomosis and round ulcers in a mucous membrane of a stomach the proliferation of obkladochny cells arising in response to receipt in a stomach of large numbers of intestinal contents of alkaline structure is defined.
A gullet artificial at children
Need for creation of an artificial gullet at children first of all is connected with effects of corrosive burns of a gullet — cicatricial impassability or its narrowing. Resort to oesophagoplasty at an atresia or a tumor of a gullet much less often, and also in connection with removal of a gullet at a severe injury (perforation) or complications after operations on it.
The esophagoplasty is made also at the created cicatricial narrowing complicated by perforation, esophageal and bronchial or esophageal and pulmonary fistula.
Necessary preparatory operation at the children suffering from full cicatricial impassability of a gullet is gastrostomy (see), providing an enteroalimentation and allowing to eliminate deficit of weight. At children of early age at cicatricial impassability the risk of aspiration from a cul-de-sac of a gullet and development of recurrent inflammatory process in bronchial tubes and lungs is high. In this regard there can be a need of preliminary operation of crossing of a gullet on a neck with sewing up of the distal end and removal proximal on a neck in the form of an ezofagostoma.
Quite often resort to an esophagoplasty at cicatricial postburn stenoses if bougieurage (see) does not lead to elimination of a stenosis. The esophagoplasty in such situation should not be carried out before 6 months from the moment of a burn since in these terms still there can be inflammatory changes breaking passability of a gullet. At it is long the existing cicatricial stenoses of a gullet Yu. F. Isakov et al. (1978) the way of intraoperative audit of a gullet by extra pleural access (without resection of edges) which allows to define indications to P.'s creation is offered and. or to use of other methods of elimination of a stenosis. At the cicatricial process striking all layers of a gullet on a big extent make a resection of chest department of a gullet. In several months create P. and.
At an atresia of a gullet with big to diastases originally perform palliative operations — cervical esophagostomy (see. Esophagotomy ) with crossing of tracheosesophageal fistula, gastrostomy (see), and then create an artificial gullet. According to Waterston (D. J. Waterston, 1967) performance of an esophagoplasty in the period of a neonatality is possible. In preoperative training of such children sanitation of a tracheobronchial tree, prevention of aspiration, correction of water and electrolytic balance has special value. At cicatricial esophageal stenoses the segmented esophagoplasty an intestinal transplant with imposing of an anastomosis above and below a stricture in a chest cavity at children was not widely adopted because of a possibility of disturbance of blood circulation in a transplant, insolvency of an anastomosis and emergence of a mediastinitis. Apply total retrosternal oesophagoplasty with formation of an anastomosis of a transplant with a gullet and a stomach outside a chest cavity more often. During the formation of a transplant various departments of thin and thick guts, and also a stomach can be used. Most of surgeons gives preference to oesophagoplasty by the large intestine which is carried out isoperistaltically.
Most often use a cross colon and a part of the descending colon or find a transplant from the ascending colon and a part ileal. An anastomosis on a neck at children in view of discrepancy of diameters of a transplant and a gullet carries out by the principle the end in the end, but in the slanting direction.
The lethality at an esophagoplasty at children makes about 5%. The heaviest complication is late revealed necrosis of a transplant with development mediastinitis (see). A frequent complication is formation of fistulas in the field of an anastomosis between a transplant and cervical department of a gullet (25%) which are usually closed independently; stenoses of an anastomosis are noted not more often than in 10% of cases. Children develop in the remote terms well, most of them does not lag behind in development peers, eat usual food.
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