Tracheoesophageal fistula repair and primary esophagus anastomosis through thoracic approach

Indication Transthoracic tracheal esophageal fistula repair and esophageal one-stage anastomosis are applicable to: 1. Esophageal atresia and esophageal tracheal fistula are located at the level of the thoracic segment, and the distance between the two blind end points of the esophagus is large. 2. The general condition is still good, can tolerate chest surgery. Contraindications 1. Severe aspiration pneumonia should be controlled after surgery. 2. Combined with other organ malformations, the general condition is poor, and can not tolerate major surgery. Preoperative preparation 1. Treat the respiratory tract to attract the effective secretion of the upper esophageal blind bag, turn over the side of the esophagus every hour, put the baby in a high oxygen and high humidity incubator, and apply antibiotics to treat pneumonia. 2. Fasting and parenteral nutrition maintenance. Correct dehydration, intravenous glucose, electrolyte solution and plasma, and if necessary, blood transfusion. 3. Regular injection of vitamin K and vitamin C. Surgical procedure 1. Make a transverse incision along the right side of the shoulder blade 1 Thoracic inner diameter road: After the muscle layer is cut, the fourth intercostal space enters the chest cavity. Use your hand or hook to pull the right lung forward and inward, cut the mediastinal pleura behind the hilar, free and ligature to cut the azygous vein, and extend the mediastinal pleural incision into the posterior mediastinum: 2 pleural outer diameter: cut through the 4th intercostal space The intercostal muscles, until the parietal pleura was seen, were bluntly separated between the intrathoracic fascia and the parietal pleura by a wet gauze ball, which was sequentially separated into the third and fifth intercostals, and the parietal pleura was pushed open. The range of separation required is up to the top of the chest; down to the 6th to 7th ribs or lower; back to the ribs. Care must be taken when separating to prevent rupture of the pleura. Place the chest opener, cut off the azygous vein, and enter the posterior mediastinum to expose the esophagus and trachea. The advantage of the extrapleural approach is that it is easier to treat the anastomotic leakage after surgery, but the intrathoracic approach has the advantages of satisfactory exposure and convenient operation. At present, the intrathoracic approach is often used. 2. Free distal esophageal tracheal fistula It can be found near the bifurcation of the lower part of the trachea. In each breath, you can see the fistula bulging, use a gauze to do the traction, carefully release the fistula, cut the fistula from about 1 to 2 mm from the trachea, and use the 6-0 non-invasive synthetic suture to suture the fistula. Inject a small amount of normal saline into the suture of the fistula, and pressurize and breathe at the same time to check for air leakage. If necessary, strengthen the suture. The fistula stump on the tracheal side should not be kept too long to avoid the formation of a diverticulum, but it should not be cut close to the trachea to avoid narrowing the trachea. When the end-to-side anastomosis is proposed, the fistula can be not cut, and the proximal trachea can be double-slited or ligated with 2-0 or 0 silk. The lower esophageal blood supply is poor, and the freeness should not be too much. 3. Free upper end of the esophagus If you put a good stomach tube before surgery, it is easy to find. After finding the blind bag, suture two needles at the top for traction, without clamping to avoid damage to the tissue. The upper esophagus should be separated as far as possible to reduce the tension of the anastomosis and determine whether there is another fistula. 4. Esophagus The principle of esophageal anastomosis is to avoid anastomotic tension, and to preserve the blood supply in the lower part of the esophagus. The abdomen of the lower esophagus was removed a little before the anastomosis. When the tip is small and the lumen is very thin, a diagonal incision can be made. The esophageal wall should not be clamped to avoid damage to the tissue. There are two methods for anastomosis: end-to-end anastomosis (1) End-end anastomosis: It can be divided into single-layer suture method and nesting suture method. The single-layer suture method is an anastomosis method in which two esophagus are made into a layer of suture. The 6-0 non-invasive synthetic suture is used for the full-thickness suture of the posterior wall, and the gastric tube is inserted into the stomach through the anastomosis and fixed. Also suture the anterior wall, pay attention to the mucosa at both ends of the anastomosis when suturing. The key to the anastomosis is not the stitching but the stitching. Nested suture method, the mucosa and submucosa of the proximal esophageal capsule are anastomosed to the distal full layer, the knot is hit in the cavity, and then the proximal esophageal muscle layer and the lower esophageal outer membrane are covered by the anastomosis. . (2) End-to-side anastomosis: only the fistula is cut off and only the ligation is performed, and then the upper and lower sections are used for end-to-side anastomosis. In order to prevent recurrence and recanalization after fistula ligation, the mucosa in the fistula can be gently scraped off with a metal curette through the incision to be anastomosed before ligation of the fistula. The blind end of the esophagus was pulled closer to the lower esophageal wall for intermuscular suture. The upper end of the esophagus is cut obliquely, and the side wall of the lower esophagus is sutured, and the knot is hit in the cavity. Before the suture of the posterior wall is completed, the thin plastic tube inside the esophagus is passed to the lower segment. (3) Muscle layer extension method: If the distance between the two ends of the esophagus is large, it can not directly match or estimate the tension after the anastomosis is too large, and the myotomy can be performed at the proximal end of the esophagus to shorten the distance between the esophageal ends. The cuff catheter is first inserted into the free proximal esophageal opening, and the purse string is fixed and not inflated, which makes the operator easy to manipulate. Do not inflate the cuff, so that the normal mucosal folds of the esophagus disappear. A circular incision was made 2 cm from the esophageal opening. The muscle layer was carefully separated between the muscular layer and the submucosa by scissors, and the blood vessels supported by the layer were protected. The muscle layer can be extended by 1 to 1.5 cm after the incision and separation, and the esophagus is sutured. (4) Delayed suture method: If the distance between the two ends of the esophagus is too far during the operation, one-stage anastomosis cannot be performed. The surgeon faces two choices; one is to cut the fistula, sew a metal marker at the distal end of the esophagus, try to close the two ends of the esophagus, and apply a gastrostomy to maintain nutrition. After 1 week, the proximal blind pocket was expanded with a probe or a mercury bag. After several months, the esophageal anastomosis was performed. The second is to cut the suture esophageal tracheal fistula, the upper esophagus is used as an esophagus ostomy through the neck incision, and the stomach is used for feeding in the abdomen. The neck stoma handles a small bag of stored secretions. During this period, the baby is trained to eat by mouth, although the food is in the pocket, but it plays a role in psychological training for later eating. After the baby is up to 12 months, the second stage of esophagus reconstruction is used, and the jejunum, colon or stomach large curved tube is used as a substitute. In patients undergoing pleural surgery, the mediastinal incision should be sutured and covered with an anastomosis. The upper esophagus is fixed to the anterior fascia with a few needle sutures to reduce the movement of the esophagus during swallowing and reduce the tension of the anastomosis. A pleural cavity closed drainage tube was placed between the 6th or 7th intercostal space of the midline of the iliac crest, and then the chest wall was sutured layer by layer. If the patient undergoes an pleural surgery, an extrapleural drainage tube is placed in the posterior mediastinum proximal anastomosis and is withdrawn from the other incision through the fifth intercostal incision. complication 1. Esophageal anastomosis. 2. Esophageal stricture. 3. Esophageal tracheal hernia recurrence or legacy. 4. Esophageal motor function is abnormal.

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