Мультимодальный подход к хирургическому лечению и реабилитации больных с рубцовыми стенозами трахеи

Аннотация

Topicality and relevance of the theme of the dissertation. According to the World Health Organization, as well as the recommendations of the European Respiratory Society (ERS) and the American Association of Thoracic Surgeons (ATS), cicatricial stenosis of the trachea (CST) until recently, are among the rare surgical diseases. «The development and achievements of modern anesthesiology and resuscitation make possible the salvation of patients previously considered as a incurable and hopeless. Perioperative and postoperative management of these patients often requires prolonged mechanical ventilation».1 «In turn, emergency respiratory support through continuous mechanical ventilation through an endotracheal or tracheostomy tube is the main cause of damage to the tracheal wall with the formation of tracheal stenosis»." «The incidence of CST after mechanical ventilation and / or tracheostomy according to different researchers may reach 25%. The number of patients with this pathology has increased steadily in recent years. The annual growth rate of stenosis of the larynx and trachea is 5%».3 During the years of independence in our country was created a new high-tech and effective system of providing specialized and emergency medical services, based on high-tech and modern equipment of medical facilities and highly qualified staff potential, which causes increase in the frequency of patients with CST in recent years, due to the increase of patients from dire survival and critical states. «There are various options for surgical treatment of this disease, including endoscopic techniques for expanding the lumen of the trachea and stenting, plastic tracheal defects and the replacement of the tracheal wall by flaps, complex and expensive reconstructive surgery».4 However, previous studies have not clarified the indications for the choice of the optimal method of treatment depends on the extent, location, degree of narrowing and the general condition of the patient on the comorbidity. There remain open questions regarding the tactics and the sequence of the CST treatment, which dictates the need for a differentiated and multi-modal approach in the treatment of these patients. This dissertation research is to a certain extent the tasks provided for the decision of the President of Uzbekistan dated February 22, 2016 for the PP-4782 "On measures to further improve the system of social support and medical and social assistance to vulnerable categories of the population." Given this, the relevant questions are provided to improve the efficiency of surgical care, learning and improving techniques of tracheal stenosis correction, rehabilitation, reduce disability and improve quality of life and social adaptation of patients with CST. The aim of the research was to improve the results of treatment of patients with CST by defining a differentiated approach to the complex surgical treatment and rehabilitation of patients. The scientific novelty of the research is as follows: on the basis of the clinical manifestations of the dependence of the location and extent of the CST on the age, time of formation of the stenosis, as well as the etiopathogenic factors of development; we studied the immediate and long-term results of treatment of patients with CST taking into account the application of modem high-tech methods of endoluminal surgery and open surgical techniques; a versatile tool for the installation of the stent into the trachea, which greatly facilitates the operation, it minimizes trauma and reduces the risk of postoperative complications; proved the efficiency of the two-stage plastic tracheal with the lumen formation on T-shaped endoprosthesis in the treatment of multifocal and extended CST; improved plastic methods of eliminating persistent and extensive tracheal defects and soft tissues of the neck after laryngo-trachea stoma; grounded the possibility of major resection in the surgical treatment of extended CST both in the primary stage of treatment in the absence of comorbidity, and in restenosis after previous stages of treatment; scientifically grounded the use of differentiated and multidisciplinary approach in the surgical treatment and rehabilitation of patients with CST. Conclusion 1. Pathognomonic for multifocal and extended CST is age and gender: male patients at 2.4 (p<0.05) and at 2.12 (p>0.05) times more than female. Patients aged 18 to 39 years, i.e. which are the most active, able-bodied and socially significant segment of the population, accounted for the vast majority - 68.8%. Moreover, among these patients in groups with extended (Group 2) (84%) and trachea-larynx (Group 3) stenosis (71.4%), was significantly more, than patients from limited (1 Group) narrows (60%) and multifocal (4 Group) stenosis (62.5%), difference (p<0.05). 2. "Difficult" in the diagnostic and treatment stenosis (extended, trachea-larynx and multifocal stenosis) more often are after tracheostomy (39.3%), after intubation (27.6%) и combined after tracheostomy/after intubation stenosis (20.5%), while the short (Limited by length) cicatricial narrowing of the trachea are often postoperative (5.9%) (stenosis of the anastomosis), post-traumatic (4.5%) and idiopathic (1.8%). 3. Assessment CST parameters specific instrumental methods in comparison with intraoperative figures established the specificity of MSCT and PBS by length of narrowing is 92.9% и 82.6 respectively, specificity of MSCT и PBS by diameter contraction was 78.3% and 91.4% respectively. 4. At the stage of endoscopic treatment in some patients can achieve the formation of a sufficient breathing tracheal lumen, ie, transfer of CST from critical, decompensated and subcompensated stage at compensated form. At the same time efficiency of endoscopic methods was 54.3%, in patients from short CST, 8% when prolonged 17%, at trachea-larynx, 16.7% at multifocal CST. In the case of restenosis required conduct circular resection of the narrowed section trachea, with availability contraindications performance of T - plastics. 5. Application of the designed device for installation of the stent at trachea at endoscopic treatment of CST increases its efficiency by improvements fixing and unfolding of the stent at trachea, minimizes trauma intervention and decreases risk of postoperative complications. 6. Reconstruction at the T- endoprosthesis at patients with trachea-larynx and extended CST allows rehabilitate patients by severe concomitant diseases, eliminate evidence infringement expectoration of the bronchi, save opportunity breath across natural breathing path and reestablish phonation, excludes migration risk and obturation of the endoprosthesis and allows form a stable and sufficient lumen of the trachea from followed by performing plastic surgery by closure of the defect. 7. In multifocal constriction (2-3 leveled stenosis of the trachea), in conjunction with stenosis subglottic department of larynx, and also at scar obliteration lumen above tracheostomy plastic lumen on T-shaped endoprosthesis is the method of choice, allow intraoperative create lumen on all level from the possibility of longterm dilation. 8. When an extended cicatricial stenosis of tracheal with involvement in the process more than 30-50% trachea, up to 5-6 cm, possible to carry out an extensive circular resection of the trachea at conditions of sufficient mobilization on the required levels for exceptions of tension at the created anastomosis. In this, resection of trachea at border healthy semirings from their anastomosis allows perform extensive resection of extensive stenosis of the trachea without restenosis. 9. In the absence of contraindications of the comorbidities circular resection of the trachea can be done in the first stage of treatment. In the case of contraindications to its performance, the need for rehabilitation of the patient may perform a resection of the trachea at the next stage of treatment. In this endoscopic intervention and T-plastic do not increase the length of the restriction, while multifocal stenoses opposite can reduce the number of levels. 10. To close the persistent tracheal defects and soft tissues of the neck after larynx-tracheaplastics effective are local skin - muscle flaps at the size of the defect not greater than 2 cm at width and up to 4 cm at height , with large defects can be effectively used complex skin-bone-muscle grafts of adjoining area of the neck and different departments chest. 11. In patients with CST must implemented multimodal an approach, depending on degree, localization, the extent and level of narrowing, with account the severity of concomitant pathology by using complex of endoscopic, resection и reconstructive - plastic methods of treatment and rehabilitation.