Malformations of the esophagus in newborns. Pediatric surgery: lecture notes (M. V. Drozdova)

Various diseases esophagus occur in all children age groups. Most often, the need for urgent surgical intervention arises due to birth defects development and damage to the esophagus.

Slightly less common indications for emergency care caused by bleeding from dilated veins of the esophagus with portal hypertension.

Malformations of the esophagus

Malformations of the esophagus are among the diseases that often cause the death of children in the first days of life or the occurrence of serious complications in them that impair further development. Among the many birth defects esophagus for emergency surgery Of interest are those types that are incompatible with the life of a child without urgent surgical correction: congenital obstruction (atresia) and esophageal-tracheal fistulas.

Esophageal obstruction

Congenital obstruction of the esophagus is caused by its atresia. This complex developmental defect is formed on early stages intrauterine life of the fetus and, according to our data, occurs relatively often (for every 3500 children, 1 is born with a malformation of the esophagus).

Possible formation of 6 main types congenital obstruction esophagus (Fig. 7).

With atresia, in most cases, the upper end of the esophagus ends blindly, and the lower part communicates with the trachea, forming a tracheoesophageal fistula (90-95%). It is clear that amniotic fluid and the liquid that the child swallows after birth cannot enter the stomach and accumulates along with saliva in the upper blind sac of the esophagus, then regurgitated and aspirated. The presence of a fistula in the upper segment of the esophagus accelerates aspiration - after swallowing, the liquid partially or completely enters the trachea. The child quickly develops aspiration pneumonia, which is aggravated by the throwing of stomach contents into the trachea through the esophageal-tracheal fistula of the lower segment. A few days after birth, the child dies from aspiration pneumonia. Such children can only be saved by emergency surgical correction vice.

A favorable outcome of treatment of congenital obstruction of the esophagus depends on many reasons, but primarily on the timely detection of atresia. With early initiation of special treatment, the possibility of aspiration is reduced. A diagnosis made in the first hours of a child’s life (before the first feeding!) will prevent or significantly alleviate the course of aspiration pneumonia. However, pediatricians in maternity hospitals do not know enough about the symptoms of congenital obstruction of the esophagus. So, for example, among 343 children operated on by us during the period from 1961 to 1981, only 89 were sent on the 1st day after birth, and the rest were admitted from 1 to 23 days.

The general condition of the patient and the degree of lung damage are directly dependent on the time of admission: in the group of patients admitted on the 1st day, only 29 were clinically diagnosed with pneumonia; in 126 children admitted on the 2nd day, the condition was regarded as severe and bilateral pneumonia was diagnosed; Almost all newborns who were referred over 2 days of age (128) had a more severe process in the lungs (in 1/3 of them, in addition to pneumonia, atelectasis of varying degrees was detected on one or both sides).

Clinical picture. The first, earliest and most consistent sign that suggests esophageal atresia in a newborn is a large amount of foamy discharge from the mouth and nose. Unfortunately, this sign, which is noted in the documentation of maternity hospitals for all children, is not always given due importance and assessed correctly. Suspicion of esophageal atresia should increase if, after normal suctioning of mucus, the latter continues to rapidly accumulate in the large quantities. The mucus at times has a yellow color, which depends on the reflux of bile into the trachea through the fistula of the distal segment of the esophagus. In all children with esophageal obstruction, by the end of the 1st day after birth, quite distinct breathing disorders (arrhythmia, shortness of breath) and cyanosis can be detected. Auscultation reveals a large amount of moist rales of various sizes in the lungs. Abdominal bloating indicates an existing fistula between the distal segment of the esophagus and the respiratory tract.

For early detection of the defect, we consider it necessary for all newborns and especially premature babies to undergo probing of the esophagus immediately after birth. This will not only help identify atresia, but also allow you to suspect other anomalies of the digestive tract. It should be noted that for a newborn who does not have any malformations, intubation will be beneficial, since the evacuation of stomach contents prevents regurgitation and aspiration.

If the first indirect signs of atresia were identified in the maternity hospital, then the diagnosis should also be confirmed or rejected by probing the esophagus.

For sounding, use a regular thin rubber catheter (No. 8-10), which is inserted through the mouth or nose into the esophagus. With atresia, a freely pushed catheter is delayed at the level of the top of the sac of the proximal segment of the esophagus (10-12 cm from the edge of the gums). If the esophagus is not changed, then the catheter easily passes over a greater distance. It must be remembered that in some cases the catheter may fold, and then a false impression is created about the passage.

bridge of the esophagus. To clarify the diagnosis, the catheter is inserted to a depth of more than 24 cm, and then its end (if there is atresia) will definitely be found in the child’s mouth.

At the first feeding, obstruction of the esophagus is detected quite clearly. All the liquid you drink (1-2 sips) is immediately poured back out. Feeding is accompanied a sharp violation breathing; the newborn turns blue, breathing becomes shallow, arrhythmic, and it stops. A coughing attack can last from 2 to 10 minutes, and difficulty and arrhythmia of breathing can last even longer. These phenomena occur during each feeding. Cyanosis gradually increases. When listening to the lungs, a large number of moist rales of different sizes are revealed, more on the right. The child's general condition is progressively deteriorating.

With exhaustive completeness and reliability, the diagnosis is established on the basis of an X-ray examination of the esophagus using a contrast agent, which is carried out only in a surgical hospital. The obtained data are a necessary part of the preoperative examination and serve as a guide for choosing the method of surgical intervention. X-ray examination of children with suspected esophageal atresia begins with a plain chest x-ray (it is very important to carefully assess the condition of the lungs!). Then a rubber catheter is inserted into the upper segment of the esophagus and the mucus is sucked out, after which 1 ml of a 30% water-soluble contrast agent is injected into the esophagus through the same catheter using a syringe. The introduction of a large amount can lead to an undesirable complication - overflow of the blind upper segment of the esophagus and aspiration with filling of the bronchial tree with a contrast agent . Radiographs are produced at vertical position child in two projections. After the X-ray examination, the contrast agent is carefully aspirated. The use of barium sulfate for examination of the esophagus in newborns with any form of atresia is contraindicated, since its possible entry into the lungs causes atelectatic pneumonia.

In the case of a child’s general serious condition (late admission, stage III-IV prematurity, etc.), it is possible not to undertake examinations with a contrast agent, but to confine oneself to the introduction of a thin rubber catheter into the esophagus (under the control of an X-ray screen), which will allow one to quite accurately determine the presence and level of atm. -resions. It should be remembered that with rough insertion of a low-elastic thick catheter, the pliable film of the blind oral segment of the esophagus can be displaced, and then a false impression is created about the low location of the obstacle.

A characteristic radiological symptom of esophageal atresia when examined with a contrast agent is a moderately dilated and blindly ending upper segment of the esophagus (Fig. 8) -. The level of atresia is more accurately determined on lateral radiographs. On the-

the presence of air in the gastrointestinal tract indicates an anastomosis between the lower segment of the esophagus and the respiratory tract.

The visible superior cecum and the absence of gas in the gastrointestinal tract suggest atresia without a fistula between the distal esophagus and trachea. However, this radiological symptom does not always completely exclude the presence of a fistula between the distal segment of the esophagus and the respiratory tract. The narrow lumen of the fistula can be clogged with a mucous plug, which serves as an obstacle to the passage of air into the stomach.

The presence of a fistula between the upper segment of the esophagus and the trachea can be detected radiographically by the throwing of a contrast agent through the fistula into the respiratory tract. This examination does not always help to detect a fistula, which in such cases is found only during surgery.

When analyzing clinical and radiological data and making a final diagnosis, one should remember about possible combined malformations, which, according to our data, occur in 44.7% of patients, and some of them (26%) require emergency surgical correction or are incompatible with life ( 5%).

Differential diagnosis has to be carried out with asphyxial conditions of the newborn caused by birth trauma and aspiration pneumonia, as well as isolated tracheoesophageal fistula and “asphyxial strangulation” of the diaphragmatic hernia. In such cases, esophageal atresia is excluded by probing.

Treatment. Published data and analysis of our observations show that the success of surgical intervention depends on early diagnosis of the defect, and hence the timely start of preoperative preparation, rational choice of surgical method and correct postoperative treatment.

Many combined defects significantly affect the prognosis. It is extremely difficult to treat premature babies, the number of whom among those referred to our clinic reached 38%, and in the last 5 years - 45.4%. Newborns in this group experience rapidly developing pneumonia, decreased child resistance, and a peculiar reaction to surgical intervention, which often creates insurmountable difficulties in treatment.

It should be noted that in the last 5 years, among the 44 premature babies we operated on, 23 recovered (of which 8 were without associated developmental defects).

Preoperative preparation. Preparation for surgery begins from the moment the diagnosis is made in the maternity hospital. The trachea is intubated, humidified 40% oxygen is continuously given, antibiotics and vitamin K are administered. The mucus released in large quantities is carefully sucked out through a soft rubber catheter inserted into the nasopharynx at least every 10-15 minutes. Oral feeding is absolutely contraindicated.

The patient is transported to the surgical department according to the rules provided for newborns, with a mandatory continuous supply of oxygen and periodic suction of mucus from the nasopharynx. From remote areas and regions, newborns are delivered by plane (the child usually tolerates the flight satisfactorily).

Further preparation for the operation continues in surgical department, striving mainly to eliminate the phenomena of pneumonia. The duration of preparation depends on age and general condition child, as well as the nature of pathological changes in the lungs.

Children admitted within the first 12 hours after birth do not require long preoperative preparation (1 1/2-2 hours is sufficient). During this time, the newborn is placed in a heated incubator, humidified oxygen is constantly given, and mucus is sucked out of the mouth and nasopharynx every 10-15 minutes. Antibiotics and vitamin K are administered.

Children admitted to more late dates after birth, with symptoms of aspiration pneumonia, 6-24 hours are prepared for surgery. The child is placed in an elevated position in a heated incubator with a constant supply of humidified oxygen. Every 10-15 minutes, mucus is sucked out from the mouth and nasopharynx (an individual nursing station is required!). During long-term preparation, mucus is sucked out from the trachea and bronchi every 6-8 hours. Antibiotics are administered, an aerosol is prescribed alkaline solutions and antibiotics. For late admission, parenteral nutrition is indicated (for fluid calculations, see Chapter 1). Preoperative preparation is stopped when there is a noticeable improvement in the child’s general condition and a decrease in the clinical manifestations of pneumonia.

If during the first six hours preoperative preparation does not have noticeable success, then one must suspect the presence of a fistulous tract between the upper segment and the trachea, in which mucus inevitably enters the respiratory tract. Continuing preoperative preparation in such cases is useless; it is necessary to proceed to surgical intervention.

Surgery in case of esophageal atresia, it is carried out under endotracheal anesthesia and protective blood transfusion. The operation of choice should be the creation of a direct anastomosis. However, the latter is possible only in cases where the diastasis between the segments of the esophagus does not exceed 1.5 cm (with a high location of the upper segment, at the Th 1, -Th 2 level, the creation of an anastomosis is possible only with the help of a special stapler). Anastomosis with high tissue tension of esophageal segments is not justified due to technical difficulties and possible eruption seams in postoperative period.

In newborns weighing less than 1500 g, multi-stage “atypical” operations are performed: delayed anastomosis with preliminary ligation of the esophageal-tracheal fistula, etc. (Babljak D. E., 1975, etc.].

Based on clinical and radiological data, it is almost impossible to establish the true distance between the segments. This issue is finally resolved only during surgery. If during thoracotomy a significant diastasis (more than 1.5 cm) between the segments or a thin lower segment (up to 0.5 cm) is detected, then the first part of the two-stage operation is performed - the esophageal-tracheal fistula of the lower segment is eliminated and the upper end of the esophagus is brought to the neck. These measures prevent the development of aspiration pneumonia, thereby saving the patient’s life. The created lower esophagostomy serves to feed the child until

Stage II of the operation - the formation of an artificial esophagus from the colon.

The operation of creating an anastomosis of the esophagus. It is most rational to use extrapleural surgical access, which, according to our observations (156 newborns), significantly facilitates the course of surgical intervention and the postoperative period.

Extrapleural access technique. The child lies on his left side. Right hand fixed in a raised and anterior position. A rolled-up diaper is placed under the chest. The incision is made from the middle axillary line to the paravertebral line along the IV rib. Bleeding vessels are carefully ligated. The muscles in the fourth intercostal space are carefully dissected. The pleura is slowly peeled off (first with a finger, then with a damp small tuff) along the incision up and down 3-4 ribs. Using a special small-sized screw wound retractor, the edges of the chest wall wound are spread apart, after which the lung covered with pleura is retracted anteriorly and downwards. The mediastinal pleura is peeled off above the esophagus up to the dome. If the anatomical relationships allow the creation of a direct anastomosis, then mobilization of the esophageal segments begins.

Technique for mobilizing food segments. Find the lower segment of the esophagus. The reference point is the typical location of the vagus nerve. The latter is removed inwardly, the esophagus is relatively easily isolated from the surrounding tissues and taken onto a holder (rubber strip). The lower segment of the esophagus is mobilized over a short distance (2-2.5 cm), since significant exposure of it can lead to disruption of the blood supply. Directly at the point of communication with the trachea, the esophagus is tied with thin ligatures and crossed between them. The stumps are treated with an alcohol solution of iodine. The ends of the thread on the short stump of the esophagus (at the trachea) are cut off. Suturing of a tracheal fistula is usually not required. Only a wide gap (more than 7 mm) is an indication for applying one row of continuous suture to the stump. The second thread at the free lower end of the esophagus is temporarily used as a “holder”. The upper segment of the esophagus is found by a catheter inserted into it through the nose before the operation. A “holder” suture is placed on the top of the blind sac, by which it is pulled up, peeling off the mediastinal pleura, and carefully isolated upward with a damp tupper (do not touch it with tweezers!). The oral segment has a good blood supply, 1 which allows it to be mobilized as high as possible. Dense adhesions to the posterior wall of the trachea are carefully cut with scissors. If there is a fistula between the upper segment and the trachea, the latter is crossed, and the holes formed in the trachea and esophagus are sutured with a single-row continuous marginal suture with atraumatic needles. The mobilized sections of the esophagus are pulled towards each other by the “holder” threads (Fig. 9). If their ends freely overlap each other, then they begin to create an anastomosis.

Technique for creating anastomosis. Creation of the anastomosis is the most difficult part of the operation. It should be noted that difficulties arise not only due to diastasis between segments of the esophagus, but also depend on the width of the lumen of the distal segment. The narrower its lumen, the more difficult it is to apply sutures, more likely their eruption and the occurrence of narrowing of the anastomosis site in the postoperative period. According to our data, most often the distal segment has a lumen width of up to 0.4-0.6 cm.

Due to the variety of anatomical options for esophageal atresia, various methods creating an anastomosis. Atraumatic needles are used for suturing.

Anastomosis by connecting segments of the esophagus in an “end to end” manner. The first row of separate silk sutures is applied through all layers of the lower end of the esophagus and the mucous membrane of the upper segment (Fig. 10, a, b, c). The second row of sutures is passed through the muscle layer of both segments of the esophagus (Fig. 10, d. e). The greatest difficulty of this method is in applying the first row of sutures to extremely thin and delicate tissues, which erupt with the slightest tension. Anastomosis is used for small diastasis between segments of the esophagus and a wide lower segment.

To connect the ends of the esophagus, you can use special wrap-type sutures. Four pairs of such threads, applied symmetrically to both segments of the esophagus, initially serve as “holds” by which the ends of the esophagus are pulled. After their edges come together, the corresponding threads are tied. When tying the sutures, the edges of the esophagus are turned inward. The anastomosis is strengthened with a second row of separate silk sutures. Such sutures make it possible to apply an anastomosis with some tension, without fear of cutting through the delicate tissues of the organ with threads (Fig. 11, a).

The technique of oblique anastomosis of the esophagus significantly reduces the possibility of stricture formation at the site of suturing (Fig. 11, b). We have developed and used in the clinic since 1956 a method of anastomosis that lengthens segments of the esophagus. On the lateral surfaces of the central segment of the esophagus, at a distance of approximately 0.7 cm from its apex, the 1st and 2nd sutures are applied, grasping only the muscular layer of the esophagus with each thread 2-3 times (“wraparound” suture, Fig. 12, a ). The free ends of these threads temporarily serve as “holds”, by pulling on which it is possible to completely avoid trauma to the esophagus with instruments. The 3rd suture is placed along the front surface 0.5 cm above the side ones, and the 4th suture is also placed on the front surface, but slightly lower than the previous one. An arcuate incision is made between the 3rd and 4th sutures, forming a flap with a diameter of 0.5-0.7 cm from all layers of the esophageal wall. The 4th suture remains on the formed flap, and when the latter is turned downwards, it ends up on the posterior surface of the esophagus (Fig. 12, b). The 5th and 6th sutures (Fig. 12, c) are placed on the lower segment of the esophagus on both sides, departing from the top of the mobilized end by 0.5-0.7 cm. These sutures temporarily serve as “holds”. Then the lower segment is cut between the 5th and 6th sutures along the posterior surface longitudinally from the apex downwards. The length of the incision should be about 1 -1.5 cm. The 7th suture is placed at the upper edge of the anterior surface of the lower segment of the esophagus. The last, 8th, suture is placed on the posterior surface at the end of the longitudinal incision. The dissected part of the lower segment is flattened, its tap is rounded (Fig. 12, d, e).

The catheter, which is inserted through the nose into the upper segment of the esophagus before the operation, is advanced further through the formed opening into the lower segment and stomach. The corresponding “holder” threads are tied above the catheter, first the rear ones, and then the lateral and anterior ones. In this way, the first row of anastomosis is created (Fig. 12, e). The second row of anastomotic sutures is formed with separate silk threads, which should be especially carefully applied on the posterior surface of the esophagus. After completing the second row of sutures, the anastomosis can be considered complete.

In cases where during the operation it turns out that the segments of the esophagus are in contact without tension or overlap each other, we use the simplest anastomosis - “end to side”. After mobilization, ligation and cutting, from the trachea, the lower segment of the esophagus is sutured through the muscular layers of the posterior surface for up to 0.8 cm with a continuous suture to the bottom of the expanded upper segment, forming the first row of sutures on the posterior lip of the future anastomosis (Fig. 13, a). The lumen of both segments of the esophagus is opened (0.5-0.7 cm), retreating 1-2 mm from the suture line, and a second row of sutures is placed on the posterior lip of the anastomosis (Fig. 13, b). Then the catheter previously inserted into the upper segment is removed from the esophagus and a thin polyethylene tube is passed through the nose into the stomach for subsequent feeding of the child (the tube is inserted in all cases of creating an anastomosis!). The anterior lip of the anastomosis is formed above the tube with a double-row suture (Fig. 13, c, d), the second row closes the stump of the lower segment.

In our clinic, we successfully used mechanical suture of segments of the esophagus using a special stitching device from the Research Institute of Higher Artificial Research. The use of a mechanical suture significantly reduces the operation time and simplifies the technique of creating an anastomosis. Contraindications are significant diastasis between the segments, severe underdevelopment of the distal segment of the esophagus and degree III-IV prematurity.

Technique of anastomosis using a stapler. After isolating and mobilizing segments of the esophagus, ligating and crossing the esophageal-tracheal fistula, we are convinced of the possibility of creating an anastomosis. Then a blanket suture is placed on the edge of the lower segment of the esophagus without tightening it.

Before applying the anastomosis, the surgeon carefully prepares and checks the device (Fig. 14, a). To do this, the thrust head 1 is unscrewed from the rod 2, its pointed end is removed inside the body of the apparatus 3 and secured in this position with a latch 4. After checking the charging of the device with tantalum paper clips, the movable handle is retracted to its original position and the fuse 5 is closed. In this position, the assistant carefully inserts the device through

the child’s mouth is the upper segment of the esophagus (Fig. 14, b). Having opened the latch, move the rod forward, piercing the wall of the blind end of the esophagus. Then the surgeon, rotating the rod by the button, screws on the thrust head and plunges it into the lower segment. The previously applied “wrapping” stitch is tied over the thrust head, and the thread is cut off (Fig. 14, c). By pulling the rod into the body, the lower and upper segments are brought into contact (Fig. 14, d), securing this position with a clamp with a gap of 0.7 or 1.2 mm (depending on the thickness of the esophageal walls being stitched). Having opened the safety lock, the assistant, by smoothly pressing the movable handle, stitches the esophagus with staples. In this case, sections of the lower and upper segments are cut out and a lumen of the created anastomosis is formed. Next, returning the handle to its original position and opening the safety lock by turning the latch, release the rod and advance the thrust head into the lower segment by 0.5-1 cm, and then carefully move the end of the device body forward beyond the anastomosis line (Fig. 14, e, f) . Only after this, having tightly closed the thrust head with the body, the device is carefully removed from the esophagus. The device is removed strictly along the longitudinal axis of the esophagus under visual control.

Having completed the creation of the anastomosis, a thin polyethylene tube is passed through the child’s nose into the stomach - drainage for subsequent nutrition. The chest is sutured tightly in layers, leaving a thin polyethylene drainage in the mediastinum for 1-2 days.

Double esophagostomy according to G. A. Bairov is the first stage of a two-stage operation and consists of the elimination of esophageal-tracheal fistulas, removal of the oral segment of the esophagus to the neck and the creation of a fistula from its distal segment for feeding the child in the postoperative period. The milk entering through the lower esophagostomy opening does not flow out after feeding, since during this operation the cardiac sphincter remains preserved.

Technique of lower esophagostomy. Making sure that the creation direct anastomosis impossible, they begin to mobilize segments of the esophagus. First, the upper segment is isolated as far as possible. If there is a tracheal fistula, the latter is crossed, and the resulting hole in the esophagus and trachea is sutured with a continuous marginal suture. Then the lower segment is mobilized, tied at the trachea and crossed between two ligatures. Several separate silk sutures are placed on the short stump near the trachea. The vagus nerve is removed medially, and the esophagus is carefully isolated to the diaphragm (Fig. 15, a). By blunt means (opening the inserted Billroth forceps), the esophageal opening is widened, the stomach is pulled up and the peritoneum is cut around the cardiac part (to protect the vagus nerve. После этого ребенка поворачивают на спину и про--изводят верхнюю лапаротомию правым парамедианным разрезом. Мобилизованный дистальный сегмент проводят в брюшную полость через расширенное пищеводное отверстие (рис. 15, б, в). В надчревной области слева от !} midline A transverse incision (1 cm) is made through all layers of the abdominal wall.

The mobilized esophagus is inserted into the formed hole (Fig. 15, d) so that it rises above the skin by at least 1 cm. Its wall is fixed from the inside with several sutures to the peritoneum, and sutured to the skin from the outside (Fig. 15, e). A thin tube is inserted into the stomach through the removed esophagus, which is fixed with a silk thread tied around the protruding part of the esophagus. Wounds abdominal wall and the breasts are sutured tightly (Fig. 15, f). The operation is completed by removing the upper segment of the esophagus.

Technique of upper esophageal gostomy. A thin cushion (folded diaper) is placed under the child’s shoulder blades. The head is turned to the right. A skin incision up to I -1.5 cm long is made above the collarbone on the left at the internal crane of the sternocleidomastoid muscle (Fig. 16, a). The superficial fascia is dissected and the tissue is bluntly dissected to the esophagus (the latter is detected by the catheter inserted into it before surgery). The curved end of the dissector is used to bypass the esophagus, mobilize it in the distal direction, and the blind end is brought out into the wound (Fig. 16, b). Using several (4-5) separate sutures (with an atraumatic needle), its wall is fixed around its circumference in the depths of the wound to the neck muscles. Then the lumen of the esophagus is opened, cutting off its apex, and the edges are sutured to the skin through all layers (Fig. 16, c).

The second stage of the operation - the formation of the esophagus from the colon - is carried out at the age of 1 1/2-2 years.

Postoperative treatment. The success of the operation largely depends on the correct conduct of the postoperative period. For more careful care and careful observation in the first days after surgery, the child needs an individual nursing station and constant control doctor The child is placed in a heated incubator, giving the body an elevated position, and is constantly given humidified oxygen. The administration of antibiotics, vitamins K, C, group B, and UHF field to the chest are continued. A control radiograph is taken 24 hours after surgery. chest cavity. Detection of atelectasis on the side of the operation is an indication for sanitation of the tracheo-bronchial tree.

In the first hours after surgery, the child may experience a progressive increase in respiratory failure, which requires urgent tracheal intubation and assisted breathing (after suction of mucus from the trachea). After a few hours, the child's condition usually improves and the tube can be removed from the trachea. Re-intubation after creation of an anastomosis should be done with great caution and only by a doctor experienced in performing this manipulation in newborns. Incorrect insertion of the tube into the esophagus instead of the trachea can result in rupture of the anastomotic sutures.

Some surgeons form a gastric fistula to feed the child after anastomosis. We do not resort to this additional operation, since during the main intervention we insert a thin (0.2 cm) polyethylene drainage tube into the stomach, through which we begin feeding the child (every 3 hours, very slowly, with breast milk, alternating with a glucose solution) . A single amount of liquid on the first day of feeding should not exceed 5-7 ml. In the following days, breast milk and glucose are gradually added (5-10 ml each), bringing the daily volume of fluid to the age norm by the end of the week after surgery. Feeding through a tube is carried out with the child in an upright position, which prevents regurgitation of fluid through the functionally defective cardiac sphincter in the newborn. In uncomplicated cases, the probe is removed on the 8-9th day.

The patency of the esophagus and the condition of the anastomosis are monitored after 9-10 days by X-ray examination with iodolipol. The absence of signs of anastomotic leakage allows you to begin feeding by mouth from a horn or from a spoon. At the first feeding, the baby is given 10-20 ml of a 5% glucose solution, and then breast milk. half the dose that the newborn received when feeding through a tube. In the following days, for each feeding, the amount of milk is increased daily by 10-15 ml, gradually bringing it to normal according to age and body weight. Fluid deficiency is compensated parenterally by fractional daily administration of a 10% solution of glucose, plasma, blood or albumin. This allows you to avoid a noticeable drop in body weight in the newborn.

On the 10-14th day, the baby is put to the breast first for 5 minutes and a control weighing is performed. They feed the baby from a bottle. During this period, the required amount of food is calculated based on the child’s body weight: it should fluctuate between 1/5 and 1/6 of the newborn’s body weight.

Gradually increase the time of breastfeeding and at the beginning of the 4th week switch to 7 times feeding.

The postoperative management of a child who has undergone the first part of a two-stage esophageal plasty has some differences due to the possibility of feeding through the esophagostomy opening. The small size of the newborn's stomach and impairment of its motor function due to injury during the creation of a fistula require fractional feeding with a gradual increase in the amount of fluid administered. Below is an approximate scheme for feeding a child after the first stage of a two-stage operation: 1st day - 3-5 ml x 10; 2nd day - 7 ml x 10; 3-4th day - 15-20ml x 10; 5th day -25-30ml x 10; Day 6 - 30-40 ml x 10. The remaining required amount of liquid is administered parenterally. From the 7th day after surgery, the volume of the stomach increases so much that up to 40-50 ml can be slowly introduced through the esophagostomy opening (3/4 of the total amount of fluid is replenished with breast milk and 1/4-10% glucose solution). From the 10th day they switch to 7 feedings a day with normal dosages in volume.

In the first days and weeks after the intervention it is necessary careful care behind fistulas on the neck and anterior abdominal wall. The latter especially needs frequent changes of dressings, treatment of the skin with antiseptic pastes, and ultraviolet radiation. A thin rubber drain inserted into the stomach is not removed 10-1 2 days until complete formation of the lower esophageal fistula. Then the tube is inserted only during feeding.

Sutures are removed on the 10-12th day after surgery. Children are discharged from the hospital (if the course is uncomplicated) after a stable increase in body weight is established (week 5-6). If a newborn has had a double esophagostomy, the mother of the child must be taught proper care for fistulas and feeding techniques.

Further monitoring of the child is carried out on an outpatient basis by a surgeon together with a pediatrician. Preventive examinations should be carried out every month before the child is sent to the second stage of the operation - the creation of an artificial esophagus.

Surgical complications in in the postoperative period occur mainly in newborns who have undergone simultaneous esophageal plasty.

The most severe complication should be considered the failure of the anastomotic sutures, which, according to published data, is observed in 10-20% of operated patients. The resulting mediastinitis and pleurisy are usually fatal, despite the creation of a gastrostomy tube, drainage of the mediastinum and the pleural cavity. If anastomotic suture dehiscence is detected early, an urgent rethoracotomy and double esophagostomy must be created.

creation of a gastrostomy and drainage of the mediastinum (with an increase in the phenomena of mediastinitis).

After the inflammatory changes subside and the final formation of the fistula tract is indicated reoperation. Sometimes recanalization is combined with stenosis in the anastomotic area.

After immediate creation of an esophageal anastomosis, all children are subject to dispensary observation at least 2 years, since late complications may occur during this period.

Some children, 1 1/2-2 months after surgery, develop a rough cough, which is associated with the formation of adhesions and scars in the area of the anastomosis and trachea. Carrying out physiotherapeutic measures helps to get rid of this late complication, which is usually eliminated at the age of 5-6 months.

In the period up to 1-1 1/2 years after surgery, isolated narrowing of the esophagus in the area of the anastomosis may occur. Treatment of this complication usually does not cause difficulties: several sessions of bougienage (under esophagoscopy control) lead to recovery.

In rare cases, conservative measures are unsuccessful, which is an indication for repeated thoracotomy and plastic surgery of the narrowed part of the esophagus.

Long-term results What we have tracked in children for 5-40 years after the creation of an anastomosis shows that they do not lag behind their peers in development. The use of a mechanical suture of the esophagus does not adversely affect the development of the organ.

An examination of 35 children who completed the second stage of a two-stage operation (retrosternal plasty of the esophagus with the colon) revealed that the created esophagus functions well, there is no regurgitation due to preserved cardiac sphincter.

The incidence of congenital anomalies of the esophagus is 1:1000 newborns. Atresia - complete absence the lumen of the esophagus in any area or along its entire length. Atresia in 40% of cases is combined with other developmental defects. In the first hours and days, newborns experience constant secretion of saliva and mucus from the mouth and nose; coughing, shortness of breath and cyanosis as a result of aspiration of the contents of the esophagus into the respiratory tract. When feeding begins, the baby regurgitates uncurdled milk.
Stenosis can develop as a result of hypertrophy of the muscular lining, the presence of a fibrous or cartilaginous ring in the wall of the esophagus, the formation of thin membranes by the mucous membrane (internal stenosis) or compression of the esophagus from the outside by cysts or abnormal vessels. Minor stenoses long time are asymptomatic and manifest dysphagia only when taken rough food. With severe stenosis, dysphagia is observed. regurgitation during and after eating. expansion of the esophagus.
Congenital bronchoesophageal and esophageal-tracheal fistulas, see “Esophageal-tracheal fistulas”.
Duplication of the esophagus - rare anomaly. The lumen of the duplications can be isolated or have a connection with the main canal of the esophagus, filled with secretion secreted by their mucous membrane. Sometimes they look like cysts that can communicate with the trachea or bronchus. As the cysts grow, symptoms of compression of the esophagus and respiratory tract develop, and patients develop dysphagia, cough, and shortness of breath.
Congenital chalazia (cardia insufficiency) is a consequence of underdevelopment of the neuromuscular apparatus of the lower esophageal sphincter or straightening of the angle of His. Clinical picture similar to the manifestations of congenital short esophagus.
Congenital short esophagus is a developmental defect in which part of the stomach is located above the diaphragm. The clinical picture is due to cardia insufficiency. accompanied by gastroesophageal reflux. After feeding, children experience regurgitation. vomiting (sometimes mixed with blood as a result of the development of esophagitis).
The diagnosis of a congenital anomaly is established by X-ray examination, during which 1-2 ml of iodolipol is injected into the lumen of the esophagus through a thin catheter. The study allows you to detect the blind end of the esophagus, the level of its location, the length and magnitude of the narrowing, suprastenotic dilatation of the esophagus, the presence of communication between the lumen of the esophagus and the bronchi or trachea. When the esophagus is doubled, an additional shadow with clear contours is noted, adjacent to the shadow of the mediastinum and pushing aside the esophagus. With a short esophagus, it has no bends*, and part of the stomach is located above the diaphragm. Lower esophageal sphincter insufficiency manifests as gastroesophageal reflux of contrast material during examination.
Main role Esophagoscopy and bronchoscopy play a role in the diagnosis of esophageal malformations.
Complications. The most a common complication at congenital atresia, stenosis, esophageal-tracheal and bronchoesophageal fistulas is aspiration pneumonia. Atresia of the esophagus can lead to the child's death from starvation; with stenosis, congestive esophagitis develops. Compression of the bronchi by the double esophagus causes repeated pneumonia, development of bronchiectasis. If a cyst is present, it may fester and rupture into the respiratory tract or pleural cavity. The lining of cysts from the ectopic gastric mucosa may undergo ulceration with the development of bleeding and perforation. With a congenital short esophagus and insufficiency of the lower esophageal sphincter, reflux esophagitis, peptic ulcer, and then esophageal stricture occur; A common complication is aspiration pneumonia.
Treatment. When the esophagus is cut off, an end-to-end anastomosis is performed in the case. if the discrepancy between the separated ends of the esophagus does not exceed 1.5 cm. If there is a significant discrepancy between the ends of the esophagus, the proximal part of it is brought out to the neck in the form of an esophagostomy, a gastrostomy is applied to feed the child, and subsequently esophagoplasty is performed.
For congenital stenosis of the esophagus up to 1.5 cm in length, a longitudinal dissection of its wall is performed with transverse suturing of the edges of the wound over the catheter. If the length of the narrowing area does not exceed 2.5 cm, then resection of the esophagus with end-to-end anastomosis is possible; if the length of the narrowing is more than 2.5 cm, esophagoplasty is indicated. If the narrowing is localized in the area of the lower esophageal sphincter, an extramucosal myotomy (Geller cardiomyotomy) with Nissen fundoplication is performed.
For esophageal-tracheal and bronchoesophageal fistulas, the fistula tract is crossed and the resulting defects in both organs are sutured.
In the case of double esophagus, enucleation or resection of the diverticulum-like area is indicated.
In case of congenital short esophagus and the absence of complications, conservative treatment is carried out. Severe reflux esophagitis is an indication for pyloroplasty or transpleural fundoplication leaving the stomach in the chest cavity.
Congenital deficiency The lower esophageal sphincter is treated conservatively. Usually, over time, its function normalizes.

LECTURE No. 4. Malformations of the esophagus. Esophageal obstruction

Various diseases of the esophagus occur in children of all age groups. Most often, the need for urgent surgical intervention arises in connection with congenital malformations and damage to the esophagus.

Somewhat less frequently, indications for emergency care are caused by bleeding from dilated veins of the esophagus during portal hypertension.

Malformations of the esophagus are among the diseases that often cause the death of children in the first days of life or the occurrence of serious complications in them that impair further development. Among the numerous congenital defects of the esophagus, those of interest for emergency surgery are those that are incompatible with the life of a child without urgent surgical correction: congenital obstruction (atresia) and esophageal-tracheal fistulas.

Esophageal obstruction

Congenital obstruction of the esophagus is caused by its atresia. This complex malformation is formed in the early stages of intrauterine life of the fetus and, according to research, is relatively common (for every 3,500 children, 1 is born with a pathology of the esophagus).

With atresia, in most cases, the upper end of the esophagus ends blindly, and the lower part communicates with the trachea, forming a tracheoesophageal fistula (90–95%). Amniotic fluid and fluid that the child swallows after birth cannot enter the stomach and accumulate along with mucus in the upper blind sac of the esophagus, then regurgitate and aspirate. The presence of a fistula in the upper segment of the esophagus accelerates aspiration - the liquid, after swallowing, partially or completely enters the trachea. The child quickly develops aspiration pneumonia, which is aggravated by the throwing of stomach contents into the trachea through the esophageal-tracheal fistula of the lower segment. A few days after birth, death occurs from aspiration pneumonia. Such children can only be saved by urgent surgical correction of the defect.

A successful outcome of treatment for congenital obstruction of the esophagus depends on many reasons, but above all, on the timely detection of atresia. When starting early special treatment the possibility of aspiration is reduced. A diagnosis made in the first hours of a child’s life (before the first feeding) will prevent or significantly alleviate the course of aspiration pneumonia.

Clinical picture

The first earliest and constant sign A sign that suggests esophageal atresia in a newborn is a large amount of foamy discharge from the mouth and nose. Suspicion of esophageal atresia should increase if, after normal suction of mucus, the latter continues to rapidly accumulate in large quantities.

The mucus at times has a yellow color, which depends on the reflux of bile into the trachea through the fistula of the distal segment of the esophagus. In all children with esophageal obstruction, by the end of the 1st day after birth, quite distinct breathing disorders (arrhythmia, shortness of breath) and cyanosis can be detected.

Auscultation reveals a large amount of moist rales of various sizes in the lungs. When the upper segment of the esophagus communicates with the trachea, aspiration pneumonia is diagnosed immediately after birth. Abdominal distension indicates a fistula between the distal esophagus and the airway.

If the first indirect signs of atresia were detected in the maternity hospital, the diagnosis should be confirmed or rejected by probing the esophagus. With atresia, a freely pushed catheter is delayed at the level of the top of the sac of the proximal segment of the esophagus (10–12 cm from the edge of the gums). If the esophagus is not changed, then the catheter easily passes over a greater distance.

It must be remembered that in some cases the catheter may fold, and then a false impression is created about the patency of the esophagus. To clarify the diagnosis, the catheter is inserted to a depth of more than 24 cm, and then its end (if there is atresia) is inevitably found in the child’s mouth.

At the first feeding, obstruction of the esophagus is detected quite clearly. All drunk liquid (1-2 sips) is immediately poured back. Feeding is accompanied by a sharp disturbance in breathing: the newborn turns blue, breathing becomes shallow, arrhythmic, and it stops. A coughing attack can last from 2 to 10 minutes, and difficulty and arrhythmia of breathing can last even longer. These phenomena occur during each feeding.

Cyanosis gradually increases. When listening to the lungs, a large number of moist rales of different sizes are revealed, mostly on the right. The child's general condition is progressively deteriorating.

With exhaustive completeness and reliability, the diagnosis is made on the basis of an X-ray examination of the esophagus using a contrast agent, which is carried out only in a surgical hospital. The obtained data are a necessary part of the preoperative examination and serve as a guide for choosing the method of surgical intervention. X-ray examination of children with suspected esophageal atresia begins with a plain chest radiograph (it is very important to carefully assess the condition of the lungs).

Then a rubber catheter is inserted into the upper segment of the esophagus and the mucus is sucked out, after which 1 ml of iodolipol is injected into the esophagus with a syringe through the same catheter. The introduction of a large amount of iodized oil can lead to an undesirable complication - overflow of the blind upper segment of the esophagus and aspiration with filling of the bronchial tree with a contrast agent.

Pictures are taken in a vertical position of the child in two projections. The contrast agent after the x-ray examination is carefully sucked out.

The use of barium sulfate as a contrast agent for examining the esophagus in newborns with any form of atresia is contraindicated, since its entry into the lungs, possible during this study, causes atelectatic pneumonia.

In the case of a child’s general serious condition (late admission, stage III–IV prematurity), it is possible not to undertake examinations with a contrast agent, but to confine oneself to the insertion of a thin rubber catheter into the esophagus (under the control of an X-ray screen), which will allow one to quite accurately determine the presence and level of atresia. It should be remembered that with rough insertion of a low-elastic thick catheter, the pliable film of the blind oral segment of the esophagus can be displaced, and then a false impression is created about the low location of the obstacle.

A characteristic radiological symptom of esophageal atresia when examined with a contrast agent is a moderately dilated and blindly ending upper segment of the esophagus. The level of atresia is more accurately determined on lateral radiographs.

The presence of air in the gastrointestinal tract indicates an anastomosis between the lower segment of the esophagus and the respiratory tract.

The visible superior cecum sac and the absence of gas in the gastrointestinal tract suggest atresia without a fistula between the distal esophagus and trachea. However, this radiological symptom does not always completely exclude the presence of a fistula between the distal segment of the esophagus and the respiratory tract.

The narrow lumen of the fistula can be clogged with a mucous plug, which serves as an obstacle to the passage of air into the stomach.

Differential diagnosis

Differential diagnosis must be made with asphyxial conditions of the newborn caused by birth trauma and aspiration pneumonia, as well as isolated tracheoesophageal fistula and “asphyxial strangulation” of the diaphragmatic hernia. In such cases, esophageal atresia is excluded by probing.

Treatment

The success of surgical intervention depends on early diagnosis of the defect, and hence the timely start of preoperative preparation, rational choice of surgical method and correct postoperative treatment.

Many combined defects have a significant impact on the prognosis.

It is extremely difficult to treat premature babies; newborns in this group experience rapidly developing pneumonia, decreased resistance, and a peculiar reaction to surgical intervention.

Preoperative preparation. Preparation for surgery begins from the moment the diagnosis is made in the maternity hospital. The child is continuously given humidified oxygen, antibiotics and vitamin K are administered.

The mucus released in large quantities is carefully sucked out through a soft rubber catheter, inserted into the nasopharynx at least every 10–15 minutes. Oral feeding is absolutely contraindicated.

The patient is transported to the surgical department according to the rules provided for newborns with the mandatory continuous supply of oxygen to the child and periodic suction of mucus from the nasopharynx.

Further preparation for the operation continues in the surgical department, striving mainly to eliminate the phenomena of pneumonia. The duration of preparation depends on the age and general condition of the child, as well as the nature of pathological changes in the lungs.

Children admitted in the first 12 hours after birth do not require lengthy preoperative preparation (1.5–2 hours is enough). During this time, the newborn is placed in a heated incubator, humidified oxygen is constantly given, and mucus is sucked out from the mouth and nasopharynx every 10–15 minutes. Antibiotics, cardiac medications and vitamin K are administered.

Children admitted later after birth with symptoms of aspiration pneumonia are prepared for surgery within 6-24 hours.

The child is placed in an elevated position in a heated incubator with a constant supply of humidified oxygen. Every 10–15 minutes, mucus is suctioned from the mouth and nasopharynx (the child needs an individual nursing station). During long-term preparation, mucus is sucked out from the trachea and bronchi every 6–8 hours through a respiratory bronchoscope or by direct laryngoscopy.

Antibiotics and cardiac medications are administered, and an aerosol with alkaline solutions and antibiotics is prescribed. For late admission, parenteral nutrition is indicated.

Preoperative preparation is stopped when there is a noticeable improvement in the child’s general condition and a decrease in the clinical manifestations of pneumonia.

If during the first 6 hours preoperative preparation does not have noticeable success, the presence of a fistulous tract between the upper segment and the trachea, in which mucus inevitably enters the respiratory tract, should be suspected.

Continuing preoperative preparation in such cases will be useless; it is necessary to proceed to surgical intervention.

Surgery for esophageal atresia, it is performed under endotracheal anesthesia. The operation of choice should be the creation of a direct anastomosis. However, the latter is possible only in cases where the diastasis between the segments of the esophagus does not exceed 1.5 cm (if the upper segment is located high, anastomosis can only be created with a special stapler).

Anastomosis with high tissue tension of esophageal segments is not justified due to technical difficulties and possible cutting of sutures in the postoperative period.

In newborns weighing less than 1500 g, multi-stage, “atypical” operations are performed: delayed anastomosis with preliminary ligation of the esophageal-tracheal fistula.

Based on clinical and radiological data, it is almost impossible to establish the true distance between the segments. This issue is finally resolved only during surgery.

If during thoracotomy a significant diastasis (more than 1.5 cm) between the segments or a thin lower segment (up to 0.5 cm) is detected, then the first part of the two-stage operation is performed - the esophageal-tracheal fistula of the lower segment is eliminated and the upper end of the esophagus is brought to the neck.

These measures prevent the development of aspiration pneumonia, thereby saving the patient’s life. The created lower esophagostomy serves to feed the child until the second stage of the operation - the formation of an artificial esophagus from the colon.

The operation of creating an anastomosis of the esophagus

Extrapleural access technique. Position of the child on the left side. The right arm is fixed in a raised and forward position. A rolled-up diaper is placed under the chest. The incision is made from the nipple line to the angle of the scapula along the 5th rib.

Bleeding vessels are carefully ligated. The muscles are carefully dissected in the fourth intercostal space. The pleura is slowly peeled off (first with a finger, then with a damp small tuff) along the incision up and down 3-4 ribs. Using a special small-sized screw wound retractor, the hooks of which are wrapped in damp gauze, the edges of the wound of the chest cavity are spread apart, then with a spatula

Buyalsky (also wrapped in gauze) the lung covered with pleura is retracted anteriorly. The mediastinal pleura is peeled off above the esophagus up to the dome and down to the diaphragm.

The true length of diastasis between segments is measured. If the anatomical relationships allow the creation of a direct anastomosis, then mobilization of the esophageal segments begins.

Technique for mobilizing esophageal segments. Find the lower segment of the esophagus. The reference point is the typical location of the vagus nerve. The latter is removed inside, the esophagus is relatively easily isolated from the surrounding tissues and taken on a holder (rubber strip).

The lower segment of the esophagus is mobilized over a short distance (2–2.5 cm), since significant exposure of it can lead to disruption of the blood supply. Directly at the point of communication with the trachea, the esophagus is tied with thin ligatures and crossed between them.

The stumps are treated with tincture of iodine. The ends of the thread on the short stump of the esophagus (at the trachea) are cut off. Additional suturing of the tracheal fistula is usually not required. Only a wide gap (more than 7 mm) is an indication for applying one row of continuous suture to the stump. The second thread at the free lower end of the esophagus is temporarily used as a “holder”. The upper segment of the esophagus is found by a catheter inserted into it through the nose before the operation.

A suture is placed at the top of the blind sac, by which it is pulled up, peeling off the mediastinal pleura, and carefully isolated upward with a damp tuff. The oral segment has a good blood supply, which allows it to be mobilized as high as possible.

Dense adhesions to the posterior wall of the trachea are carefully cut with scissors. If there is a fistula between the upper segment and the trachea, the latter is crossed, and the holes formed in the trachea and esophagus are sutured with a double-row continuous marginal suture with atraumatic needles.

The mobilized sections of the esophagus are pulled towards each other by threads. If their ends freely overlap each other (which is possible with a diastasis of up to 1.5 cm, in premature babies - 1 cm), then they begin to create an anastomosis.

Anastomosis technique. Creation of the anastomosis is the most difficult part of the operation. Difficulties arise not only due to diastasis between segments of the esophagus, but also depend on the width of the lumen of the distal segment.

The narrower its lumen, the more difficult it is to apply sutures, the greater the likelihood of their cutting through and the occurrence of narrowing of the anastomosis site in the postoperative period.

Due to the variety of anatomical options for esophageal atresia, various methods of creating anastomosis are used. Atraumatic needles are used for suturing.

Anastomosis by connecting segments of the esophagus “end to end”. The first row of separate silk sutures is placed through all layers of the lower end of the esophagus and the mucosa of the upper segment.

The second row of sutures is passed through the muscle layer of both segments of the esophagus. The greatest difficulty of this method is in applying the first row of sutures to extremely thin and delicate tissues, which erupt with the slightest tension. Anastomosis is used for small diastasis between segments of the esophagus and a wide lower segment.

After bringing their edges together, the corresponding threads are tied. When tying the sutures, the edges of the esophagus are screwed inward. The anastomosis is strengthened with a second row of separate silk sutures. Such sutures make it possible to apply an anastomosis with some tension without fear of cutting through the delicate tissues of the organ with threads.

The technique of oblique anastomosis of the esophagus significantly reduces the possibility of stricture formation at the site of suturing.

Double esophagostomy according to G. A. Bairov is the first stage of a two-stage operation and consists of the elimination of esophageal-tracheal fistulas, removal of the oral segment of the esophagus to the neck and the creation of a fistula from its distal segment for feeding the child in the postoperative period. The milk entering through the lower esophagostomy opening does not flow out after feeding, since during this operation the cardiac sphincter remains preserved.

Technique of lower esophagostomy surgery. Having made sure that creating a direct anastomosis is impossible, they begin to mobilize the esophageal segments. First, the upper segment is isolated as far as possible.

If there is a tracheal fistula, the latter is crossed, and the resulting hole in the esophagus and trachea is sutured with a continuous marginal suture. Then the lower segment is mobilized, tied at the trachea and crossed between two ligatures. Several separate silk sutures are placed on the short stump at the trachea.

The vagus nerve is pulled inwards and the esophagus is carefully dissected down to the diaphragm. By blunt means (opening the inserted Billroth forceps), the esophageal opening is widened, the stomach is pulled up and the peritoneum is dissected around the cardial region (attention should be paid to the close location of the vagus nerve).

After this, the child is turned onto his back and an upper laparotomy is performed using a right paramedian incision. The mobilized distal segment is passed into the abdominal cavity through the dilated esophageal opening.

In the epigastric region to the left of the midline, a transverse incision (1 cm) is made through all layers of the abdominal wall. The mobilized esophagus is inserted into the formed hole so that it rises at least 1 cm above the skin. Its wall is fixed from the inside with several sutures to the peritoneum, and sutured to the skin from the outside.

A thin tube is inserted into the stomach through the removed esophagus, which is fixed with a silk thread tied around the protruding part of the esophagus. Wounds of the abdominal wall and chest are sutured tightly. The operation is completed by removing the upper segment of the esophagus.

Postoperative treatment. The success of the operation largely depends on correct implementation postoperative period. For more careful care and careful monitoring in the first days after surgery, the child needs an individual nursing station and constant monitoring by a doctor. The child is placed in a heated incubator, giving the body an elevated position, and is constantly given humidified oxygen. The administration of antibiotics, vitamins K, C, B is continued, and UHF currents are prescribed to the chest. 24 hours after surgery, a control radiograph of the chest cavity is taken. Detection of atelectasis on the side of the operation is an indication for sanitation of the tracheobronchial tree.

In the first hours after surgery, the child may experience progressive respiratory failure, which requires urgent intubation and assisted breathing (after suction of mucus from the trachea).

After a few hours, the child's condition usually improves and the tube can be removed from the trachea. Re-intubation after creation of an anastomosis should be done with great caution and only by a doctor experienced in performing this manipulation in newborns.

Incorrect insertion of the tube into the esophagus instead of the trachea can result in rupture of the anastomotic sutures.

Oxygen barotherapy has a positive effect. In the postoperative period, after immediate restoration of the continuity of the esophagus, children receive parenteral nutrition for 1–2 days. The correct calculation of the amount of fluid required for parenteral administration to a child is very important. A single amount of liquid on the first day of feeding should not exceed 5–7 ml. In the following days, breast milk and glucose (5-10 ml each) are gradually added, bringing the daily volume of fluid to the age norm by the end of the week after surgery. Feeding through a tube is carried out with the child in an upright position, which prevents regurgitation of fluid through the functionally defective cardiac sphincter in the newborn. In uncomplicated cases, the probe is removed on the 8th–9th day.

The patency of the esophagus and the condition of the anastomosis are monitored after 9-10 days by X-ray examination with iodo-lipol. The absence of signs of anastomotic leakage allows you to start feeding by mouth from a bottle or from a spoon. At the first feeding, the child is given 10–20 ml of 5% glucose. and then - breast milk in half the dose of the amount that the newborn received when feeding through a tube.

In the following days, the amount of milk is increased daily by 10–15 ml for each feeding, gradually bringing it up to the norm for age and body weight. Fluid deficiency is compensated parenterally by fractional daily administration of a 10% solution of glucose, plasma, blood or albumin. This allows you to avoid a noticeable drop in body weight in the newborn.

On days 10–14, the baby is placed to the breast for 5 minutes and a control weighing is performed. They feed the baby from a bottle. During this period, the required amount of food is calculated based on the child’s body weight: it should fluctuate between 1/5 and 1/6 of the newborn’s body weight.

Gradually increase the time of breastfeeding and at the beginning of the 4th week switch to 7 feedings a day.

The postoperative management of a child who has undergone the first part of a two-stage esophageal plasty has some differences due to the possibility of feeding through the esophagostomy opening. The small size of the newborn's stomach and impairment of its motor function due to injury during the creation of a fistula require fractional feeding with a gradual increase in the amount of fluid administered. From the 7th day after surgery, the volume of the stomach increases so much that up to 40–50 ml of liquid can be slowly introduced through the esophagostomy opening (3/4 of the total amount of liquid is replenished with breast milk and a 10% glucose solution). From the 10th day they switch to feeding 7 times a day with normal dosages in volume.

In the first days after the intervention, careful care of fistulas in the neck and anterior abdominal wall is necessary. The latter especially needs frequent changes dressings, skin treatment with antiseptic pastes, irradiation ultraviolet rays. A thin rubber drainage inserted into the stomach is not removed for 10–12 days until the lower esophageal fistula is completely formed. Then the tube is inserted only during feeding.

Sutures are removed 10–12 days after surgery. Children are discharged from the hospital (with an uncomplicated course) after a stable increase in body weight is established (5–6 weeks). If a newborn has had a double esophagostomy, the child's mother must be taught proper fistula care and feeding techniques.

Further monitoring of the child is carried out on an outpatient basis by a surgeon together with a pediatrician. Preventive examinations must be carried out every month before the child is sent to the second stage of the operation - the creation of an artificial esophagus.

Surgical complications in the postoperative period occur predominantly in newborns who have undergone simultaneous esophageal plasty.

The most severe complication should be considered the failure of the anastomotic sutures, which, according to the literature, is observed in 10–20% of operated patients. The resulting mediastinitis and pleurisy usually end fatal, despite the creation of gastrostoma, drainage of the mediastinum and pleural cavity.

If anastomotic suture dehiscence is detected early, an urgent rethoracotomy and double esophagostomy must be created.

In some cases, after the creation of a direct anastomosis, recanalization of the tracheoesophageal fistula occurs, which is manifested by sharp bouts of coughing with each attempt to feed by mouth. The complication is recognized by examining the esophagus with a contrast agent (iodolipol flows into the trachea), and the final diagnosis is made by subanesthesia tracheobronchoscopy. Treatment is carried out by creating a gastrostomy and draining the mediastinum (with an increase in the symptoms of mediastinitis). After the inflammatory changes have subsided and the final formation of the fistula tract, a repeat operation is indicated. Sometimes recanalization is combined with stenosis in the area of the anastomosis.

After the immediate creation of an esophageal anastomosis, all children are subject to clinical observation for at least 2 years, since late complications may occur during this period.

Some children, 1–2 months after surgery, develop a rough cough, which is associated with the formation of adhesions and scars in the anastomosis and trachea. Carrying out physiotherapeutic measures helps to get rid of this late complication, which is usually eliminated at the age of 5–6 months.

In the period up to 1–2 years after surgery, isolated narrowing of the esophagus in the area of the anastomosis may occur. Treatment of this complication usually does not cause difficulties: several sessions of bougienage (under esophagoscopy control) lead to recovery.

In rare cases, conservative measures are unsuccessful, which is an indication for repeated thoracotomy and plastic surgery of the narrowed esophagus.

– disorders of the embryonic development of the esophagus, leading to the formation of an anatomically and histologically abnormal structure of the organ. Manifested by dysphagia and inability to enteral nutrition. Pathologies are often accompanied by respiratory symptoms: cough, shortness of breath of varying severity. Aspiration pneumonia may develop. Diagnosis of esophageal anomalies is based on clinical signs of malformations and requires x-ray and endoscopic confirmation. Surgical treatment is carried out plastic surgery, in some cases - using intestinal tissue.

If the esophagus is atretic in the middle part, contrast agent does not pass into the stomach. Gas bubble is absent in the stomach except in cases where there is a lower tracheoesophageal fistula, and large quantities of air enter the stomach from the respiratory tract. Stenosis of the esophagus is visible by the narrowing of the organ in the image. Top part The esophagus is often dilated due to excess food mass formed during feeding. Other esophageal abnormalities, such as diverticula and cysts, are also visible radiographically. An endoscopic examination is carried out according to indications to confirm stenosis and visualize the mucosa if other pathologies are suspected.

Treatment, prognosis and prevention of anomalies of the esophagus

Treatment is surgical. If an abnormal development of the esophagus is suspected, the child is transferred to a specialized surgical hospital. Tracheal intubation and mechanical ventilation are performed. Surgery can be performed through open access or thoracoscopically. When atresia of the esophagus is necessary, suturing the fistula opening and anastomosis between the blind ends of the esophagus are necessary. In the case of a defect in the middle part of the organ, the length of the ends is often not enough to create a direct anastomosis, so esophagoplasty is performed using a section of the colon lining. Other developmental anomalies of the esophagus are also indications for surgical treatment.

The prognosis for esophageal atresia is usually favorable, 95-100% of children tolerate the operation well and subsequently live a normal life. However, isolated atresia (without fistula) is rare, and the presence of communication with the respiratory tract significantly increases the risk of developing aspiration pneumonia. The latter occurs in short time and can cause the death of a child. Prevention of developmental anomalies of the esophagus is possible during pregnancy and consists of preventing intrauterine infections, excluding bad habits, timely treatment existing somatic diseases.

DISEASES OF THE ESOPHAGUS (SURGERY FOR CHILDREN)

Somewhat less frequently, indications for emergency care are caused by bleeding from dilated veins of the esophagus with portal hypertension.

DEVELOPMENTAL MALFORMATIONS OF THE ESOPHAGUS

Malformations of the esophagus are among the diseases that often cause the death of children in the first days of life or the occurrence of serious complications in them that impair further development. Among the numerous congenital defects of the esophagus, those of interest for emergency surgery are those that are incompatible with the life of a child without urgent surgical correction: congenital obstruction (atresia) and esophageal-tracheal fistulas.

Esophageal obstruction

Congenital obstruction of the esophagus is caused by its atresia. This complex malformation is formed in the early stages of intrauterine life of the fetus and, according to our data, is relatively common (for every 3,500 children, 1 is born with a malformation of the esophagus).

The formation of 6 main types of congenital obstruction of the esophagus is possible (Fig. 7).

With atresia, in most cases, the upper end of the esophagus ends blindly, and the lower part communicates with the trachea, forming a tracheoesophageal fistula (90-95%). It is clear that amniotic fluid and the liquid that the child swallows after birth cannot enter the stomach and accumulate together with saliva in the upper blind sac of the esophagus, then regurgitate and aspirate. The presence of a fistula in the upper segment of the esophagus accelerates aspiration - after swallowing, the liquid partially or completely enters the trachea. The child quickly develops aspiration pneumonia, which is aggravated by the throwing of stomach contents into the trachea through the esophageal-tracheal fistula of the lower segment. A few days after birth, the child dies from aspiration pneumonia. Such children can only be saved by urgent surgical correction of the defect.

Clinical picture. The first, earliest and most consistent sign that suggests esophageal atresia in a newborn is a large amount of foamy discharge from the mouth and nose. Unfortunately, this sign, which is noted in the documentation of maternity hospitals for all children, is not always given due importance and assessed correctly. Suspicion of esophageal atresia should increase if, after normal suction of mucus, the latter continues to rapidly accumulate in large quantities. The mucus at times has a yellow color, which depends on the reflux of bile into the trachea through the fistula of the distal segment of the esophagus. In all children with esophageal obstruction, by the end of the 1st day after birth, quite distinct breathing disorders (arrhythmia, shortness of breath) and cyanosis can be detected. Auscultation reveals a large amount of moist rales of various sizes in the lungs. Abdominal bloating indicates an existing fistula between the distal segment of the esophagus and the respiratory tract.

If the first indirect signs of atresia were identified in the maternity hospital, then the diagnosis should also be confirmed or rejected by probing the esophagus.

bridge of the esophagus. To clarify the diagnosis, the catheter is inserted to a depth of more than 24 cm, and then its end (if there is atresia) will definitely be found in the child’s mouth.

At the first feeding, obstruction of the esophagus is detected quite clearly. All the liquid you drink (1-2 sips) is immediately poured back out. Feeding is accompanied by severe breathing difficulties; the newborn turns blue, breathing becomes shallow, arrhythmic, and it stops. A coughing attack can last from 2 to 10 minutes, and difficulty and arrhythmia of breathing can last even longer. These phenomena occur during each feeding. Cyanosis gradually increases. When listening to the lungs, a large number of moist rales of different sizes are revealed, more on the right. The child's general condition is progressively deteriorating.

With exhaustive completeness and reliability, the diagnosis is established on the basis of an X-ray examination of the esophagus using a contrast agent, which is carried out only in a surgical hospital. The obtained data are a necessary part of the preoperative examination and serve as a guide for choosing the method of surgical intervention. X-ray examination of children with suspected esophageal atresia begins with a plain chest x-ray (it is very important to carefully assess the condition of the lungs!). Then a rubber catheter is inserted into the upper segment of the esophagus and the mucus is sucked out, after which 1 ml of a 30% water-soluble contrast agent is injected into the esophagus through the same catheter using a syringe. The introduction of a large amount can lead to an undesirable complication - overflow of the blind upper segment of the esophagus and aspiration with filling of the bronchial tree with a contrast agent . Radiographs are taken with the child in an upright position in two projections. After the X-ray examination, the contrast agent is carefully aspirated. The use of barium sulfate for examination of the esophagus in newborns with any form of atresia is contraindicated, since its possible entry into the lungs causes atelectatic pneumonia.

In case of general serious condition of the child (late admission, prematurity III - IV degrees, etc.) you can not undertake examinations with a contrast agent, but limit yourself to inserting a thin rubber catheter into the esophagus (under the control of an X-ray screen), which will allow you to fairly accurately determine the presence and level of atresia. It should be remembered that with rough insertion of a low-elastic thick catheter, the pliable film of the blind oral segment of the esophagus can be displaced, and then a false impression is created about the low location of the obstacle.

the presence of air in the gastrointestinal tract indicates an anastomosis between the lower segment of the esophagus and the respiratory tract.

Differential diagnosishas to be carried out with asphyxial conditions of the newborn caused by birth trauma and aspiration pneumonia, as well as isolated tracheoesophageal fistula and “asphyxial strangulation” of the diaphragmatic hernia. In such cases, esophageal atresia is excluded by probing.

Treatment.Published data and analysis of our observations show that the success of surgical intervention depends on early diagnosis of the defect, and hence the timely start of preoperative preparation, rational choice of surgical method and correct postoperative treatment.

It should be noted that in the last 5 years, among the 44 premature babies we operated on, 23 recovered (of which 8 were without associated developmental defects).

Children admitted later after birth with symptoms of aspiration pneumonia are prepared for surgery within 6-24 hours. The child is placed in an elevated position in a heated incubator with a constant supply of humidified oxygen. Every 10-15 minutes, mucus is sucked out from the mouth and nasopharynx (an individual nursing station is required!). During long-term preparation, mucus is sucked out from the trachea and bronchi every 6-8 hours. Antibiotics are administered, an aerosol with alkaline solutions and antibiotics is prescribed. For late admission, parenteral nutrition is indicated (for fluid calculations, see Chapter 1). Preoperative preparation is stopped when there is a noticeable improvement in the child’s general condition and a decrease in the clinical manifestations of pneumonia.

Surgery in case of esophageal atresia, it is carried out under endotracheal anesthesia and protective blood transfusion. The operation of choice should be the creation of a direct anastomosis. However, the latter is possible only in cases where the diastasis between the segments of the esophagus does not exceed 1.5 cm (with a high location of the upper segment, at the level Th 1,- Th 2 creation of an anastomosis is possible only with the help of a special stapler). Anastomosis with high tissue tension of esophageal segments is not justified due to technical difficulties and possible cutting of sutures in the postoperative period.

II stage of the operation - the formation of an artificial esophagus from the colon.

Extrapleural access technique. The child lies on his left side. The right arm is fixed in a raised and forward position. A rolled-up diaper is placed under the chest. The incision is made from the mid-axillary line to the paravertebral line along the IV ribs Bleeding vessels are carefully ligated. The muscles in the fourth intercostal space are carefully dissected. The pleura is slowly peeled off (first with a finger, then with a damp small tuff) along the incision up and down 3-4 ribs. Using a special small-sized screw wound retractor, the edges of the chest wall wound are spread apart, after which the lung covered with pleura is retracted anteriorly and downwards. The mediastinal pleura is peeled off above the esophagus up to the dome. If the anatomical relationships allow the creation of a direct anastomosis, then mobilization of the esophageal segments begins.

Technique for mobilizing food segments. Find the lower segment of the esophagus. The reference point is the typical location of the vagus nerve. The latter is removed inwardly, the esophagus is relatively easily isolated from the surrounding tissues and taken onto a holder (rubber strip). The lower segment of the esophagus is mobilized over a short distance (2-2.5 cm), since significant exposure of it can lead to disruption of the blood supply. Directly at the point of communication with the trachea, the esophagus is tied with thin ligatures and crossed between them. Stumps are processed alcohol solution Yoda. The ends of the thread on the short stump of the esophagus (at the trachea) are cut off. Suturing of a tracheal fistula is usually not required. Only a wide gap (more than 7 mm) is an indication for applying one row of continuous suture to the stump. The second thread at the free lower end of the esophagus is temporarily used as a “holder”. The upper segment of the esophagus is found by a catheter inserted into it through the nose before the operation. A “holder” suture is placed on the top of the blind sac, by which it is pulled up, peeling off the mediastinal pleura, and carefully isolated upward with a damp tupper (do not touch it with tweezers!). The oral segment has a good blood supply, 1 which allows it to be mobilized as high as possible. Dense adhesions to the posterior wall of the trachea are carefully cut with scissors. If there is a fistula between the upper segment and the trachea, the latter is crossed, and the holes formed in the trachea and esophagus are sutured with a single-row continuous marginal suture with atraumatic needles. The mobilized sections of the esophagus are pulled towards each other by the “holder” threads (Fig. 9). If their ends freely overlap each other, then they begin to create an anastomosis.

Technique for creating anastomosis. Creation of the anastomosis is the most difficult part of the operation. It should be noted that difficulties arise not only due to diastasis between segments of the esophagus, but also depend on the width of the lumen of the distal segment. The narrower its lumen, the more difficult it is to apply sutures, the greater the likelihood of their cutting through and the occurrence of narrowing of the anastomosis site in the postoperative period. According to our data, most often the distal segment has a lumen width of up to 0.4-0.6 cm.

Due to the variety of anatomical options for esophageal atresia, various methods of creating anastomosis are used. Atraumatic needles are used for suturing.

In our clinic, we successfully used mechanical suture of segments of the esophagus using a special stitching device from the Research Institute of Higher Artificial Research. The use of a mechanical suture significantly reduces the operation time and simplifies the technique of creating an anastomosis. Contraindications are significant diastasis between segments, severe underdevelopment of the distal segment of the esophagus and prematurity III - IV degrees.

Technique of lower esophagostomy. Having made sure that creating a direct anastomosis is impossible, they begin to mobilize the esophageal segments. First, the upper segment is isolated as far as possible. If there is a tracheal fistula, the latter is crossed, and the resulting hole in the esophagus and trachea is sutured with a continuous marginal suture. Then the lower segment is mobilized, tied at the trachea and crossed between two ligatures. Several separate silk sutures are placed on the short stump near the trachea. The vagus nerve is removed medially, and the esophagus is carefully isolated to the diaphragm (Fig. 15, a). By blunt means (opening the inserted Billroth forceps), the esophageal opening is widened, the stomach is pulled up and the peritoneal layer is cut around the cardiac section (take care nervus vagus. После этого ребенка поворачивают на спину и про--изводят верхнюю лапаротомию правым парамедианным разрезом. Мобилизованный дистальный сегмент проводят в брюшную полость через расширенное пищеводное отверстие (рис. 15, б, в). В надчревной области слева от средней линии производят поперечный разрез (1 см) через все слои брюшной стенки. !}

The mobilized esophagus is inserted into the formed hole (Fig. 15, d) so that it rises above the skin by at least 1 cm. Its wall is fixed from the inside with several sutures to the peritoneum, and sutured to the skin from the outside (Fig. 15, e). A thin tube is inserted into the stomach through the removed esophagus, which is fixed with a silk thread tied around the protruding part of the esophagus. Wounds of the abdominal wall and chest are sutured tightly (Fig. 15, f). The operation is completed by removing the upper segment of the esophagus.

Technique of upper esophageal gostomy. A thin cushion (folded diaper) is placed under the child’s shoulder blades. The head is turned to the right. Skin incision up to I -1.5 cm is carried out above the collarbone on the left at the internal tap of the sternocleidomastoid muscle (Fig. 16, a). The superficial fascia is dissected and the tissue is bluntly dissected to the esophagus (the latter is detected by the catheter inserted into it before surgery). The curved end of the dissector is used to bypass the esophagus, mobilize it in the distal direction, and the blind end is brought out into the wound (Fig. 16, b). Using several (4-5) separate sutures (with an atraumatic needle), its wall is fixed around its circumference in the depths of the wound to the neck muscles. Then the lumen of the esophagus is opened, cutting off its apex, and the edges are sutured to the skin through all layers (Fig. 16, c).

The second stage of the operation - the formation of the esophagus from the colon - is carried out at the age of 1 1/2-2 years.

Postoperative treatment. The success of the operation largely depends on the correct conduct of the postoperative period. For more careful care and careful monitoring in the first days after surgery, the child needs an individual nursing station and constant monitoring by a doctor. The child is placed in a heated incubator, giving the body an elevated position, and is constantly given humidified oxygen. The administration of antibiotics, vitamins K, C, group B, and UHF field to the chest are continued. 24 hours after surgery, a control radiograph of the chest cavity is taken. Detection of atelectasis on the side of the operation is an indication for sanitation of the tracheo-bronchial tree.

In the first hours after surgery, the child may experience progressive respiratory failure, which requires urgent tracheal intubation and assisted breathing (after suction of mucus from the trachea). After a few hours, the child's condition usually improves and the tube can be removed from the trachea. Re-intubation after creation of an anastomosis should be done with great caution and only by a doctor experienced in performing this manipulation in newborns. Incorrect insertion of the tube into the esophagus instead of the trachea can result in rupture of the anastomotic sutures.

Gradually increase the time of breastfeeding and at the beginning of the 4th week switch to 7 times feeding.

In the first days and weeks after the intervention, careful care of fistulas in the neck and anterior abdominal wall is necessary. The latter especially needs frequent changes of dressings, treatment of the skin with antiseptic pastes, and ultraviolet radiation. A thin rubber drain inserted into the stomach is not removed 10-1 2 days until complete formation of the lower esophageal fistula. Then the tube is inserted only during feeding.

Sutures are removed on the 10-12th day after surgery. Children are discharged from the hospital (if the course is uncomplicated) after a stable increase in body weight is established (week 5-6). If a newborn has had a double esophagostomy, the child's mother must be taught proper fistula care and feeding techniques.

Further monitoring of the child is carried out on an outpatient basis by a surgeon together with a pediatrician. Preventive examinations should be carried out every month before the child is sent to II stage of the operation - creation of an artificial esophagus.

Surgical complications inin the postoperative period occur mainly in newborns who have undergone simultaneous esophageal plasty.

creation of a gastrostomy and drainage of the mediastinum (with an increase in the phenomena of mediastinitis).

After the inflammatory changes have subsided and the fistula tract has finally formed, a repeat operation is indicated. Sometimes recanalization is combined with stenosis in the anastomotic area.

After the immediate creation of an esophageal anastomosis, all children are subject to clinical observation for at least 2 years, since late complications may occur during this period.

In rare cases, conservative measures are unsuccessful, which is an indication for repeated thoracotomy and plastic surgery of the narrowed part of the esophagus.

Long-term resultsWhat we have tracked in children for 5-40 years after the creation of an anastomosis shows that they do not lag behind their peers in development. The use of a mechanical suture of the esophagus does not adversely affect the development of the organ.

Examination of 35 children who completed II stage of a two-stage operation (retrosternal plasty of the esophagus with the colon), revealed that the created esophagus functions well, there is no regurgitation due to the preserved cardiac sphincter.

Esophageal tracheal fistulas

The presence of a congenital anastomosis between the esophagus and trachea without other anomalies of these organs is rare. Over the past 30 years, we have operated on 28 children aged from the first days of life to 10 years with isolated esophageal-tracheal fistulas. In addition, 31 newborns with suspicion of this pathological condition were sent to the clinic. After a thorough examination, the disease was ruled out.

There are three main variants of the defect (Fig. 17), among which there is a predominantly short and wide fistulous tract. The anastomosis, as a rule, is located high, at the level of the first thoracic vertebrae.

The presence of a fistulous tract between the esophagus and trachea leads to the rapid development of pneumonia due to aspiration of fluid swallowed by the child. An unrecognized and untreated fistula usually causes the death of a child. Only with a narrow anastomosis the symptoms are sometimes mild, and in such cases patients can live a long time.

Clinical picture. Symptoms of esophageal-tracheal fistula appear V in most cases after the child’s first feedings, but their intensity depends on the type of malformation.

A narrow and long fistulous tract (Fig. 17, a) is usually not detected during the newborn period. Such children rarely experience severe attacks cough. Parents do not attach importance to them, since feeding the child in a certain position relieves him of seizures. The child often suffers from pneumonia.

In cases of a wide and short fistula (Fig. 17, b), feeding a newborn is almost always accompanied by a coughing fit, cyanosis, foamy discharge from mouth. In such children, aspiration pneumonia quickly develops. After eating, the amount of moist coarse bubbling rales in the lungs increases. Feeding the child in an upright position reduces the possibility of milk flowing through the fistulous tract into the trachea, and coughing occurs less frequently and is not accompanied by cyanosis.

A large anastomosis, in which both organs at some distance are represented as if by one common tube (Fig. 17, c), appears during the first feeding. Every sip of liquid causes a coughing attack. Respiratory failure can be prolonged, accompanied by severe cyanosis. The general condition progressively worsens due to severe pneumonia and extensive pulmonary atelectasis.

X-ray examination is of particular importance for the diagnosis of esophageal-tracheal fistula. Plain radiographs reveal the nature of pathological changes in the lungs. If aspiration pneumonia is clinically and radiologically determined, then special studies are postponed until the process in the lungs subsides (treatment of pneumonia is part of preoperative preparation). In older children, the fistulous tract can be detected x-ray when examining the esophagus with a liquid contrast agent - iodolipol or lipoidol. The child is placed on the screen on the X-ray table in a horizontal position. The contrast agent is given from a spoon or administered through a catheter inserted into the initial part of the esophagus. It is generally accepted that partial or complete filling of the bronchial tree with a contrasting agent indicates the presence of an anastomosis. The latter is usually not detected on an x-ray. By carefully observing through the screen the passage of the contrast agent through the esophagus, sometimes you can catch the moment it passes through the fistula into the trachea.

Clinical and radiological data on the presence of an esophageal-tracheal fistula can be confirmed by esophagoscopy. When an esophagoscope is inserted and the esophagus is examined, the fistulous tract becomes noticeable by small air bubbles released from it in time with breathing. A narrow fistula is usually not visible during esophagoscopy; it is masked by folds of the mucous membrane.

A clearly defined fistulous tract is determined only during tracheobronchoscopic examination, which is performed under anesthesia in all children with suspected esophageal-tracheal fistula. When a bronchoscope is inserted to a depth of 8-12 cm, usually 1-2 cm above the tracheal bifurcation along its postero-right surface, a slit-like defect (fistula) located along the cartilaginous ring is visible. Identification of a fistula is facilitated by injecting a 1% solution of methylene blue into the esophagus, which, penetrating into the trachea through the fistula, emphasizes its contours.

Differential diagnosis difficult during the neonatal period, when it is necessary to exclude an esophageal-tracheal fistula if the child has birth trauma accompanied by impaired swallowing or paresis soft palate. When feeding, such newborns periodically experience coughing attacks, disturbances in breathing rhythm, and pneumonia increases. X-ray examination of the esophagus with iodolipol in these cases does not clarify the diagnosis, since in both diseases a contrast agent can be thrown (aspiration) into the respiratory tract (bronchography). For differential diagnosis, feeding the child begins only through a tube inserted into the stomach. After aspiration pneumonia subsides, tracheobronchoscopy is performed, which allows you to confirm or exclude the diagnosis of esophageal-tracheal fistula.

Treatment.Elimination of congenital esophageal-tracheal fistula is possible only surgically. Surgery is performed immediately after diagnosis.

Preoperative preparation. Preoperative preparation begins immediately after identifying the clinical symptoms of an esophageal-tracheal fistula. The child is completely excluded from oral feeding - all the required amount of liquid is introduced into the stomach through a tube, which is removed after each feeding. From the first day, active anti-pneumonic treatment begins: antibiotics, oxygen therapy, UHF field chest, alkaline aerosol with antibiotics, mustard wrap, intravenous administration of blood plasma, vitamins. The child is in a heated incubator with high humidity. Several sessions of oxygen barotherapy are performed. The duration of preoperative preparation varies: 2-10 days (until the elimination or noticeable reduction of pneumonia).

Surgery for congenital esophageal-tracheal fistula is performed under endotracheal anesthesia and protective blood transfusion. The child's position is on the left side.

Operation technique. The most convenient access for infants is extrapleural, in the fourth intercostal space on the right (for a high fistula - C 1 - Th 1 -recommend access through an incision in the neck). The lung, covered with pleura, is retracted anteriorly and medially, and the mediastinal pleura is peeled off above the esophagus. The esophagus is mobilized over 1.5-2 cm upward and downward from the place of its communication with the trachea.

If there is a long fistula tract (see Fig. 17, a), the latter is isolated, tied with two silk ligatures, crossed between them, and the stumps are treated with an alcohol solution of iodine. Over the Crossed fistulous course one row of submersible silk sutures with an atraumatic needle is applied to the esophagus and trachea.

With a wide and short fistula (see Fig. 17, b), the esophagus is carefully cut off from the trachea with scissors, and the resulting holes are closed with a double-row continuous suture with atraumatic needles. To prevent postoperative narrowing of the esophagus, the latter is sutured in the transverse direction (above the catheter inserted before surgery).

The most difficult to eliminate is a large esophageal-tracheal fistula, in which both organs have common walls for some extent (0.7-1 cm) (see Fig. 17, c). In such cases, the esophagus is crossed above and below the level of the connection with the trachea (Fig. 18, a). The holes formed on the trachea are sutured with two rows of silk sutures (Fig. 18, b), then the continuity of the esophagus is restored by creating an end-to-end anastomosis (Fig. 18, c). A thin polyethylene tube is inserted into the stomach to feed the baby. With extrapleural access to the mediastinal space, a thin (3-4 mm) polyethylene tube is brought to the area of the esophageal sutures (through a separate puncture in the sixth intercostal space) for 2-3 days. The chest cavity is closed tightly. With transpleural access, the mediastinal pleura is sutured. The air remaining in the pleural cavity after suturing the chest wall (detected on control radiographs) is sucked out with a syringe during puncture.

Postoperative treatment. In the postoperative period, the child continues to receive active therapy against pneumonia, since surgery usually causes an exacerbation of the process in the lungs. The patient is placed in an elevated position, aerosol therapy is prescribed, humidified oxygen is constantly given, antibiotics and cardiac drugs are administered. On the first day after the operation, mustard plasters are placed on the chest on the left, and with next day A UHF field is assigned to the lung area. According to indications, bronchoscopy and mucus suction are performed.

On the first day, the child needs parenteral nutrition, then feeding is carried out in fractional doses every 3 hours through a thin tube left during surgery. The amount of fluid is calculated depending on the age and body weight of the child. Over the course of 2-3 days, 3 volumes of liquid are administered through a tube, the remaining amount is administered intravenously. The tube is removed on the 5-6th day (when creating an end-to-end anastomosis, feeding through a tube is continued for 9-10 days). From day 6 to 8, the child should receive the usual age norm breast milk. Older children are prescribed liquid food from the 7-8th day after surgery.

The patient is discharged home on the 20-25th day when the symptoms of pneumonia are eliminated (in infants, in addition, a stable increase in body weight should be established). Before discharge, a control check is performed. X-ray examination esophagus with contrast. In cases where narrowing is detected in the area former fistula a course of bougienage should be carried out, which begins no earlier than a month after the operation.

DAMAGE TO THE ESOPHAGUS

In children, damage to the esophagus is observed relatively rarely, occurring mainly in connection with chemical burns or perforation of the organ wall (foreign bodies, instruments). Clinical course and therapeutic measures These types of injuries, which are different in nature, have their own characteristics.

Chemical burns

The severity of a burn to the esophagus and the degree of its pathological changes depend on the amount and nature of the chemical substance ingested by the child.

When exposed to acids, the depth of damage to the wall of the esophagus is less than when exposed to alkalis. This is explained by the fact that acids, neutralizing tissue alkalis, coagulate cell protein and at the same time

take water away from them. As a result, a dry scab is formed, which prevents acids from penetrating deeper. Exposure to alkalis on tissue is accompanied by liquefaction necrosis. The absence of a scab leads to deep penetration of the caustic substance into the tissues and damage them. S. D. Ternovsky et al. (1963) distinguish three degrees of esophageal burn: mild, moderate and severe.

Mild degreecharacterized by damage to the mucous membrane like desquamative esophagitis. In this case, hyperemia, edema and areas of superficial necrosis are noted. Calm down inflammatory process and epithelization occur within 7-10 days. The resulting superficial scars are elastic, do not narrow the lumen of the esophagus and do not affect its function.

At medium degree the lesions are deeper. Necrosis extends to all layers of the organ. After 3-6 weeks, as necrotic tissue is rejected, the wound surface becomes covered with granulations and then scars. The depth and prevalence of scar changes depend on the severity of damage to the esophageal wall.

Severe degreecharacterized by deep and extensive damage to the esophagus with necrosis of all layers of its wall. The burn is accompanied by mediastinitis.

Clinical picture burn of the esophagus depends on the nature of the substance that caused the burn and the degree of damage to the esophagus. From the first hours after the burn, the condition of children is serious due to the developing phenomena of shock, swelling of the larynx and lungs, as well as intoxication and exicosis. As a result of rapidly increasing inflammation, profuse salivation is observed, often repeated, painful vomiting. From the moment the caustic substance enters, a burning pain appears in the mouth, in the pharynx, behind the sternum and in the epigastric region. It intensifies with swallowing, coughing and vomiting movements, so all children persistently refuse to eat and drink. The inflammatory process is accompanied by an increase in body temperature to high levels. The phenomena of dysphagia can be explained as pain , and swelling of the mucous membrane of the esophagus.

The clinical course of the disease is divided into three periods. The first period is characterized by acute inflammation of the mucous membrane of the eyes, pharynx and esophagus, and in the coming hours the swelling and pain increase, the child refuses to eat, and a high fever is noted. This often continues for up to 10 days, and then the child’s condition improves, pain disappears, swelling decreases, body temperature normalizes, patency of the esophagus is restored - children begin to eat any food. The acute stage gradually turns into an asymptomatic period. Apparent well-being sometimes lasts up to 4 weeks. 3-6 weeks after the burn, a period of scarring begins. The phenomena of esophageal obstruction gradually increase. Children vomit and experience chest pain.

X-ray examination with contrast during the period of scarring allows us to identify the nature, degree and extent of the pathological process.

Treatment.A child who has received a chemical burn to the esophagus must be urgently hospitalized. In the acute stage of the disease, measures are taken to eliminate the state of shock and vigorous detoxification therapy aimed at preventing or reducing the local and general effects of the poison. To do this, the victim is given painkillers and cardiac medications, and the stomach is washed through a tube. Depending on the nature of the caustic substance, rinsing is done with either a 0.1% solution of hydrochloric acid (for a burn with alkali) or a 2-3% solution baking soda(for acid burns) in a volume of 2-3 liters. According to S. D. Ternovsky, there are no complications from the insertion of a gastric tube. The fear of esophageal perforation during this manipulation should be considered unfounded.

The complex of anti-shock measures, in addition to the administration of cardiac drugs and pantopon, includes intravenous infusions of plasma, glucose solution, vagosympathetic cervical novocaine blockade. To prevent pulmonary complications, constant inhalation of humidified oxygen and an elevated position are advisable. The possibility of secondary infection layering dictates early application antibacterial therapy (antibiotics wide range actions).

The stomach is washed not only during emergency care, but also 12-24 hours after the burn. This removes any remaining chemicals in the stomach.

An important therapeutic factor is the use of hormones, vitamin therapy and prescription rational nutrition. In severe cases, when children refuse food and water, protein preparations and liquid are administered intravenously for 2-4 days to relieve intoxication and for the purpose of parenteral nutrition. Once the general condition improves, the patient is prescribed oral feeding with high-energy chilled food, first liquid (broth, egg, milk), and then well pureed ( vegetable soups, cottage cheese, porridge). From the first days after injury, children should receive oral I a dessert spoon of vegetable or vaseline oil, it has a softening effect and improves the passage of the food bolus through the esophagus.

Before recent years The main method of treating burns of the esophagus is bougienage. There are early, or preventive, bougienage and later, therapeutic, for cicatricial stenosis of the esophagus. Treatment tactics are determined by the degree of burn to the oral cavity, pharynx and esophagus. To identify and assess the nature of the lesion and its extent, diagnostic esophagoscopy is performed.

Early bougienage prevents the formation of cicatricial stenosis of the esophagus. Bougienage begins on the 5-8th day after the burn. Only special soft bougies are used. By this time, acute inflammatory changes in the wall of the esophagus subside, granulations appear, the general condition of the child improves, and body temperature normalizes [Biezin A.P., 1966]. Bougienage is carried out without anesthesia 3 times a week for 1 1/2-2 months. During this period, the child is in the hospital. Then he is discharged to outpatient

Thorough treatment by prescribing bougienage once a week for 2-3 months, and in the next six months - 1-2 times a month.

In rare cases, with severe and widespread burns accompanied by mediastinitis, the child cannot eat. To prevent exhaustion, they resort to creating a gastrostomy, which is also necessary for complete rest of the organ. This has a beneficial effect on the course of the inflammatory process and promotes regeneration. Only after the child is brought out of a serious condition, the question of the method of further treatment is decided. Usually, from the 5th to 7th week, attempts at direct bougienage using an esophagoscope begin. The presence of a gastrostomy allows the use of “bougienage by thread”.

With timely and correct treatment chemical burns esophagus in children, good long-term results are obtained in almost 90% of cases [Ternovsky S. D. et al., 1963; Biezin A.P. et al., 196.6], Cicatricial obstruction of the esophagus that occurs after a burn is an indication for plastic surgery of the esophagus with an intestinal graft.

Perforation of the esophagus

Perforation of the esophagus in children occurs mainly during bougie-drying due to cicatricial stenosis, damage by a sharp foreign body, or during instrumental examination. Up to 80% of these complications occur in medical institutions, which creates favorable conditions for early recognition and provision of necessary medical care. However, due to the fact that damage to the esophagus is more often observed in children in the first years of life, timely diagnosis of complications can be extremely difficult. Usually, the attending physician thinks about perforation of the esophagus in connection with the development of signs of media astinitis. Most surgeons explain the extremely severe course and prognosis of this complication in children anatomical features structures of the mediastinum.

Clinical picture acute purulent mediastinitis in children, especially younger age, unstable and V depends largely on the nature of the damage to the esophagus.

With the slow formation of perforation, observed in connection with a pressure sore of the esophageal wall with a foreign body (coin, bone), the surrounding tissues are gradually involved in the process, which react with inflammatory demarcation. This leads to some delimitation of the process, and it is extremely difficult to detect the moment of damage to the esophagus. The complication in such cases is diagnosed by a combination of rapidly developing general symptoms, physical and radiological data.

One of the first symptoms of acute purulent mediastinitis is chest pain. The localization is difficult to determine, and only in older children can it be clarified that it can be retrosternal and intensifies with swallowing.

The child’s resistance to examination usually excludes the possibility of using “painful” symptoms for diagnosis - the appearance of pain when throwing back the head or passive displacement of the trachea.

The child becomes inactive, any change in position in bed causes anxiety and resistance due to increasing pain. The patient's general condition is rapidly deteriorating. Shortness of breath appears. The disease is often accompanied by a persistent cough. Body temperature rises to 39-40 0 C. Physical examination reveals moist rales, and in some cases shortening of the percussion sound in the interscapular space. When examining blood, a sharp increase in the number of leukocytes and neutrophils is noted with a shift in leukocyte formula to the left.

X-ray examination, as a rule, confirms the presumptive diagnosis. Widening of the mediastinal shadow, the presence of emphysema, and contrast studies usually help determine the level of damage to the esophagus. Esophagoscopy for acute purulent mediastinitis in children is usually not performed, since additional trauma to the organ can worsen the already serious condition sick.

Mediastinitis, which occurs in children due to perforation of the esophagus by sharp foreign bodies, is diagnosed with less difficulty. The very fact of the presence of an acute body in the esophagus suggests damage to the wall of the organ. If instrumental removal of the foreign body turned out to be impossible and the patient experienced a sharp deterioration in his general condition, chest pain appeared, and body temperature increased, then there is no doubt about the diagnosis. Recognition of mediastinitis is helped by X-ray data (stationary position of the foreign body, expansion of the mediastinal shadow, and sometimes the presence of gas in it). In such cases, immediate surgical removal foreign body.

Perforation of the esophagus with instruments usually occurs during bougieration due to cicatricial narrowing or during esophagoscopy. Published data indicate a serious prognosis for this complication. Diagnosis, as a rule, does not cause difficulties due to the appearance of sharp pain at the time of damage to the wall of the esophagus. Perforation is accompanied by symptoms of shock, the child turns pale, the pulse rate decreases, and blood pressure noticeably decreases. After removing the bougie and carrying out special therapy (painkillers, intravenous infusion of calcium chloride, blood, anti-shock fluid), the patient’s condition improves somewhat, but the chest pain continues to bother. Developing quickly general symptoms mediastinitis: body temperature rises, shortness of breath, pneumonia appear, the blood picture changes, and health sharply worsens. If the esophagus is damaged and inflammation is localized in lower parts In the mediastinum, pain under the xiphoid process and symptoms of peritoneal irritation are noted. Subcutaneous emphysema is often detected. The leading role in establishing the diagnosis of esophageal perforation is played by

X-ray examination. Direct radiological symptoms are the presence of air in the soft tissues of the mediastinum and neck, as well as the flow of contrasting mass beyond the contours of the esophagus.

Treatmentchildren with perforation of the esophagus and the development of a purulent focus in the mediastinum requires an individual approach and should be comprehensive. Immediately after the diagnosis is made, intensive conservative therapy is started.

Conservative therapy consists of intravenous drip administration of blood, 10% glucose solution, protein preparations, antibiotics, and physiotherapy. Eating by mouth is completely excluded. Our observations show that only minor damage to the esophagus during bougienage (covered) can be treated with conservative methods. However, such patients require close attention from the surgeon. The lack of improvement in general condition during the first day forces surgery. In such cases, the conservative measures taken are preoperative preparation, the duration of which is determined individually, but in severe cases should not exceed several hours.

Surgical treatment begin with the creation of a gastrostomy tube. Further surgical tactics depends on the nature of the damage to the esophagus and the extent of mediastinitis.

Judging by the published data, the question of the method of surgical intervention for significant damage to the esophagus has not yet been resolved. Most authors indicate that in children it is necessary to perform urgent suturing of the perforation hole.

The presence of an acute foreign body in the esophagus, leading to perforation and the development of mediastinitis, is an indication for urgent mediastinotomy. The operation in such cases has two goals - 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 (bedsore) associated with long stay foreign body in the esophagus, drainage of the mediastinum is indicated. The nature of the surgical approach depends on the level of inflammation: the upper sections are drained by cervical mediastinotomy according to Razumovsky, the middle and posterior sections are drained using extrapleural access according to Nasilov. Regardless of the drainage methods, 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.

If the complication is diagnosed relatively late, and the child has a formed, delimited abscess, then drainage of the mediastinum is also necessary and is often effective.

Damage to the esophagus and the rapid spread of a purulent process in the mediastinum usually leads to a breakthrough of the abscess into the pleural cavity. In such cases, urgent thoracotomy with drainage of the pleural cavity is indicated. However, the surgeon starting the operation should

Remember that interventions are rarely “typical.” Sometimes you have to deal with extremely severe damage to the esophagus, which requires resection.

A 3"/2 year old boy was sent to our clinic, who a month ago accidentally drank caustic husk. As his general condition improved, the esophagus was perforated during an attempt at bougienage in the hospital at his place of residence. During the operation, we discovered melting of the esophagus from Th 4 to the diaphragm and its longitudinal rupture along the rear wall. Resection of the changed part of the organ was performed. The upper segment of the esophagus is brought to the neck, the lower segment is sutured, the mediastinum is drained. A gastrostomy according to Kader was created. After 3 years, retrosternal plasty of the esophagus with an intestinal graft was performed.

Postoperative treatment Treatment of children with esophageal perforation and mediastinitis requires persistence and great attention, and the use of the entire range of therapeutic measures.

After the operation, the child is placed in an elevated position and constantly humidified oxygen is prescribed. Painkillers are administered after 4-6 hours. Intravenous drip infusion is continued for 2-3 days. Transfusion of blood and protein preparations (plasma, albumin) is carried out daily in the first week, then after I -2 days. The child is prescribed broad-spectrum antibiotics (according to sensitivity), producing them. replacement in 6-7 days. Tampons are tightened after 2-3 days and then removed. Drainage in the mediastinum is left until purulent discharge stops. An esophageal fistula usually closes on its own. The child is given physiotherapeutic treatment (UHF, potassium iodide electrophoresis). If there is a connection between the mediastinal abscess and 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. (0.490-0.686 kPa). Tube from pleural cavity removed after the elimination of the esophageal fistula and pleurisy.

The child is fed through a gastrostomy tube with high-energy food. After the elimination of mediastinitis and healing of the esophageal wound, oral feeding begins (if there is no stenosis). Plastic surgery on the esophagus (intestinal transplantation, resection) is possible at least 2 years after full recovery from mediastinitis.

Bleeding from dilated veins of the esophagus with portal hypertension

The most severe and common complication of portal hypertension syndrome is bleeding from esophageal varices. The reasons for its occurrence are mainly an increase in pressure in the portal vein system, peptic factor, as well as disorders in the blood coagulation system [Patsiora M.D., Eramishantsev A.K., 1977]. Bleeding from dilated veins of the esophagus may be the first clinical manifestation of portal hypertension. Often, the complication occurs in children who have previously been operated on for this disease due to the progression of the underlying pathological process.

Clinical picture.The first indirect signs of beginning bleeding are the child’s complaints of weakness, malaise, nausea, and lack of appetite. Body temperature rises. The sudden appearance of profuse bloody vomiting explains the sharp deterioration in the child’s general condition. Vomiting recurs after a short period of time. The child turns pale and complains about headache, dizziness, becomes lethargic, drowsy. Tarry, foul-smelling stool appears. Blood pressure decreases to 80/40-60/30 mm Hg. Art. (10.7/5.3-8.0/4.0 kPa). A blood test reveals increasing anemia. The volume of circulating blood decreases sharply. After 6-12 hours, the severity of the condition is aggravated by intoxication as a result of the absorption of blood breakdown products from the gastrointestinal tract.

Differential diagnosis.The symptom of hematemesis in children can be caused not only by bleeding from varicose veins of the esophagus. To determine the cause of bleeding, anamnestic data are of primary importance. If a child is admitted to the surgical clinic again due to bleeding due to portal hypertension syndrome or has undergone surgery for this disease, then the diagnosis should not be in doubt. More difficult to carry out differential diagnosis, if bleeding was the first manifestation of portal hypertension, since similar clinical symptoms occur in children with a bleeding gastric ulcer (as a complication of a peptic ulcer or with an acute ulcer in hormonal patients), with redheadedness hiatus diaphragm, after severe nosebleeds (in children with Werlhof's disease and hypoplastic anemia).

Children with bleeding from chronic gastric ulcer usually have a characteristic and long-term “ulcerative” history. Profuse bleeding occurs extremely rarely in them. Acute ulcer in children who have been receiving hormonal therapy for a long time, it is also rarely complicated by bleeding (perforation is more typical), but if there is an appropriate history, diagnosis usually does not cause difficulties.

In children with hiatal hernia periodic bloody vomiting is not profuse, and the presence of “black” stool is usually not always observed. The child's general condition deteriorates slowly over many months. Children are usually admitted to the hospital due to mild anemia unknown etiology. Clinical and x-ray examination establishes the presence of a hiatal hernia.

The cause of bloody vomiting that occurs after nosebleeds is clarified by taking a detailed history and examining the patient.

Treatment.In many cases of bleeding, treatment should be startedWithcomplex therapy.

Conservative therapy in some cases it leads to stopping bleeding. Once the diagnosis is established, the child is given a blood transfusion of the same group (preferably fresh citrate). To do this, the subclavian vein is punctured (according to Seldinger) or a venesection is performed. The amount of blood administered depends on the general condition of the child, hemoglobin content, red blood cell count, hematocrit number and blood pressure.

Sometimes 200-250 ml is required, and in case of severe unstoppable bleeding, 1.5-2 liters of blood are transfused on the first day. For hemostatic purposes, concentrated plasma, Vicasol, pituitrin are administered orally, e-aminocaproic acid, adroxon, thrombin, and a hemostatic sponge are prescribed.

The child is completely excluded from oral feeding by prescribing parenteral administration appropriate amount of fluid and vitamins (C and group B). The infusion is carried out slowly, since a sudden overload of the vascular bed can lead to re-bleeding. For prevention hyperthermic syndrome solutions are administered cooled. An ice pack should be placed on the epigastric area.

All children are prescribed broad-spectrum antibiotics and detoxification therapy. To combat hypoxia, humidified oxygen is constantly given through nasal catheters. In case of severe intractable bleeding, hormonal therapy is included (prednisolone 1-5 mg/kg of the child’s body weight per day). For patients with intrarenal form of portal hypertension for prevention liver failure a 1% solution of glutamic acid is prescribed. If conservative treatment is successful, after 4 hours the general condition improves somewhat. Pulse and blood pressure are normalized and made stable. The child becomes more contact and active. All this gives reason to believe that the bleeding has stopped, but despite the improvement in the general condition, treatment measures should be continued. In the absence of repeated bloody vomiting, the drip infusion system is removed after 24-36 hours. The child is given cold kefir, milk, and cream. Gradually the diet is expanded, on the 3-4th day puree, 10% semolina porridge, broth are prescribed, from the 8-9th day - a common table. Blood transfusions are carried out 2-3 times a week, and the administration of vitamins continues. The course of antibiotics is completed on the 10-12th day. Hormonal drugs are canceled, gradually reducing their dosage. Once the child’s general condition improves, a detailed biochemical research blood, splenoportography and tonometry to establish the form of blockade of the portal vein system and select a rational method of further treatment.

Along with the indicated conservative therapy, an attempt should be made to mechanically stop the bleeding. This is achieved by inserting an occluding Blackmore probe into the esophagus. the inflated cuff of which presses the varicose veins of the esophagus (Fig. 19). Sedatives are prescribed to reduce anxiety associated with the tube being in the esophagus. If during this period the conservative measures taken have not led to stopping the bleeding, then the question of urgent surgical intervention should be raised.

The choice of method of surgical treatment at the height of bleeding primarily depends on the general condition of the patient and on whether the child has been operated on for portal hypertension before or the bleeding occurred as one of the first manifestations of portal hypertension. In children who have previously been operated on for portal hypertension (splenectomy, creation of organ anastomoses), the operation is reduced to direct ligation of varicose veins of the esophagus or cardia of the stomach. In patients who have not previously been operated on for portal hypertension, surgery should be aimed at reducing the pressure in the portal vein by reducing blood flow to varicose veins of the esophagus [Bairov G. A. et al., 1970; Akopyan V.G., Shvedova L.P., 1976].

Technique for ligation of dilated veins of the esophagus. The patient's position is on the right side. Thoracotomy in the seventh intercostal space on the left. After opening the pleural cavity lung pushed up. The mediastinal pleura is opened, the esophagus is mobilized in the lower third for 6-8 cm and rubber strips called “holds” are placed under it. A longitudinal esophagotomy 5-6 cm long is performed. Large vein nodes are clearly visible in the lumen of the organ (in the submucosal layer). The knots are stitched with a blanket stitch in a checkerboard pattern (3-5 stitches). The esophageal wound is closed in layers with double-row sutures, and rare sutures are placed on the mediastinal pleura. After straightening the lung with an anesthesia apparatus, the wound of the chest wall is sutured tightly.

This operation cannot be considered radical, and, in addition, it has a number of disadvantages. At the time of suturing varicose nodes, severe bleeding may occur; esophagotomy is sometimes complicated by infection of the mediastinum, the development of purulent mediastenitis and pleurisy.

To reduce blood flow to varicose veins of the esophagus, a modified Tanner operation can be used - suturing the precordial veins without opening the lumen of the stomach. The latter significantly shortens the surgical intervention (which is especially important during surgery at the height of bleeding), reduces the risk of infection of the abdominal cavity and minimizes the possibility of gastric suture failure.

Technique of a modified Tanner operation without opening the lumen of the stomach (Fig. 20). The abdominal cavity is opened with an incision parallel to the left costal arch. The stomach is removed into the wound, the vessels of the greater and lesser omentum are ligated, the cardiac part is mobilized and its wall is sutured circularly through all layers with interrupted silk sutures, then the line of the main sutures is closed with submerged serous-muscular sutures.

In children who have not previously been examined for portal hypertension, surgical splenoportography and splenometry are performed to resolve the issue of the form of the disease and the extent of intervention. If an intrahepatic blockade is detected, in addition to suturing the cardiac part of the stomach, it is rational to simultaneously create organ anastomoses: suturing the omentum to the decapsulated kidney and to the left lobe of the liver after marginal resection. In the presence of pronounced hypersplenism, the spleen is removed. The abdominal cavity is then closed tightly after antibiotics are administered.

Postoperative treatment is a continuation of the activities carried out before the operation. A child needs parenteral nutrition for 2-3 days. Then the patient begins to drink, gradually expanding the diet (yogurt, 5% semolina, broth, etc.). By the 8th day, the usual postoperative table is prescribed. Hormone therapy canceled on the 4-5th day, the administration of antibiotics is completed on the 7-10th day after surgery. Blood and plasma transfusions are prescribed daily (alternating) until anemia is eliminated.

With a smooth postoperative period, on the 14-15th day, children are transferred to the somatic department for further treatment.