Diseases of the esophagus. Developmental defects. Pediatric surgery: lecture notes (M. V. Drozdova)

Lecture notes are intended to prepare students medical universities to passing exams. The lecture notes presented to your attention are intended to prepare students of medical universities for passing the exam. The book includes a full course of lectures on pediatric surgery, is written in accessible language and will be an indispensable assistant for those who want to quickly prepare for the exam and pass it successfully. The lecture notes will be useful not only for students, but also for teachers.

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

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 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 of the esophagus for emergency surgery, those types of interest 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. At early start 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 most consistent sign to suggest 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 data obtained is a necessary part of the preoperative examination and serves as a guide for choosing a method 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.

If the child’s general condition is severe (late admission, stage III–IV prematurity), you may not undertake examinations with a contrast agent, but rather confine 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.

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.

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 respiratory tract. This examination does not always help to detect a fistula, which in such cases is found only during surgery.

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 rapid developing pneumonia, decreased resistance, a peculiar reaction to surgery.

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.

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

Further preparation for the operation continues in 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 character 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 to more late dates after birth with symptoms of aspiration pneumonia, preparation for surgery takes 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 it is indicated parenteral nutrition.

Preoperative preparation is stopped when there is a noticeable improvement in the child’s general condition and a decrease in clinical manifestations 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 the esophageal segments is not justified due to technical difficulties and possible eruption 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 inward, 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 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 good blood supply, which allows you to mobilize it as high as possible.

Dense adhesions with back wall the trachea is 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 creating an anastomosis. 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.

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 holders by which the ends of the esophagus are pulled.

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. Bluntly (opening the inserted Billroth forceps) expand hiatus, tighten the stomach and dissect the layer of peritoneum around the cardiac region (care should be taken 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 abdominal wall. The mobilized esophagus is inserted into the formed hole 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.

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.

End of introductory fragment.

Sanitation of the purulent cavity is carried out by puncture, with suction of pus, washing with antiseptic solutions and administration of antibiotics. The cyst is punctured again after 2–3 days (depending on the accumulation of exudate). At the same time the patient is prescribed therapeutic exercises in drainage position.

With insufficient drainage function of the adductor bronchus into the complex therapeutic measures It is advisable to include repeated tracheobronchoscopy. The degree of cavity sanitation is controlled by inoculating its contents. It is often possible to achieve complete inhibition of the growth of pathogenic microflora. The patient receives alkaline aerosols with antibiotics and local anti-inflammatory physiotherapy.

Drainage of festering cysts with the establishment of passive or active aspiration is not indicated due to the possible formation of a persistent internal bronchial fistula.

As a result of the sanitation of the purulent focus in the patient, the symptoms of intoxication are reduced, which is also facilitated by vigorous restorative therapy - transfusions of blood, plasma, intravenous administration liquids, parenteral administration vitamins and massive antibiotic therapy.

For giant tense cysts, as well as for cysts with a valve mechanism emergency measure help that allows a child to be rescued from a serious condition caused by respiratory failure is puncture of the cyst. Reducing intrapulmonary pressure can significantly improve the general condition of the patient and successfully carry out urgent surgical intervention.

Surgical treatment. The extent of the operation depends on the nature of the pathological process. It should be remembered that putting patients with tense cysts into a state of anesthesia has its own characteristics: forcible injection of air into the lungs and into the cyst during artificial respiration leads to an increase in pressure in the air cavity, and therefore the conditions of pulmonary ventilation significantly worsen.

A vicious circle arises - despite vigorous artificial respiration, hypoxia continues to increase. This complication can be prevented by puncturing the cyst with an open needle before intubating the patient and keeping the needle in its cavity until thoracotomy.

For single cysts, surgical intervention can be reduced to thoracotomy and enucleation of the cyst.

Operation technique. Thoracotomy is performed according to the general rules with an anterolateral incision. The lung is isolated from the adhesions. The pleura is carefully dissected over the cyst, after which the lung is gradually peeled off from the wall of the cyst. The fibrous cords that connect the cyst to the surrounding lung tissue are cut and ligated.

There are especially many strands at the hilar pole of the cyst. Here it is possible to pass quite large vessels and one or more bronchial branches that communicate with the cyst.

They are ligated with silk. Bleeding areas of the pulmonary edge are covered with catgut. If it is impossible to enucleate the cyst, a lobectomy is performed according to the general rules. After removing the cyst, drainage is left in the pleural cavity for 24–48 hours.

The extent of surgical intervention for polycystic lung depends on the extent of the lesion. In lobar localization, the operation is reduced to lobectomy. In case of cystic degeneration of the entire lung, pneumonectomy is performed.

Drainage of the pleural cavity after pneumonectomy is not mandatory.

However, after a traumatic operation or if there are doubts about the reliability of the bronchial suture, it is better to introduce drainage for 36–48 hours, with the help of which passive aspiration of exudate is carried out.

Postoperative treatment. Mainly the treatment of patients who have undergone surgery for lung cysts, does not differ from that with lobar emphysema. After removing previously infected cysts, you should special attention devote antibacterial therapy. Careful care is also required postoperative wound– daily dressings, suture treatment, ultraviolet irradiation.

In children who have undergone pneumonectomy, after removal of the drainage, the residual pleural cavity is filled with a displaced mediastinum and an organizing blood clot. In these cases, it is especially important to prevent infection of the cavity and the development of pleural empyema, so careful antibiotic therapy takes on special meaning.

The fight against intoxication and respiratory failure is carried out systematically with intravenous infusions of blood, plasma, and constant oxygen therapy. Such children require clinical observation and periodic sanatorium-resort treatment.

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 with 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

A successful outcome of treatment for congenital obstruction of the esophagus depends on many reasons, but above all, 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.

Clinical picture

The most common malformations of the esophagus: esophageal atresia, esophageal-tracheal fistula, congenital esophageal stenosis, congenital short esophagus, chalasia cardia.

Esophageal atresia occurs with a frequency of 1 in 3000-4000 newborns. The defect is formed in the period from the 4th to the 12th week of intrauterine development of the fetus, when the esophagus and trachea are separated from the common rudiment - the cranial section of the foregut. There are 5 main types of esophageal atresia (Fig. 6). The most common type (85-90% of observations) is type III atresia, in which the upper end of the esophagus ends blindly, and the lower end is connected to the trachea by a fistulous tract.

Rice. 6. Types of congenital esophageal atresia.

Symptoms of esophageal atresia appear in the first hours after the birth of the child. A characteristic symptom is the discharge of a large amount of foamy mucus from the nose and mouth, which quickly leads to the development of aspiration pneumonia. Repeated suction of mucus helps for a short time: it soon accumulates again. Continuous foamy discharge from the nose and mouth with bouts of cyanosis gives reason to suspect atresia already in the first 2-4 hours after birth, i.e. before the first feeding. With atresia types III and V, swelling may be observed upper sections abdomen due to the presence of a fistula between the trachea and the lower segment of the esophagus. In these cases, severe pneumonia also quickly develops due to gastric contents being thrown into the trachea. In type IV atresia, breathing disorders predominate.

The diagnosis of atresia is clarified using quite simple research: A thin urethral catheter with a rounded end is inserted into the esophagus through the mouth. Normally, the catheter passes freely into the stomach. With atresia, the catheter usually stops at a distance of 10-12 cm from the edge of the gums, which corresponds to the II-III thoracic vertebra. The mucus is sucked out with a syringe, and then 10 cm3 of air is injected through the catheter. With atresia, it noisily comes back through the mouth and nose (Elephant test). The effectiveness of this simple technique has allowed many pediatric surgeons to strongly recommend esophageal catheterization to all newborns without exception immediately after birth.

Having established the diagnosis of esophageal atresia, the child is excluded from feeding, a thin catheter is inserted through the nose into the upper caecum of the esophagus for periodic suction of mucus, and the child is transported to the surgical department in a semi-sitting position.

Next, to clarify the diagnosis and identify pneumonia, X-ray examination. A radiopaque catheter is inserted into the proximal segment of the esophagus; in case of atresia, it is folded into a ring in a blind sac. The introduction of water-soluble contrast agents through a catheter to detect an esophageal-respiratory fistula is not currently used due to the risk of developing severe aspiration pneumonia. To localize the fistula and determine its size, fibrotracheobronchoscopy is performed under anesthesia.

When examining newborns with esophageal atresia, it is necessary to take into account that 20-50% of such patients also have other developmental defects. This significantly worsens the prognosis.

The diagnosis of esophageal atresia is an indication for urgent surgery. Children admitted to the surgical clinic in the first 10-12 hours after birth, as a rule, do not require long-term preoperative preparation. For later admission, intensive preoperative preparation is carried out, including treatment of pneumonia, elimination of respiratory failure, correction of disturbances in water-electrolyte and protein metabolism, acid-base status, and parenteral nutrition. Sometimes for good nutrition a gastrostomy tube is first applied.

With a more or less pronounced improvement in the condition, an operation is started, which consists of a right-sided thoracotomy, mobilization of the ends of the esophagus, closure (ligation and intersection) of the esophageal tracheal fistula and the application of esophagoesophageal anastomosis according to one of the proposed methods, which is most often formed using precision single-row atraumatic sutures, using synthetic absorbable suture material.

It is not always possible to form an esophageal anastomosis at once. In case of large diastasis of the ends of the esophagus (more than 1.5 cm), the operation is divided into two stages: the first stage - thoracotomy, closure of the esophageal-tracheal swish, esophagostomy in the neck with removal of the entire blind sac of the esophagus, gastrostomy; the second stage (usually over the age of one year) is plastic surgery of the esophagus, most often with a segment of the colon.

In the second type of atresia (large diastasis of the ends of the esophagus), which is very rare (1 - 1.5% of cases), sometimes a technique is also used to gradually lengthen the blind ends of the esophagus using spherical magnets inserted there (this requires, of course, the application of a gastrostomy). However, in most cases, this technique cannot be used due to the large diastasis of the ends of the esophagus (usually 6-7 cm).

Esophageal-tracheal fistula. This defect is rare, forming at the same stage of embryogenesis as esophageal atresia, when the esophagus and trachea are still connected to each other. The fistula is usually located in the upper thoracic esophagus.

The clinical picture depends on the width of the fistula tract. Characteristic attacks of coughing and cyanosis while feeding the child, especially when lying on the left side. In another variant of the course of the disease, recurrent pneumonia predominates.

The diagnosis is established using an X-ray contrast study: in a horizontal position, a water-soluble contrast agent is injected into the esophagus through a catheter. The fistula tract may be poorly visible with simple X-ray examination, in such cases, X-ray cinematography (video radiography) is used. The diagnosis is clarified by performing tracheobronchoscopy with contrasting of the fistula tinted with methylene blue saline solution inserted through a catheter into the esophagus.

Treatment of the defect is only surgical - closure of the fistula through a right-sided thoracotomy approach.

Stenosis. Congenital esophageal stenosis is also a rare developmental defect. There are several variants of congenital stenosis. The most common form is a circular narrowing of the lumen, usually at the border of the middle and lower thirds of the esophagus, and the degree of narrowing can vary.

Very rarely, a membranous form of stenosis occurs, formed by a circular or eccentrically located fold of the normal mucosa. Stenosis caused by the growth of ectopic gastric mucosa in the esophagus (Barrett's esophagus) is also rarely observed.

The clinical picture is variable and depends primarily on the degree of stenosis. The first signs of dysphagia may appear in infancy or later as the child gets older. Most often, dysphagia and regurgitation first appear with the introduction of complementary foods. Symptoms are aggravated by eating thick and solid foods, while fluid passes freely, but episodes of complete dysphagia may also occur.
The diagnosis is established using X-ray contrast examination of the esophagus and fibroesophagoscopy.

Treatment depends on the form of stenosis. For short strictures, bougienage may help. For membranous stenosis, the method of choice is excision or cruciform dissection of the membrane through an endoscope. In other cases they resort to surgical treatment— segmental resection of the area of stenosis with restoration of esophageal patency using end-to-end anastomosis. A variant of the operation is a longitudinal dissection of the esophageal wall through the area of stricture with suturing of the wound in the transverse direction.

Short esophagus. The origin of the congenital short esophagus (brachiesophagus, or thoracic stomach) is associated with a delay in the intrauterine descent of the stomach from the chest cavity into the abdominal cavity, which occurs in the period from the 8th to the 16th week of intrauterine development of the fetus. Anatomically, a congenital short esophagus differs from an acquired one in the absence of a hernial sac. Moreover, in an externally correctly formed esophagus, part of the mucous membrane (usually in the lower third) can be represented by columnar epithelium, i.e. epithelium of the gastric mucosa.

When the stomach is undescended, the His angle usually exceeds 90°, the obturator function of the lower esophageal sphincter is disrupted, which creates conditions for the free flow of aggressive gastric contents into the esophagus. As a result, severe reflux esophagitis and peptic stricture of the esophagus develop.

The clinical picture depends on the stage of the disease. For early period characterized by frequent vomiting of gastric contents, often mixed with blood (with the development of erosive-ulcerative esophagitis). Over time, as a peptic stricture forms, dysphagia and regurgitation begin to prevail. The diagnosis is made using X-ray contrast studies, with the most revealing data obtained from the study in a horizontal position.

Indirect signs of shortening of the esophagus include the absence or reduction in the size of the gas bladder of the stomach, its displacement upward and to the right, wedge-shaped deformation of the superomedial part of the gas bladder, and the high location of the epiphrenic ampulla. The diagnosis is confirmed by fibroesophagogastroscopy.

Quite often recommended conservative treatment brachiesophagus for several months in the hope of spontaneous prolapse of the stomach (elevated position, especially during feeding, fractional feeding of thick foods, restorative therapy). However, the development of such severe complications as ulcerative esophagitis and peptic stricture dictates the need for surgical treatment. The method of choice is antireflux surgery (fundoplication); in some cases, resection of the esophagus may be necessary.

Chalazia (insufficiency, gaping of the cardia). The essence of the defect lies in the disruption of the development of the nervous elements of the wall of the esophagus, namely the underdevelopment of the sympathetic sprout. As a result, the lower esophageal sphincter loses its normal tone. Although the cardia is in its usual place (under the diaphragm), its closing reflex after the end of the act of swallowing is impaired. This also creates conditions for free reflux of aggressive gastric contents into the esophagus with all the ensuing consequences (severe reflux esophagitis, peptic stricture of the esophagus).

Clinically, the disease is characterized by persistent vomiting that occurs soon after feeding the child, often in a lying position, as well as when the child screams or cries. If in children in the first days of life a slight regurgitation is physiological, then in the future this symptom requires more careful attention.

The diagnosis is established using X-ray contrast examination of the esophagus and stomach in a horizontal position and Trendelenburg position. In this case, there is a free flow of the contrast agent from the stomach into the esophagus, and the absence of a distal narrowing of the esophagus is also characteristic. The diagnosis is confirmed using fibroesophagogastroscopy.

Treatment begins with conservative measures - feeding in an upright position (preferably with thicker food), giving an elevated position after feeding, during sleep. Often all symptoms disappear within a few months as the nerve elements of the esophagus mature and the tone of the cardia is restored. In cases where there is no improvement in the second half of life, it is necessary to lean towards surgical treatment. The method of choice is organ-preserving antireflux surgery such as fundoplication.

A.F. Chernousov, P.M. Bogopolsky, F.S. Kurbanov

Embryology. The esophagus and trachea develop from the primitive gut of the embryo. Their separation begins in the carina area and continues in the cranial direction. If this is violated complex process defects such as esophageal atresia and tracheal atresia may occur. Since the trachea normally has cartilage, in case of anomalies in the development of the esophagus, it, as a rule, also has cartilaginous remains in its wall.

The muscular wall of the esophagus consists of internal circular and external longitudinal muscles. The esophagus does not have a serous membrane. Its upper third, represented by striated muscles, is under voluntary control, while the distal two thirds, consisting of smooth muscles, are controlled autonomously. The esophageal mucosa is equipped with its own glands, which, in the presence of acute obstruction, produce large amounts of mucus.

From a surgical point of view, the esophagus can be divided into cervical, thoracic and abdominal parts. Cervical region intimately connected with the larynx. The thinnest wall of the esophagus is immediately below and posterior to the cricopharyngeal muscles. This is the part of the esophagus where the risk of perforation is especially high, and which receives its blood supply from the thyroid-cervical vessels.

The thoracic part of the esophagus is bent around the lateral side by the aortic arch and, due to an anomaly called the vascular ring, is significantly compressed. In this section, the esophagus is in intimate contact with the aorta and pericardium, which, accordingly, can also be affected by foreign bodies or chemical burns esophagus.

The abdominal part of the esophagus provides the mechanism of action of the lower esophageal sphincter and is supplied with blood from the diaphragmatic branches and gastric vessels. Rupture of the mucous membrane of this section as a result of severe vomiting and the development of varicose veins with portal hypertension are potential sources of heavy blood loss from the lower third of the esophagus.

4.7.1 Esophageal atresia(AP) – a developmental defect in which its upper segment ends blindly, and the lower in most cases flows into the trachea, forming an anastomosis. Other forms of atresia are also known.

Pathogenesis. On the 19th day of gestation, the foregut of the human embryo is represented by a single-layer tube located between the pharynx and stomach. After a few days, the ventral part of this intestine begins to thicken and forms a groove lined with stratified ciliated columnar epithelium, which subsequently becomes the mucous membrane of the respiratory tract. The separation of the dorsal part of the foregut (esophagus) from the ventral part (trachea) occurs first in the carina and then spreads in the head direction. By day 26 of gestation, these two structures become completely separated down to the level of the larynx.

Interruption for one reason or another of the process of separation of the esophagus and trachea leads to the formation of a tracheoesophageal fistula (TEF). Grunewald and some other authors believe that the cause of AP is the initially (before the AP) formed TJ. According to these researchers, the trachea grows so quickly in the caudal direction that if the esophagus is fixed by a fistula to the trachea, then its dorsal wall is pulled forward and down to “keep up” with the trachea and remain connected to it, which leads to the formation of AP.

The etiology of AP is not fully understood. And although there is no obvious evidence of a hereditary nature, there are a number of reports of familial cases of AP. For example, several observations of AP have been described in identical twins, as well as in mother and child, and father and child. Moreover, a case is described in which one family had 5 male members with this pathology. From the pregnancy history, polyhydramnios and the threat of miscarriage in the first trimester are typical.

AP is often combined with other developmental defects - congenital heart defects, gastrointestinal tract, genitourinary system, etc. Population frequency - 0.3:1000. The combination of male and female is 1:1.

Anatomy and classification. AP and TPS can occur as independent isolated defects, but their combination is most often noted. There are numerous, constantly developing and expanding classifications of these defects.

Ø AP with distal TJ (88%)– the most common form of the defect. The upper segment of the esophagus in this option ends blindly, usually at the level of Th 3, although it can be significantly higher (C 7), or, conversely, low (Th 5). Its muscular wall is thickened, and its diameter is much larger than the diameter of the lower segment, which starts from the trachea, usually from the membranous part of it lower section. Sometimes the fistula departs from the bifurcation of the trachea; in this case, the trachea has a “trifurcation”, as it were. The connection of a fistula with a bronchus is rarely observed. There is usually a diastasis between the segments of the esophagus, the size of which determines the choice of treatment method.

Ø Isolated AP (without TPS - 5%) almost always accompanied by a large diastasis between the segments. In the absence of a lower TJ, the distal segment is very short, sometimes protruding only 1–2 cm above the diaphragm.

Ø Isolated TPS (without AP – 3%), the diameter of which, as a rule, is 2–4 mm, usually has an oblique direction from the anterior wall of the esophagus upward diagonally to the membranous part of the trachea. The TPS can be at any level, but most often arises from the lower cervical or upper thoracic part of the trachea.

Ø In AP with proximal TJ (1%) The fistula usually begins 1–4 cm above the bottom of the upper segment and runs diagonally upward, flowing into the membranous part of the trachea. In this type of defect, the distal TJ is usually absent, so the lower segment is short and the diastasis is correspondingly large.

Ø In AP with proximal and distal (two) TJ (3%) the upper segment with a fistula, as well as the lower one, do not differ anatomically from each of these forms described above when they occur separately. Typically, diastasis with this type of defect is small.

Clinic. Diagnostics.“It seems that the child really wants to eat and greedily grabs with his mouth everything that is given to him from a spoon, but when he is about to swallow, the food seems to encounter an obstacle and does not pass inside, but returns through the mouth and nose, while the child falls into a condition similar to a convulsive attack.” This first description by Gibson (1696) of the behavior of a child with esophageal atresia remains valuable to this day.

The first symptom of AP is copious discharge saliva that the child cannot swallow. If a newborn begins to be fed, he chokes, coughs, and often develops cyanosis and regurgitation. After suctioning out the contents of the nasopharynx, it soon appears again. Very quickly, wheezing begins to be heard in the lungs, and shortness of breath increases. The diagnosis is confirmed by esophageal catheterization thin urethral catheter with a rounded end. The catheter is inserted through the nose; Having passed to a depth of 6-8 cm, the catheter rests on the blind end of the esophagus or, wrapping itself, exits through the child’s nose. Suction of mucus is performed. Air introduced into the blind end of the esophagus is noisily released from the nasopharynx (positive Elephant's symptom). Considering the great importance of early diagnosis of esophageal atresia - before the occurrence of aspiration pneumonia, it is advisable to perform esophageal probing in all infants with respiratory distress syndrome immediately after birth. The clinical picture may have some features depending on the form of atresia. In the most common form of atresia with distal tracheoesophageal fistula, abdominal distension is detected, especially in the epigastric region. The severity of aspiration syndrome depends on the diameter of the tracheoesophageal anastomosis.

The final diagnosis is made after X-ray examination. The catheter is inserted into the esophagus until it stops, after which a plain X-ray of the chest and organs is taken abdominal cavity. With atresia, a radiopaque catheter is clearly visible in the blind segment of the esophagus. Detection of air in the stomach and intestines indicates the presence of a fistula between the trachea and the abdominal segment of the esophagus.

In children with fistulous forms of atresia, the length of the diastasis between the ends of the esophagus can be judged to some extent by a lateral radiograph. The use of radiopaque solutions, especially barium suspension, for diagnostics is highly undesirable due to the risk of aspiration pneumonia. An abnormal variant of the defect can be specified bronchoscopically directly on the operating table before surgery. Some surgeons believe that bronchoscopy is indicated for all newborns with AP to identify proximal TPS and tracheomalacia. Sagittal examination can help determine diastasis between segments computed tomography(CT).

The diagnosis of AP can be made antenatally if polyhydramnios is detected on ultrasound and the fetal stomach is not visible. Sometimes an enlarged proximal esophagus is detected, which further confirms AP.

Combined anomalies. Approximately half of children with AP and TPS have concomitant anomalies, which are often severe and adversely affect the results of treatment. Combination pathology is much more likely than AP itself to be the cause of death. Associated anomalies are more common in premature infants with AP. In 1973, the VATER association was described (see Chapter 1), which includes the AP. If the combination of defects is denoted by the abbreviation VACTER, then the VATER combination also includes cardiac (cardiac) defects - most often combined with AP and determining an unfavorable outcome in most cases. Also, often with AP there are anomalies of the limbs (limb), and then the term takes on the most modern sound - VACTERL. In children with VACTERL association, as a rule, there is a high proximal segment of the esophagus, a complicated course, and higher mortality than in newborns with AP without this combination. If a child has one of the anomalies included in this association, others should be suspected and looked for.

Treatment. Only early surgical intervention can save the life of a child with esophageal atresia. Already in the maternity hospital, preoperative preparation should begin, including aspiration of the contents of the oropharynx and nasopharynx every 15-20 minutes, complete exclusion of oral feeding. Transportation must be carried out by a specialized team as quickly as possible. short term. The total duration of preoperative preparation is determined by the severity of disorders of homeostasis and hemodynamics, respiratory failure, and the degree of dehydration. At obvious signs aspiration, respiratory failure, and even more so in case of pneumonia or atelectasis, it is necessary to resort to direct laryngoscopy with tracheal catheterization and aspiration as early as possible. If the latter is ineffective, bronchoscopy or tracheal intubation with careful aspiration of the contents is performed under anesthesia. The patient is placed in an incubator, providing a continuous supply of oxygen, aspiration of the contents of the oropharynx, and warming. Prescribe infusion, antibacterial, symptomatic therapy. The choice of surgical intervention method is determined by the form of atresia and the patient’s condition. In the most common form of atresia with distal tracheoesophageal fistula in patients with low surgical risk (full-term, without combined defects of vital organs and symptoms of intracranial birth trauma) it is advisable to start with thoracotomy, division of the tracheoesophageal fistula. If the diastasis between the ends of the esophagus does not exceed 1.5-2 cm, a direct anastomosis is performed. In case of large diastasis of segments of the esophagus, a cervical esophagostomy and Kader gastrostomy are applied. In non-fistula forms due to significant diastasis, gastrostomy and esophagostomy are performed. In patients with a high surgical risk, surgical intervention often begins with a double gastrostomy (the first is for feeding through a tube inserted into the duodenum, the second - for decompressing the stomach and reducing aspiration). The second stage of the operation is performed after the condition improves after 2-4 days. In the postoperative period, the started intensive care. The child is fed through a tube inserted intraoperatively through an anastomosis or into a gastrostomy after intestinal passage has been restored. On the 6-7th day, the consistency of the anastomosis is examined. If there are no complications, the child is started to be fed orally. 2-3 weeks after the operation, a control fibroesophagogastroscopy is performed to assess the degree of patency of the anastomotic zone, the condition of the cardia, and symptoms of esophagitis. Narrowing of the anastomosis, which occurs in 30-40% of cases, requires bougienage (bougie No. 22-24). The duration of bougienage is controlled by esophagoscopy. In the postoperative period during the first year of life, constant dispensary observation. Dysphagia may occur, complicated by obstruction in the anastomotic area, which requires urgent esophagoscopy. In this regard, children in the first year of life are recommended to be given homogenized food mass. Cardiac insufficiency and gastroesophageal reflux, often complicating postoperative period, are clinically manifested by nocturnal regurgitation, repeated pneumonia, regurgitation and require timely diagnosis. Due to surgical trauma to the recurrent nerve, children may experience hoarseness in the next 6-12 months. In children with esophago- and gastrostomy aged from 2-3 months to 3 years, the second stage of the operation is performed - plastic surgery of the esophagus with a colonic graft.

4.7.2 Isolated congenital tracheoesophageal fistula (TCF) refers to severe malformations: its frequency is 3% among all esophageal anomalies. The first observation was described by Lamb in 1873. The occurrence of a malformation is associated with a violation of the separation of the esophagus and trachea in the early stages of embryonic development (4th – 5th week).

There are three types of tracheo-esophageal fistulas depending on the diameter of the anastomosis (G. A. Bairov, Z. A. Trofimova, 1986):

with a narrow and long fistula tract,

with a short and wide anastomosis (most common),

· with no separation between the esophagus and trachea over a large area.

There are descriptions in the literature of cases where a patient had two or even three fistulas at the same time. In some classifications TPS without AP is usually called N-type TPS; the patency of the esophagus is not impaired.

Clinic The severity of symptoms depends on the diameter of the fistula and the angle of entry into the trachea. A wide fistula is characterized by a triad of symptoms:

1) coughing attacks when taking liquids and food;

2) dilation of the stomach after coughing;

3) lung damage (bronchitis, bronchiectasis, etc.).

With narrow fistula tracts, the disease occurs either asymptomatically or under the guise of chronic pneumonia and respiratory diseases(V.I. Geraskin, 1971; Schlosser et al., 1969).

Diagnostics tracheoesophageal fistula is difficult, especially with narrow fistulas. The complex of studies includes x-ray and instrumental methods. X-ray performed with the child in a horizontal position. A water-soluble contrast agent is injected through a probe inserted into the initial section of the esophagus. Flowing into the trachea indicates the presence of a fistula. The information content of this method is low. Tracheoscopy has greater diagnostic value. The trachea is examined along its entire length from the glottis to the bifurcation. A direct sign of a fistula is the appearance of air bubbles with mucus.

Treatment only operational. Preoperative preparation consists of sanitation of the tracheobronchial tree and treatment of aspiration pneumonia. For this purpose, a sanitation bronchoscopy is performed, UHF, antibacterial, infusion therapy. Oral feeding is completely avoided. The operation of mobilization, ligation and intersection of the anastomosis is performed using a right-sided cervical approach; less commonly, a posterolateral thoracotomy is performed. At timely diagnosis the prognosis is favorable.

Malformations of the esophagus include its dysgenesis, relating to its shape, size and topographic relationship to surrounding tissues. The frequency of these defects is on average 1:10,000, the sex ratio is 1:1. Anomalies of the esophagus can affect only one esophagus, but can also be combined with anomalies of the trachea - a fact that is understandable if we take into account that both the esophagus and the trachea develop from the same embryonic rudiments. Some anomalies of the esophagus are incompatible with life (the death of a newborn occurs a few days after birth), others are compatible, but require certain interventions.

Congenital malformations of the esophagus include narrowing, complete obstruction, agenesis (absence of the esophagus), hypogenesis affecting various parts esophagus, esophagotracheal fistula. According to the famous researcher of developmental defects P.Ya. Kossovsky, and English authors led by the famous esophagologist R. Schimke, most often there are combinations of complete obstruction of the esophagus with an esophageal-tracheal fistula. Less commonly observed is a combination of narrowing of the esophagus with an esophageal-tracheal fistula, or the same combination, but without narrowing of the esophagus.

In addition to malformations of the esophagus itself, which doom newborns either to quick death by starvation or to traumatic surgical interventions, congenital dysphagia can be caused by malformations of organs adjacent to the normal esophagus (abnormal origin of the right carotid and subclavian arteries from the aortic arch and from its descending part on the left, which determines the pressure of these abnormally located large vessels on the esophagus at the point of intersection - dysphagia lussoria). I.S. Kozlova et al. (1987) highlight the following types esophageal atresia:

atresia without esophageal-tracheal fistula, in which the proximal and distal ends end blindly or the entire esophagus is replaced by a fibrous cord; this form accounts for 7.7-9.3% of all esophageal anomalies;
atresia with esophageal-tracheal fistula between the proximal segment of the esophagus and the trachea, accounting for 0.5%;
atresia with esophageal-tracheal fistula between the distal segment of the esophagus and the trachea (85-95%);
esophageal atresia with esophagotracheal fistula between both ends of the esophagus and the trachea (1%).

Often esophageal atresia is combined with other malformations, in particular with congenital heart defects, gastrointestinal tract, genitourinary system, skeleton, central nervous system, and facial clefts. In 5% of cases, esophageal anomalies occur with chromosomal diseases, for example, with Edwards syndrome (characterized by congenital anomalies in children, manifested by paresis and paralysis of various peripheral nerves, deafness, multiple dysgenesis of internal organs, including breast organs) and Down syndrome (characterized by congenital dementia and characteristic features physical deformities - short stature, epicanthus, small short nose, enlarged folded tongue, “clown” face and many others. etc.; 1 case in 600-900 newborns), in 7% of cases it is a component of non-chromosomal etiology.

Esophageal atresia. In case of congenital obstruction of the esophagus, its upper (pharyngeal) end ends blindly approximately at the level of the sternal notch or slightly lower; its continuation is a muscular-fibrous cord of greater or lesser length, which passes into the blind end of the lower (cardial) segment of the esophagus. The connection with the trachea (esophageal-tracheal fistula) is often located 1-2 cm above its bifurcation. Fistula openings open either into the pharyngeal or into the cardial blind segment of the esophagus, and sometimes into both. Congenital obstruction of the esophagus is detected from the first feeding of a newborn and is especially pronounced if it is combined with an esophageal-tracheal fistula. In this case, this malformation is manifested not only by obstruction of the esophagus, which is characterized by constant drooling, regurgitation of all swallowed food and saliva, but also severe disorders caused by fluid entering the trachea and bronchi. These disorders are synchronized with every sip and manifest themselves from the first minutes of the child’s life with coughing, choking, and cyanosis; they occur with a fistula in the proximal esophagus, when fluid from the blind end enters the trachea. However, even with an esophageal-tracheal fistula in the area of the cardial segment of the esophagus, respiratory disorders soon develop due to the fact that gastric juice. In this case, persistent cyanosis occurs, and free hydrochloric acid is detected in the sputum. In the presence of these anomalies and without emergency surgical intervention, children die early either from pneumonia or from exhaustion. The child can only be saved through plastic surgery; gastrostomy can be used as a temporary measure.

The diagnosis of esophageal atresia is established on the basis of the above-mentioned signs of aphagia, using probing and radiography of the esophagus with iodolipol contrast.

Esophageal stenosis with partial patency mostly refers to stenoses compatible with life. Most often, the narrowing is localized in the lower third of the esophagus and is probably due to a violation of its embryonic development. Clinically, esophageal stenosis is characterized by impaired swallowing, which manifests itself immediately when eating semi-liquid and especially dense foods. An X-ray examination reveals a smoothly tapering shadow of the contrast agent with a fusiform expansion above the stenosis. With fibrogastroscopy, stenosis of the esophagus with an ampulla-shaped expansion above it is determined. The mucous membrane of the esophagus is inflamed, in the area of stenosis it is smooth, without scar changes. Esophageal stenosis is caused by food blockages with dense foods.

Treatment of esophageal stenosis involves widening the stenosis using bougienage. Food debris is removed during esophagoscopy.

Congenital disorders of the size and position of the esophagus. These disorders include congenital shortening and expansion of the esophagus, its lateral displacements, as well as secondary diaphragmatic hernia, caused by the divergence of the fibers of the diaphragm in its cardiac part with retraction into chest cavity cardiac part of the stomach.

Congenital shortening of the esophagus is characterized by its underdevelopment in length, as a result of which the adjacent part of the stomach exits through the esophageal opening of the diaphragm into the chest cavity. Symptoms of this anomaly include periodic nausea, vomiting, regurgitation of food mixed with blood, and the appearance of blood in the stool. These phenomena quickly lead the newborn to weight loss and dehydration.

The diagnosis is made using fibroesophagoscopy and radiography. This anomaly should be differentiated from an esophageal ulcer, especially in infants.

Congenital dilatations of the esophagus are an anomaly that occurs extremely rarely. Clinically, it is manifested by congestion and slow passage of food through the esophagus.

Treatment in both cases is non-operative (appropriate diet, maintaining an upright posture after feeding the child). In rare cases, with severe functional disorders- plastic surgery.

Deviations of the esophagus occur with anomalies in the development of the chest and the appearance of volumetric pathological formations in the mediastinum, which can displace the esophagus relative to its normal position. Deviations of the esophagus are divided into congenital and acquired. Congenital correspond to anomalies in the development of the thoracic skeleton; acquired, which occurs much more often, are caused either by a traction mechanism resulting from some cicatricial process that has captured the wall of the esophagus, or by external pressure caused by diseases such as goiter, tumors of the mediastinum and lungs, lymphogranulomatosis, aortic aneurysm, spinal pressure, etc.

Deviations of the esophagus are divided into total, subtotal and partial. Total and subtotal deviations of the esophagus are a rare phenomenon that occurs with significant cicatricial changes in the mediastinum and, as a rule, they are accompanied by deviation of the heart. The diagnosis is made on the basis of an x-ray examination, which establishes the displacement of the heart.

Partial deviations are observed quite often and are accompanied by deviations of the trachea. Typically, deviations occur in the transverse direction at the level of the clavicle. An X-ray examination reveals the approach of the esophagus to the sternoclavicular joint, the intersection of the esophagus with the trachea, angular and arcuate curvatures of the esophagus in this area, combined displacements of the esophagus, heart and large vessels. Most often, deviation of the esophagus occurs to the right.

Clinically, these displacements themselves do not manifest themselves in any way; at the same time, the clinical picture of the pathological process that causes the deviation can have its own significant pathological impact on the general condition of the body, including the function of the esophagus.