Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_665_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 33 • Debulking and Peritoneal Stripping in Carcinomatosis 405
Figure 33-16 Figure 33-17
Figure 33-18
Port site
Tunnel site
Figure 33-19
Figure 33-20 Figure 33-21
406 Chapter 33 • Debulking and Peritoneal Stripping in Carcinomatosis
u
The adhesion barrier is wrapped around the peritoneal dialysis catheter within the abdominal
cavity to protect the catheter from any adhesion formation. The surfaces of the small bowel
are also covered. The pelvis and the surfaces under the diaphragm are also protected (Figure
33-22).
u
The ileostomy is brought out through the appropriate site at the previously marked stoma
site. An adhesive barrier is placed around the stoma and over the peritoneal dialysis catheter
lateral to the ileostomy site to provide adequate diffusion space lateral to the stoma (Figure
33-23). The abdominal wall is closed with a running No. 1 absorbable suture. The subcuta-
neous skin is irrigated and closed with skin staples. The wound is protected, and the ileostomy is matured by placing three-point sutures of 3-0 absorbable material around the
circumference to create a 2.5-cm spigot. The ostomy appliance is applied taking care to avoid
any contamination to the access port sites. The patient is returned to the surgical ICU for
close monitoring, fluid replacement, and blood product replacement as needed.
Step 4: Postoperative Care
The usual course of a patient undergoing this massive operation is 2 weeks in the hospital with
1 week spent in an ICU setting or at least an observation unit setting. The peritoneal dialysis
catheters should not be used for at least 1 month after the procedure. Before infusion of chemotherapy, a technetium-99m scan should be performed with injection of both ports to ensure
that there is space for infusion of chemotherapy. If one port does not function properly, the
other port may function adequately to provide benefit to the patient.
The return of ileostomy function signals the bowel is ready for alimentation. Patients are
advanced in their diet and learn stoma care from the enterostomal therapy nurse. Patients are
maintained on antibiotics throughout the course of the hospital stay because the catheters
are placed in a potentially contaminated setting. Chemical and mechanical deep vein thrombosis
prophylaxis is continued. Ambulation is possible early after the operation. Follow-up is usually
within 2 weeks after discharge.
Chapter 33 • Debulking and Peritoneal Stripping in Carcinomatosis 407
Figure 33-22
Figure 33-23
408 Chapter 33 • Debulking and Peritoneal Stripping in Carcinomatosis
Step 5: Pearls and Pitfalls
Total proctocolectomy is not always necessary for complete debulking. The minimization of
anastomoses within the abdominal cavity is important. However, complete debulking of the
tumor should be the goal, as opposed to preservation of bowel or organs.
The dialysis catheters may not function properly at the early injection of technetium-99m
during the planning of intraperitoneal chemotherapy. If the patient returns 2 to 4 weeks later
and repeats the infusion, the adhesive process may have softened enough to allow diffusion
through one or the other of the catheters.
Infection of the catheter or access port requires removal, as does erosion of the catheter or
port through the skin. Care must be taken to avoid superficial placement of the peritoneal
dialysis catheter during the tunneling process. The goal should be that this is always behind
Scarpa’s fascia.
The decision to proceed with a massive debulking and creation of a short bowel syndrome
should be discussed with the patient before the operation. If this outcome is a possibility, abortion of the procedure is the usual approach rather than forcing the patient to accept a lifetime
of total parenteral nutrition and high stoma output. The use of octreotide, codeine, opium drops,
and maximalization of loperamide (Imodium) and diphenoxylate (Lomotil) can sometimes
reverse the short bowel syndrome. However, if the patient is an accepting candidate for operation and postoperative chemotherapy, a procedure resulting in maximum debulking is appropriate. The indications for this procedure are rare. Embarking on this course of treatment for an
unknowing, unsuspecting patient can bring suffering to the patient and the physician. A complete, well-informed consent is necessary before recommending such an invasive operation.
Selected Readings
Vaira M, Cioppa T, D’Amico S, et al. Treatment of peritoneal carcinomatosis from colonic cancer by cytoreduction, peritonectomy and
hyperthermic intraperitoneal chemotherapy (HIPEC): experience of ten years. In Vivo 2010;24:79–84.
Verwaal VJ, Bruin S, Boot H, et al. 8-year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy
versus systemic chemotherapy in patients with peritoneal carcinomatosis of colorectal cancer. Ann Surg Oncol 2008;15:2426–32.