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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_725_Библиотеки_им_академика_М_И_Перельмана
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tothatstupidlittlevoiceinyourbraintellingyouthatitisn’tblack!
High-outputstoma
A fully adapted end ileostomy has a daily output of approximately
500ml.Intheinitialpostoperativeperiod,ileostomyoutputisoftenmuch
greaterthanthis(1000-1800ml).Ahigh-outputstateoccursinabout15%
ofpatientshavinganileostomy.Thishighvolumeofstomaoutputusually
reducesinthefirstfewpostoperativedays.Thefactorscausingahigh-
outputstoma(greaterthan2L/day)areallmorecommoninpatients
havingemergencysurgery:
•
Proximalstomata(i.e.jejunostomy).
•
Intra-abdominalsepsis.
•
Following resolution of postoperative ileus or small bowel
obstruction.
Ifa stoma is producing more than 1000ml/day, then intravenous fluid
replacementwithHartmann’ssolution(Ringer’s)ornormalsalinewillbe
needed.Restrictionoforalhypotonicfluidswillhelpreducestomaoutput.
Close monitoring of electrolytes is important; deficiencies of sodium,
magnesium,andpotassiumarecommoninthesepatients.
Otheradjunctstoreduceahigh-outputstomainclude:
•
Low-fiberdiet.
•
Protonpumpinhibitors(suchasomeprazole,40mgdaily).
•
Antimotilityagentssuchasloperamide(inthiscircumstance,ahigh
dose of up to 8mg four times a day may be needed) or codeine
phosphate(60mgfourtimesaday).
Mucocutaneousseparation
Mucocutaneous separation is relatively common after an
emergency operation to form a stoma. The degree of separation is
usuallyfairlyminorandwithcarefulstomamanagementmostwillhealon
theirown.Attemptsatresuturingareusuallynothelpful;resisttheurgeto
revise the stoma early on as this will be difficult and potentially
hazardous.
Otherstomacomplications
Asasurgeonpracticingemergencyabdominalsurgery,youwillbewell
aware of the many other later complications which can occur after
creating a stoma. Further discussion of the management of these
complicationsisbeyondthescopeofthisbook.Theinterestedreaderis
advised to consult my chapter (#14) in Schein’s Common Sense
Prevention and Management of Surgical Complications for a more indepthdiscussion.
Finalremarks
A well-constructed stoma can make all the difference between success and failure of an
emergencyabdominaloperation.Considerthestomatobeananastomosisbetweenskinand
bowelandyouwon’tgofarwrong.Don’tclosetheabdomen and go for a coffee,leavingthe
residenttomaturethestomaunsupervised;atinyerrorherecanmakeahugedifference.
Thisbookisaboutemergencytreatmentsowewon’tboreyouwithlate
complications or the ‘take down’ of the stoma. But we’ll end with a
commentbyawiseman.
“There is no law that says that a colostomy must be
closed.”
LeoA.Gordon
1
For a comprehensive treatise on anastomotic leak, look at Chapter 6, Schein’s Common
Sense Prevention and Management of Surgical Complications. Shrewsbury, UK: tfm
publishing,2013.
2
ProfessorLuisCarriquirycontributedtothissectioninthepreviousedition.
Chapter15
Esophagealemergencies
BrandonH.TieuandJohnG.Hunter
1
On esophageal perforations: When it [occurs] it can be
recognized but it cannot be remedied by the medical
profession.
HermanBoerhaave
The evaluation and management of esophageal emergencies is a
daunting task that may result in restless nights if done incorrectly. The
esophagusis a musculomembranous tubewithout a serosal membrane
that is responsible for transmitting oral intake from the mouth to the
stomach. When this fails to happen in a coordinated and organized
fashion,adverse events canoccurresulting in obstruction,retchingand
perforation. Mediastinitis can rapidly develop from the spillage of
oral and enteral bacteria into the loose, areolar, and poorly
vascularizedplanesofthemediastinum.
Thischapterwillcoverthepresentation,evaluation,andmanagement
of esophageal perforations as well as foreign body ingestion and
obstruction.
Esophagealperforation
Theadmiralhadeatenaheavymeal.Duringthenextfewhourshehadtakensmallcupsofa
mildemetic,aswasusualwhenhewasfeelingheavy.Fourtimeshehadabout28gofoliveoil
andlaterdrankabout180gofbeer.Whenthisdidnothavethedesiredeffect,hetookanother
fourcups.Hetriedtothrowup,butsuddenlyscreamedbecauseofanexcruciatingpaininthe
chest.Heimmediatelydeclaredhimselfdying and started praying. It was averysickpatient,
though free of fever, who met Boerhaave. The house physician, Dr. de Bye, had tried
bleeding.Therewerenosymptomsofanyknowndiseaseorpoisoning,andthetwophysicians
ordered another bleeding, something non-alcoholic to drink and warm compresses. But, in
vain,thebaron succumbed the next day. HermanBoerhaave (1668-1738) conducted
anautopsythatrevealedtherentintheoesophagusandthecontentsofapreviousmeal,gas,
andfluidinthechest.
Esophageal perforations are uncommon but potentially lethal
conditions that require prompt diagnosis and treatment. Historically,
mortality rates have been as high as 80%. Due to its rarity, most
surgeonshavealimitedexperienceinthemanagementofthiscondition.
However, overthelasttwodecades,with the advances in imaging
techniques and critical care medicine, and the entrenchment of
uniform management modalities, mortality rates have significantly
improvedfollowingesophagealperforation.
Etiology
Cervicalesophagealperforations
Iatrogenic injury (endoscopy, anterior spinal fusions, or endoscopic
repair of Zenker’s diverticulum) causes the majority of cervical
esophageal perforations, followed by penetrating trauma, or foreign
body ingestion. Sharp foreign bodies (needles, bones) can cause an
immediate perforation, while a blunt foreign body can cause pressure
necrosisandadelayedperforation.Thismostcommonlyoccursatthe
level of cricopharyngeus, which is the narrowest portion of the
esophagus.
Thoracicandabdominalperforations
In these locations perforations occur from a variety of causes:
iatrogenicinjury,causticingestion(accidentalorintentional—suicidalor
homicidal…),foreignbody ingestion, penetrating trauma, or barotrauma
(retchingand vomiting— Boerhaave’ssyndrome!).Iatrogenicinjurycan
occurduringendoscopywithinappropriatesedation,duringdilatationfor
benign strictures orachalasia, with sclerosing therapy for varices, after
esophageal biopsies, during removal of a foreign body, and with
transesophageal echocardiography. Operative injuries resulting in
perforationcanoccurwithantirefluxproceduresorafteranunrecognized
mucosal injury during a myotomy for achalasia. Caustic ingestion can
resultinacuteordelayedperforationsdependingontheseverityofinjury.
The severity of injury is dependent on the pH of the substance (alkali
worse than acid), volume ingested, and duration of exposure. With
penetratinginjuriestotheesophagus,especiallyfromagunshotwound,
the patient often suffers associated cardiovascular or tracheobronchial
injuries that require immediate attention and take precedence over the
esophagealinjury.
Barotrauma due to retching/vomiting resulting in spontaneous
perforation (Boerhaave’s syndrome) accountsfor about 10-15%of
thoracicperforations.Itiscausedbyalackofcoordinatedrelaxationof
the esophageal sphincters when there is increased intra-abdominal
pressure created by rapid descentof the diaphragm and contractionof
the abdominal wall. This results in increased intraesophageal
pressure that leadsto rupture alongthe left posterolateral wall of
theesophagus.
Somebasics…
A thorough history and/or direct communication with the endoscopist
will generally give thecause and location ofthe suspected perforation.
Patients most commonly present complaining of pain but can also
complainofdyspnea,nausea/vomiting,anddysphagia.Neckpainwitha
cervicalperforationisworsenedwithswallowingandneckflexion.
Cervicalperforationsare bettercontaineddue tothelimited spacefor
spreadprovidedbythemiddleanddeepcervicalfascia.However,ifan
uncontainedcervicalleakisleftuntreatedtheinfectioncanspread
through the thoracic inlet along the prevertebral space or the
anterior pretracheal space — descending substernally and cause
mediastinitis.
Pain from a thoracic perforation may cause precordial, back or
epigastric discomfort. Perforations into the abdomen will lead to
abdominalpainandperitonitis.
On examination, there may be subcutaneous emphysema and
crepitusin the neck oranteriorchest wall. On auscultation,aHamman
sign—aprecordialcrunchingsoundthatissynchronouswiththeheart
beating against the pneumomediastinum — can be appreciated. The
combination of fever, tachycardia, leukocytosis, and hypotension
strongly points to the presence of mediastinitis and systemic
infection.
Diagnosticwork-up
•
On chest X-ray, findings include pneumomediastinum, a widened
mediastinum with a fluid collection, pneumothorax, subcutaneous
emphysema extending to the neck, and/or a pleural effusion. For
cervical perforations, a lateral neck film may show a widened
prevertebralspaceandanteriordisplacementoftheesophagusand
trachea.
•
Traditional esophagograms with water-soluble contrast, followed
bybariumifthewater-solubletestsarenegative,arestillvaluableto
diagnosea leak. However,there is a 10% false-negativerate in
thoracic perforations and it can be higher for cervical
perforations.
•
A CT esophagogram with contrast can provide additional detail
including the extent of the perforation, degree of contamination of
the mediastinum or pleural space, and associated esophageal
pathology (distal obstruction, mass, dilated esophagus
suggestive of achalasia) that will affect the management or
operative intervention. Other subtle signs to look for that
suggest esophageal injury on CT include: esophageal wall
thickening, a focal esophageal wall defect, and mediastinal
inflammation. We have found the additional information and detail
with CT to be worth the cost. Anyway, these days when we are
called to see these patients they have already had a CT fromthe
scalptotheirtoes…
•
Flexibleendoscopy remainsan important component to evaluate
the esophagus in penetrating neck trauma, especially in the
intubated or unstable patient. When an esophageal injury is
suspectedat the time ofdiagnostic endoscopy,a nagogastric
tubeshouldbeinsertedunderdirectvisualization.Traditionally,
flexibleendoscopyisnotrecommendedasadiagnostictoolin
suspected thoracic and abdominal perforations. This is due to
concerns that insufflation will worsen the contamination; however,
this phenomenon has not been clearly proven. If an injury is
identified by history (“I perforated the esophagus during
endoscopy”), esophagogram, or CT esophagogram, then a
diagnosticendoscopyisnotneeded.Butdiagnosticendoscopyis
useful to identify associated esophageal pathology — mass,
ring,web,orstricture—justpriortooperativeinterventionas
thismaychangethesurgicalplan(e.g.fromprimaryrepairto
esophagectomy for localized cancer). As discussed below,
endoscopy is also useful for therapeutic interventions such as the
placement of a covered stent in stable patients with limited
mediastinalcontamination or for removalofaforeign body. On the
roleofendoscopyforcausticinjurycontinuereading…
Management
Historically, the key word emphasized in the treatment of
esophageal perforation was EARLY. During the last century, the
standard approach was operative intervention with outcomes linked to
‘early’ repair within the first 24 hours. Delayed or ‘late’ therapeutic
interventionresultedinafour-foldincreaseintheriskofmortality.
Today, while the importance of early diagnosis and treatment is still
valid — the emphasis is on tailoring the management to the site and
natureoftheperforationintheindividualpatient.Someperforationscan
be successfully treated with non-operative management or
minimally invasive therapies when the principles listed below are
followed. Today, patients with delayed/neglected perforations can be
salvaged—thatis,iftreatedalongthelinesdescribedbelow.
So again: themanagementand outcomes aredependent on the
patient’scondition, any associated esophagealdisorder,and (very
important!)earlyrecognitionanddiagnosisoftheperforation.
Thegeneraltenetsinthemanagementofperforationsinclude:
Controllingthesourceofinfection.
Earlyandadequatedrainage.
Administrationofantibiotics.
Providingadequatenutrition.
Afewmorebasics…
Oncethediagnosisisestablishedthepatientshouldbemadenil
per mouth (NPO), started on broad-spectrum antibiotics, and
resuscitated as needed. Intravenous antibiotics should cover for
aerobes and anaerobes; suitable examplesare piperacillin/tazobactam,
ampicillin/sulbactam,orcarbapenem.Antifungalcoverageisreserved
for immunosuppressed patients, hospitalized patients already on
antibiotic therapy, and those who fail to improve on standard
antibiotictherapy.
When surgical repair is indicated (see below) the following
principles should be followed: devitalized tissue should be debrided
fromthesiteofperforation,themuscularlayershouldbeincisedsothat
theentireextentofthemucosalinjuryisexposed,andthemucosaland
muscular layers must be approximated precisely to avoid narrowing of
thelumen.An important aspect to rememberis that notallperforations
arecreated equal. However, if thegeneral tenets ofmanagementlisted
abovearefollowed, thepatientwillhavethe bestchanceofafavorable
outcome.
Perforationsthatpermitatrialofconservativetherapy
Non-operative management of intramural perforations or small,
containedleaksinpatientswithoutobstructiveesophagealdisease
shouldbeconsidered.Mostiatrogenicendoscopicinjuriesarelocalized
andcontained, andifrecognized quicklywill have limitedcontamination
ofthemediastinum.
Figure15.1.ImagefromaCTesophagogramofacontainedperforationfollowinganight
ofalcohol consumption and retching.Thepneumomediastinum outlines the esophagus
andgreatvesselswithoutamediastinalfluidcollectionorpleuraleffusions.Thispatient
wassuccessfullymanagednon-operatively.
Generally,theesophagogramandCTwillshowairintheneckor
mediastinum but without free extravasation of contrast, a fluid
collectionorpleuraleffusions( Figure15.1).Thesepatientsshould
show no signs of systemic infection or sepsis, have minimal
symptoms (neck or chest pain) and not have a malignancy, distal
obstruction,orstricture.
In the setting of a cervical or thoracic perforation, frequent
reassessmentofthepatient’sclinicalstatusforsignsandsymptoms(e.g.
newor increasingneckand chestpain,odynophagia, newor persistent
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