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_725_Библиотеки_им_академика_М_И_Перельмана
.pdf
fevers, tachycardia, and rising leukocytosis) of an uncontrolled
perforation, abscess, or mediastinitis are required while the patient is
NPOandonsystemicantibiotics.Oneshouldhavealowthresholdfor
early intervention (see below) if the patient’s clinical status
changes.
Arepeatesophagogramafter5daysofconservativetherapyshouldbe
performedandadietinitiatedifnoleakisdetected.Closemonitoringfor
another day is necessary to account for the occasional false-negative
esophagogramonceoralintakeisstarted.
Perforationsthatneedoperativeintervention
Patients that arrive with an esophageal perforation in need of early
intervention present with severe neck, chest or abdominal pain. Those
withmediastinitis,peritonitis,orsystemicinfectiontypicallywillbefebrile,
tachycardic, and hypotensive with a leukocytosis. Crepitus, a Hamman
crunch, or peritonitis can be noted on exam and suggest the area or
extent of perforation. A chest X-ray, esophagogram, or CT
esophagogram will demonstrate uncontained extravasation of contrast
alongwith subcutaneous emphysema intheneck, pneumomediastinum
or pneumoperitoneum, hydropneumothorax, and mediastinal or
peritoneal fluid collections based on the location of the perforation (
Figure15.2).
Traditionally, attempted primaryrepairof a perforationhas been
limitedtopresentationswithin24hours,butovertheyearsthattime
periodhasbeenliberalizedasmoreexperience hasbeengathered
aboutsuccessfulrepairof‘older’perforations.
Figure15.2. Image of aCT esophagogram with anon-containedleak from spontaneous
perforationofthethoracicesophagusfollowingretching. The CT esophagogram shows
contrastextravasation(ontheright)withlargebilateralpleuraleffusions.
Theoperation:acuteinjuriesandprimarysurgicalrepair
Cervicalperforations
Anincisionismadealongthelowerthirdoftheanteriorborderof
thesternocleidomastoid(SCM).This can be done from either side of
theneckbasedonthesiteofextravasationorabscess,buttraditionallyis
approachedfromtheleftneck.TheSCM,internaljugularveinandcarotid
sheathare retractedlaterally.Themiddlethyroidveinisligated toallow
forbetterexposureofthetracheaandesophagus.
Bluntly dissect down to the prevertebral space and behind the
esophagus. Allis clamps on the thyroid can help rotate the
laryngotracheal complex over for better exposure of the esophagus.
Complete the dissection of the esophagus awayfrom the membranous
trachea,avoidinginjurytotherecurrentlaryngealnerve,andidentifythe
areaofperforation.
Alldevitalizedtissueshouldberesectedandatwo-layerprimaryrepair
is then performed. The mucosal layer is repaired with an absorbable
suture (4-0 polydioxanone or polyglactin) and the muscular layer
approximated with your suture of choice (we use3-0 silk). For patients
withadvancedlocal/systemicsepsiswewouldbuttresstherepairwiththe
help of the SCM — this, we believe, can help prevent postoperative
leaks.TheSCMflapshouldalsobeusedasan‘onlay’patchwhenthere
is a large defect (>1/3-1/2 of the circumference) in the esophagus to
prevent narrowing of the lumen with primary repair. The SCM is
mobilizedofftheclavicle,mediallyrotatedandsewntotheedgesof
thedefectafterthedevitalizedtissuehasbeenresected.
In rare instances (e.g. a reoperative field with severe contamination
andobliterationofthetissueplanes;asmalldefect),theperforationmay
notbeclearlyidentifiedandthustheareashouldbewidelydrainedwith
19Fr Jackson-Pratt® (JP) drains. Fluid collections in the upper
mediastinum can also be drained through this approach with finger
dissectionalongtheprevertebralspaceandanteriormediastinum.Once
again,JPdrainsareusedtodrainthemediastinum.
Thoracicperforations( Figures15.3and15.4)
Perforationsortraumatotheproximaltwo-thirdsoftheesophagus
shouldbeapproachedfromarightthoracotomythroughthe4th-6th
intercostal space. Repairof distal esophageal perforations should
bethroughaleftthoracotomyinthe7thor8thintercostalspace.
We usually start with endoscopy in the operating room. This
allowsusto visualize directly the location andsizeofthe defect. If it is
large and/or long then we may choose to harvest an omental flap to
provideanadequateamountofvascularizedtissueforcoverage.
To avoid a ‘triple flip’ of the patient (lateral-decubitus-supinelateral-decubitus);thelaparotomyfortheJ-tube(andharvestingof
theomentum,ifnecessary)wouldbedonefirst.
With perforations that are identified early and have limited
contamination of the mediastinum, the planes of dissection will be
preserved. On the other hand, older perforations with severe
contamination of the mediastinum and pleural space will have
edematous,inflamedtissuethatwillobscurethenaturaloperativeplanes.
In this scenario, the area of perforation is usually located at the most
inflamed and edematous areas. Therefore, to get around the
esophagus,startyourdissectionawayfromthisarea. Forexample,
withadistalperforation,dissectouttheesophagusabovethelevelofthe
carina. Special attention to dissectionof theesophagus off the trachea
willpreventaninadvertentinjurytothemembranousairway.
Figure 15.3. Primary repair of a distal esophageal perforation secondary to barotrauma
throughaleftthoracotomy.Theatraumaticforcepsidentifytheareaofperforation.
Once the esophagus has been mobilized, place a Penrose drain
around it, andthen using this as a guide, dissect out its distal portion.
Themarginsoftheperforationshouldbeidentifiedanddebridedbackto
viabletissue. Anasogastrictubeisnowplacedandguidedintothe
stomach.
The defect is then closed in twolayers — asmentioned above. Itis
imperative to assure the entire length of the mucosal defect is
repaired. An intercostal muscle flap (see below) is used as a
buttress by suturing it over the repair (interrupted 4-0 polyglactin).
Other options forautologous flaps include pericardial fat, diaphragm or
omentum(again,see below).Twochesttubes(atleast28F)are placed
with one lying in the posterior mediastinum to drain any postoperative
leaksandthethoracotomyisclosed.
Figure15.4.Theperforationhasbeenrepairedandbuttressedwithanintercostalmuscle
flap.ICM=intercostalmuscle.
The omentum is brought through a separate incision in the
diaphragm — preferably a circumferential incision along the
posterolateral diaphragm to avoid injury to the phrenic nerves or their
majorbranches.Onceitisbroughtthroughthisdefect,itissecuredover
the esophageal repair and at the diaphragm to reduce tension. The
diaphragmaticdefectis reapproximatedaround theomentumtoprevent
herniation,butshouldnotstrangulatetheomentalflap.
Finally, a few words on how to mobilize an intercostal muscle
(ICM)flap. Startby mobilizingtheICM andpleuraoffthe inferior ribby
incisingthe periosteumusingelectrocautery. Thesuperioraspect ofthe
ICM, pleura, and neurovascular bundle is mobilized off the upper rib
carefully so as to not injure the neurovascular bundle. The ICM is
mobilized as far anteriorly aspossible stopping usually 1-2cm fromthe
internalmammaryarteryandthenasfarasneededposteriorlybasedon
thelengthof thedefect.ItistransectedanteriorlyandtheICarteryand
veinareligated.
Abdominalperforations
Uncontainedperforations in the abdomen can quickly spreadthrough
the peritoneal cavity resulting in peritonitis and sepsis necessitating
operativerepair.Amidlinelaparotomyincisionisgenerallyused,but
a laparoscopic approach can be used by the experienced
laparoscopic surgeon. Open or laparoscopic, the perforation is
primarilyrepairedandbuttressed withapartial wrapofthegastric
fundus. Alternatively, the omentum can be used as a buttress. A
nasogastric tube is carefully guided into the stomach and a
jejunostomy tube is placed for enteral nutrition. If the perforation
leads to contamination of the mediastinum, this can be adequately
drained through the esophageal hiatus while pleural effusions can be
treatedwithchesttubes.
Transendoscopictherapy
Originally, esophageal stents were used to treat malignant strictures.
Morerecently,withthedevelopmentof completely covered stents, they
havebeenusedtotreatperforations,esophagealanastomoticleaks,and
fistulas.
Indicationsfortheiruse:
•
Immediately recognized injury or perforation during endoscopy or
dilationprocedures.
•
A contained perforation with only the presence of
pneumomediastinumorminimalcontrastextravasation.
•
Septicpatientsasatemporarymeasureofsourcecontrol.
•
Anastomoticleaks.
•
Palliativetherapyformalignantperforationsorfistulas.
Both plastic and metal covered stents have been used with good
technicalandclinicalsuccess(i.e.healingtheperforation).Thestentsare
typically deployed under both endoscopic and fluoroscopic guidance.
Some of the drawbacks to this approach are the need for technical
expertise, lack of clear guidelines of when to remove the stents and
potential costs. Complications include stent migration and the need for
reintervention and stent perforation. Migration is more common after
placement in a ‘normal’ esophagus. Appropriate stent sizing and
placement just proximal tothe gastroesophageal junction can minimize
theriskofmigration.
Endoscopic clips are now available (and FDA approved in the
USA)torepairintestinaldefects.Theyshouldbeusedforsmall(<2cm)
immediatelyrecognizediatrogenicinjuries.
If mediastinal or pleural fluid collections are noted, they need to be
drained. Hybrid procedures are now commonly employed;
endoscopic treatment of perforations is used in conjunction with
image-guided drains or minimallyinvasive surgery (thoracoscopy)
totreatthesecollectionsandothercomplicatingprocessessuchas
empyemaortrappedlung.
Remember:ifyouwishtoexperimentwithsuch minimal access
modalities—bereadytobecomeaggressive,ifneeded,beforeitis
toolate!
Perforations:difficultclinicalscenarios
Delayedpresentationordiagnosisofperforation
Somepatientswillpresentorbediagnosedinadelayedfashion.They
will often present with sepsis and require aggressive resuscitation and
hemodynamic support. Inthese instances, definitive repair may not
be an option. The principles of treatment remain the same (control
source of sepsis, drain infected fluid collections, administer antibiotics,
and provide nutritional support), but alternative strategies are used to
accomplish the required tasks. If available to the surgeon, esophageal
stenting and drain placement canprovide immediatesource control.At
surgery,theesophagus willbeedematous andextremelyfriable making
successfulprimaryrepairunlikely.
OptionstoconsiderarerepairoveraT-tube,creatingacontrolled
fistula, or esophageal exclusion. T-tube placement is considered
when there is a significant delay in diagnosis, in unstable patients, or
when successful primary repair is unlikely or will result in severe
narrowingduetoextensivemucosalormusculardamage2.Esophageal
diversion is considered if there is a non-viable, necrotic esophagus,
hemodynamicinstability,andtheunderlyingpathologyprecludesprimary
repair.Thisconsistsofacervicalesophagostomy(weperforman‘end’esophagostomybecausewecompletely dividethe proximalesophagus.
However,someprefertodoaside-esophagostomybecausetheyusean
absorbable suture to tie off the proximal esophagus temporarily) and
stapling of the distal esophagusat thegastroesophageal junction;then
weplaceagastrostomyandajejunostomytube.Thethoracicesophagus
doesnotneedtoberesected,providedtheposteriormediastinumiswell
drained, and an end-cervical esophagostomy is created using the left
neck dissection described above. Every effort should be made to
maximize the remaining length of proximal esophagus. If the proximal
esophagus is long enough, the esophagostomy can be created on the
anterior chest wall by tunneling it in the subcutaneous tissue over the
clavicle.Thestomaappliancesitsbetteronthechestandcanbehidden
under the patient’s clothes. This extended length allows for easier
reconstructionwitheitheragastricconduitorcoloninterpositionat
alaterdate.Itisnotuncommonforthesedelayedpresentationstohave
anassociatedempyema.Ifthelungisfoundtobetrappedatsurgery,
then a decortication should be performed and all loculated fluid
collectionsdrained.
Bethatasitmay,everyattemptshouldbemadetopreservethe
esophagus and gastrointestinal continuity — it is becoming
exceedinglyrarethatesophagealexclusionisneeded.
Benignstrictures
Primaryrepairofaperforationassociatedwithadistalstrictureis
unlikely toheal. Perforations do not develop spontaneously but arise
fromattempteddilationofthestricture.Iftheperforationoccursatornear
adistalbenignstricture,thenthestomachshouldbeusedaspartofthe
repair or as a buttress by creating a partial fundoplication. The
esophagus is usually foreshortened in these instances and a Collis
gastroplasty is needed to lengthen the esophagus. If repair is not
technicallyfeasibleduetoalongstricturethenanesophagectomyshould
beperformed.Ifthepatientisdeemedunfitforsuchamajor procedure,
thenaT-tubeisplacedalongwithdrainsuntilthepatientisabletohave
an esophagectomy. Inflammation and fibrosis from the perforation and
stricture will make the mediastinal dissection challenging, so an IvorLewis or McKeown (3-field) approach will help with the thoracic
dissection.
Motilitydisorders
Whenaperforationoccursafterpneumaticdilatationforanunderlying
motilitydisordersuchasachalasiaordiffuseesophagealspasm,thenthe
primary repair should be accompanied by a long myotomy, performed
180°opposite therepair,andpartial gastricfundoplication. Ifthe patient
was predetermined to have a defunctionalized esophagus from the
motility disorder (e.g. end-stage achalasia), then he should have an
esophagectomy.
Malignancy
Patients that present with a perforation in the setting of widely
disseminated esophageal cancer or tracheoesophageal fistulas
should be treated with stent placement. Esophagectomy should be
reserved for hemodynamically stable patients with non-disseminated
disease. Reconstruction can be performed immediately if the patient
remains hemodynamically stable and there are no concerns about the
gastric conduit (no ischemia); otherwise a cervical esophagostomy is
createdwith placementofa gastrostomyand feeding jejunostomytube.
Wedonotfindthat placementofagastrostomytubelimitsourabilityto
usethestomachasaconduitduringsubsequentreconstruction.
Causticinjuries
Asmentionedabove,theseverityofcausticinjuryisdependentonthe
substance ingested, volume, and duration of exposure. Alkali agents
tendtopenetratetheoropharynxandesophagusmorethanacid,leading
toa‘deeper’injuryandhigher riskofimmediateperforation.Inaddition,
alkali agents are usually odorless andtasteless soa greatervolume is
consumed. In contrast, acids tend to taste bitter and cause immediate
discomfortwithingestion,causingthepatienttospititoutbeforethereis
significantexposuretotheesophagus.
Patientswith severe injuries willpresentwith oral pain, aninabilityto
toleratetheir saliva, and evidence of laryngealedemawith hoarseness,
stridor,ordyspnea.Thesurgeonneedstohavetheequipmentready
forimmediate intubationoranemergencysurgical airway. Induced
vomitingiscontraindicated asitwill re-exposetheesophagustocaustic
injury.
Diagnosis
AchestX-rayandCTscanareobtainedtolookforaperforation,
but the definitive test to evaluate the severity of injury is early,
flexibleendoscopy.Extremecautionshouldbeusedduringendoscopy
with the use of a pediatric scope and minimal insufflation to lessen the
risk of an iatrogenic perforation. The scope should be passed only
untiltheinitialareaofinjuryisnotedandseverity ofinjurycanbe
accessed,asnavigationbeyondthisareacarriesahighriskofiatrogenic
mucosal injury or full-thickness perforation. With first-degree injuries,
there is mucosal hyperemia and edema signifying a mucosal injury.
Second-degree injuries will have hemorrhagic, exudative, or ulcerative
pseudomembranes. These injuries arethrough the mucosa butnot the
muscularis. Third-degree injuries are full-thickness injuries with eschar
andcharring,orcompleteobliterationofthelumenbyedema.
Treatment
Patients are made NPO and started on broad-spectrum antibiotics.
Themajorityofpatientscanbemanagednon-operativelybutareat
highriskforlatestrictures—themanagementofwhichisbeyondthe
Соседние файлы в папке Библиотека им академика М.И. Перельмана