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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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scopeofthischapter.
Patientswithperforationsfromcausticinjuriesshouldbetakento
surgery.Ifthere is an obviously necrotic esophagus then proceed with
resection.Attempttopreserveasmuchproximalesophagusaspossible.
If you are unsure about the viability of the esophagus or the extent of
resectionthenplacedrainsandplanforasecond-lookoperationin12-24
hours. A laparotomy is performed for gastrostomy and feeding
jejunostomyplacement.Basedontheviabilityofthestomach,apartialor
total gastrectomy may be required. Reconstruction is delayed for 3-6
monthstoallowthepatienttorecover.
Sothekeypointsare…
•
Suspectaperforation.
•
Earlyrecognitionanddiagnosisshouldbeapriority.
•
Assessandidentifyanyunderlyingesophagealpathology.
•
Initiate broad-spectrum antibiotics, provide nutritional support,
controlthesourceofinfection,andachieveadequatedrainageofall
fluidcollections.
•
Mostesophagealperforationscanbeprimarilyrepaired.
•
Alternativetreatment of esophageal perforations (i.e.non-operative
therapy,esophagealstents)canbeconsideredinselectedcases.
Esophagealforeignbodyingestionorobstruction
Thebasics…
Foreignbody(FB)ingestionor obstructionis morecommonly seenin
children, the elderly, prisoners, or adults with psychiatric disorders. It
accounts for approximately 1500 deaths annually in the United States.
Objects such as coins and small toys are the most commonly
ingestedFBinchildren,whilefoodbolusesaccountforthemajority
ofFBimpactionsinadults.Bonesplintersandothersharpobjects(like
chicken bones) usually get lodged in the hypopharynx or cervical
esophagus,and resultininjuries tothe esophageal wall.FB impactions
canoccuralongtheentirelengthoftheesophagusbutaremorelikelyto
belodgedinareasthatarephysiologically(upperesophagealsphincter,
aorticarch,orloweresophagealsphincter)orpathologically(strictureor
tumor)narrowed.
Ahistoryof,orwitnessed,FBingestionaidsintheearlydiagnosisand
potential treatment. Symptoms suggestive of FB or food impaction are
odynophagia,dysphagia,regurgitationandaninabilitytoswallowsaliva.
Any history regarding previous episodes, swallowing difficulties, or
underlying esophageal pathology is helpful. If there is a strong
suggestion of FB ingestion, radiographic evaluation starts with a
conventionalX-rayoftheneck,chestandabdomen.Certainradiopaque
objects(coins, batteries, nails)canbe visualized andlocalized with this
modality.Ifthehistoryanddiagnosisarelessclear,thenaCTshouldbe
obtainedtoaidinthediagnosis,localizeanyFB,evaluateforperforation,
andtoidentifyanydistalmassorstricture.
Note that not all cases presenting with acute esophageal obstruction are children or crazy
adults. Many such patients are relatively normal adults who experience a bolus of food
impactedintheirgullet. For instance,lastyear,while relishingagrilledchicken,achunkof its
breast, covered with oily skin jammed in my mid-esophagus — even a few mouthfuls of red
winefailedtoflushitdown.Theodynophagiaandretchingwhichdevelopedwerecuredonlyby
anendoscopy,pushingthechickenintothestomach.Thedistalesophaguswasobservedtobe
a little inflamed due to reflux.Mostfoodboluseswillberelieved bygentle
pushingwithaflexiblescope.Anyresistancemeans:stopandget
someone who knows how to use a rigid scopeand canpick the
stuff out piecemeal. Then exclude distal esophageal pathology.
Moshe
(WearenotabsolutelysurethatMosheisa‘non-crazyadult’!TheEditors.)
Management( Figure15.5)
The majority of swallowed FB will pass into the stomach without
difficulty; however, approximately 10-20% of them will need to be
removed. Nearly all impacted FB can be removed with endoscopy
withonly1-2%requiringsurgeryforextraction.Discbatteriescontain
a high concentration of alkali solution that is released and may cause
severecausticinjurytotheesophagus—thustheyshouldberemoved
urgently! Emergency removal of other impacted foreign bodies is less
critical but earlier extraction decreases the risk of esophageal injury
(pressure necrosis and perforation). As mentioned above, the
overwhelmingmajorityofingestedFBwillpassintothestomachsosome
small, round, non-corrosive objects can be initially observed.
Unfortunately,theamountoftimeoneshouldwaitforthistooccurisnot
welldefined.Wewouldrecommendthatifanon-obstructiveFBhas
not progressed distally or completely passed into the stomach
within12hoursthenendoscopyshouldbeperformed.
Thegoalsofendoscopyshouldbetoevaluatetheesophagus,extract
the FB, and perform a post-extraction evaluation of the esophagus for
injury. Objects located in the hypopharynx can be removed with direct
laryngoscopy and McGill forceps. Otherwise, flexible endoscopy is
performed and small particles or objects are removed with fenestrated
forceps,awirebasket,orpolypnet.Werecommendthisbeperformed
withgeneralanesthesiabecauseitprovidestheoptimalconditions
forthe procedure:astillpatient,all thetimeyouneed, andairway
protectiontoreducetheriskofaspiration.
Rigidesophagoscopyrequiresspecialexpertisebuttherigidscopes
come in different diameters and lengths to allow the use of larger
graspersforFBextraction.Withsharpobjects,theyshouldbeextracted
withthe sharp edge asthetrailing point. Ifextractionis notpossible,
some impactions can be pushed into the stomach. This should be
donewithcautionasunderlyingesophagealpathology,ifnotknownpreoperatively,canleadtocomplicationswithattemptedadvancementofthe
impaction.Ifanyresistanceisencounteredthenadvancementshouldbe
aborted and surgical extraction performed. Once the impacted FB is
extracted, endoscopy should be repeated to assess theesophagus for
anyinjuryorunderlyingcausesuchasastrictureormass.
Rarely(<1%),iftheendoscopicextractionfails,isnotfeasible,orthere
is an obvious associated perforation,then surgicalremoval isrequired.
The surgical approach to removal is dependent on the location of the
impaction and can be done with techniques described above for the
managementofesophagealperforations.
Figure15.5.Patient:“Doctor,IthinkIswallowedasmallfish.”Surgeon:“Ineedalivebait
—getanightcrawlerstat!”
Keypoints…
•
Round disc batteries should be promptly removed to prevent
corrosivedamagetotheesophagus.
•
Nearly all FB ingestions and impactions can be treated
endoscopically.
•
Surgeons should be skilled in the use of both a flexible and rigid
endoscope(yes,Iknowitiswishfulthinking...).
•
Post-extraction endoscopy should be performed to assess the
esophagusforinjuryoranunderlyingpathology.
“The esophagus is a difficult surgical field… for its
inaccessibility,its lackofserouscoat, anditsenclosure
instructureswhereinfectionisespeciallydangerousand
rapid.”
IvorLewis
1
Dr.TomHorancontributedtothischapterinthepreviouseditions.
2
Fordetailsaboutouruseof T-tubesinsuchsituations,seeChapter 6.2 by John Hunter in
Schein’s Common Sense Prevention and Management of Surgical Complications.
Shrewsbury,UK:tfmpublishing,2013.
Chapter16
Diaphragmaticemergencies
DannyRosin
The diaphragm is a muscular partition that separates
disordersofthechestfromdisordersofthebowels.
AmbroseBierce
Thediaphragmnormallyseparatestheabdomenfrom thechest.
The surgeon is interested when it fails in this function. When its
integrity is disturbed, either acutely (trauma), chronically or congenitally
(herniation),thepressuredifferencesbetweenthetwocavitiescausethe
abdominal organs to shift upwards. The diaphragm is also a powerful
muscle that allowsus to breathe— but this is not so interesting to us
rightnow.
Most diaphragmatic operations are elective, so when discussing
emergencyabdominaloperationswearelimitedtoonlytwosituations:
•
Diaphragmatic laceration, which results from either penetrating
trauma(knife,bullet)orblunttrauma(rupture).
•
Acute presentation of chronic or congenital diaphragmatic
hernia,duetoincarcerationortwistingoftheherniatedcontents.
Although this chapter is short and simple we still need some
background knowledge in order to understand the treatment options
when faced with a diaphragmatic emergency. Our aim is to treat the
contents, preferably by justputting the organs backwhere they belong
(but resection is sometimes necessary), and restore diaphragmatic
integrity,hopefullybyalastingrepair.
So let’s start with some definitions, to get familiar with the
commonpathologies.
Diaphragmatichernia
Thiscan be congenital oracquired.Being a breachinthe integrity of
thediaphragm,thecongenitalherniasresultfrom‘non-closure’,whilethe
acquiredarisefromwideningofanexistingopening—thehiatus.
Therearetwotypesofcongenitalhernias:
•
Bochdalekhernia is themorecommon, representing a congenital
posterolateral defect — usually on the left side. Its main effect is
respiratory,astheprotrusionoftheabdominalorgansintothechest
cavity leads to pulmonary hypoplasia; the life-threatening
respiratorydistressafterbirthmakesitaneonatalemergency,
whichisbeyondthescopeofthisbook.
•
Morgagniherniaisamuchlessfrequentformofcongenitalhernia,
definedbyananterior,retrosternaldefect.Rarely,congenitalhernias
are small and can go unnoticed, only to be diagnosed later inlife,
presentingsimilarlytoacquiredhernias.
Hiatalhernia
Sliding hiatal hernia is an upward shift of the stomach (the
gastroesophageal junction migrates proximal to the hiatus) and,
therefore, anatomically it is a ‘sliding’ hernia, without a hernia sac.
Therefore, there is no risk of acute complications (e.g.
incarceration,strangulation,obstruction)relatedtosuchherniation
(althoughreflux-induced esophagitis mayresultin upper GIbleeding—
butthatisnotreallyasurgicalemergency…).
Paraesophagealhernia,ontheotherhand,ismorerelevanttoour
topic. The defect in the diaphragm is actually the hiatus itself, which
widensandallowsthepassageofthestomach(andotherorgans,ifbig
enough) alongside the esophagus. This hernia is potentially the most
problematic, as its symptoms are related to changes in the stomach
position,andithasthepotentialtoincarcerate.
Muchmentaleffortissometimesexpendedinanattempttoaccurately
classifydifferenttypesofherniaonananatomicalbasis:truesliding,true
paraesophagealandmixedtypes.Inpractice,asyouwillreadlater,this
doesnothelpinsurgicaldecision-making.
Diaphragmatictrauma(seealso Chapter32)
Diaphragmatic rupture or laceration is the result of trauma, the
formerusuallytheresultofblunttraumaandthelatterassociatedwitha
penetrating one. In diaphragmatic trauma the tear includes the
peritoneum,so there’sno hernia sac butdirect shiftof abdominal
organsinto thepleuralspace.As in congenitaland acquired hernias,
theliverprotectstherightdiaphragm,soproblemsaremorecommonon
the left — but it doesn’t mean that the right diaphragm is immune to
injury,andwehaveseenherniationoftheliveritselfintothechest.
Intraumapatients,ifyoucan’tseetheliver,lookfortheholeinthediaphragm…Ari
Diaphragmatic rupture is usually associated with other injuries,
and treated at the same time (primary repair by non-absorbable
sutures).Whileitmaybeobvious(youseetheNGtubecurlinginsidethe
leftchestandyouknowthestomach is up there), it can sometimes be
missed, even by a CT scan. When suspected, and there is no other
indication for laparotomy, it is one of the few conditions in abdominal
traumawherelaparoscopymayhaveaplace(atleastinpenetratingleft
thoracoabdominal wounds): explore the diaphragm, and repair if
necessary.
When not suspected, and consequently missed, a diaphragmatic
laceration can slowly enlarge and present, even years later, as a
diaphragmatic hernia, possibly with incarceration. The lack of a hernia
sac, and the resultant adhesions to the thoracic organs, may make
surgery difficult, and for this reasonsome surgeonsprefer to approach
thesecasesbythoracotomy.
Andnowwecometothemainitemofthischapter…gastricvolvulus!
Gastricvolvulusinaparaesophagealhernia
Gastric volvulus, abnormal rotation of the stomach, is usually
associatedwithaparaesophagealhernia,althoughitcanrarelybeseen
withoutanyherniation—causedbywhatIcall‘generalfloppiness’ofthe
stomach.
Thestomachcantwistalongtwodifferent(andperpendicular)axes.In
organoaxial volvulus — which is the more common variant — the
stomach rotates around the axis that connects the gastroesophageal
junction and the pylorus. The less common variant, mesenteroaxial
volvulus, occurs around the more horizontal axis that runs from the
center of the greater curvature of the stomach to the lesser curvature,
twistingaroundthe‘mesentery’wheretheleftgastricarterycanbefound
( Figure16.1).
Figure16.1.X-rayofmesenteroaxialvolvulus.ImagecourtesyofDr.VictorBruscagin.
ThisclassificationisnicefortheradiologistswhointerprettheCTscan
(orthegoodoldbariumswallow),buttoyouwhatmattersiswhether
thestomachisobstructed,andifthereisanypossibilityofgastric
ischemiaandnecrosis,regardlessoftheexactaxis.
Clinicalpresentation
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