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
Figure16.2.Patient:“Please help me tovomit.”Doctor:“Yourstomachisinthechest.I
amafraidofaspiration…”
ManyyearsagoMoritzBorchardt(1868-1948,asurgeonfrom Berlin who was later forced to
emigratetoArgentina,wherehedied)describedthediagnostictriadofgastricvolvulus:
Epigastric/substernalpain.
Retchingwithoutvomiting.
Inabilitytopassanasogastrictube.
Youwillnotbewakenedatnightbyuncomplicatedhiatalhernias,and
even those with complex reflux problems will be managed by the
gastroenterologist and his medications. The trouble lies with the
paraesophageal hernia and its ‘relatives’ — the missed
diaphragmatic injury and the late-presenting congenital hernia —
that act like real hernias and may lead to incarceration and even
strangulation. Interestingly, until relatively recently every diagnosed
paraesophageal hernia was a clear indication for surgery, even the
asymptomatic ones, because of theperceived riskof strangulationand
the associated morbidity and mortality. Some surgeons stick to this
approacheventoday…Butasthetypicalpatientisusuallyoldand
frail we are more selective in offering surgery — to symptomatic
patientsonly.
Presentingsymptomsrelate to a difficulty orpainwithswallowing, as
theherniatedpartofthestomachpressesupontheesophaguswhichcan
be partially obstructed at the hernia neck. Acute obstruction will be
associatedwithretrosternal pain (the abdomen is usually soft and nontender),and retching— asthe incarceratedpart ofthestomachcannot
empty,evenwithforcefulattemptstovomit( Figure16.2).Anasogastric
tube may be difficult to pass, or fails to decompress the incarcerated
stomach.
Figure16.3.ChestX-ray of an incarceratedparaesophagealherniawithagastric bubble
inthemediastinum.
Sincetheascentofthestomachintothe chestisrarelystraight,
some element of torsionis almost always present, but true acute
gastricvolvulusmayquiterapidlyleadtogastricnecrosis.Asthese
patientscomplainofretrosternalpain,andareusuallyinsomerespiratory
distress, you can be sure that a chest X-ray will already be available
whenyouarecalledbytheERdoc;butdon’ttrusthimtohavenotedthe
gastricairbubbleupinthemediastinum—havealookyourself( Figure
16.3).
Figure 16.4. CT of gastric volvulus. In this mesoaxial rotation, the lower part of the
stomachisfoundhigh in thechest—afterherniatingthrougha paraesophagealdefect.
The incarcerated part of the stomach still has a narrow connection with the intraabdominalpart,allowingcontrasttoenter—butitisdistendedandcompressingthelung
upwardandtheesophagusmedially.
Of course, nowadays a CT scan is an integral part of the
diagnosisanddecision-makingintheER( Figures16.4and16.5).It
willalsoshowyouotherstructuresthat maybeinvolved:thetransverse
colon may be stuck up there too, and you really don’t want to
procrastinatewhen the colon isatrisk of ischemia andperforationhigh
upinthechest.
AlthoughCTisdiagnostic,thesepatientscommonlylandinthehands
ofinternists/gastroenterologistswhofeelobligedtoinsertanendoscope.
Thetypicalendoscopicfeaturesofgastricvolvulus(organoaxial)are:
a tortuous stomach, paraesophageal hernia (viewed by retroflexingthe
scope)andaninabilitytolocate,andpassthrough,thepylorus;evidence
of gastric ischemia may be observed. There are reports of successful
endoscopic-guided insertion of a nasogastric tube and detorsion —
allowingasubsequentelectiveoperation.
Figure16.5. CT of gastricvolvulus — lateral view,whichbetterdelineated the posterior
pressureontheheart.
Management
Inserting a nasogastric tube may change an emergency into an
elective problem, because if you succeed in decompressing the
stomach,andthestomachhasnotyetnecrosed,youwillbeableto
operateinbetterconditions: thesepatients arecommonly elderlyand
debilitated, and the added respiratory distress, together with the local
conditionsoftheedematous,incarceratedstomach,makeanemergency
repair less favorable. Unfortunately, in true and complete gastric
volvulus,youwillnotbeabletoplaceatubeanddecompress.
When surgery is unavoidable, with the imminent risk of gastric
necrosis, you’d better act fast (obviously after having optimized the
patient and given broad-spectrum antibiotics). Access is through the
abdomen—toreducethecontentsand,ifneeded,resectifitistoolate.
Uppermidlinelaparotomyistheclassicapproach,butlaparoscopymay
allowyou toachievewhat youneed todo— ifyouare familiarenough
withthisapproachforthispathology.
Reduction of the herniated viscera may be difficult, and sometimes
adding a thoracotomy is inevitable. Reduction may be aided by two
maneuvers: inserting a wide tube through the diaphragmatic defect
abolishes the negative, ‘sucking’, thoracic pressure and then a
nasogastric tube may be manipulated into the distended stomach to
reduceitssize.If still unsuccessful you can try and directly aspirate air
andfluidvia a needle puncture, oreventhrough a small gastrotomy —
butbecarefultoavoidspillageandprotectyourpatientfromempyema.
After a successful reduction of a viable stomach you should
continuewithyourdiaphragmaticrepair,completingallthefamiliar
componentsyou knowfromelective surgery: excise the hernia sac,
close the defect by suturing the diaphragmatic crura, and complete a
fundoplication,ornot,based on your beliefs (I do). Some surgeons will
recommend gastropexy to prevent arecurrent volvulus,or evena tube
gastrostomy for both fixation and drainage, but these are rarely
necessaryifyoucompletetherepair.If,however,thepatientisnotin
‘greatshape’,andyouneedtogetoutoftherequickly—forgetthe
diaphragmatic repair and the fundoplication. Under unfavorable
conditionsjustfixingthereducedstomachtotheabdominalwallis
agoodidea.
Ifthepatient,theERdocoryouhavewaitedtoolong—whichinreal
life is not a rare scenario — and you find a necrotic stomach, your
optionsare more limited. Insuchdire circumstances thepatientwill
alsolimityouroptionsbyhis/hergravecondition,andtheeventual
mortality is high. Do what you really have to do: resect the
gangrenous portion of the stomach, clean the mediastinum of spilled
contentsifperforationhasalreadyoccurred,andclosethestomachifyou
can.Iftotalgastrectomyandreconstructionareneeded—makesurethe
patientisinaconditiontowithstandsuchalonganddifficultprocedure.If
not — consider staging: insert a nasogastric tube to drain the distal
esophagus, close the duodenal stump and place a tube jejunostomy.
Roux-en-Y jejunoesophagostomy will be performed once the patient is
stabilizedandreadyforamajorreintervention.
WerecallsomecasespresentedintheM&Mmeetingwithastorylinelikethis:anoldthinlady
with vague chest pain, hours in the ER ‘ruling out heart attack’, admission to medicine for
dyspepsia, interns or even nurses failing to insert a nasogastric tube, gastroenterologists
scopingthepatientandfailingtorealizewhattheysee.Atoperationthenextday,orevenlater,
thewholestomachisdead.Veryfewsurvive!Wehopeyouwilldobetter.TheEditors
Remember: Presentation may be vague and a delay in treatment is disastrous.
Thinkaboutit—suspect—proceedrapidlywithdiagnosticstepsandtreataccordingly.
Chapter17
Uppergastrointestinalbleeding
MosheSchein
I wasn’t sure I remembered what or where the stomach
was, but refreshed my memory on Wikipedia. Yes, I do
recallan operationortwoonthat organ,but Ihad thought
maybehumanshadlostitthrusomerapidevolution,sinceI
never get stomach consults anymore. I think my partner
exploredanupperGIbleederaftera10-unitbleednotlong
ago.Idon’tknowwhetherGIorIRisseeingthesepatients
at our hospital, assuming they still exist. Haven’t been
consultedforvaricesin20years.
JohnKennedy
This tongue-in-cheek comment by our colleague from Atlanta
reflectstheemergingparadigm—surgeryforuppergastrointestinal
bleeding(UGIB)isbecoming(orhasbecome)ararityinmanyparts
oftheworld.
During my residency in the 1980s not a week passed without a few
operations for bleeding duodenal or gastric ulcers. Emergency
gastrectomies, antrectomies, truncal vagotomies, and highly selective
vagotomieswereourdailybreadandbutter.Butgraduallythingsstarted
tochange. First the H2 antagonistsappeared,followedbyprotonpump
inhibitors (PPIs), and then anti-Helicobacter therapy emerged. In
addition,novel methods of achieving endoscopic hemostasis appeared.
Asaresult,operationsforUGIBhavebecomeararityandourapproach
tothemhasbeenradicallymodified.However,ifyouworksomewherein
theso-calleddevelopingworld,wheremodernanti-ulcermedicationsare
not freely available — or where expertise with endoscopic/radiologic
managementoptionsarelacking— youmay stillbe exposedto theold
patternofUGIBandthetraditionalmethodsofdealingwithit.
HowcommonareoperationsforUGIB?
From a non-formal poll we conducted among the international
groupofsurgeonslinkedonSURGINET,itappearsthattheaverage
activegeneralsurgeondoesnotoperateforUGIBmorethanoncea
year—orevenless.Largeurbanacademiccentersmaydealwithupto
acasepermonthbutsuchexperienceisdividedamongmanysurgeons
— not only because of a lowerincidence but alsobecause better nonoperativemanagementisavailable forthe ‘serious’cases,as described
below.
Sothepatternofetiologyofthebleedinghasshifted,and,inaddition,
failed, repeated attempts at non-operative management leave us
withsickerpatients who then present with morecomplex surgical
anatomy(e.g. the duodenum repeatedly tortured by the endoscopist is
pristinenomore).Asaresult,thecasesyouarecalledtosave,afterthe
others have failed, are becoming more demanding, while you, in all
likelihood, are less and less familiar and skilled in the operative
management of UGIB. (Confess — on how many cases of bleeding
duodenalulcerdidyouoperateduringyourresidency?Howmanypartial
gastrectomieshaveyoudone?).Therefore,youneedtolistentous…
Whataboutbleedingesophagealvarices?
Wedonotknowofasurgeonanywherearoundtheworldwhostill
operates on acute variceal bleeding in patients with portal
hypertension. Anybody who remembers thebloody-morbid emergency
devascularization procedures, or the no less exasperating portocaval
shunts, must be relieved that modern endoscopic and radiological
approacheshavereplacedtheoldbutchery.Hence,wehavemovedthe
sectiononbleedingvaricesfromthischapterto Chapter25.
Nowletusgobacktosomebasics…
Theproblem
UGIB implies a source of bleeding proximal to the ligament of
Treitz. What is the etiology of bleeding in need of your surgical
attention?
•
Chronic duodenal (DU) orgastric ulcers (GU), while much less
prevalent than before (do you know anyone who is not munching
Zantac®orchewingaPPI?OurfriendAngusofOntarioevenclaims
that there is some PPI in the local water supply), are still
predominant among the cases you are called upon to operate for
bleeding.YouwillseemoreDUsthanGUs.
•
Bleeding gastrointestinal stromal tumors (GISTs) requiring
surgical hemostasis have been mentioned by members of
SURGINET.
•
Dieulafoy’s lesion, a manifestation of a gastric submucosal
vascular abnormality, has also emerged as a relatively frequent
indicationforanemergencyoperation.
•
Rarecausesareseenfromtimetotime,e.g.necroticgastriccancer
afterchemotherapyoraorto-entericfistula( Chapter34).
•
Acutegastricmucosallesions(e.g.stressulcers,erosivegastritis
andothertermsthatmeanmoreorlessthesame)areusuallydue
toingestionofanalgesicsand/or alcohol(aspirin forthehangover).
With the routine use of anti-ulcer prophylaxis in hospitalized
‘stressed’ patients, significant UGIB from mucosal lesions is now
extremelyrare—luckily,youwillneverbecalledupontooperateon
suchcases.Inpracticenowadays,hemorrhageinstressedpatients
oftenoriginatesfromreactivatedchronicpepticulcers.
Presentation
Thesedaysyouusuallyseethesepatientsonlyaftertheyhavepassed
throughtheskilledhandsofyourmedicalfriends.Butagain,wewantyou
toknowthebasics.
Patients present either with hematemesis, vomiting fresh blood or
‘coffee ground’ (melenemesis) or melena (passage of black stool per
rectum).Hematochezia(passageoffreshoralterednon-blackbloodper
rectum) usually originates from a source below the ligament of Treitz.
Nevertheless, with massive UGIB and rapid intestinal transit,
unalteredblood,producingloosestool,mayappearintherectum.
Remember:
Melenaisblack,stickyandverysmelly.
Maroonfecesarenotmelena.
RedfecesarenotUGIbleeding.
BlackbloodperrectumalmostalwaysmeansUGIB.
Fresh,red bloodper rectum in a hemodynamically stable patientmeans that
thesourceisNOTintheUGItract.
Anytypeofblood—freshorold,vomitedorretrievedthroughthenasogastric
tube—meansthatthesourceisintheUGItract.
Thecharacterofbloodoriginatingfromthesmallboweldependsontheamount
ofbleedingandthelocationofthesource:oftenitismaroon.
You do not need panendoscopy to diagnose UGIB — contrary to the gastroenterologists’
credo.Afinger,anasogastrictubeandasetofeyesarejustasgood.
Key issues: Is the hemorrhage ‘serious’? When should
youbealarmed?
These are key issues because the seriousness of hemorrhage
determinesyourdiagnostic-therapeuticstepsandthepatient’soutcome.
In general, the larger the bleeding vessel, the more ‘serious’ the
hemorrhage.Themore‘serious’thehemorrhage,thelesslikelyitis
to stop without an intervention, and the more likely it is to recur
after it has stopped — spontaneously or after endoscopic
hemostasis.
Massive bleeding from a large vessel requires your immediate
Соседние файлы в папке Библиотека им академика М.И. Перельмана