Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_747_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

30.08.2026

Размер:

49 Мб

Скачать

☆

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 4243 / 5043 44 45 46 47 48 49 50 > Следующая >>>

404 Transhiatal esophagectomy

https://t.me/med1917

Traction is then applied on the rubber drain encircling

the gastroesophageal junction, and the opposite hand is inserted palm downward through the diaphragmatic hiatus along the anterior surface of the esophagus and is advanced upward into the superior mediastinum behind the trachea. The portion of upper esophagus that was circumferentially mobilized can be identiﬁed with the ﬁngertips. Once the intact lateral attachments are palpated, the esophagus is trapped against the prevertebral fascia by the index and middle ﬁngers, and a gentle downward raking motion of the hand avulses the remainder of the ﬁlmy periesophageal attachments.

Sizable vagal branches may be palpated along the middle

and distal esophagus at this point, and by placement of narrow deep retractors into the diaphragmatic hiatus, they can be identiﬁed, divided, and ligated using long right-angled clamps. At times, ﬁnger fracture between the index ﬁnger and thumb of subcarinal or subaortic periesophageal adhesions may be required.

In elderly patients with cervical arthritis which

https://t.me/med1917

8a–c

patients with a “bullneck” habitus, access to the cervical and upper thoracic esophagus may be facilitated by a partial upper sternal split, which provides exposure almost to the level of the carina.

Once the entire intrathoracic esophagus is mobile, an 8- to 10-cm length is delivered into the cervical wound, where an Endo GIA surgical stapler is applied and ﬁred obliquely in an anterior to posterior direction, leaving the anterior tip of the divided esophagus slightly longer than the posterior corner. The stomach is then drawn out of the abdominal wound with the attached esophagus.

Once the esophagus has been delivered from the posterior mediastinum, narrow deep retractors are inserted into the diaphragmatic hiatus so that the posterior mediastinum can be inspected for bleeding and the mediastinal pleura for lateral rents that indicate the need for a chest tube. Blood is again evacuated from the posterior mediastinum using the Argyle Saratoga sump catheter inserted through the cervical wound. A 28-Fr. chest tube is inserted into the appropriate pleural cavity if entry has occurred during the esophagectomy. A large abdominal pack is then placed in the low posterior mediastinum through the diaphragmatic hiatus and a narrow “thoracic” pack in the superior mediastinum through the cervical incision to tamponade any vascular oozing. Attention is then turned toward preparing the stomach for its transposition into the chest. The stomach and attached esophagus are placed on the anterior abdominal wall, and the point along the high greater curvature that will reach most cephalad to the neck is identiﬁed and held by the assistant with a moist pack. The lesser curvature of the stomach is then cleared of fat by dividing the vessels and fat between clamps at the level of the second vascular arcade from the cardia.

prevents extension of the neck, or obese

Operation 405

A GIA stapler with a 6-cm cartridge is then applied

beginning at this point on the lesser curvature and proceeding toward the gastric tip. Each time the stapler is removed, traction is applied to the gastric fundus to allow the stomach to be straightened progressively so that its cephalad reach is maximized. The GIA stapler is applied on average three times. As wide as possible a gastric tube is created to maximize submucosal collateral circulation and vascularity of the conduit; a narrow gastric tube is avoided.

406 Transhiatal esophagectomy

https://t.me/med1917

Once the partial proximal gastrectomy has been

stomach are removed from the ﬁeld, and the gastric staple suture line is oversewn with two running 4/0 polypropylene Lembert stitches. This same technique is used when resecting carcinomas localized to the cardia and proximal stomach. Rather than carry out a traditional proximal hemigastrectomy, which wastes valuable stomach (stippled area of Figure

10) that can be used for esophageal replacement and commits the surgeon to an intrathoracic esophageal anastomosis, the surgeon divides the stomach as described earlier 4–6 cm distal to the palpable tumor, thereby preserving the greater curvature and the point along the gastric fundus that reaches to the neck (asterisk in Figure 10).

The previously placed mediastinal packs are removed, and with the narrow deep retractors placed into the hiatus, a last inspection is made for any bleeding, which can be controlled under direct vision through the diaphragmatic hiatus. Again, the 28-Fr. Argyle Saratoga sump inserted through the neck wound provides a dry ﬁeld as the posterior mediastinum is inspected through the hiatus. To ensure an adequate posterior mediastinal tunnel for the stomach, the surgeon inserts the entire hand and forearm through the diaphragmatic esophageal hiatus and advances them through the posterior mediastinum until three or four ﬁngers are visible in the cervical incision. During this procedure, the blood pressure must be watched carefully.

completed, the esophagus and attached proximal

Attention is now redirected to the diaphragmatic hiatus.

The stomach is then again delivered onto the anterior

will extend most cephalad is identiﬁed.

chest wall, and the point along the gastric fundus that

The diaphragmatic hiatus is elevated with a narrow

https://t.me/med1917

and manipulated progressively upward through the diaphragmatic hiatus into the posterior mediastinum. No drain is sutured to the stomach, and no suction device to pull the stomach through the mediastinum is used to minimize trauma to the stomach. Once the gastric fundus can be pulpated with the index ﬁnger inserted through the cervical incision, a Babcock clamp is inserted downward into the superior mediastinum through the cervical incision, and the tip of the gastric fundus is manipulated into the clamp by the hand within the posterior mediastinum. The gastric tip is grasped with clamp, which is not ratcheted closed, and is drawn into the cervical wound more by pushing the stomach upward beneath the aortic arch by the hand in the posterior mediastinum than by pulling the Babcock clamp. As soon as there is sufﬁcient stomach visible within the cervical incision, the clamp is removed from the ﬁeld in order to minimize gastric trauma, and the tip of the stomach is grasped with the ﬁngertips and guided into the neck wound. (inset) The hand in the posterior mediastinum is withdrawn.

palpated through the diaphragmatic hiatus and the cervical incision to insure that the stomach has not been twisted during its positioning in the chest. When the stomach has been brought through the posterior mediastinum without torsion, the oversewn staple suture line should be oriented toward the patient’s right side. The stomach is not sutured to the prevertebral fascia in order to avoid traumatizing an already relatively ischemic gastric tip. The position of the stomach in the cervical wound is maintained by inserting a small moistened thoracic gauze pack alongside the stomach in the thoracic inlet to prevent it from slipping back downward into the mediastinum.

tents, the cervical gastroesophageal anastomosis is not begun until the abdominal incision is closed completely and excluded from the ﬁeld. Before the abdomen is closed, however, a ﬁnal inspection for bleeding, particularly in the area of the spleen, is made. The diaphragmatic hiatus is narrowed with one to three #1 silk sutures so as to admit three ﬁngers along the side of the stomach easily. The edge of the diaphragmatic hiatus is tacked to the adjacent anterior gastric wall with one or two 3/0 silk sutures to prevent intrathoracic herniation of bowel. The pyloromyotomy is covered by adjacent omentum, and the previously retracted left hepatic lobe is returned to its normal position. The feeding jejunostomy tube is then brought out through a left upper quadrant stab wound, and the jejunum is ﬁxed to the anterior abdominal wall with several interrupted sutures. The abdominal incision is then closed and isolated from the ﬁeld by covering it with a sterile towel and sheet. Attention is now redirected to the neck, where the cervical gastroesophageal anastomosis is performed.

Deaver retractor, and the stomach is gently grasped

The anterior surface of the intrathoracic stomach is greatly

To avoid contamination of the abdomen by intraoral con-

Operation 407

408 Transhiatal esophagectomy

https://t.me/med1917

Cervical gastroesophageal anastomosis

When the stomach has been properly mobilized,

13a

level of the clavicles against the prevertebral fascia and well behind the divided cervical esophagus.

4–5 cm of the gastric tip rest in the neck above the

13a

13b

The traction suture is used to elevate the anterior

secured to the drapes with a hemostat. The site of the anastomosis (dotted line) is determined by lowering the divided end of the esophagus against the gastric wall, and a 1.5- to 2-cm vertical gastrotomy is made with the cutting electrocautery current. This gastrotomy must be placed low enough on the stomach so that a 3-cm staple cartridge can be accommodated in the tip of the stomach superior to this point.

surface of the stomach to the level of the skin and is

The end of the divided esophagus is grasped and

13b

rior surface of the stomach as near to the sternum as possible is grasped with a Babcock clamp, elevated further into the cervical wound, and rotated medially in order to displace the gastric staple suture line away from the site of the subsequent anastomosis. A 3-0 silk seromuscular gastric traction suture is placed as far inferiorly near the sternum as possible.

elevated to the right with an Allis clamp. The ante-

The esophageal staple suture line is retracted inferi-

https://t.me/med1917

obliquely with a DeBakey forceps, and the staple line amputated sharply using the forceps as a guide against the knife. This end is submitted to pathology as the “proximal esophageal margin.” It is important to remember that once the anastomosis is completed and the gastric traction suture cut, the stomach will partially retract downward toward the mediastinum. Therefore overaggressive shortening of the remaining esophagus should be avoided in order to minimize tension on the anastomosis. Alternatively, if the residual esophagus proximal to the anastomosis is too redundant, the ultimate functional outcome may not be good.

orly with two Allis clamps, the esophagus grasped

Operation 409

Placement of two stay sutures is extremely important

wall and the anterior wall of the stomach. One suture passes through the anterior tip of the divided esophagus. The other suture passes in and out of the upper corner of the gastrotomy and then from outside in on the posterior end of the esophagus.

in insuring alignment of the posterior esophageal

While applying continual downward trac-

17a,b

blade (anvil) of an Endo GIA 30-3.5 staple cartridge (United States Surgical Corp, Norwalk, CT, USA) is inserted into the stomach, and the thicker staple-bearing portion into the esophagus. The jaws of the stapler are partially approximated as the stapler is gradually rotated so that the cartridge points toward the patient’s right ear, carefully aligning the posterior esophageal and anterior gastric walls.

tion on the above two sutures, the thinner

3 cm

After closing the stapler, but before ﬁring it, two

either side between the gastric wall and adjacent esophagus.

“suspension” absorbable 4-0 sutures are placed on

410 Transhiatal esophagectomy

https://t.me/med1917

The knife assembly of the stapler is advanced, thereby

terior wall of the esophagus and creating a 3 cm long side-toside anastomosis. The stapler is removed from the ﬁeld, and a nasogastric tube is inserted by the anesthesiologist and guided into the intrathoracic stomach by the surgeon.

joining the anterior wall of the stomach and the pos-

An absorbable 4-0 “corner stitch” is placed on either

opened esophagus and stomach are approximated in two layers of 4-0 monoﬁlament absorbable suture, the ﬁrst, a running full-thickness inverting suture.

side of the opened stomach and esophagus. The

The second layer consists of interrupted full thick-

this closure will not compromise the anastomosis, which is more posterior under the “hood” of the esophagus. A silver metallic hemostatic clip is placed on both of the corner sutures, which are then cut. The clips serve as markers of the anastomosis for future radiographic studies. The cervical wound is then irrigated, and a 1⁄4-inch rubber drain placed to its depth. Muscle fascia is approximated loosely with three to ﬁve absorbable 3-0 interrupted sutures, and the skin with a running 4-0 nylon suture. After placement of dressings on the abdominal and cervical incisions and the chest tube(s) and jejunostomy tube sites, a portable chest radiograph is obtained in the operating room to document full expansion of the lungs and exclude an unrecognized hemo- or pneumothorax.

COMPLICATIONS

Intraoperative complications associated with transhiatal esophagectomy include entry into one or both pleural cavities during the transhiatal dissection, disruption of the tracheobronchial tree, and hemorrhage. As indicated earlier, the mediastinal pleurae are inspected after removal of the esophagus from the posterior mediastinum, and if pleural entry has

ness inverting sutures. Overaggressive inversion of

occurred, a chest tube is inserted and connected to suction before the stomach is positioned in the posterior mediastinum. Tracheal tears during transhiatal esophagectomy are rare, generally small and linear, and involve the posterior membranous trachea. They are heralded by a rush of air from the ventilator felt either through the diaphragmatic hiatus or the neck wound during the transhiatal dissection. If the air leak is sizable, the endotracheal tube balloon should be

Postoperative care 411

https://t.me/med1917

deﬂated and the tip of the endotracheal tube guided into the left mainstem bronchus by the hand inserted through the diaphragmatic hiatus. One-lung ventilation may then be achieved in a more controlled fashion. Addition of a partial upper sternal split may provide sufﬁcient exposure of the membranous trachea for direct repair. Before tracheal repair is begun, however, the transhiatal esophagectomy should be completed, if possible, to improve exposure of the posterior membranous trachea. Larger tears may necessitate a right thoracotomy and direct suture closure. Major intraoperative hemorrhage should not occur during transhiatal esophagectomy if proper patient selection is used, and attempts to resect an esophagus that is ﬁxed to adjacent structures by tumor or ﬁbrosis are abandoned. Should untoward bleeding occur during the transhiatal dissection, the 28-Fr. Argyle Saratoga sump catheter inserted through the neck incision is used to evacuate the posterior mediastinum as the anterior surface of the aorta is inspected and direct control of the bleeding is obtained. If hemostasis is not possible using this technique, the posterior mediastinum should be packed with large laparotomy pads, and several minutes should be allowed to elapse and intravascular volume replaced before the mediastinum is again inspected. If bleeding resumes, the pack should be reinserted, the abdomen quickly closed, and the patient repositioned and turned to the appropriate side for a thoracotomy – left if the intraoperative bleeding occurred during dissection of the lower third of the esophagus – and right if the bleeding occurred during dissection of the middle or upper thoracic esophagus.

Intraoperative recurrent laryngeal nerve injury should not occur if care is taken to avoid direct injury to the recurrent laryngeal nerve in the tracheoesophageal groove. No metal retractors should be placed against the trachea during the cervical portions of the operation to prevent this complication.

If the patient develops fever of 101∞F or more 48 hours after transhiatal esophagectomy, this is presumptive evidence of an anastomotic leak until proven otherwise and is an indication for a contrast study of the esophagus regardless of how uninﬂamed the cervical wound may be. A water-soluble contrast material such as Gastrograﬁn may result in severe chemical pneumonitis if aspirated and should be avoided. It is best to use dilute barium for this study, as this better deﬁnes the mucosal detail. If, on the other hand, the patient begins to drain swallowed liquids from the cervical wound drain site, obviously a leak has occurred, and the neck wound should be opened at the bedside in its entirety by removing the ﬁve or six sutures used to close it. Good mechanical cleansing of the open neck wound can be obtained by having the patient swallow water while at the same time aspirating with a suction catheter any liquid that issues from the cervical wound. The neck wound is packed loosely with saline-moistened sponges several times a day. Most cervical esophagogastric anastomotic leaks will close within 1 week. Closure is often facilitated by passage of 36-, 40-, and 46-Fr. tapered Maloney dilators at the bedside. This dilation ensures that no associated distal obstruction (edema or spasm) is present.

Postoperative chylothorax may occur after transhiatal esophagectomy and manifests as prolonged and excessive chest tube drainage (typically greater than 200–400 ml per 8hour shift). If chylothorax is suspected, cream can be administered through the feeding jejunostomy tube, which will result in a change of the character of the chest tube drainage from serosanguineous to milky white ﬂuid. An aggressive approach is adopted toward treatment of postoperative chylothorax in the patient who has undergone transhiatal esophagectomy. A transthoracic approach to the thoracic duct with direct identiﬁcation and suturing of the leak facilitated by administration of cream through the jejunostomy tube is preferred to prolonged chest tube drainage and intravenous hyperalimentation.

POSTOPERATIVE CARE

Patient’s are typically extubated in the operating room, as epidural anesthesia provides sufﬁcient pain management so that postoperative mechanical ventilation is unnecessary. After several hours in the recovery room, patients are transferred to a monitored hospital bed, but admission to an intensive care unit is seldom indicated. Because of the routine preoperative emphasis on use of an incentive inspirometer to facilitate postoperative pulmonary hygiene, resumption of use of the inspirometer is begun the afternoon of the operation. Ambulation is begun on the ﬁrst postoperative day. Because transhiatal esophagectomy is basically an upper abdominal procedure requiring little manipulation of the intestines or the root of the mesentery, postoperative ileus beyond 48–72 hours is unusual, and administration of 5% dextrose and water through the jejunostomy feeding tube may begin at a rate of 30 ml/hour on the second or third postoperative day. If this rate is tolerated for 12 hours, the volume is increased to 60 mL/hour, jejunostomy tube feedings are begun the next day and advanced as tolerated. The arterial catheter is removed in the recovery room the day of operation once the endotracheal tube has been removed. The intravenous catheters are removed once jejunostomy feedings are tolerated, the cervical wound drain on the third postoperative day, and the nasogastric tube on the third postoperative day when jejunostomy feedings are started. Once the patient has tolerated having no nasogastric tube for 24 hours, oral intake is progressively advanced from a liquid to a soft diet during the ﬁrst postoperative week. A barium swallow examination is obtained on the seventh postoperative day. The barium swallow assesses: (1) anastomotic integrity; (2) emptying of the intrathoracic stomach; and (3) passage of contrast past the jejunostomy tube site. Oral intake should not be withheld until the barium swallow study is obtained, because the patient is swallowing saliva from the moment he or she emerges from general anesthesia, and it is unrealistic to think that nothing is going across the anastomosis because of the presence of a nasogastric tube. As oral intake is advanced, the rate of jejunostomy tube feedings may

412 Transhiatal esophagectomy

https://t.me/med1917

be progressively decreased, and eventually tube feedings delivered only at night so as to not interfere with the patient’s appetite during the day. Complaints of postvagotomy dumping (varying degrees of cramping and diarrhea) typically respond to an appropriate antidumping diet, avoiding overdistension of the intrathoracic stomach by minimizing the amount of liquid consumed with meals, and antispasmodics such as tincture of opium or diphenoxylate hydrochloride (Lomotil).

The patient is commonly discharged from the hospital after a satisfactory postoperative barium swallow examination on the seventh postoperative day. Supplementation of oral caloric intake at night with two or three cans of tube feedings through the jejunostomy tube may be helpful early after discharge from the hospital, but this is not mandatory if the patient is eating relatively well in the hospital. When the patient returns for the initial postoperative assessment 2–4 weeks after discharge, if the feeding jejunostomy tube is not being used, it is removed.

Early mild postoperative cervical dysphagia may result from anastomotic edema, but this is far less common with the 3-cm stapled side-to-side esophagogastric anastomosis. This complaint generally requires no speciﬁc therapy and gradually subsides with time. However, any complaint of cervical dysphagia occurring 2–4 weeks after discharge is managed by passage of 36-, 40-, and 46-Fr. Maloney dilators through the anastomosis on an outpatient basis.

OUTCOME

In the past two and a half decades, Orringer and associates have performed transhiatal esophagectomy without thoracotomy in more than 2000 patients. In their 1999 report of their initial 1085 transhiatal esophagectomies, 285 (26%) had benign disease and 800 (74%) carcinoma (4.5% upper, 28% middle, and 73.5% lower third and/or cardia). Benign esophageal disease included neuromotor dysfunction (33%); strictures (26%); Barrett’s mucosa with high grade dysplasia (19%); recurrent gastroesophageal reﬂux (7%); acute perforation (5%); acute caustic injury (5%); and others (5%). Of the patients with benign disease, 52% had undergone at least one previous esophageal operation. Transhiatal esophagectomy was possible in 98.6% of the patients in whom it was attempted, the remainder requiring conversion to a transthoracic approach. The stomach was used as the esophageal substitute in 96% of these patients, ﬁrmly establishing the principle that the properly mobilized stomach will virtually always reach to the neck for construction of a cervical esophagogastric anastomosis. In 98% of these patients, the esophageal substitute was positioned in the posterior mediastinum.

The hospital mortality rate for these 1085 patients was 4% (44 deaths), and in most cases death was unrelated to the technique of operation. There were three intraoperative

deaths due to uncontrollable hemorrhage. Complications included intraoperative entry into one or both pleural cavities requiring placement of one or more chest tubes (77%), anastomotic leak (13%), clinically signiﬁcant pneumonia or atelectasis (<2%), recurrent laryngeal nerve paralysis (<1%), and chylothorax and tracheal laceration (less than 1% each). Reoperation for mediastinal bleeding was required within 24 hours of operation in ﬁve patients (<1%). The average intraoperative blood loss was 689 ml (795 ml for benign disease and 652 ml for carcinoma). The Kaplan–Meier actuarial survival of our patients undergoing transhiatal esophagectomy for carcinoma was similar to that reported after more traditional transthoracic esophagectomy; the overall 2-year survival was 47% and the 5-year survival, 23%. Among the patients with benign disease, long-term follow-up has indicated good or excellent functional results after a cervical gastroesophageal anastomosis in nearly 80%. It is the author’s practice to pass a Maloney esophageal dilator on an outpatient basis for any complaint of cervical dysphagia after transhiatal esophagectomy, no matter how mild. With this liberal use of dilatation, nearly 75% require an esophageal dilatation at some time, but at last follow-up 81% were swallowing well without the need for dilatations. With the side-to-side stapled cervical esophagogastric anastomosis we have used for nearly 6 years, the anastomotic leak rate has been reduced to less than 3%, and predictably, the need for postoperative anastomotic dilatations concomitantly decreased. Clinically troublesome gastroesophageal reﬂux is unusual after a cervical esophagogastric anastomosis and has occurred in less than 8% of these patients. Our results support our contention that a thoracic incision is seldom required to resect the esophagus for either benign or malignant disease. Transhiatal esophagectomy is safe and well tolerated if performed with care and for proper indications.