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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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POSTERIORSTOMACHWALLMARKING STITCH
■ Constructionofthefundoplicationitselfisthesinglecriticalstepwhereerrors aremadethataffecttheshort-andlong-termsuccessoftheoperation.To combatthis,weplacealoosestitchontheposteriorgastricwalltomarkthe proposedsiteforthefirststitchofthefundoplication.Ideally,thisstitchis placed3cmdistaltotheGEjunctionand2cmfromthegreatercurvature (FIG12).
PASSTHEFUNDUSPOSTERIORTOTHE GASTROESOPHAGEALJUNCTION
■ TheGEjunctionisthenretractedwiththePenrosedrainandtheposteriorgastric fundusisgraspedfromthepatient’srightandbroughtposteriortotheGE
junction(FIG13).(Note:Ifthepreviouslyplacedmarkingstitchwaswell placed,itwillbecomevisibleasthefundusispassedfromthepatient’sleftto therightandwillservetomarkthelocationofthefirstfundoplicationstitch tobeplaced.)
IDENTIFYANDGRASPTHEANTERIORSTOMACH
■ Anoptimalfundoplicationwillbeachievedbysymmetricgeometry.Thisis accomplishedbyidentifyingtheplaceontheanteriorgastricwallthatisof similardistancefromtheGEjunctionandthegreatercurvatureasthe previouslyplacedposteriorgastricwallmarkingstitch(FIG14).Oncethis locationisidentified,boththeanteriorandposteriorgastricwallsare approximatedaroundthedistalesophagusatthe10o’clockposition.The wrapshouldbesnugwithoutexcessiveredundancybutnottootighteither.
FUNDOPLICATIONCREATION
■ Oncesymmetricfundoplicationgeometryisconfirmed,fourseromuscular permanentsuturesareplacedfromanteriorfundustoposteriorfundusto securethefundoplicationoveratotalof3cm.Oncethefirstseromuscular stitchisplaced,thePenrosedrainisremovedanda52-Frintraesophageal bougieisguidedintothestomachtoaidinfundoplicationsizing.Toorientthe fundalfoldsappropriatelyforthesecond,third,andfourthfundus-to-fundus stitches,graspthefirstfundus-to-fundusstitchandretractitcephaladtothe rightcrus(FIG15).Thiswillresultinappropriatealignmentofthefundal suturelineatthe10o’clockto11o’clockpositions(FIG16).
FUNDOPLICATIONANCHORING
■ Thefundoplicationisthenanchoredwithseparatestitchestotherightandleft cruraaswellasesophagus(fundus-esophagus-crus)toanchorthe fundoplicationintheabdomenandpreventherniation.Cautionmustbeused soasnottoteartheesophagealorcruralfiberswiththesestitches.Afinal stitchfromtheposteriorfundustothecruralclosurecanbeplacedtoprevent posteriorherniation.(Theanteriorspaceisprotectedbytheleftlaterallobeof theliver.)
INTRAOPERATIVEENDOSCOPY
■ Intraoperativeendoscopyisusedtoconfirmawell-positionedfundoplication priortodesufflationoftheabdomenandremovaloftrocars.
PEARLSANDPITFALLS
Indications ■Objectiveevidenceofabnormalgastroesophageal
refluxby24-hourpHmonitoringisessentialto considerantirefluxsurgerybecausesymptomsalone canbemisleading.
■Additionalmandatorypreoperativestudiesfor
operativeplanning:esophagealmanometry,upper endoscopy,andesophagogram.
Hiatusdissection ■Eitheraleft-to-rightoraright-to-lefthiatal
dissectionisacceptable.Wepreferstartingthe dissectionontheleftasitminimizestheriskof inadvertentlytearingshortgastricvesselsand splenicinjurywhenworkingfromtheright.
■Mediastinalesophagealmobilizationisnecessaryto
gainadequateintraabdominalesophageallengthfor properfundoplicationcreation.
Fundoplication calibration
■A52-Frintraesophagealbougieisnecessaryto
calibratethefundoplicationsize.
■Thefirstfundoplicationstitchiseasierwithoutthe
bougieinplace.Afterthefirststitch,advancingthe bougieintothestomachmustbedonewithcaution asthebougiecanperforatetheGEjunction.
Fundoplication orientation
■Anidealfundoplicationwilllaysothatthesuture
lineisatthe10o’clockto11o’clockpositionson theesophagus.
POSTOPERATIVECARE
■ Postoperativedietarymodifications:Clearliquidsarestartedpostoperativelyand areadvancedtofullliquidsthefollowingday.Thepatientistypically dischargedonthefirstpostoperativeday.Over2weeks,dietisadvancedtoa softandthenfinallyaregulardietasthepatient’sdysphagiaresolves.
■ Otherpostoperativeinstructions:Todecreasepostoperativebloating,nostraws areusedandcarbonatedbeveragesareavoided.
■ Activityrestrictions:Noliftinggreaterthan10to15lboraggressivephysical activityisstrictlyobservedfor6weekstoavoidstresstothediaphragmatic
sutures.
OUTCOMES
■ Long-termoutcomes(median69-monthfollow-up)forlaparoscopicantireflux surgeryreveal90%ofpatientshaveresolvedorimprovedheartburnand regurgitation.Seventy-fivepercentofpatientshaveresolvedorimproved dysphagia.Sixty-ninepercentofpatientshaveresolvedorimprovedcough andhoarseness.
■ Postoperativesideeffectsincludenew-onsetbloating(9%),diarrhea(11%),and dysphagia(2%).
■ Ninetypercentofpatientsreportthattheywerehappywiththeirdecisionto undergolaparoscopicantirefluxsurgery.
2
COMPLICATIONS
■ Splenicorliverinjury
■ Hollowviscusperforation
■ Dysphagia
■ Pneumothorax
REFERENCES
1.VakilN,vanZantenSV,KahrilasP,etal.TheMontrealdefinitionandclassificationof gastroesophagealrefluxdisease:aglobalevidence-basedconsensus.AmJGastroenterol. 2006;101:1900–1920.
2.OelschlagerBK,QuirogaE,ParraJD,etal.Long-termoutcomesafterlaparoscopicantireflux surgery.AmJGastroenterol.2008;103(2):280–287.
3.BelloB,ZoccaliM,GulloR,etal.Gastroesophagealrefluxdiseaseandantirefluxsurgery—what istheproperpreoperativework-up?JGastrointestSurg.2013;17(1):14–20.
4.JohnsonLF,DeMeesterTR.Twenty-fourhourpHmonitoringofthedistalesophagus.A quantitativemeasureofgastroesophagealreflux.AmJGastroenterol.1974;62:325–332.
Chapter6
RedoFundoplication
C.DanielSmith
DEFINITION
■ Avarietyoffundoplicationproceduresareusedtoday(Table1),primarilyto treatgastroesophagealrefluxdisease(GERD).
■ The360-degreefundoplication(Nissenfundoplication)isthemostpopularof thevariousfundoplicationtechniques.
■ Althoughfundoplication,whendonebyanexperiencedsurgeon,resultsin controlofGERDandsignificantimprovementinqualityoflifeinthe majorityofpatients,thisoperationdoesfail,necessitatingfurthersurgeryora redofundoplication.
1–3
■ Broadlyspeaking,therearethreereasonsthatanoperationwillfailtocontrola patient’ssymptomsand/orGERD.
■
Errorsinworkuporpatientselection
■
Errorsinoperativemanagement
■
Naturalhistoryoftheparticularantirefluxoperationorconditionbeingtreated
DIFFERENTIALDIAGNOSIS
■ Fundoplicationfailureisdefinedaseitherrecurrenceoftheconditionor symptomsthatnecessitatedthefundoplication(e.g.,recurrentGERDor recurrenthiatalhernia)orthedevelopmentofnewsymptomsnotpresent preoperatively(e.g.,dysphagia,nausea,orregurgitation).
■ Onetypicallyseesfailureofafundoplicationinafewdistinctpatterns.
4–6
These
areoutlinedinTable2andFIGS1and2.
■ Whenconsideringthesereasonsforfailure,hiatalherniaisthemostcommon cause(44%ofcases).Wrapdisruptionorbreakdownisthenextleading cause,accountingfor16%offailures.Slippedwrapsaccountfor11.7%of failure,andfinally,wrapsimproperlypositionedatthetimeoftheirinitial constructionisfoundin3.9%ofcases.
7
■ Wraporcruralstenosisisararecauseoffailureandoftentimeshardto determineasaprimaryetiologyoffailure.
■ Ifmeshwasusedattheinitialoperation,adistinctlydifferentpatternoffailure andmanagementstrategyisneeded.
8
PATIENTHISTORYANDPHYSICALFINDINGS
■ CommonsymptomsoffailureoffundoplicationareoutlinedinTable3.
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