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

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■ RecurrentGERDisthemostcommon(59%)anddysphagia(31%)thenextmost common.Althoughthesesymptomscanoccurwithanyorallofthepatterns offailure,therearepatternsofsymptomsthatcorrelatehighlywithagiven mechanismoffailure(FIG3).
■ Grossanatomicabnormalitiessuchashiatalherniaorseverewrap/cruralstenosis aremorelikelytopresentwithsymptomsrelatedtopooresophagealtransit andemptying.Thesesymptomscommonlyincludedysphagia,chestpain,and regurgitation.
■ Thewrapthathasloosenedorcomeundonemorecommonlypresentswith recurrentGERDsymptoms,oftenidenticaltothosebeingexperiencedbefore thefirstantirefluxprocedure.Commonly,thisincludestypicalsymptomssuch asheartburn,regurgitation,andchestpainbutcanalsobemoreatypical symptomssuchascough,laryngitis,orasthma.Again,therelationshipand
similarityofsymptomstothosebeforetheinitialoperationisstrongly predictiveofwrapdisruptionorloosening.
■ Aslippedwrapwilloftenhaveabroadconstellationofsymptomswithmore prevalenceofnauseaandepigastricpainthantheotherpresentations.
■ Afavorableresponsetoantisecretoriesandposturalregurgitationpredictswrap looseningorincompetence,whereaspoortoleranceofheavydensefoodsor weightlosspredictshiatalherniationoresophagealoutletissues. Improvementwithdilationsupportsesophagealoutletrestriction.Failureof symptomstorespondtoanyinterventionismorelikelywithwrapslippage.
■ Aconfusingpresentationisthepatientwithearlypostprandialbloatingormeal- induceddiarrhea.Withthissymptomconstellation,oneshouldbesuspicious ofvagalnerveinjuryorinflammation(dysfunctionalgastricemptying).This symptomcomplexintheabsenceofanobviousanatomicabnormalityora positivepHtestshouldleadonetopursuefurtherworkupratherthanaredo antirefluxoperation.
IMAGINGANDOTHERDIAGNOSTICSTUDIES
■ Testingforsuspectedfundoplicationfailurefallsintotestingtosecurea diagnosisorreasonforfailureandtestingforoperativeplanning.An algorithmfortheworkupofpatientssuspectedtohavefailedaprior fundoplicationisshowninFIG4.
EstablishingtheDiagnosis
■ Inpursuitofadiagnosisoffailure,theworkupshouldstartwithananatomic assessment.Thisusuallyincludesanupperendoscopy (esophagogastroduodenoscopy[EGD])andcontrastesophagram.
■ Often,acontrastesophagramisallthatisneededtoidentifythepatternof failure.FIG5depictstheesophagramfindingscorrespondingtothevarious patternsoffailure.
■ Alternatively,anEGDmayclearlyshowananatomicabnormality.Thecommon endoscopicfindingsoffailureareoutlinedinTable4.
■ Inmanycases,ifthepresentingsymptomscorrelatewithfindingsonan esophagramorEGD,thisisallthatisneededtodiagnosefailureandtheneed forreoperation.
■ IfrecurrentGERDisthedominantpresentation,thenpHtestingshouldbe obtained.
PlanningforOperativeManagement
■ Withadiagnosisoffundoplicationfailuresecured,furthertestingmaybe indicatedtohelpplanthemosteffectivereoperativestrategy.
■ Themostcommonconditionsassociatedwithfailurethatneedtobeinvestigated areesophagealmotilityproblemsandimpairmentingastricemptying.All patientsshouldundergoanesophagealmotilitystudyandagastricemptying studybeforeredosurgery.
■ Impairmentinesophagealmotilitymayindicatetheneedforapartial270-degree fundoplicationratherthana360-degreefundoplication.Classically,apartial fundoplicationshouldbeconsideredifnormalesophagealperistalsisis presentinlessthan70%ofswallowsoresophagealbodypressureislessthan 30mmHg.
■ Delayedgastricemptyingmayrequiretheadditionofagastrostomytubeto
providegastricdecompressionintheearlypostoperativeperiod,thereby preventinggastricdistension–inducedcruralorwrapdisruption.
SURGICALMANAGEMENT
■ Redofundoplicationcanbebothrewardingandchallenging.Althoughtheright diagnosisandproperpreparationareimportant,theyarenosubstitutefor experiencewithallmannerofforegutsurgery.Redofundoplicationshouldnot beundertakenbyageneralsurgeonwhooccasionallyperformselective fundoplication.
PreoperativePlanning
■ Foraskilledlaparoscopicsurgeon,almostallredoscanbeapproached laparoscopically.Earlyconversiontoanopenapproachismorelikelyinthe followingsituations:
■
Multiplepriorforegutprocedures,especiallyprioropenrepairs
■ Hiatalherniawithasignificantamountofthestomachincarceratedinthe chest,especiallyifmeshwasused
■ Prioroperationsthatwerecomplicatedbypostoperativeleak,fistula,orearly reoperation
■ Inthesesituationswhereonemaypredictahigherlikelihoodofconversion,itis prudenttobepreparedfornotonlyanopenapproachbutalsoa thoracoabdominalapproach.
■ EGDshouldbeavailableintraoperativelyforallredos,andanEGDperformed bythesurgeonbeforescrubbingprovidesvaluablefirsthandanatomic informationthatisusefulintraoperatively.Leavingthescopeinthestomach allowsintraoperativeidentificationofkeyanatomicstructuressuchasthe
squamocolumnarjunctionorthelocationofthefundoplication.
Positioning
■ Asplit-legapproachisusedinnearlyallcases(FIG6).Ifconversiontoanopen approachisanticipated,onearmshouldbetuckedsothatatable-mounted retractionsystemcanbesecuredatthepatient’sshoulder,wellawayfromthe surgeons’standingpositionatthepatient’ssideforopenaccess.
TECHNIQUES
GAININGABDOMINALACCESSANDPORTPLACEMENT
■ Ifthepriorfundoplicationwasperformedlaparoscopically,itisreasonableto attemptabdominalaccessbypassingaVeressneedlethroughanareainthe upperabdomenfreeofpriorincisions.Thesafestmeansofaccessisa visualizedaccessusinganopentechnique.
■ Afive-trocartechniqueasdepictedinFIG7isused.
IDENTIFYANDEXPOSEHIATALANATOMY
■ Thedissectioncommencesbyapproachingtheesophagealhiatusfromtheleft. Thegreatercurveofthestomachisfoundandfollowedupwardtowardthe angleofHiswhileusingatissue-sealingdevicetodivideanyremainingshort gastricvesselsorvascularizedscartissue(Table5).
■ Oncethebaseoftheleftcrusisfound,theleftcrusisclearedofadhesionsupto andaroundthecruralarchasfaraspossible(FIG8).Often,theleftlobeof
theliverisfusedtothefundusstartingalongthecruralarchlimitinghow muchcruralarchcanbeexposedatthispointintheoperation.
■ Themediastinumisenteredfromtheleftasfarposterioraspossible.Usually, thisopensaplanejustanteriortotheaortaandbehindtheesophagus(FIG9). Thisplaneisoftenveryfriendlyallowingtheposteriormediastinumtobe clearedproximallyandtotheright,overthetopoftheaortatowardthespine. A½-inPenrosedraincut6-inlongcanbeleftintheposteriormediastinum (FIG10)tobefoundlaterwhenthemediastinumisenteredfromtheright posteriorly.
■ Withatleast½oftheesophagealhiatusexposedfromtheleft,themore complicateddissectionoftherightcruscanbeundertakenmoresafelywith someawarenessoftheesophagealhiatusrelationshiptothescarplatethat tendstoenveloptherightsideofthehiatus.
■ Startingdistalalongthelessercurveofthestomachandwellbelowthe adhesionsoftheleftlobeofthelivertotheanteriorsurfaceofthestomach willoftenrevealafriendlydissectionplaneleadingunderthecaudatelobeof theliverandtothebaseoftherightcrus(FIG11).
■ Oncethebaseoftherightcrusisexposed,themediastinumisenteredfromthe
rightandthePenrosedrainleftinthemediastinumfromtherightisretrieved (FIG12).Atthispoint,thePenrosedraincanbebroughtaroundtheentire hiatalcontentsandusedasaretractortofacilitatetheremainderofthehiatal dissection.
■ Thistechniqueofstartingontheleftandusingthecruraastheedgesof dissectionassuressafeisolationofhiatalcontenttherebyminimizingtherisk ofesophagogastricperforationorvagalnerveinjury(FIG13).
■ Atthispoint,anEGDisusefultoconfirmanatomy,assessforanyunsuspected perforation,andhelplocalizethefundoplicationinpreparationforundoing
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