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

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☆
IMAGINGANDOTHERDIAGNOSTICSTUDIES
■ Clinicalhistory,basedonsymptomsonly,hasalowdiagnosticaccuracyof GERDinabout30%ofpatients.
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■ Upperendoscopyisoftenthefirsttestperformedtoconfirmthediagnosisof GERD.However,about50%ofpatientswithclinicalsymptomsofGERDdo nothaveendoscopicsignofesophagitis.3Inaddition,endoscopicevaluation ishighlyoperatordependent,especiallyintheassessmentoflow-grade esophagitis.4Therefore,themajorroleofendoscopyistodetectBarrett’s esophagus(usuallypresentin1%to5%ofpatientswithGERD)andto excludegastricandduodenalpathology.
■ Bariumswallowisusefulfordetectingandcharacterizingthetypeandsizeofa hiatalhernia;fordeterminingthelocationandsizeofastricture;andfor evaluatinglength,diameter,andfunctionoftheesophagus.Thistest, however,isnotdiagnosticofGERDasahiatalherniaorrefluxofbariumcan bepresentintheabsenceofabnormalrefluxorabsentinthepresenceof clinicallysignificantGERD.
■ Esophagealmanometryprovidesinformationabouttheloweresophageal sphincter(LES)intermsofrestingpressure,length,andrelaxationandthe amplitudeandpropagationofesophagealperistalticwaves.Inaddition, manometryisessentialforproperplacementofthepHprobeforambulatory pHmonitoring(5cmabovetheupperborderoftheLES).
■ 24-hourambulatorypHmonitoringisconsideredthegoldstandardforthe diagnosisofGERD(FIG1).Itsroleiskeyintheworkupasitdeterminesthe presenceandamountofabnormalrefluxanditestablishesatemporal correlationbetweensymptomsandepisodesofreflux(particularlyimportant whencoughorchestpainarepresent).5Anabnormalscorenotonlyconfirms thediagnosisbutalsoisanindependentpredictorforthesuccessfuloutcome ofantirefluxsurgery.6Finally,pHmonitoringismandatoryfortheproper
evaluationofpatientswhohaverecurrentsymptomsafterantirefluxsurgery.
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■ CombinedmultichannelintraluminalimpedanceandpHtesting(MII-pH) detectsepisodesofreflux,regardlessofthepHoftherefluxate,byidentifying changesinductedbythepresenceofliquidsandgasintheesophagus.The episodesareclassifiedasacid,weaklyacid,ornonacidonthebasisof concomitantpHmonitoring.Thistestisusefulinidentifyingbilerefluxand doesnotrequirecessationofprotonpumpinhibitorsfortesting.
SURGICALMANAGEMENT
■ Alaparoscopicfundoplicationiscurrentlyconsideredtheprocedureofchoicefor thetreatmentofGERD.
■ Eventhoughseveraleponymsareusedtodescribedifferentantireflux procedures,webelievethatitismoreimportanttofocusonthetechnical elementsthatmakeafundoplicationeffectiveandlonglasting.
■ Thetypeoffundoplication(totalvs.partial)istailoredtothequalityof esophagealperistalsisasdocumentedbythepreoperativemanometry.Inthe UnitedStates,apartialfundoplicationisproposedonlytopatientswithvery impairedorabsentesophagealperistalsisinordertoreducetheriskof postoperativedysphagia(FIG2).
PreoperativePlanning
■ Acarefulsymptomaticevaluationtestingisperformedineverypatientbefore surgicalintervention.
Positioning
■ Afterinductionofgeneralendotrachealanesthesia,thepatientispositionedin lowlithotomypositionwiththelowerextremitiesextendedonstirrupswith kneesflexed20to30degrees.Alternatively,asplit-legtablemaybeused.
■ ToavoidslidingasaconsequenceofthesteepreverseTrendelenburgposition usedduringtheentireprocedure,abeanbagisinflatedtocreatea“saddle” undertheperineum.
■ Becauseincreasedabdominalpressurefrompneumoperitoneumandthesteep reverseTrendelenburgpositiondecreasevenousreturn,pneumatic compressionstockingsarealwaysusedasprophylaxisagainstdeepvenous thrombosis.
■ Anorogastrictubeisplacedtokeepthestomachdecompressedduringthe procedure.
■ AFoleycatheterisinsertedatthebeginningoftheoperationandremovedatthe
end.
■ Thesurgeonstandsbetweenthepatient’slegs.Thefirstandsecondassistants standontherightandleftsideofoperativetable(FIG3).
TECHNIQUES
PLACEMENTOFPORTS
■ Five10-mmtrocarsareusedfortheprocedure(FIG4).
■ Thefirstincisionismadeinthemidline14cmdistaltothexiphoidprocess andaVeressneedleisintroducedintotheperitonealcavity.Theperitoneal cavityisinitiallyinsufflatedtoapressureof15mmHg.Subsequently, underdirectvision,anopticalportwitha0-degreescope(port1)is placed.Oncethisportisplaced,the0-degreescopeisreplacedwitha30­degreescopeandtheothertrocarsareinsertedunderlaparoscopicvision.
■ Port2isplacedintheleftmidclavicularlineatthesamelevelofport1.Itis
usedbytheassistantfortractiononthegastroesophagealjunctionandto takedowntheshortgastricvessels.
■ Port3isplacedintherightmidclavicularlineatthesameleveloftheother twoports.Aretractorisusedthroughthisporttolifttheleftlateral segmentofthelivertoexposethegastroesophagealjunction.Theretractor isheldinplacebyaself-retainingsystemfixedtotheoperatingtable.
■ Ports4and5areplacedundertherightandleftcostalmarginssothattheir axesandthecameraformanangleofabout120degrees.Theseportsare usedbytheoperatingsurgeonfortheinsertionofgraspers,scissors,and dissectingandsuturinginstruments.
■ Theinstrumentationnecessaryforlaparoscopicpartialfundoplicationisreported inTable1.
DISSECTION
■ Thegastrohepaticligamentisdivided,beginningthedissectionabovethe caudatelobeoftheliver,wheretheligamentisthinner,andcontinuingtoward thediaphragmuntiltherightpillarofthecrusisidentified(FIG5).
■ Therightpillarofthecrusisseparatedfromtheesophagusbybluntdissection untiltheleftcrusisrecognizedandtheposteriorvagusnerveisidentified (FIG6).
■ Subsequently,theperitoneumandthephrenoesophagealmembraneoverlyingthe esophagusaredivided,andtheanteriorvagusnerveisidentified.
■ Theleftpillarofthecrusisthenseparatedfromtheesophagusanddissected towardthejunctionwiththerightpillarofthecrus(FIG7).
DIVISIONOFTHESHORTGASTRICVESSELS
■ Theshortgastricvesselsaretakendownallthewaytotheleftpillarofthecrus, startingfromapointmidwayalongthegreatercurvatureofthestomach(FIG
8).
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CREATIONOFAWINDOWANDPLACEMENTOFA PENROSEDRAINAROUNDTHEESOPHAGUS
■ TheesophagusisretractedupwardwithaBabcockclampappliedatthelevelof theesophagogastricjunction.
■ Awindowisopenedbyabluntandsharpdissectionundertheesophagus, betweenthegastricfundus,theesophagus,andtheleftpillarofthecrus(FIG
9).
■ Thewindowisenlarged,andaPenrosedrainispassedaroundtheesophagus.
■ Anyhiatalherniaiscompletelyreducedandaminimumof3cmof intraabdominalesophageallengthisachieved.
CLOSUREOFTHECRURA
■ Interrupted2-0silksuturesthataretiedintracorporeallywithanEndoStitch device(Covidien,Norwalk,CT)areusedtoclosethediaphragmaticcrura (FIG10a).
■ Retractionoftheesophagusupwardandtowardthepatient’sleftwiththe Penrosedrainprovidesproperexposure.
■ Thefirststitchshouldbeplacedjustabovethejunctionofthetwopillars.
■ Additionalstitchesareplaced1cmapart,andaspaceofabout1cmisleft betweentheuppermoststitchandtheesophagus.
INSERTIONOFTHEBOUGIEINTOTHEESOPHAGUSAND THROUGHTHEESOPHAGEALJUNCTION
■ Theorogastrictubeisremoved,anda56-Frbougiedowntheesophagusthrough theesophagogastricjunctionisinserted.
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■ Thecruramustbesnugaroundtheesophagusbutnottootight:Aclosedgrasper shouldslideeasilybetweentheesophagusandthecrura.
PARTIALFUNDOPLICATION
■
Partialposteriorfundoplication
■ Thegastricfundusisgentlypulledundertheesophaguswithtwograspers.
■ Therightandleftsidesofthewrapareseparatelysuturedtotheesophagus, leaving80to120degreesoftheanterioresophagealwalluncovered.
■ Three2-0silksuturesareplacedoneachsidebetweenthemuscularlayersof theesophagealwallandthegastricfundus(FIG10b).
■ Twocoronalstitchesarethenplacedbetweenthetopofthewrap,the esophagus,andtherightorleftpillarofthecrus(FIG10c).
■ Oneadditionalstitchisplacedbetweentherightsideofthewrapandthe closedcrura(FIG10d).
■ Theresultingwrapmeasuresabout240to280degrees.
■ Partialanteriorfundoplication(SeeChapter9formoredetails.)
■ Itisa180-degreeanteriorfundoplication.
■ Tworowsofsutures(2-0silk)areused.Thefirstrowisontheleftsideofthe esophagusandhasthreestitches.Thetopstitchincorporatesthefundusof thestomach,themuscularlayeroftheleftsideoftheesophagus,andthe leftpillarofthecrus.
■ Thesecondandthirdstitchesincorporatethegastricfundusandthemuscular layeroftheleftsideoftheesophagus.
■ Thefundusisthenfoldedovertheesophagussothatthegreatercurvatureof
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