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

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☆
thestomachisnexttotherightpillarofthecrus.
■ Thesecondrowofsuturesontherightsideoftheesophagusconsistsofthree stitchesbetweenthefundusandtherightpillarofthecrus.
■ Finally,twoadditionalstitchesareplacedbetweenthefundusandtherimof theesophagealhiatustoeliminateanytensionfromthefundoplication.
PEARLSANDPITFALLS
Indications ■Acarefulevaluation,includingmanometry,24-hour
pHmonitoring,upperendoscopy,andbarium swallowmustbedone.
Placementofports ■Extremecaremustbetakenwhenpositioningport1,
becausethesiteofinsertionisjustabovetheaorta.
■Werecommendusinganopticaltrocarwitha0-
degreescopetoobtainaccess.
■Ifport3istoolow,theleftlateralsegmentofthe
liverwillnotbeproperlyretracted,resultingin inadequateexposureoftheesophagogastric junction.
■Ifport2istoolow,theesophagogastricjunctionor
theuppershortgastricvesselswillbedifficultto reach.
■Ifports4and5aretoolow,thedissectionatthe
beginningoftheprocedureandthesuturingatthe endwillbechallenging.
■Ifport3istoomedial,theliverretractormay
interferewiththeinstrumentusedthroughport4.
Dissection ■Anaccessorylefthepaticarteryoriginatingfromthe
leftgastricarteryisfrequentlypresentinthe gastrohepaticligament.Ifthisvessellimitsthe exposure,itmaybesafelydivided.
■Theelectrocauteryshouldbeusedwithextreme
caution.Becauseofthelateralspreadofthe monopolarcurrent,vagusnervesmaybedamaged evenwithoutdirectcontact.Abipolarinstrument representsasaferalternative.
Shortgastricvessels division
■Bleeding,eitherfromtheshortgastricvesselsor
fromthespleen,anddamagetothegastricwallare possiblecomplications.
■Excessivetractionanddivisionofavesselnot
completelycoagulatedareusuallythemaincauses ofbleeding.
■Aburncausedduringdissectionoftheshortgastric
vesselsortractionappliedwiththegraspersorthe Babcockclamparethemostcommonmechanisms ofdamagetothegastricwall.
Creationofawindow andplacementofa Penrosedrainaround theesophagus
■Leftpneumothoraxandperforationofthegastric
fundusaretwomaincomplicationsthatcanoccur duringthisstepoftheprocedure.
■Leftpneumothoraxisusuallycreatedwhenthe
dissectionisperformedinthemediastinumabove theleftpillarofthecrusratherthanbetweenthe crusandthegastricfundus.
■Properidentificationanddissectionoftheleftpillar
ofthecrusarecrucial.
■Perforationofthegastricfundusisusuallycausedby
pushingabluntinstrumentundertheesophagusor byusingmonopolarelectrocauteryfordissection.
Closureofthecrura ■Thebougieisnotplacedinsidetheesophagusduring
thisstepoftheprocedureinordertohaveaproper exposureforsuturing.
Insertionofthebougie intoesophagusand throughesophageal junction
■Themostseriouscomplicationduringthisstepisan
esophagealperforation.
■Lubricationofthebougieandinstructiontothe
anesthesiologisttoadvancethebougieslowlyand
tostopifanyresistanceisencounteredhelpto preventthiscomplication.
■Allinstrumentsmustberemovedfromthe
esophagogastricjunctionandthePenrosedrain mustbeopened.Inthisway,thecreationofan anglebetweenthestomachandtheesophagus, whichincreasestheriskofperforation,is prevented.
Partialfundoplication ■Atraumaticgraspersmustbeusedtoreducetherisk
ofinjurytothegastricwall.
POSTOPERATIVECARE
■ Patientsareusuallydischargedafter23to48hours.
■ Patientsstartclearliquidsandthenasoftdietthemorningaftersurgery.
■ Theyareinstructedtoavoidmeat,bread,andcarbonatedbeveragesforthe following2weeks.
■ Thetimetofullrecoveryrangesbetween2and3weeks.
OUTCOMES
■ Long-termstudiesconductedinUnitedStateshavereportedalesseffective controlofGERDwithapartialfundoplicationratherthanatotal fundoplication.
10–12
■ At5-yearfollow-up,recurrenceofGERDconfirmedbypHmonitoringis reportedinmorethan50%ofpatientsafterpartialfundoplication.
10
COMPLICATIONS
■ Esophagealorgastricperforationcanbecausedeitherbytractionorbyan inadvertentelectrocauteryburnduringanystepofthedissection.
■ Aleakusuallymanifestsitselfduringthefirst48hours.
■ Peritonealsignswillbepresentifthespillageislimitedtotheabdomen; shortnessofbreathandapleuraleffusionwillbenotedifspillagealsooccurs inthechest.
■ Thesiteoftheleakmustalwaysbeconfirmedbyacontraststudyusingawater- solublecontrastagent.
■ Optimalmanagementconsistsofareoperationanddirectrepair.An esophagectomymaybeindicatedincaseofatooextensivedamageorwhen theextentoftheinflammatoryreactionmakesthedirectrepairimpossible. Widedrainage,feedingjejunostomytube,anduseofacoveredesophageal stentmayalsoassistinhealingtheinjurywhenitcannotbedirectlyrepaired.
■ Gastroesophagealjunctionandwrapslippageintothechestrarelyoccurswhen coronalsutureisplacedandthecruraareclosed.8Themainsymptomsof recurrencearedysphagiaandregurgitation.Abariumswallowconfirmsthe diagnosis.
■ Theincidenceofparaesophagealherniamaybeincreasediftheclosureofthe cruraisnotperformedorifitistooloose.
8
REFERENCES
1.Moraes-FilhoJ,CecconelloI,Gama-RodriguesJ,etal.Brazilianconsensusongastroesophageal refluxdisease:proposalsforassessment,classification,andmanagement.AmJGastroenterol. 2002;97:241–248.
2.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Gatreoenterol. 2006;101:1900–1920.
3.PattiMG,DienerU,TamburiniA,etal.Roleofesophagealfunctiontestsinthediagnosisof gastroesophagealrefluxdisease.DigDisSci.2001;46:597–602.
4.AmanoY,IshimuraN,FurutaK,etal.Interobserveragreementonclassifyingendoscopic diagnosesofnonerosiveesophagitis.Endoscopy.2006;38:1032–1035.
5.PattiMG,ArceritoM,TamburiniA,etal.Effectoflaparoscopicfundoplicationon gastroesophagealrefluxdisease-inducedrespiratorysymptoms.JGastrointestSurg.2000;4:143–149.
6.CamposGM,PetersJH,DeMeesterTR,etal.Multivariateanalysisoffactorspredictingoutcome afterlaparoscopicNissenfundoplication.JGastrointestSurg.1999;3:292–300.
7.GalvaniC,FisichellaPM,GorodnerMV,etal.Symptomsareapoorindicatorofrefluxstatus afterfundoplicationforgastroesophagealrefluxdisease:roleofesophagealfunctiontests.ArchSurg. 2003;138:514–518.
8.PattiMG,ArceritoM,FeoCV,etal.Ananalysisofoperationsforgastroesophagealreflux disease.Identifyingtheimportanttechnicalelements.ArchSurg.1998;133:600–606.
9.PattersonEJ,HerronDM,HansenPD,etal.Effectofanesophagealbougieontheincidenceof dysphagiafollowingNissenfundoplication:aprospective,blinded,randomizedclinicaltrial.Arch Surg.2000;135:1055–1061.
10.HorvathKD,JobeBA,HerronDM,etal.LaparoscopicToupetfundoplicationisaninadequate
procedureforpatientswithsevererefluxdisease.JGastrointestSurg.1999;3:583–591.
11.OleynikovD,EubanksTR,OelschlagerBK,etal.Totalfundoplicationistheoperationof
choiceforpatientswithgastroesophagealrefluxanddefectiveperistalsis.SurgEndosc.2002;16:909–
913.
12.PattiMG,RobinsonT,GalvaniC,etal.Totalfundoplicationissuperiortopartial
fundoplicationevenwhenesophagealperistalsisisweak.JAmCollSurg.2004;198:863–869.
Chapter8
TheMinimallyInvasive SurgicalApproachto GastroesophagealReflux Disease
W.ScottMelvinLukeM.Funk
DEFINITION
■ Endoscopictherapiesforgastroesophagealrefluxdisease(GERD)include transoralincisionlessfundoplication(TIF)andtheapplicationof radiofrequencyenergytotheloweresophagealsphincter(LES).Minimally invasiveLESaugmentationsurgeryinvolvestheplacementofamagnetic bandacrosstheLES.AllthreetherapiesaredesignedtoreduceGERD symptomsbyminimizingtherefluxofgastriccontentsintotheesophagusand arealternativestotraditionalsurgicalfundoplicationtechniques.
DIFFERENTIALDIAGNOSIS
■ TypicalGERDsymptoms
■
Achalasia
■
Biliarycolic/cholecystitis
■
Delayedgastricemptying
■
Esophagealcancer,esophagitis,esophagealmotilitydisorders
■
Gastritis
■
Hiatalhernia
■
Helicobacterpyloriinfection
■
Irritablebowelsyndrome
■ AtypicalGERDsymptoms
■
Coronaryarterydisease
■
Asthma
■
Bronchogeniccarcinoma
PATIENTHISTORYANDPHYSICALFINDINGS
■ Historytakingshouldfocusonidentifyingbothtypicalandatypicalsymptoms associatedwithGERD.
■ Typicalsymptomsincludeheartburn,regurgitation,waterbrash(saltytaste relatedtosalivarysecretion),anddysphagia.
■ Atypicalsymptomsincludedyspnea,cough,wheezing,chestpain,recurrent pneumonias,hoarseness,anddentalerosions.
■ Responsetoantirefluxmedications,suchasprotonpumpinhibitorsandH
2
blockersisimportanttoillicit,asthemajorityofpatientswithtypicalGERD symptomswillrespondtothesemedications.Failuretorespondtothese medicationsshouldheightenthesurgeon’sconcernthatthepatient’s
symptomsmaybeunrelatedtoGERD.
■ OncethediagnosisofGERDisconfirmedwithobjectivetesting,severalkey pointsshouldbediscussedwiththepatient:
■ Medicaltherapy,includinglifestylemodifications(i.e.,dietmodification, weightloss,smokingcessation)andantirefluxmedications,shouldcontrol typicalGERDsymptomsformostpatients.Surgicalinterventionis indicatedforGERDpatientswho(1)cannottakeantirefluxmedications duetosideeffects,(2)wouldprefernottotakeantirefluxmedicationsdue tocostorlifestyleimpact,or(3)continuetoexperiencesymptomsdespite antirefluxmedications.
■ Laparoscopicgastricfundoplication(i.e.,Nissenfundoplication)isconsidered tobethegoldstandardsurgicaltherapyforthetreatmentofGERD. EndoscopictherapiesandlaparoscopicLESaugmentationsurgeryshould probablybereservedforGERDpatientswhoarecandidatesforsurgical interventionand(1)wouldpreferalessinvasiveoptionthanlaparoscopic fundoplicationsurgeryor(2)wouldbeconsideredtoohighriskfor laparoscopicfundoplicationduetocomorbiditiesorpreviousabdominal surgery,includingpriorlaparoscopicfundoplication.
■ Ofthethreeproceduresdiscussedinthischapter,laparoscopicLES augmentationsurgeryistheonlyonethatrequiresgeneralanesthesia, althoughTIFalsoinvolvesgeneralanesthesiainthevastmajorityofcases. Conscioussedationisusuallyadequateforradiofrequencytherapy.Thus,poor candidatesforgeneralanesthesia(i.e.,thosewithcardiopulmonaryconditions suchasseverechronicobstructivepulmonarydisease[COPD]orcongestive heartfailure[CHF])maybebettercandidatesforradiofrequencytherapy.The presenceofthesecomorbidconditionsshouldbesoughtoutinthehistory. AdditionalcontraindicationsfortheseproceduresarelistedinTable1.
■ BecausetherearefewphysicalexamfindingsassociatedwithGERD,the physicalexamshouldfocusonconditionsthatmightsuggestanalternative explanationforthepatient’ssymptoms.Theseincluderecentweightlossor progressiveinabilitytotoleratesolidsandliquids(malignancy),atypical symptomsassociatedwithexertion(coronaryarterydiseaseorasthma),or diarrhea(irritablebowelsyndrome).
■ Thepresenceofabdominalsurgicalscarsorabdominalwallherniasisimportant toidentifyiflaparoscopicLESaugmentationsurgeryisbeingconsideredas theymaymakeaccesstotheperitonealcavityandthegastroesophageal(GE) junctionchallenging.
■ LaparoscopicLESaugmentationsurgery,whichinvolvesplacementofa magneticdevicearoundtheGEjunction,isconsiderednotsafeformagnetic resonanceimaging(MRI).Patientsshouldbeawareofthiscontraindication priortosurgery.
IMAGINGANDOTHERDIAGNOSTICSTUDIES
■ EstablishingGERDastheetiologyofthepatient’ssymptomsiscriticalbefore proceedingwithanyintervention.Patientsmayhavesubjectivecomplaintsof heartburnordysphagiathatareunrelatedtotheirrefluxdisease.Thefour
diagnosticteststhataremostcommonlyusedtoestablishadiagnosisare upperendoscopy,bariumesophagram,pHtesting,andmanometry.
■ Upperendoscopy(esophagogastroduodenoscopy[EGD])
■ AllpatientsundergoinganantirefluxprocedureshouldhaveanEGD.
■ EGDscanidentifythepresenceofhiatalherniasandruleoutotherpathology, whichmaybecontributingtothepatient’ssymptoms,suchaspepticulcer diseaseormalignancy.
■ GERD-relatedcomplicationssuchasesophagitis,Barrett’sesophagus,and esophagealstricturescanalsobeidentified(FIG1).
■ AmbulatorypHtesting
■ Thisisconsideredtobethegoldstandardtestfordiagnosingthepresenceof symptomaticGERD.
■ Patientsshouldtypicallynotbetakingtheirantirefluxmedicationswhenthe studyisperformed.
■ pHtestingcanbeperformedviacatheter-basedsystems(i.e.,24-hourpH probetesting)orwirelesssystems(i.e.,48-hourBravotesting).
■
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