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

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anastomosis.TheNGTisfedunderdirectvisionintotheconduitpriorto completionofthislayer.AlltheholesoftheNGTarepositionedinthegastric conduittopreventevacuatingtheCO2insufflation.Anadditionalrowof
interrupted3-0silksuturesisthenplacedtocompletethedouble-layered anastomosisanteriorly.
■ Atongueofomentumcomingoffthegastroepiploicarteryisbroughtupfrom beneaththegastricconduitandtackedovertheanteriorsideofthe anastomosiswithsilksutures(FIG23).Ifpossible,theomentumcanbe positionedbetweentheanastomosisandtheairway(leftmainstem bronchus/trachea)topreventfistulaformation.Theconduitissuturedtothe righthemidiaphragmnearthehiatustopreventherniationofabdominal contentsintothechest(FIG24).
REMOVALOFTHESPECIMEN/CONCLUSIONOF SURGERY
■
Thespecimenisremovedwithalargebagviatheassistantport,andfrozen sectionexaminationisperformedtoconfirmthattheproximalanddistal marginsareclearoftumorand/orBarrett’smucosa.Achesttubeisplaced directlyposteriorlyandtowardtheapexthroughtheincisionforroboticarm
2.TheportsareremovedwiththeCO2insufflationturnedofftoensurethe
absenceofbleeding.Therobotisundockedandmovedawayfromthepatient. Thelungisreexpandedandtheincisionsareclosed.Wefrequentlyremove theNGTpriortoextubation.
PEARLSANDPITFALLS
Nutritionalevaluation ■Assessnutritionalstatuspreoperativelyandhavea
lowthresholdforpretreatmentJ-tubeplacementto improvenutritionalstatuspriortoesophagectomy.
Aberrantarterial anatomy
■Clipaccessoryorreplacedlefthepaticarteryinthe
gastrohepaticligamentandassessliverviability priortotransection.
Excessive intraabdominalfat
■Carefullylocatetherightgastroepiploicvesselsprior
todividingthegastrocolicligament.
■Liberaluseoffatstaystoretractomentumtoexpose
theshortgastricvessels.
Avoiduseof monopolarcautery aroundtheairway
■Balancerisksofairwayinjurywithbenefitoftaking
allperibronchialnodes.
■Devascularizationinjurytotheairwaycanresultin
delayedesophagobronchialfistulaandassociated mortality.
Bedsidefiberoptic endoscopic examinationof swallowing(FEES) priortoinitiatingoral intake
■Aspirationiscommonfollowingesophagectomy.
PerformFEESpriortocontraststudyevaluatingthe anastomosis.
■Someadvocatefordelayedoralintakefor4–6
weeksfollowingesophagectomy.
Delayedgastric emptying
■Emptyingofthegastricconduitispoorevenwith
theuseofconcomitantemptyingprocedures.
■Patientsmustbecounseledtokeeptheirheadofbed
elevatedandnoteatclosetobedtime.
POSTOPERATIVECARE
■ Thepostoperativecareofpatientswhoundergoesophagectomyisbasedona teamapproach.Mostliteratureshowsimprovedoutcomesinhigh-volume centers.Thisissecondarytoamoreexperiencedteamnotonlyinthe operatingroom(OR)butalsoonthefloor.Low-molecular-weightheparinis administeredpriortosurgeryandoneverypostoperativeday(POD).Our postoperativecarealgorithmisasfollowsforeachPOD:
■
POD1
■ Thepatientreceivesabout100to125mLperhouroflactatedRinger’s solution.
■ TheJ-tubeisplacedtogravity.
■ Patientbeginsambulatingthreetofourtimesaday.
■
POD2
■ TrophictubefeedsarestartedthoughtheJ-tubeat10mLperhour.
■ Theintravenousfluidgivenisdecreasedbasedonurinaryoutput,and changedto5%dextroseinhalfnormalsaline.
■ Ambulatefourtosixtimesaday.
■
POD3
■ Thechesttubeisusuallyremoved.
■ Thepatientcontinuestoambulatefourtimesaday.
■ J-tubefeedingsareadvancedastolerated.
■
POD4
■ Thepatientreceivesabedsidefiberopticendoscopicexaminationof swallowing(FEES).
■ IfthevocalcordsarenormalonFEES,thepatientissenttoradiologyfor anuppergastrointestinal(UGI)swallow.Thistestevaluatestwo importantcomponents:
■
Theanastomosis
■
Thetimeforemptyingofthegastricconduit
■
POD5
■ Iftheswallowisnegative,thepatientisadvancedto30mLperhourof thickenedliquidsbymouth.
■
POD6orPOD7
■ Thepatientisusuallydischargedhome.
OUTCOMES
■ Wepresentedtheworld’slargestseriesofconsecutiveroboticIvor-Lewis
esophagectomyproceduresinJanuary2013;wehavenowcompletedover70 roboticesophagealresections.Fromourexperience,wehavelearnedthatthe keystopreventingcomplicationsinthisoperationarecontingentonthe following:
■
Performingamucosa-to-mucosaanastomosiswithouttension
■
Awell-perfusedconduit
■
Adequatefunctionalstatusofthepatientatthetimeofsurgery
COMPLICATIONS
■ Despiteadherencetothesetechnicalconceptsduringsurgery,postoperative complicationscancommonlyoccur.Themostfrequentcomplicationsinclude thefollowing:
■ Anastomoticleak:Whenitissubtle,itcanbemanagedconservativelyby keepingthepatientNPOandobservationforaweek.Ifitislarge,an esophagealstentshouldbeplacedendoscopicallyfor8to12weeks.Video­assistedthoracicsurgery(VATS)decorticationanddrainageofeffusion shouldbeperformedifthereisanyevidenceofneworinfectedpleural material.
■ Pulmonarycomplicationsarecommonafteranythoracicsurgeryandinclude atelectasisandpneumonia,includingaspirationpneumoniainparticular.
■ Chylothorax:Thisisacomplicationthatcanrequirereoperation.We generallychoosetomanagethiswithpercutaneousembolizationofthe thoracicductforhigh-outputfistulas.Iftheoutputisgreaterthan400mL perday,itshouldbeimmediatelytreated.
■ Atrialfibrillation:Theincidenceofatrialfibrillationafteranesophagectomy
isreportedtobeabout20%andcorrelatestotheextentofthemediastinal nodedissectionperformedduringtheoperation.Assuch,patientsshould beontelemetryinthepostoperativeperiod.
Chapter15
TreatmentofEsophageal Perforation:Cervical, Thoracic,andAbdominal
NathalieBoutetMoisheLiberman
DEFINITION
■ Esophagealperforationisdefinedasatearinboththemucosaandmuscularis proprialayersoftheesophagus.
DIFFERENTIALDIAGNOSIS
■ Thepresentationofesophagealperforationsisvariableandthusthedifferential diagnosiscanbequiteextensive.Incaseswithoutobviousetiology,cardiac andpulmonarypathologieswilloftenhavebeenruledoutbeforethediagnosis ofesophagealperforationismade.Myocardialinfarction,aorticdissection, pneumonia,pneumothorax,gastroesophagealreflux,andesophagealspasm areamongthepathologiesthatcanpresentwithsymptomssimilarto esophagealperforation.
PATIENTHISTORYANDPHYSICALFINDINGS
■ Historymayincluderecenteventsofforcefulvomiting,bluntabdominaltrauma, ingestionofcausticsubstancesorforeignbodies,orrecentupper gastrointestinal(GI)endoscopy.
■ Patientsmayreportahistoryofdysphagiaofrapidonsetaccompaniedbyneck, chest,orabdominalpain.Dysphoniaandafebrilestatemayalsobereported.
■ Athoroughreviewofesophagealfunctionshouldbeobtainedassymptomsof achalasiaordysphagiamayimpactonthechoiceoftreatment.
■ Evaluationofcomorbidconditionssuchasheartdiseaseandpulmonaryfunction shouldbeperformed.Ahistoryofpriorsurgicalandradiationtherapyshould besought.
■ Physicalexammayrevealthepresenceofsubcutaneousemphysemaintheneck orchest.Reducedairentrymaysignalthepresenceofanassociatedpleural effusionorpneumothorax.
IMAGINGANDOTHERDIAGNOSTICSTUDIES
■ Evaluationofotherdiagnosesfoundinthedifferentialwilloftenleadtobasic imagingstudiesbeingperformedinthesepatients,suchasachestx-ray.One canexpecttofindairinthesubcutaneoustissuesoftheneck,chestwalland mediastinum(FIG1),andintheprevertebralspaceonthelateralviews. Associatedplainfilmfindingsmayincludepleuraleffusion,pneumothorax, hydropneumothorax,pneumoperitoneum,orpneumoretroperitoneum.
■ Cervicalandthoraciccomputedtomography(CT)scanswithoralcontrastcan beperformedtodiagnoseesophagealperforations.Anextraluminalleakof contrastmediumcanbeseenintheprevertebralorpleuralspaces(FIG2).CT scanalsoallowsfortheevaluationofotherpotentialcausesofclinical presentation.CTscanistheinvestigationofchoicewhendiagnosisis uncertain.Pneumomediastinum,pneumoperitoneum,andairinthe subcutaneoustissuesoftheneckwilloftenbeseenincasesofesophageal perforation(FIG3A,B).CTalsoallowsfortheevaluationoftheneck, mediastinum,abdominalcavity,andpleuralspaces,whichcanaidinoperative incisionplanningand/ordrainageplanninginnonoperativecases.
1
■ Gastrografinstudiescanalsobeperformedandshouldbeimmediatelyfollowed byabariumswallowintheeventofnegativefindings,asbariumstudiesare moresensitivethanGastrografin.Water-solublecontrastshouldbeavoided whentracheoesophagealfistulaisconsideredinthedifferential.WithCTscan andendoscopy,oralesophagogramsarenotusuallynecessaryinthemodern daydiagnosisofesophagealperforation.
■ Diagnosiscanalsobemadeusingendoscopy(FIG4).Endoscopyshouldalways beperformedundergeneralanesthesiaintheoperatingroomatthetimeof esophagealrepair,exclusion,stenting,clipping,ordecisionregarding
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