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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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conservativemanagement.Itshouldalwaysbeperformedbyanexperienced upperGIendoscopistandisveryimportantinnotonlyassessingthesiteof theperforationbutalsoinevaluatingfordistalobstruction,qualityofthe esophagus,sizeofthehole,associatedupperGIpathology,andmucosal quality/necrosis.Itisprimordialthatinsufflationbekepttoaminimumin ordertoavoidincreasingtheextentoftheperforation.

SURGICALMANAGEMENT

PreoperativePlanning

■ Appropriateresuscitationismandatorypriortosurgicaltreatment.Diagnosis shouldbeconfirmedeitherbyCTscan,water-solublecontrast/barium swallow,orendoscopy.Thisiscriticalasapproachestocervical,thoracic,and abdominalesophagealperforationsaredrasticallydifferent.Broad-spectrum intravenousantibioticsshouldhavebeenstartedassoonasthediagnosisis made.

■ Werecommendon-tableendoscopyundergeneralanesthesiainallcasesinorder topreciselydelineatethelocation,size,andextentoftheholeandassessthe qualityoftheesophagus(includingevaluationofpossibledownstream obstruction).Additionally,endoscopycanbeusedasatreatmentoption

(stenting,clipping)orasanadjunctiveprocedureduringrepair(perforation cannulation,percutaneousendoscopicgastrostomy,percutaneousendoscopic jejunostomy).Incasesrequiringthoracotomy,laparotomy,orcervical exploration,aflexiblesoft-tippedguidewireistypicallyplacedthroughthe perforationusingendoscopyinordertomakeitsimpleandexpedienttofind thesiteofperforationduringsurgicalexplorationandminimizedissection (FIGS5and6).

Positioning

■ Cervicalperforation

■ Thepatientisplacedindorsalpositionwithabolsterunderthescapulaeto obtainaslighthyperextensionoftheneck.Theendotrachealtubeis securedtotherightcornerofthemouthandtheheadisslightlyturnedto therightside(FIG7).

■ Uppertwo-thirdsthoracicperforation

■ Thepatientisplacedinleftlateraldecubituswithadoublelumen endotrachealtubeinplace.Theflexionpointoftheoperatingtableshould belocatedatthelevelofthe5ththoracicvertebra.Anaxillaryrollisplaced underthethoraciccage,twofingerbreadthsbelowtheleftaxillatoprotect thebrachialplexus.Thetableisflexedinordertoopentheintercostal spacesontherightside.Therightarmispositionedanterosuperiorlytothe head.Oncepositioningisadequate,thepositionofthedoublelumen endotrachealtubeisconfirmedwithbronchoscopyandtherightlungis isolatedfromventilation.

■ Lowerone-thirdthoracicperforation

■ Thepatientisplacedinrightlateraldecubituswithadoublelumen endotrachealtubeinplace.Allspecificsofpositioningarethesameasfor theleftlateraldecubituspositionpreviouslydescribed.

■ Abdominalperforation

■

Thepatientisplacedindorsalpositionwithbotharmsabducted.

TECHNIQUES

CERVICALPERFORATIONREPAIRANDDRAINAGE

SkinIncision

■ Themedialborderoftheleftsternocleidomastoidmuscleisidentified.An incisionisperformedalongtheborderofthemuscle(FIG7).Theplatysmais incisedintheorientationoftheskinincision.

Dissection

■ Thesternocleidomastoidmuscleisdissectedandretractedlaterally,exposingthe vesselsoftheneck.Thecarotidsheathisleftintactandretractedlaterally.If necessary,themiddlethyroidveinisligatedandthelarynxandtracheaare retractedtotheright.Careistakentonotdamagetheleftrecurrentlaryngeal nerve,whichliesinthetracheoesophagealgroove.Theprevertebralplaneis entered,movingtheesophagusanteriorly(FIG8A,B).Theentirespaceis dissectedasfarcaudallyasthecarina.

Repair

■ Inmostinstances,thesiteoftheperforationisnotidentifiednorshouldany extensiveamountoftimebespentsearchingforit.Iftheperforationis visualizedandeasilyaccessible,itcanberepaired.Thefirststepoftherepair isthelengtheningoftheopeninginthemuscularispropriaasthisisoften smallerthantheorificeinthemucosa(FIG9).Oncetheentirelengthofthe perforationisexposed,therepairisperformedwithsingleinterrupted absorbablesuturesonthemucosalplaneandnonabsorbablesuturesonthe muscularplane(FIG10).Inmostcases,theinflammationatthesiteof perforationwillpreventeasyidentificationofbothmucosalandmuscular planes.Insuchinstances,itisappropriatetoproceedwithasinglelayerrepair usingsingleinterruptedabsorbablesutures.Arubberbougieshouldbeplaced intheesophagusorallytoassurethattherepairdoesnotresultinesophageal obliterationorsignificantstenosis.

SternocleidomastoidFlap

■ Leaksfromprimaryrepairsofesophagealperforationsarecommonanditis preferabletoprotecttherepairwithavascularizedflap.Forperforationsof thecervicalesophagus,thesternalheadofthesternocleidomastoidmuscleis detachedusingelectrocauteryandrotatedtocoverthesiteoftheperforation. Themuscleisfixedwithmultipleinterruptedsuturesaroundtherepair.The muscleshouldbetightlyopposedtotherepairsiteandcoveritentirely(FIG

11).Inthecaseofconcomitanttrachealinjury,theflapshouldbeplacedin

betweentherepairedesophagusandthetracheatoavoidtheformationofa tracheoesophagealfistula.

Drainage

■ Regardlessofwhetherthesiteofperforationwasidentifiedand/orrepaired,the prevertebralspaceisirrigatedabundantlyanddrainsareleftinplace.Drains arebroughtoutthroughseparateskinstabwounds.

Closure

■ Theplatysmaisreapproximatedinthesuperiorportionoftheincisionwith absorbablesutures.Theskinincisionisclosedwithstaples.

THORACICPERFORATIONREPAIRAND DRAINAGE

SkinIncision

■ Withthepatientinlateraldecubitus,leftforperforationsoftheuppertwo-thirds andrightforthelowerthirdoftheesophagus,thetipofthescapulais identifiedandanincisionfollowingtheorientationoftheunderlyingribsis placedtwofingerbreadthscaudally(FIG12).

Dissection

■ Theincisioniscarriedthroughtothelatissimusdorsi.Themuscleisincised exposingtheserratusanterior.Theserratusanteriorispreservedandretracted anteriorly.Withsinglelungventilation,the5thintercostalspaceisenteredby cuttingtheintercostalmusclesimmediatelyabovethe6thrib.The6thribis sectionedanteriorlyandposteriorly.A1to2cmportionofthe6thribcanbe removed.Inveryhighperforations,a4thintercostalspacemaybechosento aidinrepair,andinverylowperforations,alowerincision(6th,7th,or8th interspace)maybechosen.

IntercostalFlapPreparation

■ Theperiosteumofthe5thribisopenedlongitudinallyinthecenterofthebone andretractedinferiorly.Theneurovascularbundleisdissectedoffofthe inferiorborderofthe5thribusingaperiostealelevator.Theintercostal musclesandtheneurovascularbundlearetransectedanteriorlyandthe resultingflapismovedposteriorlytoavoidinjurywithretractorsusedtoopen theintercostalspace(FIG13).

Repair

■ Thesiteofperforationshouldbeidentified(FIG14).Theesophagusshouldbe mobilizedcircumferentiallyaboveandbelowtheperforationandPenrose drainsshouldbeplacedaroundtheesophagustoaidinretractionandrepair (FIG15A,B).Therepairshouldproceedinoneortwolayersofinterrupted nonbraidedabsorbablesuture(3-0polydioxanone[PDS])overabougie(FIG

16).

IntercostalMuscleFlap

■ Thepreviouslypreparedintercostalflapisapproximatedtothesiteofrepairand fixedwithinterruptedhorizontalmattress,3-0silksutures(FIG17).

Drainage

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