Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_1050_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

23 Мб

Скачать

☆

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 4142 / 5042 43 44 45 46 47 48 49 50 > Следующая >>>

■ Thethoraciccavityisirrigatedabundantlyandtwothoracicdrainsareinserted andpositionedclosetothesiteofperforation.Drainsarefixedattheskin.

Closure

■ Theribsarereapproximatedwithfigure-of-eightsuturesofheavyVicryl.The lungisreexpandedbeforetyingthesuturesandappropriatedrainpositionis confirmed.Theserratusanteriorisresewntoitsfatandthelatissimusdorsi muscleisrepairedwithrunningsuturesof0Vicryl.Thesubcutaneousfatis reapproximatedwitharunningsutureof2-0Vicrylbeforeclosingtheskin withstaples.

ABDOMINALPERFORATIONREPAIRAND DRAINAGE

Skinincision

■ Amidlinelaparotomyisperformedfromthexiphoidprocesstotheumbilicus.

Dissection

■ Thegastrosplenicligamentisdissectedoffofthegreatercurvatureofthe stomachusinganenergyvascularsealingdevice.Theshortgastricvesselsare sealedanddividedandtheangleofHisisdissected.Theleftandrightcrus areidentifiedandtheesophagusisdissectedfree.APenrosedrainisplaced aroundthegastroesophagealjunctionforexposure.

Repair

■ Thesiteofperforationneedstobeidentifiedandthestepsforrepairarethesame asforcervicalandthoracicperforations.ANissenfundoplicationisthen performedtocovertheesophagealrepair(seeChapter5).Afundoplication

shouldnotbeperformedinpatientswithhistoryofachalasia.Insuchcases,a patchofomentumcanbefixedontherepairwithabsorbablesutures.

Drainage

■ TheabdominalcavityisirrigatedabundantlyandJackson-Prattdrainsareplaced aroundtheareaofrepair.

Closure

■ TherectusabdominisaponeurosisisclosedwitharunningsutureofPDS1.The skinisthenclosedwithstaples.

ESOPHAGECTOMYANDDIVERSION

■ Incasesofseveresepsis,hemodynamicinstability,anecroticesophagus,and/or averylatepresentation,esophagectomyanddiversionisalifesaving procedure.Resectionanddiversionisalwaysalastoption.

SkinIncisionandDissection

■ Esophagectomycaneitherbeperformedusingatransthoracicapproach(right thoracotomy;see“ThoracicPerforationRepairandDrainage”)orusinga transhiatalapproachthroughamidlinelaparotomy.

Resection

■ Thegastroesophagealjunctionisstapledoffandadraininggastrostomyand feedingjejunostomyareperformed.Theentireesophagusisbroughtout throughaleftcervicalincision(FIG18A)andamputatedjustproximaltothe perforation.Asmuchproximalesophagusaspossibleshouldbeleftinplace inordertoaidinfuturerestorationofGIcontinuity.

StomaFormation

■ Theesophagusisthentunnelledundertheskinoftheleftchestandbroughtout totheskinasanendesophagostomy.Thestomaissewntotheskinusing3-0 Vicrylor3-0PDSinterruptedsuturesandanenterostomalapplianceis appliedtotheskin(FIG18B).Threeto6monthsafterdiversion,theGI continuityisrestoredusingeitheragastricpull-uporacolonbypass.Primary esophagectomyandanastomosisisrarelydoneincaseofperforation.

Closure

■ Closureisperformedaspreviouslydescribedinthethoracicandabdominal perforationrepairanddrainagesections.

ENDOSCOPICAPPROACHES

EndoscopicRepair/Clipping

■ Inselectcasesofveryearlyperforationinacleanesophagusandaverystable patient,anendoscopicclosureofthemucosaldefectcanbeattempted.Thisis typicallyperformedincasesofendoscopicperforationwheretheperforation isimmediatelyrecognizedandsentdirectlytoahighlyspecializedcenter.

■

Thepatientisplacedundergeneralanesthesiaintheoperatingroomandflexible endoscopyisperformed.Themucosaldefectshouldbeinspectedforany signsofischemia,necrosis,orinfection(seeFIG4).

■ Distalobstructionshouldberuledoutusingendoscopypriortoattempting endoscopicrepair.

■ Ifthepatientisstable,themucosaldefectissmallandtheholeappearsclosable, aseriesofthrough-the-scopeendoscopicclipsmaybeappliedfromdistalto proximalinordertoattemptcompleteclosure(FIG19A–C).

EndoscopicStenting

■ Temporaryendoluminalesophagealstentingisbecomingmorepopularforthe acutetreatmentofesophagealperforation.2Thedecisiontouseastentinthe esophagusforthetreatmentofesophagealperforationisbasedontheclinical statusofthepatient,onpreoperativeimagingandonthelocation,andthesize andsiteoftheperforationonintraoperativeendoscopy.

■ Asexperiencewithstentinginesophagealperforationisincreasing,the indicationsareexpandingandastentcanoftenbeusedinaveryseptic patient.Ifspillagecanbecontrolledusingastentandpercutaneous(chest tubes,pigtaildrains)and/orthoracoscopic/laparoscopicadjunctiveprocedures areperformedtoallowforabscessdrainage,onecanoftentemporizeavery sickpatientquicklyandsavethepatientfromthelong-termmorbidityofan esophagealresectionanddiversionprocedure.

■ Ifastentingapproachischosen,apercutaneousgastrojejunostomyisfirstplaced toallowforgastricdrainageandpostpyloricfeeding.Aguidewireisthen passedintothestomachandthestentisplacedunderendoscopicor fluoroscopicvision(FIG20A).Fullycoveredmetallicstents(FIG20B)or silicone-polyester(plastic)stents(FIG20C)shouldbeusedincasesof benignesophagealperforationsothattheycanbeeasilyremovedwithout causingesophagealdamage.Stentsaretypicallyremoved4to8weeks followingperforation.Incaseofbenignesophagealperforation,esophageal stentmigrationistypicalduetothelackofstenosisortumor.Itistherefore importanttousethelargestdiameterstentpossible(typically23mm),avery longstent(tohelpwithesophagealwallappositionandpreventmigration), andtoproximallycoverthewholebyatleast6to7cmifpossible.

CONSERVATIVEAPPROACH

■ Incasesofesophagealperforationinpatientswhoarehemodynamicallystable, theperforationisdiscoveredearly(<24hours)andthereisobjectiveevidence

ofacontainedleakwithacontraststudydemonstratingcontrastextravasation withoutpoolinginthemediastinumanddrainingbackintotheesophagus,a conservativeapproachcanbechosen.

■ ThesepatientsshouldbekeptstrictNPOwithanasogastrictubeinplace (insertedendoscopically).Theyshouldbeplacedonintravenousantibiotics, intravenousfluids,andintravenousprotonpumpinhibitors.Theyshouldbe closelymonitoredforfever,tachycardia,andleukocytosis.

■ Ifsignsofsepsisdevelop,theyshouldbetakentotheoperatingroomfor endoscopicstentingoresophagealrepair/diversion.Incasesofsuccessful conservativetreatmentofesophagealperforation,aGastrografinswallow shouldbeperformedat7to10daysfollowingperforationtoassesshealingof theperforation.

■ Nutritioncanbeprovidedusingeithernasogastric/nasojejunalfeedingortotal parenteralnutrition.

Gastrostomy/Jejunostomy

■ Classically,esophagealrepairintheneck,chest,orabdomenwasperformedin additiontoalaparotomyorlaparoscopyinordertoperformagastrostomy (forgastricdrainage)andafeedingjejunostomy(forfeeding).Incaseswhere thereisnoperitonealsoilage,thiscanbeaccomplishedinlessthan5minutes priortoesophagealrepairusingaPercutaneousEndoscopicGastrostomywith Jejunalfeedinglimb(PEG-J)(FIG21).APEG-Jperformedpriortorepairor diversionontheoperatingtableatthetimeofendoscopysavesthepatienta laparotomyandgreatlyexpeditestheoperation.

PEARLSANDPITFALLS

History ■SymptomsofachalasiaprecludetheuseofaNissen

fundoplicationinabdominalperforations.

■Obstructivesymptomsshouldbeaddressed

intraoperativelytoavoidpostoperativedownstream pressurebuildupontheesophagealrepair.

Presentation ■Ahighindexofsuspicionisrequiredtodiagnose

esophagealperforations.

■Diagnosticdelaysover24hoursareassociatedwith

increasedmortality.

Preoperative evaluation

■Alwaysperformon-tableendoscopyundergeneral

anesthesiabeforemakingdefinitivedecisions regardingsurgical,endoscopic,orconservative treatment.

Endoscopictreatment ■Esophagealstentingcanbeappliedinselectedstable

patients.Itcanalsobeusedasabailoutinpatients whoareextremelyill,incombinationwith percutaneousorvideo-assistedthoracicsurgery (VATS)drainage,totemporizeasepticpatient.

Repair ■Suturingoftheesophagealdefectismandatoryin

perforationsoftheabdominalandlowertwo-thirds ofthethoracicesophagus,whereasitisoptionalin moreproximal(cervical)perforations.

■Usingflapsgreatlyreducestherisksofongoing

leakspostoperatively.

Drainage ■Adequatedrainageofthesurgicalsiteprevents

formationofabscessesand,inthecaseofpostrepair leak,allowsforcontrolledleakage.

Underlying esophagealcancer

■Primaryrepairofaperforatedesophagealcanceris

inappropriate.

Postoperativenutrition ■PercutaneousEndoscopicGastrostomywithJejunal

feedinglimb(PEG-J)canmaketheoperative managementofintrathoracicandcervical esophagealperforationquicker,simpler,andless morbid.

LastResort ■Esophagectomyanddiversionshouldbealastresort

astheoperationisextremelymorbidandmany patientsnevergoontodefinitivereconstructionfor restorationofGIcontinuity.

POSTOPERATIVECARE

■ Closemonitoringofpatientswithesophagealperforationismandatoryand treatingphysiciansshouldhaveahighindexofsuspicionforleaks.Patients shouldbekeptNPOfor7dayspostoperativelywithanasogastrictubeor gastrostomyinplace.Insandoutsshouldbemonitoredandtheappearanceof theliquiddrainednoted.Patientsshouldbekeptonintravenousantibiotics andintravenousprotonpumpinhibitorsuntiloralcontraststudy7to10days postrepair.

■ Onpostoperativedays7to10,awater-solublecontraststudyshouldbe performed.Theabsenceofleakshouldbeconfirmedwithabariumswallow

beforethenasogastrictubeisremovedandaliquiddietisbegun.Dietisthen progressedastoleratedanddrainsareremoved.

OUTCOMES

■ Outcomeisdependentonmultiplefactorsincludingthepatient’shemodynamic statusonpresentation,thepatient’sage,thesiteofperforation,delayto diagnosismorethan24hours,andthepresenceofunderlyingesophageal neoplasia.

■ Mortalityvariesfrom2%to27%andmorbidityfrom53%to81%.

COMPLICATIONS

■ Ongoingleak

■ Tracheoesophagealoresophageocutaneusfistula

■ Empyema

■ Intraabdominal,mediastinal,thoracic,orcervicalabscess

■ Esophagealstricture

■ Sepsis,septicshock

REFERENCES

1.LangMH,BrunsDH,SchmitzB,etal.Esophagealperforation:principlesofdiagnosisand

surgicalmanagement.SurgToday.2006;36:332–340.

2.SoreideJA,VisteA.Esophagealperforation:diagnosticwork-upandclinicaldecision-makingin

thefirst24hours.ScandJTraumaResuscEmergMed.2011;19:66.

3.BazerbashiS,VillaquiranJ,BennettM,etal.Stentedesophagealtransfixioninjury.AnnThorac

Surg.2008;86:1367–1369.

4.ErogluA,TurkyilmazA,AydinY,etal.Currentmanagementofesophagealperforation:20years

experience.DisEsophagus.2009;22:374–380.

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 4142 / 5042 43 44 45 46 47 48 49 50 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202624 Мб0Книга_1045_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1047_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1048_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1049_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202642 Мб0Книга_105_библиотеки_им_акад_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1050_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1052_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1053_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1054_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1056_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1057_Библиотеки_им_академика_М_И_Перельмана.pdf