RECONSTRUCCION ESOFAGICA
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Transcript of RECONSTRUCCION ESOFAGICA
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RECONSTRUCCION ESOFAGICA
DR. JESUS ESCRIVÁ MACHADO
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Resección de esófago o estómago: Neoplasia. Esófago disfuncional.
Complicaciones de resección: Fístula. Estenosis. Longitud.
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CONDUCTOS: Piel. Prótesis. Estómago. Cólon. Yeyuno. Combinación.
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INCISIONES
Nivel de la esofagectomía
Nivel de la anastomosis
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INCISIONES Ivor Lewis:
Laparotomía. Toracotomía derecha.
McKeown: Toracotomía derecha. Laparotomía. Disección cervical.
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INCISIONES
Orringer: Laparotomía media Disección transhiatal
Laparoscopía + Toracoscopía
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INCISIONES
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TRAYECTO DE LA RECONSTRUCCION
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Mediastino posterior
Retroesternal
Transpleural
Subcutáneo Preesternal
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TÉCNICAS ANASTOMOTICAS Manual.
Engrapadora.
Termino-terminal
Libre tensión
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TÉCNICAS ANASTOMOTICAS Manual:
Dos planos. Un plano. Puntos simples. surgete
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PIEL
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ESTOMAGO
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ESTOMAGO
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AKIYAMA
Surg Gynecol Obstet 177:519, 1993
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IVOR-LEWIS:ESOFAGO PROXIMAL
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WONG
J Thorac Cardiovasc Surg 70:836, 1975
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SWEET
Ann Thorac Surg 45:137, 1988
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IVOR-LEWIS
Visbal et al ATS, 2001
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IVOR- LEWIS: FASE 1
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IVOR- LEWIS: FASE 2
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IVOR- LEWIS: RESECCION
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IVOR-LEWIS:ANASTOMOSIS
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IVOR-LEWIS:ANASTOMOSIS
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IVOR-LEWIS RESULTADOS:
1992-1995 220 pacientes: cáncer H: 89 % Edad: 29-85 años (65 años) Adenocarcinoma: 86 %
Visbal et al ATS, 2001
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IVOR-LEWIS RESULTADOS:
Mortalidad: 1.4% Complicaciones: 38 % Hospitalización: 11 días (7-50 días) Dilatación: 30 %
Visbal et al ATS, 2001
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IVOR-LEWIS VENTAJAS:
Visualizar: Ganglios: perigástricos, paraesofágicos. Esófago.
Anastomosis alta.
Visbal et al ATS, 2001
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ESTOMAGO VENTAJAS:
Vascularidad Creación de tubo. Función gástrica conservada. Longitud. 1 anastomosis. “Simple”
Visbal et al ATS, 2001
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ESTOMAGO DESVENTAJAS:
Disminución reservorio. Reflujo. Regurditación. Esplenectomía
Visbal et al ATS, 2001
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ESOFAGOGASTRECTOMIA TRANSHIATAL
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ESOFAGOGASTRECTOMIA TRANSHIATAL
Denk: 1913
Turner: 1933
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ESOFAGOGASTRECTOMIA TRANSHIATAL
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ESOFAGOGASTRECTOMIA TRANSHIATAL
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ESOFAGOGASTRECTOMIA TRANSHIATAL
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ESOFAGOGASTRECTOMIA TRANSHIATAL
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ESOFAGOGASTRECTOMIA TRANSHIATAL
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ESOFAGOGASTRECTOMIA TRANSHIATAL
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ESOFAGOGASTRECTOMIA TRANSHIATAL
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ESOFAGOGASTRECTOMIA TRANSHIATAL
RESULTADOS:
1979 – 1999
1085 pacientes
Éxito: 97 %
Mortalidad: 4 % Sangrado:
Trasop: 3 Reoperación: 5
Orringer et al, WJS, 2001
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ESOFAGOGASTRECTOMIA TRANSHIATAL
RESULTADOS:
Complicaciones: 22 %
Dehiscencia: 13 %
Dilatación: 50 %
Orringer et al, WJS, 2001
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COLON
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COLON
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COLON
VENTAJAS:
Longitud. Preserva estómago. Reflujo ??
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COLON
DESVENTAJAS: Vascularidad. Obesidad. Redundante. Aumenta:
Morbilidad Mortalidad
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COLON
EVALUACION: Gabinete:
Rayos X TAC
Endoscopía.
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COLON
EVALUACION:
Angiografía: 60 años
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COLON
PREPARACION PREOPERATORIA:
Cólon Nutrición Multidisciplinario
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COLON
PREPARACION: Polietile glicol
Enemas: 12 – 18 horas
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COLON
PREPARACION:
Neomicina o eritromicina: 1gr c/ 4hrs (3 dosis)
Antibióticos: Dosis cero + 48 hrs
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COLON
SEGMENTO CORTO: Colón: derecho, transverso.
SEGMENTO LARGO: Colón: izquierdo
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COLON
¿Por qué preferir colon izquierdo?
Diámetro. Dilatación. Vascularidad. Longitud. Sólidos.
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COLON
TÉCNICAS: Mediastino posterior
Subesternal
Subcutáneo
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COLON
TÉCNICAS: Mediastino posterior
30.3 + 2 cm
Subesternal 32.2 + 3 cm
Subcutáneo 34 + 3 cm
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COLON
TÉCNICAS: Mediastino posterior
30.3 + 2 cm
Subesternal 32.2 + 3 cm
Subcutáneo 34 + 3 cm
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COLON
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COLON
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COLON TÉCNICAS.
Isoperistáltica.
Antiperistáltica.
Anastomosis gástrica posterior.
Fijación colónica
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COLON
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COLON
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COLON
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COLON
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COLON
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COLON
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COLON
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COLON
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COLON
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COLON RESULTADOS:
Mortalidad: 5 – 10 %
Fuga: 4 – 15 %
Función temprana.
Función tardía.
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YEYUNO
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YEYUNO VENTAJAS:
Peristalsis
Y Roux
Colgajo libre
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YEYUNO DESVENTAJAS:
Longitud limitada
Redundante
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YEYUNO
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YEYUNO
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YEYUNO
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YEYUNO
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YEYUNO
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YEYUNO
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YEYUNO Mortalidad: 3 – 15 %
Fuga: 2 – 24 %
Función temprana
Estenosis
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YEYUNO COLGAJO LIBRE:
Carrel: 1907
Seidenberg: 1957
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YEYUNO COLGAJO LIBRE:
Esófago cervical
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YEYUNO: COLGAJO LIBRE
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YEYUNO: COLGAJO LIBRE
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YEYUNO: COLGAJO LIBRE
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YEYUNO: COLGAJO LIBRE
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YEYUNO: COLGAJO LIBRE
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YEYUNO COLGAJO LIBRE:
Mortalidad: 3 – 5 % Fuga: 15 – 25 % Función:
excelente.
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COMBINADO
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CONCLUSIONES
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COMBINACIONES
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COMBINACIONES
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CONCLUSIONES
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CONCLUSIONES
Continuidad gastrointestinal
Calidad: nutrición
Planificar