Treatment for achalasia of cardia is multidirectional nowadays and depends on several factors such as patient’s sex and age, type and stage of disease, co-morbidity and complications. However the treatment for end-stage achalasia is still controversial. Ones who advocate organ preservation surgery consider esophagectomy an ultima ration. These authors conceive that esophagectomy is too traumatic for benign disease with low progression. Esophagectomy as a first approach for end-stage achalasia is recommended by others authors who believe that progredient course of disease (nonreversible strongly dilated and atonic esophagus), debilitating dysphagia, regurgitation, aspiration syndrome and ineffective intervention in cardia make the extirpation of the esophagus necessary. Persistent degeneration of life quality and high possibility of such devastating symptoms as aspiration and esophageal cancer alongside with unacceptable results of myotomy raise questions on the effectiveness of the organ preservation surgery for end-stage achalasia
The perioperative enhanced recovery protocol routinely uses in esophageal surgery. It acquired new aspects which were adapted to reduce the rate of morbidity and mortality. Esophagectomy still remains a high-risk operation, which carries out in high-volume centers on patients with significant comorbidities. It challenges the multidisciplinary team to personalize approach to create a safe recovery after surgery. The objective of the study is to show the aspects of evolution of the protocol after esophageal surgery. A total 393 patients with benign and malignant esophageal diseases underwent esophagectomy with simultaneous reconstruction between December 2012 and December 2021. The median age was 59 years (47;67), females were 39,7% and males—60,3%. The prevalence of the patient with nutritional deficiency was 20% (BIM < 18.5) and ASA score III-IV—66,9%. The tranthoracic and transhiatal esophagectomy were used for 42,2% and 57,8% of patients with the reconstruction by gastric pull up (92,1%), colon conduit (6,4%), jejunal loop interpostion with gastric pull-up 1% and with colon conduit 0,5%. 169 patients (43%) had postoperative complications, while 28,9% of them had one complication and 3,6% more than 4 complications at the same time. The prevalence of complications: pneumonia—8,2%, atrial dysrhythmia requiring intervention—7,7%, pulmonary embolism—1%, acute renal failure requiring dialysis—1,5%. The anastomotic leak occured in 5,4% patients and conduit necrosis—in 2,8% (2,3% extensive) patients. The prevalence of patients required repeated surgery was 6,4%. The rate of severe complications (>IIIb- Clavien-Dindo) was 14,4%. Median postoperative day was 9 (8;11). The postoperative mortality rate 1,8%. The aspects of the perioperative enhanced recovery protocol were modified to complicated surgery with simultaneous resection of other organs, esophagogastrectomy or reconstruction by combined conduit with jejunal loop with early oral feeding and rapid recovery. The decade-long experience of the evolution of the perioperative enhanced recovery protocol has led to the development of the personalized approach to the patients with significant comorbidities that allowed reducing the incidence of postoperative complications and mortality after esophagectomy.
Цель исследования-сформулировать концепцию физиологической реконструкции пищеварительного тракта при повторных операциях на желудке. Материал и методы. В 2011-2017 гг. в НМИЦХ им. А.В. Вишневского выполнили 52 повторные операции пациентам, ранее перенесшим резекционные, дренирующие и антирефлюксные вмешательства на желудке. В качестве повторной операции резекция желудка с реконструкцией по Бильрот I произведена 5 (9,6%) пациентам, по Гофмейстеру-1 (1,9%). Реконструкцию на Ру-петле осуществили 4 (7,7%) пациентам после экстирпации культи желудка. Еюногастропластику применили у 30 (57,7%) больных. Сегмент поперечной ободочной кишки в качестве пластического материала использовали у 2 (3,8%) больных, пластику левой половиной толстой кишки выполнили 8 (15,4%) больным после эзофагэктомии. У 1 (1,9%) больного, ранее перенесшего гастрошунтирование, полностью удалили пораженный опухолью малый желудок и грудной отдел пищевода, а «выключенную» часть желудка использовали в качестве изоперистальтической трубки для субтотальной эзофагопластики. Только 1 (1,9%) больному не выполнили реконструкцию по причине дефицита висцерального резерва после мультивисцеральной резекции по поводу рецидива рака в зоне эзофагоеюноанастомоза. Результаты. Послеоперационные осложнения возникли у 5 (9,6%) больных. Частичная несостоятельность эзофагоеюноанастомоза развилась у 2 (3,8%), дуоденоеюноанастомоза-у 1 (1,9%) пациента, некроз толстокишечного трансплантата, который резецировали с выведением питательной коло-и эзофагостомы-у 1 (1,9%). Умер 1 больной в 1-е сутки после операции от прогрессирования полиорганной недостаточности. На момент окончания исследования под наблюдением осталось 44 (86,3%) пациента. Осмотр пациентов выявил у 26 (59,1%) хороший, у 13 (29,5%) удовлетворительный результат. Лишь 5 (11,4%) больным повторная операция ни принесла облегчения. Выводы. Полученные результаты демонстрируют купирование патологических синдромов оперированного желудка в большинстве наблюдений, что свидетельствует о целесообразности повторных операций с гастропластикой и восстановлением дуоденального пассажа. Ключевые слова: еюно(коло)гастропластика, болезни оперированного желудка, рецидив рака желудка, повторные реконструктивные операции, физиология пищеварения, редуоденизация.
The problem of unsuccessful (incomplete) esophagoplasty is still urgent nowadays. Simultaneous esophagoplasty remains a method of choice in reconstructive surgery of the esophagus. However, in the case of ischemic disorders in the transplant, its initially insufficient length, deficiency of the organs of the plastic reserve, the completion of esophagoplasty seems to be a technically complicated task, forcing surgeons to perform multi-stage intervention techniques. These techniques are associated with longer treatment periods and deterioration in the quality of life of patients.The article highlights a rare experience of esophagoplasty with combined grafts consisting of visceral segments on a natural source of blood circulation. Applied operational techniques allowed to complete esophagoplasty in a single step, including rational disposal of compromised plastic material, and also to preserve digestion.
Introduction. Despite increasing trends toward the early initiation of oral feeding after gastrointestinal surgeries, current evidence about feeding patients after esophagectomy (EE) with gastric tube reconstruction has not been convincing. The further research is needed. The present clinical trial aimed to compare the clinical outcomes of early oral feeding (EOF) with late oral feeding following EE with gastric conduit reconstruction. Objectives. To improve the results of treatment of patients after EE with gastric tube reconstruction by choosing the method of nutritional support in the postoperative period. Materials and methods. Forty patients undergoing esophagectomy with gastric conduit reconstruction enrolled in this prospective randomized controlled trial, and were randomly assigned to a group starting EOF on the first postoperative day (POD) and another group that remained nil by mouth and got parenteral feeding until the 5 POD. The clinical and surgical outcomes were compared between the two groups. Results. Comparing the treatment results of both groups, we did not find a statistically significant difference in the number of patients with postoperative complications in the main and control groups. The patients of EOF group had statistically significant earlier gas discharge-2 vs 4 (3-5.5) POD (p = 0.001) and the appearance of stool - 3 (2-3) vs 4 (2-4.5) POD (p = 0.0002). Early activisation and nutrition support, the absence of intestinal paresis allowed us to note a tendency to reduction of the total time of postoperative hospital stay - 7 (6.5-8.5) vs 8 (7-9) POD (p = 0.1). Conclusions. Early oral nutrition in patients who have undergone EE with gastric conduit reconstruction is safe and effective. However, its use in routine practice is possible only if surgical safety is observed and within the framework of a perioperative support program that includes all the components of ERAS protocol.
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