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Dehiscencia anastomosis Esofago yeyunal en gastrectomia total por cancer gstrico

Dr. Ignacio Cifuente

Gastrectomia total

Complicaciones Gastrectomia
Morbilidad: 21%:
Infeccion Herida operatoria: 7.9% Infeccin pulmonar: 5.2% Estenosis anastomtica: 7.9% Dehiscencia anastomosis: 13.2%

Dehiscencia EYA
Prevalencia
7,5% segn literatura internacional.

En chile:
5.5%

Factores de riesgo

Factores de Riesgo
N: 444 gastrectomias totales Dehiscencia EYA:
8,2%

Factores de riesgo independiente:


Recuento linfocitos. Albumina: Diseccion linftica para-artica

Mecnica Vs. Manual

Mecnica Vs. Manual

Uso SNG o SNY

Patients not having routine tube use had:

an earlier return of bowel function (p<0.00001), a decrease in pulmonary complications (p=0.01) and an insignificant trend toward increase in risk of wound infection (p=0.22) and ventral hernia (0.09). Anastomotic leak was no different between groups (p=0.70).

Uso SNG o SNY

RESULTS: Of 717 patients in five RCTs, 361 were allocated to nasogastric or nasojejunal decompression and 356 to no decompression. Time to oral diet was significantly shorter in the latter group (weighted mean difference 0.43 (95 per cent confidence interval 0.23 to 0.62) days; P < 0.001). Time to flatus, anastomotic leakage, pulmonary complications, length of hospital stay, morbidity and mortality were similar in both groups.

Diagnstico
Estudio contrastado de regla?

BACKGROUND: The practice of routine contrast radiology before recommencing oral nutrition after total gastrectomy is not evidence based.

RESULTS: Eight patients (11 per cent) developed a clinical leak from the oesophagojejunal anastomosis, seven before the first scheduled contrast swallow. Contrast radiology identified a leak in four of six patients. Endoscopy detected a leak in both patients with a false-negative swallow and in two patients who were not fit to undergo contrast radiology.

Routine contrast radiology identified a subclinical leak in a further five patients (7 per cent), none of whom developed clinical signs. Four of seven in-hospital deaths were associated with an anastomotic leak.

Manejo

RESULTADOS: La frecuencia de la deshiscencia fue independiente del tipo de anastomosis y de la radicalidad de la cirugia. Manejo conservador (69.9%): Sonda nasoyeyunal y drenaje percutaneo absceso. Manejo quirugico: Resutura anastomosis Drenaje Mortalidad11/58 (19%) en manejo conservador y16/25 (64%) despus de reoperacion.

Manejo Endoscopico
Alternativa atractiva a reoperacin dado la morbimortalidad de esta ultima. Distintas aproximaciones
Protesis endoscopicas Clips endoscopicos Histocryl

Protesis endoscopicas
Las protesis esofgicas cubiertas podran disminuir la morbimortalidad de dehiscencias sintomticas.

Alta mortalidad de dehiscencia anastomticas: 20-50% SEMS (Self expandable esophagic Metalic stents)
Inicialmente creadas para el manejo de lesiones malignas esofgicas Uso creciente para patologa benigna.

Manejo con Reg 0, ATB y NTP. Retiro en promedio 10 semanas.

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