Abdominal Esophagus and Stomach

Fig. 45.1

Gastric injuries may be repaired with a running single-layer closure; full thickness bites of the stomach will ensure hemostasis from the well-vascularized gastric wall

Fig. 45.2

Tangential injuries to the anterior wall of the stomach can be both excised and closed simultaneously with a TA stapler. Babcock clamps are used to approximate the edges of the gastrotomy, placing the TA stapler beneath the opening in the gastric wall

Fig. 45.3

Small defects in the body of the stomach may be repaired by performing a wedge resection using GIA staplers **add new (b)

Fig. 45.4

Complex injuries to the central body or antrum of the stomach may require a partial gastrectomy (a) with reconstruction using either a Billroth I or II anastomosis (b)

Gastroesophageal junction injuries are usually more challenging to repair. For simple anterior stab wound to the abdominal esophagus, you should repair these with a transverse single layer of interrupted PDS sutures. You can then perform either a partial or full fundoplication to buttress your repair (Fig. 45.5). If the injury is a through-and-through injury, primary repair may result in a stenotic segment. Consider resecting the injured segment and pulling up the stomach for a primary end-to-end anastomosis; a wide Kocher maneuver will ensure your anastomosis is tension-free, and performing a pyloroplasty is necessary due to transection of the vagi (Fig. 45.6). Nasogastric tubes should be placed intraoperatively following repair, and correct positioning confirmed by the operating surgeon.

Fig. 45.5

Anterior traumatic gastrotomies may be repaired using a single-layer closure followed by a buttressing partial fundoplication

Fig. 45.6

Complex injuries at the gastroesophageal junction often require excision of the injured segment with a primary end-to-end esophagogastrostomy; if the vagus nerves are transected, a pyloroplasty is performed

Over the past decade, esophageal perforations have been increasingly managed with esophageal stents. Compared to open repair, esophageal stents are associated with a decrease in time to oral intake, morbidity, length of stay, and cost. Although potentially advantageous, if the injury is located in the intrathoracic esophagus, stenting has not been advocated for gastroesophageal junction perforations. Hence, application of this technology for intra-abdominal esophageal injuries has not been reported.

In the multisystem trauma patient, you should consider enteral access via a needle-catheter jejunostomy. Following gastric repair, avoid insertion of a gastrostomy tube as it will likely put tension on the suture/staple line. If abdominal closure is indicated after addressing the patient’s injuries, irrigate the abdomen with warm saline and close the midline fascia with a running heavy monofilament suture. Close the skin selectively based upon the amount of intra-abdominal contamination.

45.3.1 Damage Control Surgery Techniques

Damage control surgery techniques should be considered in any patient with a temperature <35 °C, arterial pH <7.2, base deficit <15 mmol/L (or <6 mmol/L in patients over 55 years of age), international normalized ratio (INR) or partial thromboplastin time (PTT) > 50 % of normal, or abnormal physiology including vasopressor requirements. The goal of damage control surgery is to control surgical bleeding and limit gastrointestinal spillage. The operative techniques employed are temporary measures, with definitive repair of injuries delayed until the patient is physiologically replete. Gastric lacerations can be controlled with a rapid whipstitch of 2–0 Prolene. Segmental damage to the stomach can be controlled using a GIA stapler, with resection of the injured segment, leaving the proximal and distal ends of the stomach in discontinuity.

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