Учебник по анатомии (для англ.яз)
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Thorax
Case 9 (continued)
thoracic aorta, and branches from the left gastric artery.
The transthoracic esophagectomy procedure involves
placing the patient supine. A laparotomy is performed to
assess for any evidence of disease in the abdominal
cavity. The stomach is mobilized with preservation of the right gastric and right gastro-omental arteries. The short gastric vessels and left gastric vessels are divided, and a pyloromyotomy is also performed.
The abdominal wound is then closed and the patient
is then placed in the left lateral position. A right
posterolateral thoracotomy is performed through the
fifth intercostal space, and the azygos vein is divided to
provide full access to the whole length of the esophagus.
The stomach is delivered through the diaphragmatic
hiatus. The esophagus is resected and the stomach is
anastomosed to the cervical esophagus.
The patient made an uneventful recovery.
Most esophageal cancers are diagnosed relatively late and often have lymph node metastatic spread. A number of patients will also have a spread of tumor to the liver. The overall prognosis for esophageal cancer is poor, with approximately a 2 %, -year survival rate.
Diagnosing esophageal cancer in its early stages before lymph node spread is ideal and can produce a curative procedure.
Our patient went on to have chemotherapy and enjoys a good quality of life years after his operation.
Case 10
VENOUS ACCESS
A 45-year-old woman, with a history of breast cancer in the left breast, returned to her physician. Unfortunately the disease had spread to the axillary lymph nodes and bones (bony metastatic disease). A surgeon duly resected the primary breast tumor with a wide local excision and then performed an axillary nodal clearance. The patient was then referred to an oncologist for chemotherapy. Chemotherapy was delivered through a portacath, which is a subcutaneous reservoir from which a small catheter passes under the skin into the internal jugular vein. The patient duly underwent a portacath insertion without complication, completed her course of chemotherapy and is currently doing well 5 years later.
The portacath was placed on the patient’s right anterior chest wall and the line was placed into the right internal jugular vein. The left internal jugular vein and subcutaneous tissues were not used. The reason for not using this site was that the patient had previously undergone an axillary dissection on the left,
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and the lymph nodes and lymphatics were removed. Placement of a portacath in this region may produce an inflammatory response and may even get infected. Unfortunately, because there are no lymphatics to drain away infected material and to remove bacteria, severe sepsis and life threatening infection may ensue.
How was it placed?
The ultrasound shows an axial image across the root of the neck on the right demonstrating the right common carotid artery and the right internal jugular vein. The internal jugular vein is the larger on the two structures and generally demonstrates normal respiratory variation, compressibility and a size dependence upon the patient’s position (when the patient is placed in the head down position, the vein fills and makes puncture easy).
The risks of the procedure
As with all procedures and operations there is always a
small risk of complication. These risks are always
balanced against the potential benefits of the procedure.
(continued)
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Clinical cases • case 10 |
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Case 10 (continued) |
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Placing the needle into the internal jugular vein can be |
the catheter is then placed more inferiorly at the junction |
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performed under ultrasound guidance, which reduces |
of the right atrium and the superior vena cava. The |
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the risk of puncturing the common carotid artery. |
reason for placing the catheter in such a position relates |
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Furthermore, by puncturing under direct vision it is less |
to the agents that are infused. Most chemotherapeutic |
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likely that the operator will hit the lung apex and pierce |
agents are severely cytotoxic (kill cells) and enabling |
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the superior pleural fascia, which may produce a |
good mixing with the blood prevents thrombosis and |
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pneumothorax. |
vein wall irritation. |
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The position of the indwelling catheter
The catheter is placed through the right internal jugular
vein and into the right brachiocephalic vein. The tip of
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