Acs0520 Procedures For Benign And Malignant Gastric And Duodenal Disease 2006


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Acs0520 Procedures For Benign And Malignant Gastric And Duodenal Disease 2006

  1. 1. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 1 20 PROCEDURES FOR BENIGN AND MALIGNANT GASTRIC AND DUODENAL DISEASE Thomas E. Clancy, M.D., and Stanley W Ashley, M.D., F.A.C.S. . Procedures for Benign Gastric and Duodenal Disease gical management unnecessary. Definitive surgical management is Advances in the medical management of peptic ulcer disease, indicated, however, if bleeding leads to hemodynamic instability, an including the use of effective acid-suppressing medications (e.g., his- extensive transfusion requirement (i.e., more than 6 units), or rebleed- tamine receptor antagonists and proton pump inhibitors [PPIs]) and ing after initial endoscopic management. Objective criteria for surgery the treatment of Helicobacter pylori, have led to a dramatic decrease in must be determined on a patient-by-patient basis. Precise preopera- the need for elective surgical management of uncomplicated duode- tive localization of the bleeding source is essential; a bleeding posteri- nal and gastric ulcers. In the past, surgery was the only effective long- or duodenal ulcer, for example, cannot be managed in the same way term option for peptic ulcer disease, but over the past two decades, it as hemorrhage from diffuse severe gastritis. Endoscopy should there- has become an increasingly rare choice.1 Currently, operative therapy fore be performed whenever possible. Alternatively, if brisk bleeding for peptic ulcer disease is largely reserved for the management of com- prevents clear intraluminal visualization of a bleeding site, angio- plications such as hemorrhage, perforation, and obstruction. The graphic localization may be attempted. recognition that medical management successfully prevents ulcer Occasionally, patients present for surgery with refractory gastric recurrence in most patients has caused surgical management of com- ulcers. If the ulcer has not healed after 12 weeks of optimal medical plicated ulcer disease to evolve into a more minimalist strategy that therapy, resection is indicated to rule out an occult gastric malignan- favors damage-control surgery for complications and only infrequent- cy. In such cases, the preoperative workup should include endoscopic ly resorts to acid-reducing operations.2 biopsies of the ulcer base and the surrounding gastric mucosa so that In this section of the chapter, we focus primarily on procedures per- a preoperative diagnosis of malignancy can be made if possible. In formed to treat peptic ulcer disease, though we also briefly address view of the concern about a possible gastric malignancy, it is reason- diverticulectomy for duodenal diverticular disease. Other gastroduo- able to obtain a preoperative chest x-ray and a CT scan of the denal procedures for nonmalignant disease are described in more abdomen so as to detect possible nodal or distant metastases. detail elsewhere: gastric restrictive procedures and gastric bypass are OPERATIVE PLANNING discussed in the context of bariatric surgery [see 5:19 Bariatric Procedures]; choledochoduodenostomy and transduodenal sphinctero- Patients undergoing gastroduodenal procedures should receive plasty are discussed in the context of biliary tract surgery [see 5:22 general anesthesia and have a nasogastric tube and Foley catheter in Procedures for Benign and Malignant Biliary Tract Disease]; cystogas- place. The supine position is preferred. The operation is usually done trostomy for intractable pancreatic pseudocysts is discussed in the via an upper midline incision or, occasionally, via a bilateral subcostal context of pancreatic surgery [see 5:24 Procedures for Benign and incision, with fixed retractors used in either case. Malignant Pancreatic Disease]; and duodenal diverticularization is dis- The choice of procedure is primarily dictated by the indication for cussed in the context of pancreatic and duodenal trauma [see 7:8 operation. Usually, several options are available.The first priority is to Injuries to the Pancreas and Duodenum]. manage complications (e.g., bleeding and perforation); whether an accompanying acid-suppressing procedure is indicated and which one PREOPERATIVE EVALUATION should be done depend on the clinical setting. Most commonly, duo- The appropriate extent of preoperative evaluation for a patient denal perforation is treated with closure and omental patching, with undergoing surgery for a benign gastroduodenal disorder is dictated or without an acid-reducing procedure. A bleeding ulcer is treated primarily by the nature of the presenting problem. In the case of gas- with oversewing of the the bleeding vessel, with or without an acid- tric outlet obstruction or a rare condition such as intractable peptic reducing vagotomy and pyloroplasty. Gastric outlet obstruction may ulcer disease that is refractory to medical management, the preopera- be managed with several different approaches, including vagotomy tive workup may be extensive and include detailed endoscopy, con- with antrectomy and vagotomy with drainage via pyloroplasty or gas- trast studies of the upper abdomen, cross-sectional imaging with com- troenterostomy. In the rare cases of intractability, highly selective va- puted tomography, and full laboratory panels. In most cases of com- gotomy (HSV) is the procedure of choice. plicated peptic ulcer disease, however, the emergency nature of the sit- An important component of preoperative evaluation is determina- uation necessarily renders an extensive preoperative workup impracti- tion of the severity and duration of disease. If symptoms are long- cal. For instance, patients with perforated duodenal ulcers typically standing or recurrent—particularly when the patient has already present in distress with an acute abdomen. A chest x-ray that demon- received acid-reducing or anti–H. pylori therapy—a definitive acid- strates free intraperitoneal air is all that is needed before the patient is reducing procedure should be considered. As has been demonstrated,3 taken to the operating room; the decision to proceed to operation however, ulcer recurrence is significantly reduced even without an should not be delayed by waiting for further images (e.g., CT scans). acid-reducing procedure when perforated ulcers are managed with Patients who are experiencing upper GI hemorrhage secondary to anti–H. pylori agents in conjunction with a PPI.Therefore, a compliant peptic ulcer disease should undergo endoscopy to identify the source patient who is presumed to be infected with H. pylori may not need to of bleeding [see 5:5 Upper Gastrointestinal Bleeding]. In many cases, undergo an additional acid-reducing procedure. The evidence for this endoscopic management of bleeding ulcers is possible, rendering sur- strategy is less clear with respect to bleeding or obstructing ulcers.
  2. 2. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 2 Figure 1 Omental (Graham) patch. Three or four interrupted sutures are placed along the ulcer edge. If possible, the ulcer is closed primarily and rein- forced with omentum. Primary closure may be difficult; in a true Graham patch, primary closure is not attempt- ed, and omentum is used to cover the tissue defect. OMENTAL PATCH FOR DUODENAL PERFORATION (GRAHAM Complications PATCH) Persistent leakage should be uncommon after adequate closure. Operative Technique Duodenal scarring at the area of perforation and repair may lead to gastric outlet obstruction. Incomplete exploration and irrigation of Perforated duodenal ulcers are typically treated by oversewing the the abdomen may result in late infection. perforation, then placing a portion of the greater omentum over the suture line. The duodenal ulcer wall is carefully debrided and closed with three or four interrupted silk sutures; the tails of the sutures may be used to hold the omentum in place. Alternatively, if the ulcer edges are edematous and not expected to close easily, the perforation may be closed with a true Graham patch, which involves plugging the defect with a well-vascularized omental pedicle [see Figure 1]. Care should be taken to avoid tying sutures too tightly; this can lead to devascularization of the omental pedicle. Once the operation has been completed, the abdomen is generously irrigated to remove any contamination, and a search is made for occult collections in the sub- phrenic space and the pelvis. Troubleshooting To avoid placing excessive tension on the repair, primary closure should not be attempted if the duodenal wall is overly edematous and thickened. For large perforations that are expected to result in gastric outlet obstruction if closed, consideration should be given to incor- porating the closure into a pyloroplasty. There is some controversy regarding whether an acid-reducing operation should be added to the omental patch procedure. If the patient is stable and has a history of peptic ulcer disease, a definitive ulcer operation is included; HSV may be preferable to truncal vagot- omy and pyloroplasty, in that it is less likely to give rise to dumping syndrome and postvagotomy diarrhea. If the patient has no history of Figure 2 Vagotomy and pyloroplasty. To control a bleeding duo- denal ulcer, traction sutures are placed along the cephalad and peptic ulcer disease, has a severe medical illness, is hemodynamically caudad borders of a longitudinal incision across the pylorus. unstable, has a long-standing perforation, or exhibits gross abdominal Figure-eight sutures are placed at the cephalad and caudad por- contamination, a definitive ulcer operation is omitted. In cases of tions of the ulcer to occlude the gastroduodenal artery. An addi- gross contamination of the abdomen, it is probably inappropriate to tional U-stitch is placed to control small transverse pancreatic divide the peritoneum over the esophagus during vagotomy and branches that may cause late bleeding. Care should be taken to thereby expose the mediastinum to infection. avoid the underlying CBD.
  3. 3. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 3 Figure 3 Vagotomy and pyloroplasty. For a Heineke- Mikulicz pyloroplasty, a full-thickness longitudinal incision is made that extends from a point 1 cm proxi- mal to the pylorus to a point 1 to 2 cm distal to the pylorus. The incision is closed transversely in two lay- ers. Superior and inferior stay sutures help align the incision for closure. Outcome Evaluation cautery; exposure may be facilitated by surrounding the distal esoph- With adequate acid suppression and anti–H. pylori therapy, symp- agus with a Penrose drain for downward traction. The left (anterior) toms of duodenal ulcer are unlikely to recur. The 1-year recurrence vagus is best identified by applying traction to the right and posteri- rate after omental patching is substantially lower when both therapies orly, so that the nerve can be traced into the posterior mediastinum. are employed than when only a PPI is given (5% versus 38%).3 All fibers entering the distal esophagus are divided. The main nerve trunk is clipped proximally and distally, and a 2 cm long segment is VAGOTOMY AND PYLOROPLASTY FOR BLEEDING DUODENAL excised.The right (posterior) vagus is exposed by applying traction to ULCER the left and anteriorly; the nerve can then be palpated as a taut cord Truncal vagotomy with pyloric drainage via pyloroplasty is rarely and divided in much the same manner as the anterior vagus. For a employed as primary therapy for peptic ulcer disease, but it does play complete vagotomy, the distal esophagus must be skeletonized for a role in emergency management of bleeding duodenal ulcers. This approximately 5 cm [see Figure 4]. approach to acid suppression fits well with the proximal duodenoto- my used to control the hemorrhage. Exposure of the first portion of the duodenum via a longitudinal incision in the pylorus is combined with truncal vagotomy; the pylorus is then closed in a transverse fash- ion to prevent the development of gastric outlet obstruction. Operative Technique Posterior Vagus Step 1: exposure and pyloric division A Kocher maneuver is performed. The pylorus is identified through palpation and through identification of the pyloric vein as it courses anteriorly. Two traction sutures are placed in the anterior aspect of the pylorus, one superior- ly and one inferiorly. A longitudinal incision is made that extends approximately 2 to 3 cm on either side of the pylorus. Step 2: ligation of bleeding vessel The bleeding ulcer bed is directly oversewn with at least three sutures. Figure-eight sutures are placed on the superior and inferior borders of the ulcer bed to ligate the gastroduodenal artery proximal and distal to the ulcer, and a third figure-eight suture is placed medially to control the transverse pan- creatic branch [see Figure 2]. Step 3: pyloroplasty Tension is applied to the previously placed Anterior Vagus traction sutures to convert the longitudinal incision to a transverse Divided one. The incision is then closed transversely in two layers with full- thickness bites of 3-0 or 2-0 nonabsorbable suture material (Heineke- Mikulicz pyloroplasty) [see Figure 3].Tension-free closure is facilitated by adequate duodenal mobilization (by means of the Kocher maneu- ver) and lysis of surrounding adhesions. Figure 4 Vagotomy and pyloroplasty. For the truncal vagotomy, Step 4: vagotomy To perform the vagotomy, further exposure the peritoneum over the esophagogastric junction is opened may be needed, including mobilization of the left lateral section of the widely to afford exposure. Gentle downward traction is applied liver and division of the triangular ligament. Downward traction on to the stomach to facilitate identification of the two vagus the greater curvature of the stomach is essential to apply gentle ten- nerves. Surgical clips are applied to each nerve in turn, and a 2 sion to the esophagogastric junction and the proximal vagi. The peri- to 3 cm nerve segment is removed between the clips. These seg- toneum over the esophagus is divided transversely with the electro- ments should be inspected to confirm removal of neural tissue.
  4. 4. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 4 Troubleshooting (CBD), particularly when the vascular inflow to a deeply penetrating As this procedure becomes less frequent and surgeons’ experience duodenal ulcer is being sutured. with it dwindles, location of the vagus nerves may prove an increas- ingly troublesome task. In most cases, complete skeletonization of the Complications distal esophagus in conjunction with appropriate traction should allow Leakage from a pyloroplasty is rare. Gastric outlet obstruction may palpation of the main vagal trunks. occur secondary to either scarring or edema at the operative site; If substantial duodenal scarring is present, a tension-free Heineke- often, it is relieved by nasogastric decompression and conservative Mikulicz pyloroplasty may not be possible, and a Finney pyloroplasty management. The incidence of ulcer recurrence and rebleeding is may be preferable. The Finney procedure is essentially a side-to-side quite low with adequate anti–H. pylori treatment. anastomosis that is created in two layers between the distal stomach ANTRECTOMY and the proximal duodenum [see Figure 5]. Complete mobilization of the duodenum, including adhesiolysis and a generous Kocher maneu- The primary indication for gastric resection in the setting of peptic ver, is required. ulcer disease is chronic obstruction caused by scarring, typically from Care should be taken to keep from injuring the common bile duct a pyloric channel ulcer. Antrectomy removes the gastrin-secreting por- Figure 5 Vagotomy and pyloroplasty. If a Pylorus a tension-free Heineke-Mikulicz pyloro- plasty is not feasible, a Finney pyloroplasty may be performed instead. (a) The distal stomach and the proximal duodenum are Gallbladder aligned with stay sutures; meticulous lysis of surrounding adhesions is essential. An inverted U-shaped incision is made. (b) The pyloroplasty is created in two layers. The posterior portion of the outer layer, consisting of seromuscular Lembert sutures, is placed first, followed by an inner layer constructed with a continuous full-thickness absorbable suture. (c) The anterior portion of the inner layer is closed with a continuous full-thickness suture. Some surgeons prefer a Connell suture at this site. (d) The anterior porti on of outer layer, consisting of silk b Lembert sutures, is placed. Inverted Incision Duodenum d c Duodenum
  5. 5. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 5 are divided just distal to the pylorus. The duodenum is then divided a distal to the pylorus with a tranverse anastomosis (TA) stapler. Step 3: reconstruction When feasible, a Billroth I reconstruc- Billroth I tion (primary gastroduodenostomy) is preferred for maintenance of physiologic antegrade flow (though there are no data establishing that this maintenance of flow is beneficial). In addition, this reconstruction avoids the complications associated with a Billroth II reconstruction b (e.g., afferent and efferent loop syndromes and duodenal stump leaks). A generous Kocher maneuver, if not already performed, is nec- essary to minimize tension on the anastomosis. The lower portion of the staple line is removed for the width of the duodenal stump, and the anastomosis is performed in two layers or fashioned with a GIA stapler through a gastrotomy [see Figure 6]. If a primary gastroduodenostomy is not possible, a Billroth II reconstruction (gastrojejunostomy) is indicated. This procedure involves a number of technical considerations: management of the duodenal stump, the length of and placement of the afferent limb, and the placement and method of the anastomosis. If the duodenum is not scarred or inflamed, simple staple closure will suffice; if closure proves Figure 6 Antrectomy: Billroth I reconstruction (gastroduo- difficult, a lateral duodenostomy tube may help decompress the denostomy). (a) The anastomosis is done in two layers. The inner stump. The duodenal stump should be covered with an omental layer is constructed by placing a continuous full-thickness suture. patch. (b) The outer layer is constructed with silk Lembert sutures. The The segment used for the anastomosis should be as short as possi- junction of the anastomosis and the gastric staple line has been ble while still being able to reach the stomach without tension; referred to as the angle of sorrow, a term that reflects the com- approximately 20 cm of proximal jejunum should be sufficient to mon complication of leakage at the intersection of suture or sta- ple lines. This junction may be reinforced with additional serve as the afferent limb. Passing the jejunum through a retrocolic Lembert sutures. window places less tension on the mesentery than an antecolic approach does, though gastric emptying will occur with either method. If a retrocolic approach is used, a window is created for the tion of the stomach. In addition, antrectomy may be required for jejunum; this must be closed and fixed to the small bowel. recurrent bleeding after an adequate vagotomy and pyloroplasty for a The gastrojejunostomy may be constructed either to the posterior bleeding duodenal ulcer. Alternatively, antrectomy may be the elective wall of the stomach or to the inferior portion of the excised staple line. operation of choice for intractable type I, II, and III gastric ulcers, as If the anastomosis is placed at the gastric staple line, the inferior por- well as a primary emergency surgical option for perforated or bleed- tion of the staple line is excised, often together with a wedge of stom- ing gastric ulcers. Historically, a primary Billroth I gastroduodenosto- ach behind the staple line. A two-layer anastomosis is created with an my has been the preferred procedure, but surrounding scar tissue may outer layer of Lembert sutures and an inner layer of absorbable full- limit the mobility of the duodenum, in which case a Billroth II gas- thickness sutures; the gastric staple line may be oversewn [see Figure trojejunostomy may be required for a tension-free anastomosis. 7]. Alternatively, the gastrojejunostomy may be created by means of Antrectomy is typically combined with truncal vagotomy. stapling. A GIA stapler is introduced via a gastrotomy and a small enterotomy, and the defect is subsequently closed with a TA stapler. Operative Technique Additional reinforcement is not necessary for this staple line. Step 1: exposure The lesser sac is entered via the avascular Some authors recommend the use of a Braun enteroenterostomy plane in the greater omentum, the plane between the stomach and the between the efferent and afferent limbs to reduce bile reflux and pancreas is developed, and the lesser omentum is divided. The proxi- decompress the duodenal stump [see Figure 8a]. Staple closure of the mal border of the antrum must be identified before the stomach is afferent limb above the enteroenterostomy may also be performed to divided [see Step 2, below]. On the greater curvature, the antrum limit bile reflux into the stomach; this measure creates a configuration extends to a point between the pylorus and the fundus; on the lesser referred to as an uncut Roux-en-Y [see Figure 8b]. Enteroenterostomy curvature, it extends to a point just above the incisura. Distally, the at this site may also be performed on an emergency basis to treat affer- dissection is carried past the pylorus. Along the lesser curvature, dis- ent limb syndrome. Staple closure of the afferent limb may discourage section necessitates division of the descending branch of the left gas- bile reflux, but it may also lead to long-term bile reflux gastritis and tric artery, as well as the right gastric artery. Dissection along the esophagitis.4 pylorus must be meticulous to ensure that the pancreas is not dam- aged. If a Billroth I anastomosis is planned, dissection should contin- Troubleshooting ue 1 cm beyond the pylorus to expose a sufficient length of duodenum In most instances, a noninflamed duodenum can readily be closed for the anastomosis. If a Billroth II reconstruction is planned, dissec- with a TA stapler. However, the thickened and inflamed tissue present tion need extend only far enough to allow division of the duodenum in the setting of inflammation with duodenal perforation is not past the pylorus. amenable to easy closure. Furthermore, poor afferent limb drainage can lead to increased pressure in the afferent limb, thus contributing Step 2: division of stomach A gastrointestinal anastomosis to leakage. Lateral duodenostomy tubes may be used for decompres- (GIA) stapler is used to divide the stomach at the estimated borders sion. The duodenum should be sutured to the abdominal wall in a of the antrum [see Step 1, above].The antrum is gently retracted ante- Stamm fashion at the exit site of the tube. Alternatively, if the duode- riorly and to the patient’s left.The right gastroepiploic artery and vein num cannot be closed without significant tension, closure may be
  6. 6. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 6 a b c Figure 7 Antrectomy: Billroth II reconstruction (gastrojejunostomy). (a) The inferior portion of the gastric resection line is excised, along with a small wedge of the stomach. (b, c) A two-layer anastomosis is created, with an outer layer of Lembert sutures and an inner layer of full-thickness absorbable sutures. The upper gastric staple line may be oversewn with interrupted Lembert sutures. accomplished around a red rubber or mushroom catheter. For espe- forming a technetium-99m (99mTc)-labeled hepato-iminodiacetic cially thick tissue, primary suture closure is preferable to staple clo- acid (HIDA) scan. sure. Inversion of the duodenal suture line with Lembert sutures is not Duodenal leaks can rarely be closed primarily. Duodenostomy may necessary. In addition, omental patch reinforcement of the duodenal be indicated to further decompress the afferent limb and prevent con- stump may be desirable. tinuous leakage.The goals are to create a controlled fistula to the skin and to prevent the accumulation of biliary fluid in the abdomen. Complications Delayed gastric emptying after gastrojejunostomy may occur and Leakage from the duodenal stump is a potentially devastating com- is generally managed conservatively. On rare occasions, reoperation is plication that necessitates prompt reoperation, washout, and drainage. required for delayed anastomotic function. In the case of a Billroth I The diagnosis of duodenal stump leakage is confirmed by aspirating reconstruction, takedown of the anastomosis is associated with devas- bilious fluid from a right upper quadrant fluid collection or by per- cularization and duodenal stump leakage. It is therefore preferable to Figure 8 Antrectomy: Billroth II recon- struction (gastrojejunostomy). (a) A Braun enteroenterostomy facilitates decompression of the afferent limb in a Billroth II gastrojejunostomy. It may be done as either a sutured or a stapled anastomosis. (b) An option is to close the afferent limb above the enteroenterosto- my with a TA stapler (so that the jejunal lumen is occluded but not divided). This configuration, often referred to as an uncut Roux-en-Y, temporarily discour- ages, but does not prevent, reflux of bile into the stomach.
  7. 7. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 7 leave the anastomosis in place and perform a gastrojejunostomy along the greater curvature of the stomach. In the case of a Billroth II reconstruction, revision may be required for better positioning of the anastomosis. Afferent limb obstruction may occur as a consequence of adhe- sions, internal herniation, volvulus, or a kink at the angle formed with the gastric remnant. Obstruction to outflow of the afferent limb cre- ates a closed-loop obstruction, with persistent secretion of bile and pancreatic fluids into the loop. Such obstruction often presents as recurrent pancreatitis. The diagnosis is facilitated by CT scanning; if it is confirmed, prompt exploration is mandated. Correction of the obstruction may necessitate conversion to a Roux-en-Y reconstruc- tion, shortening of the afferent limb, or a side-to-side enteroenteros- tomy with the efferent limb (see above). Bleeding, generally in the form of intraluminal blood loss, is a fre- quent occurrence after gastrectomy. A bloody aspirate from the naso- gastric tube is a common presentation. If bleeding persists for more than 5 days after the initial operation, endoscopy with endoscopic coagulation or epinephrine injection may be considered. Endoscopic approaches should be undertaken with care to minimize the risk of 7 cm distending the new anastomosis. Alkaline reflux gastritis is one of the most common long-term complications of gastrectomy, developing in 5% and 15% of patients after gastric surgery.5 This complication is most frequently associated with Billroth II reconstructions. Although reflux is common, symp- toms (e.g., epigastric pain, nausea, and bilious emesis) are relatively Figure 9 Highly selective vagotomy. Anterior and posterior rare. Medical management is generally ineffective. If surgery is branches of the nerve of Latarjet to the lesser curvature are required, conversion of the Billroth II reconstruction to a Roux-en-Y ligated and divided. The distal branches, comprising the so- reconstruction is indicated. In those patients who have a Roux-en-Y called crow’s foot, are left intact. The posterior branches may rather than a Billroth II reconstruction, the preferred treatment is to be approached via the lesser omentum. divert alkaline contents to a location 45 to 60 cm beyond the gastric remnant. typically located near the incisura angularis, approximately 6 to 7 cm HIGHLY SELECTIVE VAGOTOMY proximal to the pylorus. Gentle downward traction is applied to the Although both vagotomy with antrectomy and vagotomy with stomach, the left gastric vascular arcade is identified, and all tissue pyloroplasty drainage provide relief from duodenal ulcers, they are between this arcade and the lesser curvature is divided and ligated. also associated with significant complications, including dumping syn- The dissection therefore includes individual branches of the vagus drome, diarrhea, bile reflux, and poor gastric emptying. Highly selec- nerve to the stomach. It should proceed upward as far as the esopha- tive vagotomy, also referred to as parietal cell vagotomy, was devel- gogastric junction. The posterior branches are approached either by oped with these complications in mind; the idea was to avoid vagal rotating the stomach or by proceeding directly through the lesser denervation of viscera other than the parietal cell mass while keeping omentum [see Figure 9]. the pylorus mechanically and functionally intact.6,7 HSV was found to reduce postvagotomy diarrhea and dumping dramatically; however, it Step 3: dissection of esophagogastric junction The distal was also found to be associated with a much higher rate of recurrent esophagus is cleared of all nerve fibers for a distance of approximate- ulceration (greater than 10% at 5 years). Today, in an era character- ly 5 cm above the esophagogastric junction. The dissection must stay ized by greatly improved medical management of peptic ulcer disease, close to the lesser curvature and the esophagus, avoiding the tissues to most GI surgeons perform HSV very rarely, if at all. One possible use the right of the esophagus, where the main vagal trunks lie. The pos- for this procedure in the current context might be to treat intractable terior esophagogastric junction is exposed by means of gentle traction ulcer disease in young patients. and slight rotation of the distal esophagus. Exposure is facilitated by downward traction provided by a Penrose drain placed around the Operative Technique esophagogastric junction. Step 1: exposure and gastric mobilization Wide exposure is obtained with the help of upward retraction on the costal margin.The Troubleshooting gastrocolic omentum is entered outside the gastroepiploic vessels to Incomplete denervation of the parietal cell mass is prevented by preserve the blood supply to the greater curvature. Adhesions to the paying meticulous attention to dissection, particularly at the esopha- peritoneum over the pancreas are divided sharply, and the stomach is gogastric junction.The left side of the distal esophagus must be man- rotated upward to allow visualization of the posterior leaf of the lesser ually stripped so that the so-called criminal nerve of Grassi can be omentum and the posterior nerve of Latarjet, which runs adjacent to identified and ligated. About 4 to 5 cm of the distal esophagus should the descending branch of the left gastric artery. be stripped of vagal input. Step 2: dissection of anterior and posterior nerve branches Complications to lesser curvature The distal branches of the nerve of Latarjet are The primary complication of HSV is recurrent ulceration. The defined, with care taken to preserve the so-called crow’s foot, which is reported rates vary, but the general view is that the 5-year ulceration
  8. 8. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 8 recurrence rate may be higher than 10%.8 Most recurrent ulcers Step 1: exposure and duodenotomy A generous Kocher occur in the setting of incomplete vagal denervation. Given the small maneuver is performed to elevate the head of the duodenum. The number of patients for whom HSV is indicated, few GI surgeons are duodenum is then opened by making a 4 cm longitudinal incision likely to have accumulated sufficient experience with this technique to along the antimesenteric border, and the ampulla is either visualized be proficient at it. Fortunately, most recurrent ulcers can now be man- or palpated. To identify the ampulla, it may be necessary to place a aged medically, and few call for surgical management. catheter into the CBD via a separate choledochotomy. LAPAROSCOPIC TREATMENT OF PEPTIC ULCER DISEASE Step 2: diverticulectomy The orifice of the diverticulum is Numerous reports of laparoscopic approaches to truncal vagotomy identified, and the mucosa is inverted into the lumen of the duode- and HSV have been published over the past two decades.The laparo- num.The neck of the diverticulum is transected 2 mm from the junc- scopic versions of these procedures proceed in much the same way as tion with the duodenal wall. The diverticular opening is then closed the traditional open versions. In a laparoscopic HSV, the ultrasonic with interrupted seromuscular Lembert sutures of 3-0 silk and inter- shears are frequently used to divide the anterior and posterior vagal rupted mucosal sutures of 4-0 polyglactin.The duodenum is closed in branches to the lesser curvature from the crow’s foot to the esopha- two layers, also with an inner layer of 4-0 polyglactin and an outer gogastric junction. Mixed procedures that combine posterior truncal layer of seromuscular Lembert sutures of 3-0 silk. Closed suction vagotomy with more selective anterior gastric denervation are com- drainage adjacent to the duodenum is indicated. mon. In the Taylor procedure, an anterior seromyotomy is performed from the angle of His to the crow’s foot, and the seromuscular layers Special case: perforated duodenal diverticulum. In the setting of acute are subsequently closed primarily.9 A variant of the laparoscopic inflammation, duodenotomy is avoided. Instead, the abscess is evacu- Taylor procedure includes a anterior linear gastrectomy, in which a ated, and the diverticulum is excised along with just enough of the linear strip of the stomach wall is removed parallel to the lesser cur- adjacent duodenal wall to ensure that only healthy tissue is left. If the vature with an endoscopic GIA stapler. This procedure seems to be resulting duodenal defect is large, either sleeve resection of the duo- functionally equivalent to HSV.The majority of the studies of laparo- denum or drainage of the open duodenal defect into a Roux-en-Y scopic vagotomy, however, have been individual case series that do not jejunal limb may be required. compare the laparoscopic approach with a traditional open approach. Undoubtedly, the scarce comparative data reflect the declining indi- Troubleshooting cations for vagotomy for intractable peptic ulcer disease.Thus, where- Inadvertent closure of the CBD may be prevented by inserting a as laparoscopic HSV has been well described, it is by no means clear catheter into the duct. If the duodenum is markedly inflamed, suture that it should be recommended over open HSV for those rare patients line breakdown is likely, eventually leading to a duodenal fistula. The in whom this procedure is indicated. area can be isolated by means of pyloric exclusion or antrectomy with More data are available on laparoscopic treatment of perforated Billroth II reconstruction. In addition, bile flow can be diverted by duodenal ulcers. A meta-analysis of 13 studies comparing laparo- performing a choledochojejunostomy to a Roux-en-Y intestinal limb scopic and open approaches to perforated peptic ulcers found that to prevent combined leakage of pancreatic fluid and bile. laparoscopic repair yielded excellent results, albeit with a small but Diverticula arising from the third or the fourth portion of the duo- insignificant increase in the reoperation rate.10 The laparoscopic denum may be approached via the transverse mesocolon and may be approach is therefore considered as safe and effective as open Graham excised either primarily or via a transduodenal approach. Inverting the patch repair.The procedures generally involve either suture closure of diverticulum without excising it is not recommended, because it may the perforation followed by omentopexy or omentopexy alone, and lead to duodenal obstruction. they should be attempted only by surgeons with advanced laparo- scopic skills. The threshold for conversion to an open procedure should be low if the ulcers are particularly large ulcers or prove diffi- Procedures for Gastric Cancer cult to localize. Surgical resection remains the primary therapeutic modality for gastric cancer [see 5:8 Tumors of the Stomach, Duodenum, and Small DUODENAL DIVERTICULECTOMY Bowel].The diagnosis of gastric cancer is primarily made by means of Incidental duodenal diverticula are common. Such diverticula con- endoscopy with biopsy.There are numerous considerations that must sist of a sac that includes only mucosa and submucosa, and most be addressed before operation, including the stage of the cancer on occur within 2 cm of the ampulla of Vater. Complications include diagnostic imaging, the use of staging laparoscopy, the extent of the ulceration and bleeding, compression of the CBD with cholangitis or planned gastrectomy, the extent of the planned lymphadenectomy, the pancreatitis, and, in cases of perforation, abscess formation with peri- placement of feeding enterostomies, and the patient’s overall medical tonitis. CT scanning is useful for differentiating this condition from fitness for surgery. cholecystitis or pancreatitis. Surgery is rarely required; it is indicated PREOPERATIVE EVALUATION primarily for complications such as bleeding, perforation, and biliary or duodenal obstruction. Endoscopy, with or without endoscopic ultrasonography (EUS), is essential for diagnosis. Preoperative biopsy is helpful for confirming the Operative Technique suspected pathologic process, particularly because the extent of resec- The main surgical options are simple diverticulectomy with tion will be different if a less common lesion, such as a gastrointestinal drainage and transduodenal diverticulectomy (as described by Iida11). stromal tumor (GIST), is identified. Endoscopic localization is critical If the duodenum is free of inflammation, the transduodenal approach because the extent of the gastrectomy will depend on the precise loca- is preferred because it minimizes the need for dissection of the diver- tion of the tumor. It should be noted, however, that the true location of ticulum from the surrounding pancreas. However, if the diverticulum the tumor, as determined at laparotomy, may differ significantly from does not involve the pancreas, simple excision flush with the duode- the preoperative estimate made on the basis of endoscopy. Abdominal nal wall, followed by closure in two layers, may be sufficient.The ensu- CT scanning and chest radiography are indicated to rule out obvious ing technical description focuses on transduodenal diverticulectomy. metastatic disease, which would be an indication for a more conserva-
  9. 9. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 9 tive surgical approach or even for nonoperative therapy.The preopera- It is generally agreed that total esophagectomy is required for type tive physical examination should also focus on the detection of occult I esophagogastric junction tumors [see 4:4 Open Esophageal metastatic disease, concentrating on such sites as the supraclavicular Procedures]. The necessary extent of resection for type II and III lymph nodes and the pouch of Douglas. A bone scan is indicated if esophagogastric junction tumors has been more controversial. A metastasis to bone is suspected. Laparoscopic staging (see below) may microscopically negative (R0) surgical margin is closely associated be performed to identify occult metastatic disease (and, possibly, to with survival after resection of esophagogastric junction adenocarci- prevent an unnecessary laparotomy in an otherwise ill patient).12 If the nomas, though R0 resection can be quite difficult to achieve, given tumor is not bleeding or causing an obstruction, palliative resection the propensity of these tumors for intramural spreading. In our expe- might be avoided. Generally, curative surgery should be attempted only rience, positive margins have not been found in patients with T1 or when the tumor is believed to be limited to the stomach and the peri- T2 tumors, even when the margins are smaller than 4 cm. In patients gastric lymph nodes. On occasion, however, curative-intent surgery with T3 or T4 tumors, however, proximal margins of at least 6 cm may be considered for tumors that involve nearby resectable structures have proved necessary. For T1 and T2 tumors, total gastrectomy (e.g., the transverse colon), provided that these structures can be without thoracotomy may yield adequate margins. For T3 and T4 removed en bloc with the primary lesion. tumors, however, extended gastrectomy with thoracotomy or In Japan, where screening endoscopy is widespread, early gastric esophagectomy may be required.14 It is well documented that the cancer is identified with some frequency. In Western countries, how- margin lengths measured on prefixed esophageal specimens are only ever, the situation is different, and patients tend to present with more about 50% of the corresponding lengths measured in situ before advanced cancers. Accordingly, although procedures such as wedge completion of resection.15 Accordingly, intraoperative decisions resection for early gastric cancer have been described, most gastric about the extent of resection should be based on margin length cancer patients in the United States require formal gastrectomy and requirements that may be considerably greater than those derived lymphadenectomy. from resection specimens. OPERATIVE PLANNING Extent of Lymphadenectomy Considerable controversy has surrounded the question of how Extent of Resection extensive lymphadenectomy should be for curative resection of gastric The extent of the resection required for treatment of a gastric adenocarcinoma. One aspect of the controversy has to do with the malignancy is determined primarily by the preoperative pathologic minimum number of lymph nodes required for analysis. It has been diagnosis and the site of the tumor. Considerably smaller surgical suggested that a minimum of 15 lymph nodes must be removed dur- margins are required for rare mesenchymal tumors (e.g., GISTs) than ing gastrectomy. In a study published in 2000, 5-year survival rates are necessary for gastric adenocarcinomas, which tend to spread were significantly lower in patients with fewer than 15 lymph nodes microscopically well beyond the gross extent of the tumor. Most mes- sampled than in those with 15 or more lymph nodes examined.16 This enchymal tumors can be adequately treated with a wedge resection or decreased survival has been attributed primarily to understaging as partial gastrectomy that achieves a 1 cm gross margin. Laparoscopic the result of inadequate lymphadenectomy (though, admittedly, there approaches to such tumors have been described that employ either the is some disagreement on this point). endoscopic GIA stapler or excision with suture closure [see The particular lymph node basins that should be sampled during Laparoscopic Resection of Malignant Gastric Tumors, below]. Such gastrectomy has also been the subject of debate. Western surgeons approaches may be facilitated by endoscopic tattooing of an appro- have usually limited lymphadenectomy to the perigastric (D1) lymph priate margin or by intraoperative endoscopic guidance. For adeno- nodes. Surgeons in other countries, particularly Japan, have tended to carcinomas, a margin of at least 5 cm is recommended. prefer a much more radical lymph node dissection that includes the A 5 cm margin may be particularly difficult to achieve when the second-order (D2) nodes [see Figure 10]. Whereas Japanese surgeons tumor is located along the lesser curvature. In many such cases, have reported better overall long-term stage-for-stage survival with although the tumor appears to be distal and possibly amenable to a D2 lymph node dissections, Western surgeons have not found this subtotal gastrectomy, a 5 cm negative margin along the lesser curva- approach to be quite so beneficial. Consequently, it has not been clear ture would place the proximal resection margin far above the incisura whether more extensive lymph node dissection actually provides a angularis and near the esophagogastric junction, thus necessitating survival benefit or simply improves surgical staging.To date, four ran- total or near-total gastrectomy. For lesser-curvature tumors whose domized, controlled trials have failed to show any significant benefit location allows adequate margins to be obtained, distal gastrectomy from extended lymph node dissection. In the largest such study, per- with Billroth II gastrojejunostomy is preferred; for more proximal formed by the Dutch Gastric Cancer Group, more than 700 patients tumors, total gastrectomy with esophagojejunostomy may be were randomly assigned to undergo either D1 or D2 lymphadenecto- required. my.17 The 5-year survival rate was essentially the same in the two Special consideration must be given to tumors of the esophagogas- groups; perioperative morbidity and mortality were significantly high- tric junction. In the classification scheme described by Siewert and er after D2 lymphadenectomy. colleagues,13 such tumors are defined as lying within 5 cm of the A subsequent study from the same group found that at 10 years anatomic esophagogastric junction in either direction along the cran- after operation, D2 lymphadenectomy provided a benefit (in terms of iocaudal axis of the esophagus and the stomach. They are classified lower local recurrence) only in the subgroup with positive second- into three types as follows: order nodes; however, these patients could not be identified preoper- atively.18 For the cohort as a whole, extended lymph node dissection 1. Type I: the center of the tumor lies 1 to 5 cm proximal to the generated no long-term survival benefit. Therefore, although some esophagogastric junction. surgeons extend the lymphadenectomy to include lymph nodes along 2. Type II: the center of the tumor lies within 1 cm of the esopha- the left gastric, celiac, and common hepatic arteries (a so-called D1+ gogastric junction proximally or within 2 cm distally. dissection), the standard of care for surgeons in the United States con- 3. Type III: the center of the tumor lies 2 to 5 cm distal to the esoph- tinues to be a D1 lymphadenectomy that includes all perigastric agogastric junction. lymph nodes and the greater omentum.
  10. 10. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 10 TOTAL GASTRECTOMY the relatively avascular plane. Gentle upward traction is placed on the omentum to facilitate entry into the correct surgical plane [see Figure Operative Technique 11]. If the procedure involves a formal D2 lymph node dissection, this Step 1: incision and exposure The abdomen is entered via a is also a convenient time to enter the anterior leaf of the transverse midline or bilateral subcostal incision. If a subcostal incision is utilized, mesocolon, which is resected with the anterior covering of the pan- it may have to be extended past the xiphoid process in the midline for creas. (As noted, most U.S. surgeons perform a D1 resection or some optimal exposure.Thorough exposure of the peritoneal cavity (includ- modification thereof and thus do not dissect the anterior peritoneal ing the liver, all peritoneal surfaces, and, in women, the ovaries) is surface of the mesocolon and pancreas.) undertaken to search for signs of metastatic disease. If the patient has With the dissection starting on the right side, the right gastroepi- a proximal lesion near the gastric cardia, there may be a need for a tho- ploic artery is identified and ligated where it originates from the gas- racotomy if the distal thoracic esophagus is to be included in the resec- troduodenal artery.The short gastric vessels are divided as the dissec- tion specimen. If an incision into the thoracic cavity is being consid- tion proceeds along the greater curvature.The lesser omentum is also ered, the left chest should be surgically prepared at the time of initial divided near the liver and is included with the specimen; care should draping to allow extension of the incision across the lower left costal be taken to identify an aberrant left hepatic artery in the lesser omen- margin if desired. In this setting, if thoracotomy is possible, preopera- tum (if present). The dissection is continued onto the peritoneal sur- tive placement of a double-lumen endotracheal tube should be con- face of the distal esophagus. sidered.The abdominal portion of a thoracoabdominal incision should be performed first to allow assessment of resectability. Step 3: division of duodenum The duodenum is divided just distal to the pyloric ring either with a GIA stapler or with a TA stapler Step 2: dissection of omentum from colon The omentum is applied twice [see Figure 12]. The right gastric artery is identified and separated from the colon with an electrocautery or scissors through ligated near its base. Division of the duodenum allows elevation and a 4s 2 1 5 3 4s 6 4d 7 b 10 12 8 11 Figure 10 Illustrated are the differences between a 9 11 D1 lymphadenectomy and a D2 lymphadenectomy for gastric cancer. (a) A D1 lymphadenectomy is accomplished by removing the perigastric lymph nodes with the resection specimen; these nodes include those along the right and left cardia (1, 2), 14 those along the lesser curvature (3), those along the greater curvature (4), the suprapyloric nodes (5), and the infrapyloric nodes (6). (b) A D2 lym- 14 13 phadenectomy involves a more radical resection specimen, which includes nodes along the left gas- tric artery (7), the common hepatic artery (8), the celiac artery (9), the splenic hilum (10), the splenic 16 artery (11), the hepatoduodenal ligament (12), the 15 posterior pancreas (13), the root of the mesentery (14), the transverse mesocolon (15), and the aorta (16).
  11. 11. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 11 Figure 11 Total gastrectomy. The omentum is dissect- ed from the transverse colon with scissors or the elec- trocautery. In the course of this dissection, the right gastroepiploic artery is encountered near the pylorus and divided near its base at the gastroduodenal artery. The dissection continues along the greater curvature, including ligation of the short gastric vessels. In a for- mal D2 lymphadenectomy, the anterior leaf of the transverse mesocolon and the anterior capsule of the pancreas are dissected. In a D1 lymphadenectomy, these structures are left alone. rotation of the stomach, thereby facilitating access to the left gastric ischemic, the staple line may be inverted with Lembert sutures of artery and the surrounding node-bearing tissue. 3-0 silk. With the stomach gently retracted upward and anteriorly, dissection identifies the celiac axis and the left gastric artery [see Figure 13a].The Step 4: inclusion of necessary lymph nodes The degree of dis- origin of the left gastric artery is ligated and divided, and a suture lig- section to be performed in the porta hepatis depends on the extent of ature is placed on the proximal end. the planned lymphadenectomy. A D1 lymphadenectomy does not A standard D1 lymphadenectomy does not include splenectomy require any of the lymph nodes in this area, but a D1+ lymphadenec- and distal pancreatectomy.The spleen and pancreas are left in situ and tomy includes lymph nodes along the common hepatic artery. Gentle are separated from the resection specimen by dividing and ligating the left lateral traction is placed on the stomach before division of the left short gastric vessels (see above). gastric artery to apply some tension to the hepatic artery. The dissec- tion proceeds along the celiac and hepatic arteries to the porta hepatis. Troubleshooting. Leakage from the duodenal stump is a potential- The tissue surrounding the common hepatic artery and the left gastric ly disastrous complication. If the stapled duodenum appears artery is swept medially with the specimen. Figure 12 Total gastrectomy. The duodenum is divided just beyond the pylorus with a GIA or TA stapler. The duodenal staple line may be reinforced with interrupt- ed Lembert sutures. Right Gastroepiploic Artery Divided
  12. 12. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 12 a b c Spleen Pancreas Left Gastric Artery Figure 13 Total gastrectomy. (a) The stomach is retracted cephalad to expose the left gastric vessels, which may be divided and suture-ligated on the proximal side. Division of the distal esophagus should be preceded by placement of several stay sutures on the proximal esophagus to prevent it from retracting into the posterior mediastinum. Reconstruction is then carried out; options include stapled end-to-side esophagojejunostomy, hand-sewn end-to-side esophagojejunostomy, side- to-side esophagojejunostomy, and anastomosis to a jejunal pouch. (b) In a stapled esophagojejunostomy, the anvil is secured in the esophagus with a purse-string suture, an EEA stapler is inserted through the distal end of the Roux limb, and the anastomosis is created to the antimesenteric side of the bowel. Once the anastomosis is complete, the end of the Roux limb is amputated with a single firing of a GIA stapler. (c) A hand-sewn esophagojejunostomy may be fashioned with interrupted full-thickness sutures (as shown), with a continuous full-thickness suture, or as a two-layer anastomosis. After completion of the posterior row, a sump tube may be placed across the anastomosis into the proximal jejunum. After completion of the anterior row, several reinforcing seromuscular sutures may be placed to reduce tension on the anastomosis. Step 5: division of esophagus The peritoneum is divided over the suture of 3-0 or 2-0 polypropylene is placed in the esophagus and used anterior esophagus, and the esophagus is completely dissected free of to secure the anvil of an end-to-end anastomosis (EEA) stapler. The surrounding tissue.The esophagus is then divided either with a TA sta- body of the stapler is placed into the Roux limb, with the tip protrud- pler or with a scalpel after the placement of a noncrushing bowel clamp. ing through the end, and the esophagojejunostomy is created on the To keep the stump from retracting too far proximally, stay sutures of 2- antimesenteric border of the jejunum [see Figure 13b]. The open end 0 silk should be placed in the proximal esophagus before division. of the Roux limb is then closed with a TA stapler. To reduce tension Alternatively, the specimen may be left attached and used as a handle on the anastomosis, the staple line may be reinforced with interrupted to retract the proximal esophagus inferiorly. The esophagus may then Lembert sutures of 3-0 silk. be divided after placement of the posterior suture line. Evaluation of the A hand-sewn end-to-side esophagojejunostomy is created in a sim- proximal resection margin with frozen-section analysis is advisable. ilar fashion at a point near the end of the Roux limb on the antimes- enteric border. The posterior row is placed first, with interrupted 3-0 Troubleshooting. The proximal margin may be found to harbor silk sutures as the outer layer and interrupted full-thickness 3-0 malignancy; if so, re-resection of the proximal margin should be per- absorbable sutures as the inner layer [see Figure 13c].The knots are tied formed. Placement of stay sutures in the proximal esophagus is impor- on the inside of the bowel. The anterior row is then placed, with an tant; if this is not done, the retracting esophagus may migrate into the inner layer of interrupted full-thickness 3-0 absorbable sutures and an posterior mediastinum. outer layer of interrupted 3-0 silk sutures. Some surgeons prefer a sin- gle-layer anastomosis, either with a continuous suture or with inter- Step 6: reconstruction via esophagojejunostomy The options rupted full-thickness sutures. The available data do not favor either for reconstruction after gastrectomy include stapled end-to-side single-layer or two-layer anastomosis in this setting. esophagojejunostomy, hand-sewn end-to-side esophagojejunostomy, Side-to-side esophagojejunostomy requires a substantial length of side-to-side esophagojejunostomy, and anastomosis to a jejunal pouch. intra-abdominal esophagus and necessitates extensive mobilization of A Roux-en-Y jejunal limb is fashioned; to prevent biliary reflux, it the distal esophagus.The jejunum may be sutured to the underside of should be at least 40 to 50 cm long.The Roux limb is then brought up the diaphragm to relieve tension on the anastomosis. behind the colon to the esophagus. Some authors recommend Some authors report improved postoperative quality of life with a antecolic placement of the Roux limb to prevent obstruction in the set- jejunal pouch reconstruction. For most patients with gastric cancer, ting of recurrent disease; however, retrocolic placement may facilitate however, pouch reconstruction offers no distinct advantage. a more tension-free anastomosis. Drains are not routinely placed; drain placement may increase the For a stapled end-to-side esophagojejunostomy, a purse-string rate of leakage from the esophagojejunostomy.
  13. 13. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 13 Troubleshooting. Without a sufficient length of intra-abdominal but without division of the short gastric vessels.The omentum is sep- esophagus, primary reconstruction can be difficult. Full mobilization arated from the transverse colon with the electrocautery, and the of the intra-abdominal esophagus is essential. Because the esophagus entire omentum is taken with the specimen. A 5 cm proximal margin lacks a serosa, transversely oriented Cushing-type sutures may be is ideal. Commonly, the stomach is divided at a point inferior to the preferable to Lembert sutures on the anterior and posterior outer short gastric vessels and proximal to the incisura angularis. layer of a hand-sewn anastomosis. Additional operative details and comments on postgastrectomy complications are available elsewhere [see Procedures for Benign Step 7 (optional): feeding enterostomy Many patients with Gastric and Duodenal Disease, Antrectomy, above]. gastric adenocarcinoma become significantly malnourished after gas- LAPAROSCOPIC STAGING FOR GASTRIC CANCER trectomy.The loss of the gastric pouch may adversely affect their abil- ity to fulfill their caloric requirements in the early postoperative peri- The goal of laparoscopic staging before attempted curative resec- od.To prevent further malnutrition, some authors recommend creat- tion of gastric carcinoma is to detect occult metastatic disease, the ing a feeding jejunostomy at the time of total gastrectomy with presence of which may affect management. For example, if lapa- esophagojejunostomy.The jejunostomy should be placed downstream roscopy reveals peritoneal studding in a patient who does not have from the jejunojejunostomy (i.e., more than 50 cm distal to the anas- symptoms such as bleeding or obstruction, a decision may be made tomosis).When a feeding enteroenterostomy is indicated, we prefer a to forgo attempts at resection. In the setting of T2 or T4 tumors, Witzel jejunostomy. laparoscopic staging has been shown to detect occult metastases in 20% to 30% of patients.12 Complications The abdomen is explored with a 30º laparoscope inserted via an D2 lymphadenectomy has been associated with numerous compli- umbilical port. To facilitate exposure, additional 5 mm ports may be cations, including increased blood loss, longer operating time, colonic placed in the right upper and left upper quadrants. If laparoscopic devascularization, pancreatitis, and pancreatic leakage. Although ultrasonography is available, one of the port sites should be 10 mm to complication rates appear to be acceptably low when the procedure is allow passage of the ultrasound probe. Any suspicious lesion encoun- done by an experienced surgeon, there is still the potential for the ben- tered is sampled and sent for frozen-section analysis. efits of extensive lymphadenectomy to be outweighed by the addi- LAPAROSCOPIC RESECTION OF MALIGNANT GASTRIC TUMORS tional complications. Anastomotic leakage at an esophagojejunostomy may lead to post- Laparoscopic gastrectomy is being performed with increasing fre- operative infection. Intra-abdominal leaks may be managed by drain- quency. The principles of laparoscopic gastric resection are similar to age via percutaneous drains or laparotomy, as well as by proximal naso- those of the corresponding open procedure, though extensive lymph gastric drainage. High anastomotic leaks may result in contamination node dissections may be considerably more difficult with the mini- of the posterior mediastinum or the pleural space, and thoracotomy or mally invasive approach. Currently, there are only a few centers where tube thoracostomy may be necessary to achieve external drainage. laparoscopic resection of advanced gastric carcinoma is being per- Occasionally, bleeding may be substantial enough to necessitate reop- formed with any frequency. Accordingly, it seems appropriate, for the eration. In this situation, the gastric remnant may be entered via a trans- time being, to reserve laparoscopic gastrectomy for patients who have verse incision just proximal to the anastomosis. As a rule, the bleeding very early cancers and those who are candidates only for palliative can be successfully controlled by placing simple figure-eight sutures. resection. Laparoscopic wedge resection may be appropriate for small lesions DISTAL OR SUBTOTAL GASTRECTOMY that are potentially benign or for malignant lesions for which exten- Cancers of the distal stomach or antrum may be addressed by sive surgical margins are not required (e.g., GISTs [see Figure 14]). means of a distal gastrectomy. Particular attention should be paid to The lesion is visualized intraoperatively by means of endoscopy or tumors on the lesser curvature, where obtaining an adequate proximal marked preoperatively with India ink. Laparoscopic sutures are margin may be a problem [see Operative Planning, Extent of placed in the tissue surrounding the lesion, then retracted upward so Resection, above]. The dissection proceeds as in a total gastrectomy, that the portion of the gastric wall containing the lesion is elevated. A Figure 14 Laparoscopic resection of GIST. The tumor is visualized preopera- tively and marked with India ink; alterna- tively, the tumor may be identified intraop- eratively by means of endoscopy and its location marked with a suture. Traction sutures may be employed to “tent up” the lesion, thereby isolating it from the remainder of the stomach. The tumor is then resected with several firings of an endoscopic linear stapler. For lesions high- er along the greater curvature near the car- dia, wedge resection should be performed with an esophageal bougie in place to pre- vent inadvertent narrowing of the esopha- gogastric junction.
  14. 14. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 14 a b Superior Mesenteric Artery and Vein Duodenum Incision in Paracolic Peritoneum Area of Mesentery to be Elevated Pancreas Figure 15 Local resection of duodenal tumors. Mobilization of the right colon and upward retraction of the small bowel mesentery allows direct access to the third and fourth portions of the duodenum. Sleeve resection of the duo- denum with subsequent duodenojejunostomy can then be performed. (a) Avascular peritoneal attachments of the right colon are divided, as well as avascular attachments underneath the small bowel mesentery. Dotted lines enclose the area of mesentery to be elevated from posterior attachments. (b) Cephalad retraction of the right colon, the small bowel, and the mesenteric vessels allows exposure of the third and fourth portions of the duodenum. wedge resection is then performed with an endoscopic stapler. denectomy may be required. Exposure may be achieved through an Intraoperative assessment of the surgical margin by a pathologist is upper midline or right upper quadrant incision. useful to ensure that the margin is negative. Operative Technique The duodenum is mobilized with an extensive Kocher maneuver. Procedures for Duodenal Cancer The tumor is palpated and approached via a longitudinal duodenoto- my.The tumor is grasped and everted, and a full-thickness portion of LOCAL RESECTION OF DUODENAL TUMORS the duodenal wall is resected with the mass. Stay sutures are placed at Small duodenal tumors (e.g., polyps, villous adenomas, small the ends of the duodenotomy, and the duodenotomy is closed trans- GISTs, and neuroendocrine tumors) are occasionally amenable to versely, either with a TA stapler or with sutures. If a transverse closure local surgical resection. The diagnosis must be confirmed by endo- would place too much tension on the suture line, a longitudinal clo- scopic biopsy before resection. Endoscopy is also useful for localiza- sure is undertaken. If possible, omentum is placed over the duodenal tion of the lesion with respect to the ampulla and pancreatic head. closure. Lateral lesions are removed by local resection far more easily than lesions on the medial wall are. Troubleshooting Intraoperative endoscopy may be required to locate small duodenal Operative Planning lesions that cannot be palpated. During dissection, the location of the Endoscopic confirmation of the diagnosis and localization of the ampulla can be determined by passing a Fogarty catheter into the cys- lesion are crucial for operative planning. In addition, appropriate tic duct, down the CBD, and through the ampulla. This measure patient selection is essential. Local resection may be inappropriate for requires that a cholecystectomy be done. lesions close to the ampulla of Vater, for large duodenal lesions, for RESECTION OF DISTAL DUODENAL TUMORS carcinomas, or for lesions on the medial aspect of the duodenum abutting the pancreas. For lesions in the second or third portion of the Lesions of the distal duodenum (e.g., GISTs, carcinoids, and, rarely, duodenum that are not amenable to local excision, pancreaticoduo- adenocarcinomas) are occasionally amenable to sleeve resection. Preop-
  15. 15. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 15 erative CT and endoscopy are essential to the workup of such lesions. Step 2: resection and anastomosis The duodenum is divided Endoscopic biopsy should be performed if it is technically feasible. with the stapler approximately 1 cm proximal to the tumor. If pancre- atic invasion is identified, pancreaticoduodenectomy should be con- Operative Technique sidered.The distal bowel is brought through the transverse mesocolon, Step 1: exposure of duodenum Operative access to the distal and a side-to-side duodenojejunostomy is created with an outer layer duodenum is limited by the presence of the superior mesenteric ves- of 3-0 silk and inner layer of 3-0 polyglactin. Alternatively, the anasto- sels and the transverse mesocolon. The third and fourth portions of mosis may be performed to the second portion of the duodenum. the duodenum may be approached either by moving the duodenum under the mesenteric vessels or by temporarily mobilizing the mesen- Troubleshooting teric vessels. In the first approach, the distal duodenum and the prox- The blood supply to the third portion of the duodenum arises from imal jejunum are mobilized upward by dissecting the ligament of numerous branches of the inferior pancreaticoduodenal arcade, each Treitz away from its mesenteric attachments. The proximal jejunum of which must be meticulously dissected, divided, and ligated to pre- is divided with a stapler. After extensive mobilization, the duodenum vent pancreatic trauma. The distal duodenum receives its blood sup- is passed under the superior mesenteric vein and artery and moved to ply from branches of the superior mesenteric artery. the right side of the abdomen. The duodenum should not be simply closed distally and drained In the second approach, the superior mesenteric vessels are mobi- via a gastrojejunostomy; if this is done, the proximal duodenum will lized upward to expose the third portion of the duodenum. The right not be properly decompressed. colon is mobilized cephalad by incising the peritoneum along the white line of Toldt from the hepatic flexure to the cecum [see Figure 15a]. Di- Complications vision of the peritoneum is then continued along the cecum and medi- Delayed gastric emptying is common with duodenojejunosto- ally to liberate the terminal ileum.The avascular attachments between my; it generally responds to prolonged conservative therapy. A the small bowel mesentery and the retroperitoneum are divided by delay in the return of bowel function should generally be treated means of cauterization and gentle blunt dissection [see Figure 15b]. with nasogastric suction; on occasion, a percutaneous gastrostomy a b c c Figure 16 Ampullectomy. (a) After a longitudinal duodenotomy is made, the CBD is cannulated. Circumferential stay sutures of 4-0 polydioxanone are placed in the duodenal mucosa. A 2 cm periampullary tumor is visualized. (b) The ampullary tumor is removed from the underlying duodenum with the electrocautery. The CBD and the pancreatic duct are entered and separately cannulated. The CBD duct is typically seen at the 11 o’clock position, and the pancreatic duct is typically encountered at the 3 o’clock position. (c) The duodenal mucosa is sutured directly to the CBD and the pancreatic duct with 4-0 polydioxanone. In addition, the CBD and pancreatic duct are carefully connected with 4-0 polydioxanone sutures.
  16. 16. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 16 is required for proximal decompression. Postoperative pancreatitis the distal pancreatic duct [see Figure 16]. A Kocher maneuver is per- may occur secondary to operative trauma; conservative manage- formed, and a longitudinal duodenotomy is made to expose the ment is usually sufficient. ampulla. Identification of the ampulla may be facilitated by placing a Fogarty catheter in the CBD via the cystic duct after a cholecystecto- AMPULLECTOMY my. If the ampulla is identified during exploration, it may simply be Local periampullary resection is indicated primarily for rare benign cannulated. Circumferential stay sutures are placed in the mucosa. lesions, small neuroendocrine tumors of the pancreas, and small ade- The CBD is entered at approximately the 11 o’clock position, and nomatous or villous polyps.The likelihood of occult malignancy in an duodenal mucosa is reattached to the duct with 4-0 polydioxanone adenomatous periampullary tumor is significantly higher when the sutures. The pancreatic duct is encountered at approximately the 3 lesion is larger than 2 cm; caution is therefore indicated in attempting o’clock position; it may be cannulated separately to facilitate identifi- local resection of lesions of this size. The recurrence rate is high after cation.The pancreatic duct is approximated to the CBD, and the infe- local resection of any periampullary adenocarcinoma. The preopera- rior pancreatic duct is sewn to the duodenal wall. The duodenum is tive workup should include endoscopy with biopsy, EUS or transab- closed transversely in two layers. dominal ultrasonography, CT scanning, and endoscopic retrograde cholangiopancreatography (ERCP). Troubleshooting Frozen-section analysis may identify invasive adenocarcinoma, Operative Technique which is an indication for pancreaticoduodenectomy. This possibility The ampulla of Vater is resected together with the distal CBD and should be carefully considered before the operation. References 1. Schwesinger WH, Page CP, Sirineck KR, et al: ment of duodenal ulcer. Br J Surg 57:289, 1970 esophagus after resection for carcinoma. Ann Surg Operations for peptic ulcer disease: paradigm lost. 8. Adami HO, Enander L-K, et al: Recurrence 1 to 203:173, 1986 J Gastrointest Surg 5:1038, 2001 10 years after highly selective vagotomy in prepy- 16. Karpeh MS, Leon L, Klimstra D, et al: Lymph 2. Smith BR, Stablie BE: Emerging trends in peptic loric and duodenal ulcer disease. Ann Surg node staging in gastric cancer: is location more ulcer disease and damage control surgery in the H. 199:393, 1984 important than number? An analysis of 1,038 pylori era. Am Surg 71:797, 2005 9. Taylor TV, Bunn AA, MacLeod DAD, et al: patients. Ann Surg 232:362, 2000 3. Ng EK, Lam YH, Sung JJ, et al: Eradication of Anterior lesser curve seromyotomy and posterior 17. Bonekamp JJ, Hermans J, Sasako M, et al; for the Helicobacter pylori prevents recurrence of ulcer truncal vagotomy in the treatment of chronic duo- Dutch Gastric Cancer Study Group: Extended after simple closure of duodenal ulcer perforation: denal ulcer. Lancet 2:846, 1982 lymph-node dissection for gastric cancer. N Engl J randomized controlled trial. Ann Surg 231:153, Med 340:908, 1999 10. Lau H: Laparoscopic repair of perforated peptic 2000 18. Hartgrink HH, van der Velde CJH, Putter H, et al: ulcer. Surg Endosc 18:1013, 2004 4. Tu BN, Sarr MG, Kelly KA: Early clinical results Extended lymph node dissection for gastric can- 11. Iida F: Transduodenal diverticulectomy for peri- with the uncut Roux reconstruction after gastrec- cer: who may benefit? Final results of the random- ampullary diverticula. World J Surg 3:103, 1979 tomy; limitations of the stapling technique. Am J ized Dutch Gastric Cancer Group trial. J Clin Surg 170:262, 1995 12. Burke EC, Karpeh MS, Brennan MF: Oncol 22:1, 2004 Laparoscopy in the management of gastric adeno- 5. Eagon JC, Miedema BW, Kelly KA: Postgastrec- carcinoma. Ann Surg 225:262, 1997 tomy syndromes. Surg Clin North Am 72:445, 1992 13. Siewert JR, Stein HJ: Classification of adenocarci- 6. Amdrup E, Jensen HE: Selective vagotomy of the noma of the oesophagogastric junction. Br J Surg Acknowledgments parietal cell mass preserving innervation of the 85:1457, 1998 undrained antrum. Gastroenterology 59:522, 14. Ito H, Clancy TE, Osteen RT, et al: Adenocarcino- Figures 1 through 15 Tom Moore. 1970 ma of the gastric cardia: what is the optimal surgi- Figure 16 Courtesy of Dr. John Windsor and Dr. 7. Johnston D, Wilkinson AR: Highly selective vago- cal approach? J Am Coll Surg 199:880, 2004 Yatin Young, Auckland Hospital, Auckland, New tomy without a drainage procedure in the treat- 15. Siu KF, Cheung HC, Wong J: Shrinkage of the Zealand.