Reconstruccion post gastrectomia distal

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PRESENTACION EN LA REUNION DE LOS RESIDENTES DE CIRUGIA DEL HNERM LIMA PERU

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Reconstruccion post gastrectomia distal

  1. 1. HOSPITAL EDGARDOREBAGLIATI MARTINSEsSALUDDEPARTAMENTODE CIRUGIA GENERAL Y DIGESTIVADR. IVAN VOJVODICJEFE DEL DEPARTAMENTORECONSTRUCCION POST GASTRETOMIA<br />MR3 ROBLES VALVERDE, WALTER<br />
  2. 2. INTRODUCCIÓN:<br />Selección de un método para anastomosis después de una gastrectomía distal es un tópico en discusión.<br />3 tipos principales de anastomosis:<br />Billroth I<br />Billroth II<br />Y de Roux.<br />Diferentes variables a tener en cuenta… calidad de vida (complicaciones post operatorias… reflujo), sobrevida, etc.<br />
  3. 3. INTRODUCCIÓN:<br />Billroth I<br />Billroth II<br />
  4. 4. INTRODUCCIÓN:<br />Y de Roux<br />
  5. 5. RECONSTRUCCIÓN EN Y DE ROUX:<br />En Japón, uso de Billroth I-II... Otras (pouch)…<br />Incremento en el uso de Y de Roux:<br /> de reflujo gastroduodenal.<br />Uso en cirugía laparoscópica.<br />The Advantages and Disadvantages of a Roux-en-Y Reconstruction After a Distal Gastrectomy for Gastric Cancer. YOSHIYUKI HOYA. Surg Today (2009) 39:647–651<br />
  6. 6. RECONSTRUCCIÓN EN Y DE ROUX:<br /><ul><li>INDICACIONES:
  7. 7. Cuando la lesiónprimaria ha invadidoduodeno o cabeza de páncreas, el uso de BI resultará en recurrencia local de la anastomosis.
  8. 8. Si al intentarrealizaruna BI existetensión en la anastomosis.</li></ul>The Advantages and Disadvantages of a Roux-en-Y Reconstruction After a Distal Gastrectomy for Gastric Cancer. YOSHIYUKI HOYA. Surg Today (2009) 39:647–651<br />
  9. 9. RECONSTRUCCIÓN EN Y DE ROUX:<br /><ul><li>VENTAJAS:
  10. 10. Prevención de reflujoesofágico.
  11. 11. Prevención de gastritis y cáncergástrico en estómagoremanente.
  12. 12. Reducción del riesgo de ruptura de sutura.</li></ul>The Advantages and Disadvantages of a Roux-en-Y Reconstruction After a Distal Gastrectomy for Gastric Cancer. YOSHIYUKI HOYA. Surg Today (2009) 39:647–651<br />
  13. 13. RECONSTRUCCIÓN EN Y DE ROUX: PREVENCIÓN DE REFLUJO ESOFÁGICO<br /><ul><li>Tipos de REFLUJO ESOFÁGICO:
  14. 14. Alcalino (reflujopancreático y biliar)
  15. 15. Ácido
  16. 16. Mixto
  17. 17. ESTRUCTURAS PROTECTORAS:
  18. 18. EEI.
  19. 19. Omentomenor.
  20. 20. Pilarderechodiafragmático.
  21. 21. Ligamentofreno-esofágico
  22. 22. Ángulo de His
  23. 23. Esófagointraabdominal.
  24. 24. Mucosa de unióngastroesofágica</li></ul>(Según la longitud de asa de la Y de Roux)<br />DISMINUCIÓN DE REFLUJO DUODENAL AL ESTÓMAGO<br />(Qx, sección del nervio vago)<br />DISMINUCIÓN DE REFLUJO ESOFÁGICO<br />The Advantages and Disadvantages of a Roux-en-Y Reconstruction After a Distal Gastrectomy for Gastric Cancer. YOSHIYUKI HOYA. Surg Today (2009) 39:647–651<br />
  25. 25. RECONSTRUCCIÓN EN Y DE ROUX: PREVENCIÓN DE GASTRITIS Y CÁNCER GÁSTRICO<br />Reducción de la actividad del ácido gástrico<br />Proliferación bacteriana<br />Reflujo gastroduodenal<br />Altos niveles de gastrina sérica<br />Técnica anastomosis Riesgo de cáncer gástrico<br /><ul><li>Billroth II 70%
  26. 26. Billroth II + Braun 23%
  27. 27. Billroth I 10%
  28. 28. Y de Roux. 0%</li></ul>Langhans. The cancer risk in the stomach subjected to nonresecting procedures. An experimental long-term study. Scand J Gastroenterol Suppl 1984;92:138–41.<br />The Advantages and Disadvantages of a Roux-en-Y Reconstruction After a Distal Gastrectomy for Gastric Cancer. YOSHIYUKI HOYA. Surg Today (2009) 39:647–651<br />
  29. 29. RECONSTRUCCIÓN EN Y DE ROUX:<br /><ul><li>DESVENTAJAS:
  30. 30. Úlceraestomal:
  31. 31. < reflujoalcalino, > vulnerabilidad al ácido.
  32. 32. Cierta de secresiónácida en gastrectomía distal:
  33. 33. Disección del grupo 1 necesitasección de nerviovago anterior.
  34. 34. Resección de fondogástrico.
  35. 35. En Japón: 66%UD, 19%UG, 15%UGD
  36. 36. Riesgo de colelitiasis(10-20% en 1ros 3 años… sección de ramahepática del vago, CCK).
  37. 37. Roux stasis syndrome.</li></ul>The Advantages and Disadvantages of a Roux-en-Y Reconstruction After a Distal Gastrectomy for Gastric Cancer. YOSHIYUKI HOYA. Surg Today (2009) 39:647–651<br />
  38. 38. RECONSTRUCCIÓN EN Y DE ROUX: ROUX STASIS SYNDROME<br />30% de pacientes.<br />Síntomas de retención gástrica:<br />Dolor abdominal, nauseas, vómitos, distensión abdominal<br />Fisiopatología:<br />Desconexión con el marcapasos intestinal (duodeno proximal), lo que condiciona aparición de marcapasos ectópicos… peristalsis retrógrada.<br />Manejo médico: procinéticos… no eficacia demostrada a largo plazo.<br />Manejo quirúrgico: “uncut R-Y”<br />Síntomas son mayores cuando asa de Y de Roux > 40cm.<br />The Advantages and Disadvantages of a Roux-en-Y Reconstruction After a Distal Gastrectomy for Gastric Cancer. Yoshiyuki Hoya. Surg Today(2009)39:647–651<br />Uyama I, et al. Laparoscopy-assisted uncut Roux-en-Y operation after distal gastrectomy for gastric cancer. Gastric Cancer 2005;8:253–7.<br />
  39. 39. RECONSTRUCCIÓN EN Y DE ROUX: ROUX STASIS SYNDROME – Uncut Roux -en-Y<br />Uyama I, et al. Laparoscopy-assisted uncut Roux-en-Y operation after distal gastrectomy for gastric cancer. Gastric Cancer 2005;8:253–7.<br />
  40. 40. RECONSTRUCCIÓN EN Y DE ROUX:<br />En Japón, a diferencia del resto del mundo, Billroth I es la 1ra elección después de una gastrectomía distal:<br />Baja incidencia de fuga anastomótica.<br />Menor duración de cirugía… en comparación a R-Y.<br />The Advantages and Disadvantages of a Roux-en-Y Reconstruction After a Distal Gastrectomy for Gastric Cancer. YOSHIYUKI HOYA. Surg Today (2009) 39:647–651<br />
  41. 41. BILLROTH I o BILLROTH II para Gastrectomía Distal??? <br />Gastric cancer surgery: Billroth I or Billroth II for distal gastrectomy? Birendra K Sah, BMC Cancer 2009, 9:428<br />
  42. 42. BILLROTH I o BILLROTH II para Gastrectomía Distal???<br />Gastric cancer surgery: Billroth I or Billroth II for distal gastrectomy? Birendra K Sah, BMC Cancer 2009, 9:428<br />
  43. 43. BILLROTH I o BILLROTH II para Gastrectomía distal??? <br />Gastric cancer surgery: Billroth I or Billroth II for distal gastrectomy? Birendra K Sah, BMC Cancer 2009, 9:428<br />
  44. 44. BILLROTH I o BILLROTH II para Gastrectomía distal??? <br />Gastric cancer surgery: Billroth I or Billroth II for distal gastrectomy? Birendra K Sah, BMC Cancer 2009, 9:428<br />
  45. 45. Y de Roux y BILLROTH I para Gastrectomía Distal<br />Prospective Randomized Trial Comparing Billroth I and Roux-en-Y Procedures after Distal Gastrectomy for Gastric Carcinoma. Makoto Ishikawa et al. World J Surg (2005) 29: 1415–1420<br />
  46. 46. Y de Roux y BILLROTH I para Gastrectomía Distal<br />Prospective Randomized Trial Comparing Billroth I and Roux-en-Y Procedures after Distal Gastrectomy for Gastric Carcinoma. Makoto Ishikawa et al. World J Surg (2005) 29: 1415–1420<br />
  47. 47. Y de Roux y BILLROTH I para Gastrectomía Distal<br />5 de 24 pacts (21%) gastric stasis<br />Prospective Randomized Trial Comparing Billroth I and Roux-en-Y Procedures after Distal Gastrectomy for Gastric Carcinoma. Makoto Ishikawa et al. World J Surg (2005) 29: 1415–1420<br />
  48. 48. Billroth I vs Y de Roux: calidad de vida<br /><ul><li>Abstract
  49. 49. BACKGROUND: In the majority of gastric surgical units across Japan, Billroth 1 is the preferred method of anastomosis following subtotal distal gastrectomy for gastric cancer. However, across Europe and North America, reconstruction using a Roux-en-Y anastomosis is more common. There is a lack of comparative studies of the two methods focusing on long-term outcome. This study evaluated patient outcome, in terms of adverse gastrointestinal complaints and quality of life, at 5 years following surgery.
  50. 50. METHODS: A total of 652 patients had a subtotal distal gastrectomy for early gastric cancer between January 1993 and December 1999. We studied 229 patients with reconstruction by the Billroth 1 procedure and 214 patients with the Roux-en-Y procedure. All patients had an abdominal ultrasound and endoscopy as part of their follow-up. Quality of life was assessed by questionnaire.
  51. 51. RESULTS: We had an 87% response rate from the questionnaire assessment. The results demonstrated that patients were less likely to experience symptoms of either early or late dumping after Roux-en-Y anastomosis than after Billroth 1. In addition, there were significantly fewer patients with gastritis on endoscopy in the Roux-en-Y group. There was no significant difference in the average relative body weight between the groups. However, patients were more likely to develop gallstones after a Roux-en-Y than after a Billroth 1 reconstruction.
  52. 52. CONCLUSION: The results from this study show that, at 5 years, both symptomatically and functionally, Roux-en-Y reconstruction was superior to the Billroth I method after subtotal distal gastrectomy for gastric cancer. However, the overall outcome in both groups was good, with patient satisfaction scores of around 75% in each group.</li></ul>Billroth 1 versus Roux-en-Y reconstructions: a quality-of-life survey at 5 years.<br />Nunobe S, Okaro A, Sasako M, Saka M, Fukugawa T, Sano T.<br />Int J Clin Oncol. 2007 Dec;12(6):433-9.<br />
  53. 53. Sutura automática vs Anastomosis a mano en reconstrucciones tipo Billroth I para gastrectomía distal<br />Mechanical-Stapled Versus Hand-Sutured Anastomoses in Billroth-I<br />Reconstruction with Distal Gastrectomy. Tsunehiro Takahashi et al. Surg Today (2007) 37:122–126<br />
  54. 54. Sutura automática vs Anastomosis a mano en reconstrucciones tipo Billroth I para gastrectomíadistal<br />Mechanical-Stapled Versus Hand-Sutured Anastomoses in Billroth-I Reconstruction with Distal Gastrectomy. Tsunehiro Takahashi et al. Surg Today (2007) 37:122–126<br />
  55. 55. GASTRECTOMÍA DISTAL LAPAROSCÓPICA VS ABIERTA PARA CÁNCER GÁSTRICO<br />Abstract:<br />OBJECTIVES: The aim was to conduct a meta-analysis of the randomized evidence to determine the relative merits of laparoscopic assisted (LADG) and open (ODG) distal gastrectomy for proven gastric cancer.<br />DATA SOURCES AND REVIEW METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents, and PubMed databases identified all randomized clinical trials (RCTs) that compared LADG and OGD and were published in the English language between January 1990 and the end of June 2007. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement. The eight outcome variables analysed were operating time, blood loss, retrieval of lymph nodes, oral intake, hospital stay, postoperative complications, tumor recurrence, and mortality. Random effects meta-analyses were performed using odds ratios (OR) and weighted mean differences (WMD).<br />Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma. Memon MA. Et al. Surg. Endoscp. 2008 Aug;22(8):1781-9.<br />
  56. 56. GASTRECTOMÍA DISTAL LAPAROSCÓPICA VS ABIERTA PARA CÁNCER GÁSTRICO<br />RESULTS: Four trials were considered suitable for meta-analysis. A total of 82 patients underwent LADG and 80 had ODG. For only one of the eight outcomes, the summary point estimates favoured LADG over ODG; there was a significant reduction of 104.26 ml in intraoperative blood loss for LADG (WMD, -104.26, 95% confidence interval (CI) -189.01 to -19.51; p = 0.0159). There was however a 83.08 min longer duration of operating time for the LADG group compared with the ODG group (WMD 83.08, 95% CI 40.53 to 125.64; p = 0.0001) and significant reduction in lymph nodes harvesting of 4.34 lymph nodes in the LADG group (WMD -4.3, 95% CI -6.66 to -2.02; p = 0.0002). Other outcome variables such as time to commencement of oral intake (WMD -0.97, 95% CI -2.47 to 0.54; p = 0.2068), duration of hospital stay (WMD -3.32, 95% CI -7.69 to 1.05; p = 0.1365), rate of complications (OR 0.66, 95% CI 0.27 to 1.60; p = 0.3530), mortality rates (OR 0.94, 95% CI 0.21 to 4.19; p = 0.9363), and tumor recurrence (OR 1.08, 95% CI 0.42 to 2.79; p = 0.8806) were not found to be statistically significant for either group. However, for commencement of oral intake, duration of hospital stay, and complication rate, the trend was in favor of LADG. <br />CONCLUSION: LADG was associated with a significantly reduced rate of intraoperative blood loss, at the expense of significantly longer operating time and significantly reduced lymph node retrieval compared to its open counterpart. Mortality and tumor recurrence rates were similar between the two groups. Furthermore, time to commencement of oral intake, postprocedural discharge from hospital, and perioperative complication rate, although not significantly different between the two groups, did suggest a positive trend toward LADG. Based on this meta-analysis, the authors cannot recommend the routine use of LADG over ODG for the treatment of distal gastric cancer. However, significant limitations exist in the interpretation of this data due to the limited number of published randomised control trials, the small sample sizes to date, and the limited duration of follow up. Further large multicentre randomized controlled trials are required to delineate significantly quantifiable differences between the two groups.<br />Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma. Memon MA. Et al. Surg. Endoscp. 2008 Aug;22(8):1781-9.<br />
  57. 57. GASTRECTOMÍA DISTAL LAPAROSCÓPICA VS ABIERTA PARA CÁNCER GÁSTRICO<br />Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma. Memon MA. Et al. Surg. Endoscp. 2008 Aug;22(8):1781-9.<br />
  58. 58. GASTRECTOMÍA DISTAL LAPAROSCÓPICA VS ABIERTA PARA CÁNCER GÁSTRICO<br />Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma. Memon MA. Et al. Surg. Endoscp. 2008 Aug;22(8):1781-9.<br />
  59. 59. GASTRECTOMÍA DISTAL LAPAROSCÓPICA VS ABIERTA PARA CÁNCER GÁSTRICO<br />Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma. Memon MA. Et al. Surg. Endoscp. 2008 Aug;22(8):1781-9.<br />
  60. 60. GASTRECTOMÍA DISTAL LAPAROSCÓPICA VS ABIERTA PARA CÁNCER GÁSTRICO<br />Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma. Memon MA. Et al. Surg. Endoscp. 2008 Aug;22(8):1781-9.<br />
  61. 61. GASTRECTOMÍA DISTAL LAPAROSCÓPICA VS ABIERTA PARA CÁNCER GÁSTRICO<br />Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma. Memon MA. Et al. Surg. Endoscp. 2008 Aug;22(8):1781-9.<br />
  62. 62. gracias<br />

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