2. PERSTECTIVA HISTORICA
• En 1602 Florian Mathies – primera gastrectomía victoriosa por un cuchillo tragado
• En 1793 Mathew Baille – primera descripción acertada para ulcera y cáncer
gástrico
• Siglo 19no , Benjamin Travers reporte de perforación duodenal
• En 1810 Karl Theodor Merrem, - primera pilorectomia victoriosa en un perro
3. PERSPECTIVA
HISTORICA
• Prof. Theodore Billroth
• Primera gastrectomía parcial (Billroth I) en 1882
• Woeffler –
• Primera Gastroyeyunostomia
• Primera anastomosis-en-y para convertirse en la corta venida de
la Gastro-jejunostomia
• Cesar Roux of Lausanne
• popularizo la anastomosis-en-y
• Prof. Theodore Billroth desarrolló el (Billroth II)
• Gastrectomía parcial para un tumor pilórico inresecable
4. CIRUGIA GASTRICA EN EL TRATAMIENTO CANCER
GASTRICO
• EXTENCION DE LINFADENECTOMIA
• D0 – Disección incompleta
• D1 – Grupo 1 (Peri-gastrico) ganglios linfáticos – (Estación 1 to 6)
• D2 – Grupo 1 & II (Estación 7 a 11)
• D3 – Grupo I, II & III (Estación 12 a 14)
• D4 – Grupo I, II, III y nódulos paraaorticos y paracolicos (estación 15 y 16)
5. CIRUGIA GASTRICA EN EL TRATAMIENTO
DEL CANCER
• MARGENES DE RESECCION
• R0 – Resección macro y micro completa
• R1 – Resección macro completa pero márgenes microscópicos positivos
• R2 – Resección macro y micro incompleta
• Márgenes de al menos 3 cm para T2 o profundos con patrón de crecimiento expansivo ( tipo 1 y 2)
• Márgenes de al menos 5 cm para aquellos con patrón de crecimiento infiltrativo ( tipos 3 y 4).
• Cuando no se puede alcanzar esta meta entonces examinar los márgenes proximales por
congelación
6. CIRUGIA GASTRICA EN TRATAMIENTO DEL
CANCER GASTRICO
1. Cirugía curativa
a. Gastrectomía estándar
• Principal procedimiento quirúrgico realizado con intento curativo
• Envuelve resección de al menos 2/3 de estomago con disección de linfáticos D2.
b. Gastrectomía no estándar
• La extensión de la resección gástrica y la linfadenectomia es alterada de acuerdo al
estadio tumoral.
7. CIRUGIA GASTRICA EN EL TRATAMIENTO
DEL CANCER
1. Cirugia curativa
c. Cirugía modificada
• La extensión de la resección gástrica y la linfadenectomia es reducida (D1, D1+, etc.)
comparada a la cirugía estándar
d. Cirugía extendida
• Gastrectomia con resección combinada de órganos envueltos adyacentes y
• Gastrectomía con linfadenectomia extensa excediendo D2
8. CIRUGIA GASTRICA EN EL TRATAMIENTO
DEL CANCER
2. Cirugia no curativa
a. Cirugía paliativa
• Cirugía para aliviar síntomas e.g., obstruccion, sangrado
• Gastrectomía paliativa or gastroyeyunostomia
• Las opciones dependen de la resecabilidad del tumor primario y el riesgo quirurgico
b. Cirugía de reducción
• Ayuda a prolongar supervivencia o a dilatar el establecimiento de síntomas a través de la
reducción del volumen del tumor
9. TYPES AND DEFINITIONS OF GASTRIC
SURGERY
• Types of Gastrectomies based on volume of stomach resected
• Total - All the stomach is removed including the cardia and pylorus
• Near Total - >90% of stomach is resected
• Subtotal – 80 to 90%
• Partial – 65 to 75%
• Hemigastrectomy – 50%
• Distal Gastrectomy – 35 to 50%
10. TYPES AND DEFINITIONS OF GASTRIC
SURGERY
• Total gastrectomy -- Total resection of the stomach.
• Distal gastrectomy – resection of distal 2/3 of the stomach including the pylorus
• Pylorus-preserving gastrectomy (PPG)
• Preserving the upper 1/3 of the stomach and the pylorus along with a portion of
the antrum.
• Proximal gastrectomy - resection includes the cardi whiles preserving the pylorus
11. TYPES AND DEFINITIONS OF GASTRIC
SURGERY
• Anatomical Extent of Gastric Resection
• Segmental gastrectomy –
• Circumferential resection of the stomach preserving the cardia and pylorus.
• Local resection.
• Non-resectional surgery -- (bypass surgery, gastrostomy, jejunostomy).
15. INDICATIONS FOR TOTAL GASTRECTOMY
• Total Gastrectomy
• Extent or location of tumor does not permit adequate resection of the tumor
• Tumors located in body, cardia or fundus of the stomach
• Diffuse type of tumor -- linitis plastica
Subtotal Gastrectomy
• Tumors limited to the antropyloric region
• Benign ulcers
• Nutritional therapy
16. PRE-OPERATIVE PREPARATION
• History taking
• Physical examination
• Diagnostic Investigations
• Upper GI Endoscopy with Biopsy -- to confirm or rule out neoplasm
• Abdominal CT Scan -- Involvement of adjacent structures
• Laparoscopy -- Tumor spread, fixity of tumour
• Supportive Investigations
• FBC, GXM, BUE and Cr, LFT, Chest Xray, ECG, ECHO
17. PRE-OPERATIVE PREPARATION
• Optimize the patient
1. Correction of anaemia
2. Correction fluid and electrolyte imbalances
3. Correction of hypoalbuminaemia
• Bowel preparation
• Gastric lavage starting at least 5 days before surgery
• Repeat 1 to 2 hrs. before surgery
• Effluent must be clear before surgery
• Prophylactic antibiotic at the time of induction
18. PRE-OPERATIVE PREPARATION
• Anaesthesia
• General anaesthesia with cuffed ET tube
• Adequate muscle relaxation
• Position
• Supine on a flat table with mild reverse Trendelenburg position.
19. SURGICAL TECHNIQUE
• Incision
• Midline or paramedian abdominal incision OR
• Chevron or rooftop incision (Self-retaining subcostal retractors)
20. SURGICAL TECHNIQUE
• Exploration
• Note any ascites and peritoneal deposits
• Explore from the pelvis to toward the stomach
• Examine the greater omentum, para-aortic and the lymph nodes of
the mesentery
• Examine the full length of the small and large bowel
• Draw the omentum caudally to examine the supracolic compartment
21. SURGICAL TECHNIQUE
• Exploration
• Examine the liver, adjacent diaphragm, gall bladder, free edge of lesser omentum.
• Examine the spleen, kidneys and adrenals
• Starting from the oesophageal hiatus and working distally, look and feel for the
tumour involvement, fixity, glands
• Avoid handling or squeezing the tumor if possible
• Examine the duodenum, pancreas and the coeliac axis
22. SURGICAL TECHNIQUE
• Mobilization and Resection
• The greater omentum is freed from the transverse colon
• Dissect out the gastro-epiploic nodes
• Doubly ligate and divide the right gastro-epiploic vessels
23. SURGICAL TECHNIQUE
• Mobilization and Resection
• Incise the anterior leaf above the pylorus
and towards the cardia
• The right gastric vessel and the
Suprapyloric nodes will be revealed
• Identify the right gastric and right gastro-
epiploic arteries
24. SURGICAL TECHNIQUE
• Duodenal Division
• Mobilize the 5 -6 cm of duodenum for division (Kochers manoeuvre)
• Transect the duodenum with a linear stapler 1cm distal to the pylorus
• For total gastrectomy – proximal limit is the gastro-oesophageal junction.
25. SURGICAL
TECHNIQUE
• Gastric Transection
• Divide the gastrosplenic ligament.
• Landmarks for Subtotal Gastrectomy
• 2nd short gastric artery along the
greater curvature
• 1 cm inferior to the
esophagogastric junction along
the lesser curvature
26. BILLROTH I RECONSTRUCTION
• A posterior row of interrupted seromuscular silk sutures between
the duodenum and the stomach
• The superior portion of the duodenal staple line is removed
• The gastric staple line is opened corresponding to duodenal
opening.
• A Posterior Mucosal layer continuous suturing with 3-0 Vicryl
• An Anterior Mucosal Layer continuous suturing with 3-0 Vicryl
• Anterior Seromuscular layer interrupted suturing with silk
27.
28. BILLROTH II RECONSTRUCTION
• Choose a loop of the proximal jejunum
• The omega loop is pulled through the transverse colon mesentery
• Open the closure of the distal gastric remnant
• The posterior layers are sutured using use single stitches or a running suture
• For the anterior anastomosis, a running inverting suture is adequate
• An associated Braun's entero-enterostomy can be done to prevent bile reflux
• Side-to-side jejunostomy is done either with single stitches, a
• running suture, or a stapler device
35. ROUX-EN-Y RECONSTRUCTION
• The ligament of Treitz is identified
• Jejunum is dissected about 40–50cm distal to
Treitz’ ligament
• A retro-colic passage is made for the jejunum loop
• The distal loop is placed side-to-side to the
posterior wall of the gastric remnant.
• A side-to-side enteroenterostomy is then
constructed
36. RECONSTRUCTION AFTER TOTAL
GASTRECTOMY
• Loop esophagojejunostomy with entero-enterostomy
• Roux-en-Y reocnstruction
• Esophagojejunostomy Roux-en-Y configuration (end-to-side or end-to-.end)
• Esophagojejunostomy Roux-en-Y double tract configuration.
• Esophagojejunostomy with
• jejunal segment interposition by Longmire
• Colonic interposition
37. RECONSTRUCTION OPTIONS AFTER TOTAL
GASTRECTOMY
• Choose a loop of the proximal jejunum
• The omega loop is pulled through the transverse colon mesentery
• Open the closure of the distal gastric remnant
• The posterior layers are sutured using use single stitches or a running suture
• For the anterior anastomosis, a running inverting suture is adequate
• An associated Braun's entero-enterostomy is done between the loops pf jejunum
41. MODIFIED VERSIONS OF R-Y
RECONSTRUCTION
• RY configuration was modified by Hunt and Lawrence by creating a jejunal pouch
• Ω-pouch, S-pouch, and an aboral pouch
45. POSTOPERATIVE CARE
1. Nurse patient in a propped-up position when conscious
2. Maintain NG tube and Keep NPO
3. IV Fluid Maintenance
4. Strict monitoring of fluid and electrolytes
5. IV antibiotics
6. IV analgesics and PPI
7. DVT Prophylaxis and Early Ambulation
8. Chest physiotherapy
9. Light diet can resume on POD 3
48. EARLY COMPLICATIONS
1. Dumping Syndrome
• Early Dumping (15 -30min after meals)
• Abrupt delivery of hyperosmolar load into the small bowel
• Diaphoretic, weak, light-headed, and tachycardic
• Crampy abdominal pain, Diarrhoea
• Treatment – Recumbency and Infusion of NS
• Late Dumping (2- 3hrs after meals)
• Reactive (post-prandial) hypoglycaemia
• Relieved with sugar (dextrose)
49. POSTGASTRECTOMY PROBLEMS
1. Treatment of Dumping Syndrome
a. Dietary management
• Avoids liquids during meals
• Avoid Hyperosmolar liquids (e.g., milk shakes)
• Encourage High fibre diets
b. Medical therapy
• Indicated if dietary measures are still inadequate
• SC Octreotide 100ug BD (can be increased to 500ug BD)
• α-glucosidase inhibitor (acarbose) – useful in late dumping
c. Operative management
• Roux-en-Y is the preferred choice
50. POSTGASTRECTOMY PROBLEMS
3. Gastric Stasis
• Mechanical cause
• anastomotic stricture, efferent limb kink from adhesions or constricting mesocolon, or a
proximal small-bowel obstruction).
• Functional cause
• Retrograde peristalsis in the Roux-limb
• Clinical features –
• vomiting of undigested food, bloating, epigastric pain, and weight loss.
• Investigation
• EGD, upper GI and small bowel series, gastric emptying scan, and gastric motor testing
• Treatment
• Dietary modification with promotility agents
• Intermittent oral antibiotics
51. POSTGASTRECTOMY PROBLEMS
3. Diarrhoea
• Dietary management +/-
• Some patient respond to codeine or loperamide
• Octreotide can also be started if symptoms are persistent
52. POSTGASTRECTOMY PROBLEMS
1. Bile Reflux Gastritis and Oesophagitis
• Gastritis component - ablation or resection of the pylorus
• Oesophageal component - Dysfunction of the cardia
• Nausea, bilious vomiting, and epigastric pain,
53. POSTGASTRECTOMY PROBLEMS
1. Roux syndrome
• Disruption of the antegrade contractions in the Roux limb
• Vomiting, epigastric pain, and weight loss
• Investigations
1. Endoscopy –
• Retained food or bezoars
• Dilation of the gastric remnant,
• Dilation of the Roux limb
2. Upper GI Series – delayed gastric motility (Confirmatory test)
3. GI motility testing – regrade propulsive activity
54. POSTGASTRECTOMY SYNDROMES
1. Roux syndrome
• Medical Treatment
1. Promotility agents
• Surgical Treatment Options
1. Paring down the gastric remnant (Gastric trimming)
2. Near total or Total Gastrectomy
3. Resection of Roux-limb (if dilated and flaccid) with
• Another Roux reconstruction
• Billroth II with Braun gastroenterostomy
• Henley loop
55. POSTGASTRECTOMY SYNDROMES
1. Afferent loop Syndrome
• Intrinsic or extrinsic obstructive process along the afferent limb or at the distal anastomosis
• Aetiology
• Post-operative adhesion
• Internal hernia
• Volvulus of the intestinal segment
• Kinking of the afferent limb at the gastrojejunostomy
• Scarring due to marginal (stomal) ulceration
• Treatment
• Conversion to a Roux-en-Y
• Billroth I reconstruction
57. POSTGASTRECTOMY SYNDROMES
1. Efferent Loop Syndrome
• Cause
• Herniation of limb behind the anastomosis
• Investigation
• Barium meal – failure of contrast to enter efferent loop
• Treatment
• Reducing the retro-anastomotic hernia and closing the retro-anastomotic space
58. POSTGASTRECTOMY PROBLEMS
1. Gallstones
• Vagal denervation causing gall bladder dysmotility and stasis.
• Treatment – Cholecystectomy during gastrectomy
2. Weight loss
59. POSTGASTRECTOMY PROBLEMS
1. Anaemia
• Reduced production of gastric acid and intrinsic factor
• Poor absorption of iron, B12 and folic acid
• Periodic assessment for iron and B12 deficiency
• Supplemental iron and B12
2. Bone Disease
• Malabsorption of Ca2+ and fat (including at soluble Vitamin D)
• Presents as pain and/or fractures years after the index operation
• Supplement Calcium and Vitamin D
• Periodic skeletal survey
Editor's Notes
Development of Gastric Surgeries evolved as our understanding of Gastric Diseases Increased.
Successful partial 44-year-old woman who had developed a pyloric carcinoma
Carl
Schlatter71 of Zurich performed the first successful
total gastrectomy
Billroth developed the (Billroth II) partial gastrectomy intraoperatively for an initially unresectable pyloric tumor
D1 – Group 1 lymph nodes (Peri-gastric nodes directly attached to the less and greater curvatures)
D2 – Group 1 & II (left gastric artery, coeliac trunk, splenic artery, common hepatic) – Stations 7 to 11
A sufficient resection margin should be ensured when determining the resection line in gastrectomy with curative intent
For tumors invading the esophagus, a 5-cm margin is not necessarily required, but frozen section examination of the resection line is desirable to ensure an R0 resection
Surgical resection is the only curative treatment for gastric cancer of patients with clinically resectable locoregional disease should have gastric resection
who cannot tolerate an abdominal operation, and patients with overwhelming metastatic disease.
The role of gastrectomy is unclear in patients with metastatic gastric cancer in the absence of urgent symptoms such as bleeding or obstructio
Antrectomy (Distal Gastrectomy)
Distal gastrectomy -- Stomach resection including the pylorus. The cardia is preserved. In the standard gastrectomy, two-thirds of the stomach is resected.
Surgical resection is the only curative treatment for gastric cancer ost patients with clinically resectable locoregional disease should have gastric resection
who cannot tolerate an abdominal operation, and patients with overwhelming metastatic disease.
Distal gastrectomy -- Stomach resection including the pylorus. The cardia is preserved. In the standard gastrectomy, two-thirds of the stomach is resected.
Surgical resection is the only curative treatment for gastric cancer ost patients with clinically resectable locoregional disease should have gastric resection
who cannot tolerate an abdominal operation, and patients with overwhelming metastatic disease.
Tumors in the antropyloric region – Subtotal gastrectomy
Proximal tumors – Total Gastrectomy
Partial gastrectomy can be done for the duodenal ulcers
CLO test for H. Pylori -- Campylobacter-like organism (diagnostic test is used for the detection of Helicobacter pylori by finding the presence of urease)
Gastric lavage removes food residue, decreases mucosal edema, and restores gastric tone
Prophylactic antibiotics can be given if the surgery is expected to be long
Gastric lavage removes food residue, decreases mucosal edema, and restores gastric tone
Prophylactic antibiotics can be given if the surgery is expected to be long
Self-retaining retractor (Bookwalter)
Explore from the pelvis to toward the stomach (prevent dispersion of malignant cells)
Gastric lavage removes food residue, decreases mucosal edema, and restores gastric tone
Prophylactic antibiotics can be given if the surgery is expected to be long
The procedure begins with omentobursectomy,
the greater omentum is detached from the transverse colon
along with the anterior leaf of the transverse mesocolon
The maneuver starts by incising the periduodenal peritoneum about 1 cm from the lateral duodenal margin.
By gently pulling the bowel mediad the assistant puts traction on it.
Lift the parietal peritoneum at the level of the mid-duodenum and incise it with scissors.
Carry the dissection along the duodenum and posterior to it in the loose layer of the tela subserosa.
Straight occlusion clamp is placed at the elected sites
Crushing clamp is placed at the towards the specimen side
Stomach is then transected with a sacpel blade 15
linear stapler
The junction of the anastomosis and the gastric staple line has been referred to as the "angle of sorrow"
due to the complication of leakage at this intersection of suture/staple lines
To prevent tension on the anastomosis and internal herniation of small bowel through the opening in the transverse mesocolon,
suture the jejunal loop to the peritoneum of the transverse mesocolon with interrupted 3-0 absorbable sutures being careful to avoid the mesenteric vessels
) Delivery of gartrojajunal anastomosis inferior to the transversa mesentery and suture of the mesentery to the gastric surface.
Length of at least 25–35 cm
length of at least 25–35 cm
5-10% of patients after pyloromyotomy, pyloroplasty or distal gastrectomy.
Most patients improve with time (months and even years)
5-10% of patients after pyloromyotomy, pyloroplasty or distal gastrectomy.
Most patients improve with time (months and even years)
5-10% of patients after pyloromyotomy, pyloroplasty or distal gastrectomy.
Most patients improve with time (months and even years)
5-10% of patients after pyloromyotomy, pyloroplasty or distal gastrectomy
5-10% of patients after pyloromyotomy, pyloroplasty or distal gastrectomy.
Most patients improve with time (months and even years)
Passage of loose stools in the absence of other systemic symptoms.
intestinal dysmotility and accelerated transit, bile acid malabsorption, rapid gastric emptying,
and bacterial overgrowth.
Gastric stasis
Clinical features - EGD, upper GI and small bowel series, gastric emptying scan, and gastric motor testing
Investigation – UGI Endoscopy
Passage of loose stools in the absence of other systemic symptoms.
intestinal dysmotility and accelerated transit, bile acid malabsorption, rapid gastric emptying,
and bacterial overgrowth.
Gastric stasis
Clinical features - EGD, upper GI and small bowel series, gastric emptying scan, and gastric motor testing
Investigation – UGI Endoscopy
esophagoantral anastomosis should be avoided
Functional difficulty with gastric emptying due to
Functional difficulty with gastric emptying due to
Recurrence of cancer at or near the anastomotic site
This limb of the intestine transfers bile, pancreatic juices, and other proximal intestinal secretions toward the gastrojejunostomy and is thus termed the afferent loop.
Functional difficulty with gastric emptying due to
Although prophylactic cholecystectomy is not justified with most gastric
