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82 Atlas of Gastrointestinal Surgery: The Stomach
The anastomosis is completed with an outer layer of 3-0 silk
Lembert sutures (13).
Alternative
Stapled esophagojejunostomy
Esophagus
Jejunum
Outer layer
of anterior row
13
Alternatively, this anastomosis can be per-
formed using the end-to-end anastomosis
(EEA) circular stapler (14).
EEA
stapler
14
A small pouch is created by performing a long side-to-side jejunoje-
junostomy between the afferent and efferent limbs of the Roux-en-Y
loop. The outer posterior layer is placed using interrupted 3-0 silk
Lembert sutures. The inner layer of the posterior row is placed with a
running locking suture of 3-0 synthetic absorbable material, brought
around anteriorly in a Connell fashion (15). The anastomosis is com-
15
pleted by placing an outer anterior row of interrupted 3-0 silk
Lembert sutures. This long side-to-side jejunojejunostomy is approxi-
mately 10 cm in length and creates a new reservoir. The staple line
at the end of the Roux-en-Y loop is oversewn with 3-0 silk Lembert
sutures. Although this creates a reservoir, which at times on subse-
quent barium studies appears to be residual stomach, many surgeons
feel that the construction of a reservoir is unnecessary.
Side-to-side
jejunojejunostomy
Jejunal pouch
Liver
Total Gastrectomy for Cancer 83
End-to-side
esophagojejunostomy
Jejunal pouch
Duodenum
16
Pancreas
Transverse
colon
Mesentery
End-to-side
jejunojejunostomy
The procedure is com-
pleted by performing an end-
to-side jejunojejunostomy approxi-
mately 60 cm distal to the esophagoje-
junostomy to restore intestinal continuity (16).
This anastomosis is performed with an inner continuous layer of 3-0 synthetic absorbable suture and an outer layer of inter-
rupted 3-0 Lembert sutures. Generally, it’s not necessary to drain any of these anastomosis, but if one is concerned about
the duodenal stump closure, a closed suction drain can be placed in the right upper quadrant.
84 Atlas of Gastrointestinal Surgery: The Stomach
Antecolic
17
Many variations exist for reconstruction following a total
gastrectomy. I prefer an antecolic esophagojejunostomy to a
Roux-en-Y jejunal loop, with a new pouch created by per-
forming a 10 cm side-to-side jejunojejunostomy just beyond
the esophagojejunostomy (17).
If the transverse mesocolon and transverse colon
are thick in a particularly obese patient, one might
prefer to place the Roux-en-Y loop in a retrocolic
position (18). This is generally not necessary in a
person of average weight.
Retrocolic
18
Total Gastrectomy for Cancer 85
Antecolic
19
Braun
jejunojejunostomy
Others prefer merely to use a jejunal loop rather than
creating a Roux-en-Y loop. A gastric pouch can still be
created by a long side-to-side jejunostomy just distal to
the esophagojejunostomy. If this means of reconstruction is
used, it is preferable to perform a second more distal Braun
jejunojejunostomy between the afferent and efferent limbs in
an attempt to divert the pancreatic and biliary secretions from
the esophagus. However, even with this maneuver, esophageal
reflux can be a problem. For this reason, this means of reconstruction
is less desirable. If a loop rather than a Roux-en-Y reconstruction is used,
it can be brought up in the antecolic (19) or retrocolic position (20).
20
Retrocolic
Resection of a Small Gastrointestinal
Stromal Tumor (GIST)
Operative Indications
GISTs are tumors that can arise in the gastrointestinal tract but are most commonly seen in the stomach. They may be
found incidentally while exploring a patient for another intraabdominal procedure, or they may be detected as a submu-
cosa mass on either endoscopy or upper gastrointestinal barium study. They may reach very large size and may be pal-
pable on abdominal exam, or even visible. On endoscopy they are found in the submucosal layer, and thus do not pres-
ent as a mucosal lesion, unless they have ulcerated into the intestinal lumen. All GISTs are thought to have malignant
potential, but generally if they are less than 5 cm in diameter with few mitoses per high-powered field, they behave in
a benign fashion. Large lesions can manifest a very malignant behavior, but with the introduction of Gleevec, long-term
survival has become more common.
Operative Technique
The patient is explored through an upper midline incision. This lesion of 4 cm in
diameter could be seen and palpated along the greater curvature (1). The omen-
tum is removed, and the lesion is wedged out using the GIA stapler (2). The
staple line is inverted with a row of 3-0 silk Lembert sutures (3, 4).
Resection of a Small Gastrointestinal Stromal Tumor (GIST) 87
1
Stomach
Omentum
cleaned off
portion of greater curvature
Leiomyoma
2
GIA
stapler
Staple line
inverted
Wedge
resection
3
4
Resection of a Large Gastrointestinal
Stromal Tumor (GIST)
Operative Indications
Large malignant GISTs are often discovered only after the tumor has reached mammoth proportions. Because the lesion is
submucosal, bleeding early in the course is unusual. Large GISTs often arise in the body of the stomach, and thus can reach
a substantial size without causing obstructive symptoms (1). The lesion may be found by the patient feeling a large abdom-
inal mass or by a physician on routine physical examination. Systemic symptoms such as inanition, weight loss, and anorex-
ia may be present, but often are absent. These tumors can reach such large size that they outgrow their blood supply. This
situation can cause necrosis and excavation of the center of the tumor, often decompressing by ulcerating through the mucos-
al layer into the gastric lumen (2). Gastrointestinal bleeding may occur in this setting. In addition, on abdominal x-ray
examination and/or barium studies, and vividly on computerized tomography, air can be seen within the tumor mass. The
diagnosis can perhaps most readily be made by computerized tomography, which shows the characteristically large upper
abdominal mass in relationship to the gastric wall occasionally containing starbursts of air when the mass is connected to
the gastric lumen. Often these tumors are very mobile to palpation and at laparotomy. At the time of surgery they may be
found to invade adjacent structures; however, more commonly they have merely displaced surrounding organs and can be
easily dissected free.
Operative Technique
The patient is explored through a long upper midline incision extending below the
umbilicus. Retraction of both costal margins by retractors suspended from a frame
attached to the operating table is very helpful. In this instance the large tumor was
arising from the posterior wall of the stomach (1, 2). The tumor also involved the
tail of the pancreas. With large GISTs it is often difficult to know whether there
Gallbladder
Resection of a Large Gastrointestinal Stromal Tumor (GIST) 89
Lesser omentum
opened
Liver
Tumor in
posterior wall
of stomach
2
Pancreas
Duodenum
GIST
Greater omentum
1
Ulcer
Stomach
is direct invasion into retroperitoneal structures, such as the pancreas, or
merely displacement. Often it is the latter. This distinction may be difficult
to determine, however, and require resection of adjacent structures. In this
instance, because the tumor appeared to involve the body and tail of
the pancreas, the dissection is started distally at the pylorus. The
greater omentum is taken off the transverse colon (2), and the
Transverse
mesocolon
Sagittal section
lesser omentum is divided.
Greater
omentum
90 Atlas of Gastrointestinal Surgery: The Stomach
The first portion of the duodenum is mobilized
and divided with a GIA stapler (3).
The left gastric vessels, which often are
best approached through the lesser sac by
reflecting the stomach and omentum in a cepha-
lad direction, are approached above the lesser
curvature in this instance (4). Because of the
tumor’s attachment to the retroperitoneum, the
left gastric vessels could not be approached
through the lesser sac.
3
First portion
of duodenum
GIA
stapler
Esophagus
Liver
Pancreas
Spleen
L. gastric vessels
divided
Stomach
Pylorus
4
Duodenum
Omentum
Resection of a Large Gastrointestinal Stromal Tumor (GIST) 91
Spleen
mobilized
Antrum
5
L. gastric vessels
divided
6
Pancreas
Esophagus
Splenic a.
divided
GIST in posterior
stomach wall
The left gastric vessels are triply
clamped at their origin from the celiac
axis, divided, and triply ligated
GIST
(4). The duodenal stump closure
is inverted with a layer of 3-0
silk Lembert sutures. The
spleen is mobilized out of the
retroperitoneum (5). The
tumor was closely adherent
to the tail and distal body of
the pancreas. Thus the
Stomach
splenic artery is identified
Duodenum
Pylorus
along the superior margin of
the pancreas, shortly after its
Omentum
takeoff from the celiac axis. It is
mobilized, triply clamped, divided,
and triply ligated (6).
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