Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
.pdf
Reversal of Midjejunal Loop for
Postvagotomy Diarrhea
Operative Indications
Postvagotomy diarrhea has been a controversial entity. Many physicians think the entity does not exist. Prospective ran-
domized studies comparing truncal vagotomy with selective vagotomy, whereby the celiac axis branch of the posterior vagus
is left intact in an effort to eliminate postvagotomy diarrhea, have failed to demonstrate any substantial difference in the
prevalence of this complication. In addition, vagotomy is rarely performed today. Nevertheless, there are rare patients after
surgery for peptic ulcer disease, virtually all of whom have had a vagotomy, who are left with long-term morbidity or
intractable diarrhea. Most diarrhea that is attributed to postvagotomy abates or decreases in severity over several months
following surgery. There is a small group of patients, however, who have intractable diarrhea 1 year following surgery and
are thus candidates for remedial surgery. The procedure of choice is the reversal of a 10 cm jejunal loop 100 cm from the
ligament of Treitz.
Operative Technique
The patient depicted in this series had previously undergone a pyloroplasty and vago-
tomy. The patient is explored through a midline incision; 100 cm is carefully meas-
ured from the ligament of Treitz. At this point, a 10 cm segment of jejunum is meas-
ured. Proximally and distally the jejunal loop is isolated by firing the GIA stapler
(1). The site of the loop is picked so that there is an arcade coming off one major
vessel. The pedicle is then based on this major vessel by dividing the mesentery at
each end of the loop. The loop is rotated 180° and enteric continuity reestablished
with two end-to-end jejunojejunostomies. Both are performed with a continuous
inner layer of interrupted 3-0 synthetic absorbable suture material and an outer layer
of interrupted silk Lembert stitches. The rents in the
mesentery are closed with interrupted 3-0 silks (2).
The reversal of this jejunal loop clearly prolongs transit
time in the small bowel, permitting better mixture of pan-
creatic and biliary secretions with intestinal contents. This
operation has proven to be a very successful proce-
Reversal of Midjejunal Loop for Postvagotomy Diarrhea 163
dure for that small group of
patients with intractable
postvagotomy diarrhea.
Stomach
Prior
vagotomy
and
pyloroplasty
Transverse colon
1
10 cm portion of
jejunum is reversed
100 cm distal to
ligament of Treitz
Mesentery
2
Antiperistaltic segment
of jejunum
THE DUODENUM
Resection of Villous Adenoma of
Ampulla of Vater
Operative Indications
Villous adenomas can occur throughout the gastrointestinal tract. They are seen most frequently in the colon. They also
occur with a surprising frequency in and around the ampulla of Vater in the second portion of the duodenum (1). These
may be spontaneous, or they may be seen in the setting of familial polyposis or Gardner’s syndrome. Presentation can be
quite variable, ranging from no symptoms, with the lesion detected on a
routine upper gastrointestinal examination, to obstructive jaundice. The
diagnosis can easily be made by upper endoscopy with biopsy. Some
Gallbladder
of these lesions will contain invasive adenocarcinoma at the time of diag-
nosis. However, many will be benign. Because of the mechanical prob-
lems they are apt to cause in and around the ampulla, and
because of their propensity to become malignant,
they should be resected. These benign villous
tumors may extend well up into the pancre-
Common
bile duct
atic and bile ducts, making complete local
excision impossible. Thus a pancreatico-
duodenectomy may be required for the
Pancreatic
duct
complete excision, even though the
lesion may be benign. In other
instances, however, local excision
Villous
1
adenoma at
ampulla of Vater
through a duodenotomy is feasible.
168 Atlas of Gastrointestinal Surgery: The Duodenum
Operative Technique
The patient is generally explored through an upper midline incision. The lesion
usually can be palpated through the duodenal wall. In excising these lesions it
is helpful to have a catheter through the ampulla into the duodenum. If the
gall bladder is still in place, it should be mobilized, a small opening made in
the cystic duct, and a biliary Fogarty catheter passed into the common duct,
through the ampulla, and into the duodenum. The duodenum is then exten-
sively kocherized (2).
Mobilized
gallbladder
Biliary Fogarty
catheter
inserted into
cystic duct
Balloon through
ampulla, into duodenum
2
Tumor
Duodenum
kocherized
By palpating the tumor and the
Fogarty catheter, the exact location
for the longitudinal duodenotomy
can be determined. A long duo-
denotomy is performed (3) for
adequate exposure.
Resection of Villous Adenoma of Ampulla of Vater 169
When the patient is jaundiced preoperatively, I
favor percutaneous transhepatic cholangiography
with insertion of a biliary catheter into the biliary tree,
through the ampulla, and into the duodenum (inset). In addi-
tion, if the patient has had a previous cholecystectomy and a Fogarty
catheter would have to be inserted
Alternative
directly into the biliary tree, the
catheter should also be placed
Adenoma
Duodenotomy
Biliary Fogarty
catheter
3
percutaneously preoperatively.
Biliary catheter
placed preoperatively
170 Atlas of Gastrointestinal Surgery: The Duodenum
Once the duodenotomy has been made and the tumor palpated, the decision can be made whether to attempt local resec-
tion. If the lesion is benign, the entire mass should be soft and pliable.
If there are areas that are particularly hard or firm, a biopsy should
4
Probe in
pancreatic duct
be performed. A malignant villous adenoma involving the
ampulla should not be resected locally. The vast majority
require pancreaticoduodenectomy. If the lesion appears
benign and is well localized around the ampulla, the decision
can be made to excise it locally. An attempt is made to iden-
tify the pancreatic duct; once it is identified, it should be can-
nulated with either a lacrimal duct probe or a silver probe to
help define the anatomy (4).
The normal duodenal mucosa surrounding the villous adenoma is
injected with saline containing 1:100,000 epinephrine (5).
The villous adenoma is grasped gently with a small
Babcock clamp, and with electrocautery a circumfer-
ential incision is made in the normal duodenal
mucosa around the benign tumor.
5
Circumferential incision in duodenal mucosa
Epinephrine
injection
Resection of Villous Adenoma of Ampulla of Vater 171
This plane is easily found and developed (6). All of the tissue under-
lying the villous adenoma is mobilized and divided, except for the
distal common and pancreatic ducts.
Finally, when the villous adenoma is attached to the
duodenum only via two ductal structures, they are
6
divided and the specimen is removed from the opera-
tive field (7). The specimen is sent to the pathology
department for examination, and frozen sections are
performed to rule out invasive adenocarcinoma. The
reconstruction of the ampulla is initiated by opening
the distal common duct and the distal pancreatic duct,
overlying the catheter and probe (8). This can be
done easily with the electrocautery.
Distal common bile
and pancreatic ducts
Divided distal
common duct
Duodenal
mucosa
Adenoma
8
Distal pancreatic
duct divided
Catheter in
common bile duct
7
Probe in
pancreatic duct
Соседние файлы в папке Библиотека им академика М.И. Перельмана