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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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High Lesser Curvature (Csendes)
Gastrojejunostomy
Operative Indications
A tumor of the antrum or distal half of the stomach will sometimes extend up along the short lesser curvature and approach
the gastroesophagael junction. Obtaining a margin along the greater curvature of the stomach may be easy, but to obtain
an adequate margin along the lesser curvature, the line of gastrectomy must approach or even sometimes include a portion
of the gastroesophagael junction. If one were to close the lesser curvature in performing the standard Hofmeister gastroje-
junostomy, the distal esophagus would be narrowed (inset). An excellent alternative in this instance is the Csendes varia-
tion of the gastrojejunostomy.
Operative Technique
The initial part of this procedure is identical to the partial gastrectomy for can-
cer just described. However, because of the extension of tumor along the less-
er curvature, the resection line actually extends up onto the esophagus (1).
A Roux-en-Y jejunal loop is created and brought up in an antecolic fashion.
The jejunum is anastomosed to the entire opening in the stomach and includes
the opening in the distal esophagus. This anastomosis enlarges the circumfer-
ence of the distal esophagus and somewhat enlarges the small gastric pouch
(2). This very simple but innovative way of reconstructing the lesser curva-
ture after a high resection allows one to obtain a more adequate margin along
the lesser curvature.
Tumor
High Lesser Curvature (Csendes) Gastrojejunostomy 73
Esophagus
Narrowed
esophagus
GIA
stapler
1
Omentum
Stomach
Duodenum
Roux-en-Y
jejunal
limb
jejunostomy
Vagotomy
Spleen
Stomach
Gastro-
Pancreas
Colon
2
End-to-side
jejunojejunostomy
Total Gastrectomy for Cancer
Operative Indications
Gastric resection remains the mainstay of therapy for carcinoma of the stomach, for either curative or palliative management.
Several decades ago total gastrectomy was performed routinely for all cancers of the stomach. It was thought that perhaps
this larger resection, and a larger lymphadenectomy, would improve survival. This proved not to be the case. In addition,
the short- and long-term morbidity and mortality from total gastrectomy were increased compared to a lesser resection.
However, in some instances at the time of diagnosis the lesion is so large and extends from the gastroesophagael junction
to the pylorus in such a fashion that for either curative or palliative resections, total gastrectomy is necessary.
Previously, total gastrectomy was also the treatment of choice for the Zollinger-Ellison syndrome. Today, however, pri-
mary resection of the gastrinoma is favored whenever possible. If it is not possible, acid secretion is generally suppressed
pharmacologically, and total gastrectomy is rarely indicated for this syndrome.
Operative Technique
For total gastrectomy I prefer a long upper midline incision. The initial steps in a
total gastrectomy are similar to those for a partial gastrectomy for a distal lesion.
The omentum is taken off the transverse colon (1 and inset), and the lesser omen-
tum is divided (2 and inset).
Liver
Total Gastrectomy for Cancer 75
Gallbladder
Duodenum
1
Lesser
Stomach
omentum
Tumor
Omentum
cleaned off
transverse colon
Lesser omentum
Pancreas
Colon
Tumor
Stomach
omentum
Greater
Lesser
omentum
opened
Tumor
2
76 Atlas of Gastrointestinal Surgery: The Stomach
Posterior wall
of stomach
Lymph nodes
Omentum
After the entire omentum has been taken off the transverse
colon, the stomach can easily be retracted in a cepha-
lad direction, allowing excellent exposure of
the gastric vessels. Often there are areolar
attachments between the stomach and
the pancreas and retroperiotoneum, but
these are easily dissected. If the pancreas
is involved by the gastric tumor, as
described later, it should be resected with
the stomach. The left gastric artery is taken
Pancreas
Left gastric a.
divided
3
Duodenum
The spleen is mobilized out of the retroperi-
toneum, and the splenocolic attachments
are divided (4).
at its origin from the celiac axis. The vessel
is triply clamped, divided, and triply ligat-
ed (3). A complete celiac axis lym-
phadenectomy should be performed.
Spleen
Splenocolic
ligament
divided
Tumor
Stomach
Colon
4
L. gastric a. divided
Total Gastrectomy for Cancer 77
Spleen
Splenic a.
divided at hilum
Splenic a.
Pancreas
Posterior wall
of stomach
If the total gastrectomy is being per-
formed for palliation, one often chooses not to
perform a splenectomy. However, if it is for cure,
generally the spleen is removed. The splenic artery is dis-
sected free in the splenic hilum, ligated, and divided (5).
5
78 Atlas of Gastrointestinal Surgery: The Stomach
The splenic vein is usually best approached posteriorly,
by retracting the spleen and tail of the pancreas medi-
ally. The splenic vein is also ligated and divided (6).
Occasionally, a gastric cancer will invade the body
or tail of the pancreas. When this invasion occurs and
all gross tumor can be removed, the distal pancreas
Mobilized
spleen
should be included in the resection specimen. As
depicted here, the proximal splenic artery has been ligat-
ed and divided at its origin from the celiac axis. The
splenic vein is also ligated and divided (inset). The
pancreas is divided in midbody, removing the dis-
tal body and tail with the resection specimen.
Alternative
Pancreas
Splenic v.
divided
6
Splenic
vessels
divided at
midbody
of pancreas
First
portion of
duodenum
Bile duct
Total Gastrectomy for Cancer 79
The proximal duodenum is dissected off the neck and head of the pan-
creas. In the process, the right gastric vessels are encountered superiorly and
the right gastroepiploic vessels inferiorly. These are ligated and divided. The
Stomach
duodenum is divided with a GIA stapler (7). The duodenal closure is fur-
ther inverted with a layer of 3-0 silk Lembert structures (8). At this point
the stomach remains attached only via the esophagus. A Roux-en-Y jejunal
loop is constructed in preparation for esophageal anastomosis. The proximal
GIA
stapler
7
jejunum is divided beyond the ligament of Treitz with a GIA stapler (8).
Esophagus
Mobilized
spleen
Liver
Stomach
Duodenal
stump
First portion
of duodenum
Pancreas
Colon
Mesentery
Tumor
Omentum
Jejunum
GIA
stapler
8
80 Atlas of Gastrointestinal Surgery: The Stomach
Nasogastric
tube
The Roux-en-Y loop is brought up in an
Posterior wall of stomach
Outer layer
of posterior
row
antecolic fashion; approximately 10 cm
from the end, a point is picked for the
esophagojejunostomy. The specimen is
retracted in a cephalad direction, and
Esophagus
the outer layer of the posterior row of
the esophagojejunostomy is placed
using interrupted 3-0 silk Lembert
sutures. With the electrocautery
9
Liver
Jejunum
an enterotomy is made in the
esophagus adjacent to the
suture line, and the nasogas-
tric tube is extracted. An
enterotomy is also made in
the jejunum (9).
Duodenum,
Transverse colon
Pancreas
Proximal
jejunum
Nasogastric tube
Total Gastrectomy for Cancer 81
Esophagus
10
Esophagus
Inner layer
of posterior
row
This anastomosis is performed with two layers of interrupted
3-0 silk. The inner layer of the posterior row is placed using inter-
rupted 3-0 silk sutures full thickness through and through both
esophagus and jejunum (10). At times the amount of tissue includ-
ed in the posterior row may require the use of a small Ferguson
needle with 3-0 silk.
Esophagus
Distal
esophagus
Once both layers of the posterior row have been completed,
the remaining esophagus is divided, and the specimen is removed
from the operative field (11). The nasogastric tube is placed
down either limb of the jejunal loop.
Inner layer
of anterior row
The inner layer of the anterior row is performed using interrupted 3-0 silk sutures,
Jejunum
11
12
Staple line
oversewn
which are placed from inside out on the esophageal side and outside in on the
gastric side; this inverts the suture line. The inner layer can be placed from both
ends to the middle, and then the last two or three sutures must be placed in a
Lembert fashion (12).
Nasogastric tube
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