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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
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Section II • Esophagus, Stomach, and Duodenum
Postoperative Investigations
See ▶ Chap. 21 “Total Gastrectomy with Conventional Lymphadenectomy.”
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Postoperative Complications
z Short term
Anastomotic leakage (including duodenal stump leakage)
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Pancreatic stula
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Chylous ascites (particularly aer R2resection)
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z Long term (all indications)
Bile gastritis (particularly aer BillrothII reconstruction)
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Anastomotic ulcer disease
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z Long term (in case of malignancy)
Local recurrence (duodenal stump or resection line of stomach)
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Distant metastases
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Tricks of the Senior Surgeon
Instead of a vessel loop, a heavy resorbable suture can be used to pull the stomach or
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duodenum into the endostapler. Even if this suture is included in the staple line, this will not
compromise the anastomosis.
In lean patients it is often possible to remove one of the 10- to 12-mm trocars and directly
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introduce the 60-mm stapler or the retrieval bag, instead of using a 15-mm trocar.
Suturing is best done with the laparoscope in the middle and two needle holders on either
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side of the scope with a 60° to 90° angle between the two needle holders.
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Laparoscopic and Conventional Gastroenterostomy
John Tsiaoussis; Gregory G. Tsiotos
Indications and Contraindications
Indications
(Relative) Contraindications
Palliation of gastric outlet obstruction caused by advanced gastric, duodenal, or periampul-
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lary tumor.
Gastric drainage following vagotomy when pyloroplasty is not feasible.
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Note: Gastroenterostomies for reconstruction aer all sorts of gastrectomies are described
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in separate chapters of this Atlas.
Severe hypoalbuminemia
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Evidence of diuse metastatic spread, indicating extremely short life expectancy
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Prohibitive comorbidity
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Preoperative Investigation/Preparation for the Procedure
History Persistent vomiting
Laboratory tests Electrolytes, albumin, coagulation param-
eters (all to be corrected preoperatively)
Radiology Upper GI contrast study (to document
gastric outlet obstruction)
CT scan Assessment of primary disease/condition
Endoscopy Assessment of gastric outlet obstruction,
periampullary biopsy for tissue diagnosis
A large-bore nasogastric tube is placed the day prior to the operation for gastric decompression and irrigation.
e patient’s water and electrolyte balance are corrected preoperatively.
Procedures
Open, Hand-Sewing Technique
z Access
Midline incision from the xiphoid process to the umbilicus
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_28, © Springer-Verlag Berlin Heidelberg 2016
Section II • Esophagus, Stomach, and Duodenum
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Step1
Creation of gastrojejunostomy (interrupted sutures)
e gastroepiploic vessels are dissected, clamped, divided, and ligated starting about 5 cm proximal
to the pylorus and moving for 6 to 7 cm proximal along the greater curvature of the stomach, so
this portion of the stomach is completely dissected free from the omentum.
e jejunal loop can be brought either anterior to the transverse colon (antecolic) or
through a window in the transverse mesocolon (retrocolic). Although a retrocolic gastrojejunostomy has been considered more prone to obstruction because of its closer proximity to
an ever-enlarging unresectable periampullary tumor, this has never proved true, especially
because patients’ survival in this context rarely exceeds 6months. Conversely the retrocolic
route allows more proximal placement of the gastrojejunostomy and smoother angles between
aerent, eerent loops and stomach both in the coronal as well as in the sagittal plane. e
retrocolic route is thus described.
e mesocolic window (wide enough to allow comfortable sliding of both aerent and eerent
jejunal loops) is made in an avascular plane of the mesocolon to the le of the middle colic vessels. e ligament of Treitz is identied by liing up the transverse colon and the jejunal loop is
brought up through the mesocolic window in apposition to the greater curvature (now free from
omental vessels). e length of the aerent jejunal limb should not exceed 20 cm.
e gastrojejunostomy can be placed on either the anterior (easier and thus preferable) or the
posterior gastric wall; the latter has not proved superior in terms of gastric emptying. Place 3-0silk
traction seromuscular sutures, taking into account that the incision in the jejunum will not be
made exactly at the antimesenteric border, but at a level closer to its mesentery on the stomal side.
is provides for more comfortable lining of the completed anastomosis without any undue angles
in the transverse plane. Place 3-0silk interrupted seromuscular Lembert sutures and tie at 5-mm
intervals to create the posterior outer suture line. Two incisions along the gastric and the jejunal
apposite segments are then made. Although the gastric incision should be about 4 cm, the jejunal
incision should be a bit shorter, because it always tends to dilate and ends up being realistically
longer than initially planned or thought to be (
. Fig. 28.1).
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Chapter • Laparoscopic and Conventional Gastroenterostomy
Step1 (continued)
. Fig.28.1
Section II • Esophagus, Stomach, and Duodenum
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Step2
Creation of gastrojejunostomy (running sutures)
e posterior full-thickness inner anastomotic layer is made by two 3-0PDS running sutures in an
over-and-over fashion starting at the middle of the posterior layer and moving in opposite directions toward each corner of the anastomosis, where the two corner traction seromuscular stitches
are still present. en, the two 3-0PDS running suture lines continue into the anterior wall of the
gastrojejunostomy (again full-thickness) using the Connell technique in order to invert all gastric
and jejunal mucosa, which might otherwise protrude out through the anastomosis. Moving from the
two corners toward the middle, the sutures meet and are tied together (.
is completed by placing the anterior seromuscular layer with interrupted 3-0silk Lembert sutures
starting at the corner away from the surgeon and moving toward the surgeon, so that there are no
sutures tangling in the middle of the operative eld. ese outer sutures should be rst all placed
and then tied; “tying as we go” will lead to puckering of the serosa toward the inner suture line and
thus placement of each successive suture at an ever-increasing distance away from the inner suture
line, which may then lead to entrapment of a lot of seromuscular tissue within the suture lines and
protrusion of this so tissue mass toward the anastomosis itself with its potential obliteration.
Fig. 28.2
). e anastomosis
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Step3
Step1
. Fig.28.2
Restoration of infracolic anastomosis
Aer completion the anastomosis is brought below the mesocolic window and the gastric wall (not
the jejunal) is tacked circumferentially on the mesocolon with interrupted 3-0Vicryl sutures. A
drain tube does not need to be placed.
Open Stapling Technique
Stapled gastrojejunostomy
e greater curvature is freed from the omentum, the mesocolic window is made, and the jejunum and greater curvature are brought to apposition as previously described. Two stab wounds
are made with the electrocautery in the greater curvature (12 cm from the pylorus) and at the
antimesenteric aspect of the jejunum (20 cm from the ligament of Treitz). Two Allis clamps, incorporating full-thickness gastric and jejunal wall, are placed one each in the gastric and the jejunal
stab wounds. e cartridge fork of the GIA-60 stapler is inserted in the gastric lumen and the
anvil fork into the jejunal lumen (the move is to push the GIA’s jaws into the lumens, not to pull
the stomach and jejunum up toward the stapler). With the help and maneuvering of the two Allis
clamps, align equal lengths of gastric and jejunal walls on the forks, keep the jejunal mesentery
away from the anastomosis, close the instrument, and re. Open the handle of the stapler slowly
and slide it out. Inspect the luminal side of the staple line for possible bleeding.
Chapter • Laparoscopic and Conventional Gastroenterostomy
Step2
Closure of gastro/entertomy
e two Allis clamps are now repositioned to grab the two corners of the GIA staple line and the
inner (luminal) anastomotic line is inspected for bleeding (
and jejunal walls with two additional Allis clamps. Slip the jaws of the TA-55 beneath the Allis
clamps incorporating all tissue layers as well as the corner end staples of the GIA staple line within
the jaws. e corner ends of the two GIA staple lines should be the two corners of the TA-55 staple
line, so that these three staple lines (two from the GIA, one from the TA-55) form a triangle and the
wide patency of the anastomosis is assured. Close the instrument and re. Use a scalpel to excise
the protruding tissue along a special groove on the surface of the stapler. Open the instrument to
release the tissue and inspect for bleeding. ree single full-thickness 3-0silk reinforcing sutures
are placed at the three corners of the stapled anastomosis, as these represent the theoretically more
“vulnerable” points of the anastomosis, because this is where two staple lines meet and overlap. A
drain tube does not need to be placed.
. Fig. 28.3). Approximate the gastric
Step1
Step2
. Fig.28.3
Laparoscopic Technique
Mobilization of jejunal loop
e patient is placed supine. e senior surgeon stands on the patient’s right side and the rst
assistant on the le. Pneumoperitoneum is established with the Veres needle (by insuating at a
preset pressure of 12–15 mmHg), the 0
cal 10-mm port, but it can be moved to other ports as needed intraoperatively. en, two 10-mm
trocars and one 12-mm trocar are inserted in the anterior abdominal wall. e table is tilted at a
o
30
Trendelenburg position and a Babcock forceps (more atraumatic) is used to bring the omen-
tum and transverse colon cephalad to identify the ligament of Treitz.
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or 30o laparoscope is introduced through a supraumbili-
Preparation for stapler insertion
e rst jejunal loop is identied and approximated to the proximal antrum in an antecolic
route. If the retrocolic route is chosen, a window in the transverse mesocolon is made using the
harmonic scalpel and the jejunal loop is brought up through it. Two 3-0silk traction sutures
are placed (5–6 cm from each other) to apposite the jejunum (at a distance of 20 cm from the
ligament of Treitz) along the greater curvature (at a distance of 5 cm from the pylorus). Two
stab incisions are made at the approximated gastric and jejunal walls using the Hook device,
one opposite to the other.
Section II • Esophagus, Stomach, and Duodenum
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Step3
Insertion of laparoscopic stapler
As two graspers are holding the traction sutures on the approximated stomach and jejunum, a
45-mm Endo-GIA stapler is inserted through the 12-mm port. e jaws of the instrument are
introduced in the gastric and jejunal lumens (. Fig. 28.4). Maneuvering of the suture-holding
graspers accommodates stapler insertion. e stapler is closed, red, and eventually removed.
e staple line is inspected internally for patency and bleeding.
. Fig.28.4
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Step4
Closure of gastrotomy/enterotomy
e common gastric and jejunal opening is closed with full-thickness, running 2-0Vicryl suture
tied intracorporeally. Alternatively, an endo-GIA device can be used for closure of the common
gastric and jejunal opening. A drain tube does not need to be placed.
Robotic Technique
Utilization of robotic instrumentation has been increasing. Robots are now available in more
hospitals and operative experience is steadily increasing. Although robotic technology is not cost
eective for a gastroenterostomy, nor does it provide realistic benets compared with the laparoscopic technique, it should nevertheless be described for completeness’ sake. As with all robotic
procedures, the technique is essentially a combination of the laparoscopic technique (in terms
of operative access and minimal invasiveness) and the open technique (in terms of the actual
performance of the procedure inside the peritoneal cavity).
e incisions are the same as with the laparoscopic technique, only placed about 2 cm inferior to each of those, in order to facilitate maneuvering of the bulky “arms” of the robot. en
the procedure continues by reproducing the hand-sewn open technique, with the additional
advantage of the visual magnication and the higher precision because of this. Placing of and
tying sutures is far easier using robotic “wrist” exibility than laparoscopic instruments. Utilization of staplers during the robotic technique, although possible, may not be as expeditious as
the hand-sewn technique.
Postoperative Tests
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Gastrogran upper GI radiograph (when signicant nasogastric tube output persists for
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longer than a week postoperatively)
Chapter • Laparoscopic and Conventional Gastroenterostomy
Local Postoperative Complications
z Short term
Anastomotic bleeding
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Anastomotic leak
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Obstruction (anastomotic or functional)
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z Long term
Anastomotic stenosis
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Tricks of the Senior Surgeon
When an antecolic gastrojejunostomy is chosen, the aerent jejunal loop can be kept
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short by placing the transverse colon as much to the right of the gastrojejunostomy as
possible.
Excessive length of the aerent limb may predispose to “aerent loop syndrome.”
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Inadvertent gastroileostomy is not that uncommon! Make sure, especially when a laparo-
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scopic gastroenterostomy is performed, that the appropriate site of the jejunum is used.
Gastric emptying is based on inherent gastric motor function, not on hydraulic pressure gra-
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dients. Thus, placing the anastomosis at the “most dependent” portion of the stomach does
not have any scientic merit.
Place the anastomosis where it lies more comfortably. Provided that there is no kinking, or
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acute angles, or pressure on the eerent and aerent loops, the choice of retrocolic versus
antecolic, or distal gastric versus proximal gastric, placement of the anastomosis is not so
important.
Percutaneous Endoscopic Gastrostomy
Eleazer Yousefzadeh, Capecomorin S. Pitchumoni
Indications and Contraindications
Indications
Contraindications
Requirement of enteral feeding for more than 30 days owing to
Poor oral intake
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Failure to thrive
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Dysphagia (common examples follow)
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Mechanical dysphagia: esophageal cancer, head and neck cancer
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Neurological dysphagia: stroke, multiple sclerosis, amyotrophic lateral sclerosis, cerebral
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palsy, myotonic dystrophy
Alternatively, PEG tube placement is indicated for gastric decompression (“venting”) due to bowel
obstruction or gastroparesis
Anatomical factors causing poor apposition of anterior stomach and abdominal wall
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Peritonitis
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Abdominal wall infection
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Severe coagulopathy
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Rapidly reaccumulating ascites
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Expected survival less than 6weeks (palliative “venting” PEG excluded)
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Preoperative Investigations/Preparation for the Procedure
Consent or advanced directives
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Cardiorespiratory status assessment
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Baseline laboratory parameters
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Procedure
Step1
Step2
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_29, © Springer-Verlag Berlin Heidelberg 2016
Preparation
e patient’s medical condition is reevaluated prior to PEG placement; the expected survival may
have changed.
A single dose of intravenous antibiotics is administered. Commonly, cefazolin is used (van-
comycin if penicillin allergic).
e patient is placed in the supine position.
e abdomen is examined for surgical scars, cellulitis, and ascites. e skin over the abdomen
is prepared then draped.
Esophagogastroduodenoscopy
e endoscope is passed from the mouth to the stomach. Examination is performed to rule out
local contraindications, such as tumor, ulceration, gastric varices, and outlet obstruction.
Section II • Esophagus, Stomach, and Duodenum
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Step3
Step4
Air inflation
e gastric lumen is inated with air so that the anterior wall of the stomach abuts the abdominal
wall, pushing away any interpositioned bowel loops.
Transillumination
Transillumination is attained through the anterior abdominal wall aer darkening the room.
Failure to transilluminate suggests poor apposition of the anterior stomach to the abdominal wall,
making the procedure unsafe.
e assistant makes a nger impression over the point of transillumination. Endoscopically,
this impression must be clearly visible as a focal depression of the gastric wall (
. Fig. 29.1).
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Step5
Step6
. Fig.29.1
Local anesthesia
Aer marking the site of optimal nger impression on the skin, the assistant injects the skin with
a local anesthetic and makes a shallow 1 cm incision.
Safe track maneuver
To ensure that no loops of bowel are interposed between the stomach and the abdominal wall,
the needle used to inject local anesthetic is advanced into the gastric lumen. While the plunger
is aspirated, the needle is slowly withdrawn through the peritoneum, fascia, and abdominal wall.
Air should not enter the syringe.
Following the same trajectory of the previous puncture, an 18-gauge hollow trocar is advanced
through the incision, piercing the gastric wall.
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