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Chapter • Operation for Paraesophageal Hernia
Step6 (continued)
Sometimes one or two anterior sutures are mandatory to avoid an “S-shape” of the distal
esophagus. e inferior edge of the newly created hiatus may produce external compression leading to dysphagia (. Fig. 33.7).
Some groups use a prosthetic reinforcement with polytetrauoroethylene (PTFE) or with a
bioprosthesis to create a posterior cruroplasty to reduce the rate of postoperative wrap herniation
into the mediastinum.
. Fig.33.7
Step7
Nissen fundoplication
Perform a oppy 2-cm three-stitch Nissen fundoplication over a 56-French bougie aer mobilization of the great curvature (we divide the short gastric vessels). One or more of the most cephalad
stitches of the fundoplication incorporates the esophagus wall to prevent slippage (.
careful not to include the vagus nerves in the sutures of the fundoplication.
. Fig.33.8
Fig. 33.8
). Be
Section II • Esophagus, Stomach, and Duodenum
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Step8
Gastropexy
Wide suturing of the anterior wall of the proximal stomach to the anterior abdominal wall as a
gastropexy helps to prevent re-herniation.
Postoperative Tests
Resume alimentation the day aer surgery
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Obtain a barium esophagogram within 1month (for follow-up purposes)
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Postoperative Complications
Pneumothorax
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Pleural eusion
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Vagus nerve injury (anterior and posterior bundles)
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Cardiac dysrhythmia
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Pericarditis
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Pneumonia
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Pulmonary embolism
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Gastric volvulus
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Dysphagia
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Tricks of the Senior Surgeon
Use nonabsorbable mattress sutures to perform the posterior cruroplasty
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At the end of the procedure, perform an anterior gastropexy to avoid postoperative gastric
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volvulus
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Management of the Duodenal Stump
Yogesh K. Vashist, Florian Gebauer, Jakob R. Izbicki
One of the most serious complications aer gastrectomy is leakage from the duodenal stump.
Historically duodenal leak has been a potentially devastating complication aer BillrothII resections following emergency surgery for duodenal ulcer perforation.
Causes of duodenal stump suture dehiscence are:
Technical failure
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Postoperative pancreatitis
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Attempt to close a severely diseased and scarred, edematous duodenal stump
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Blood clots in the duodenal bed leading to super infection
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Excessive use of sutures at the stump leading to necrosis
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Indications and Contraindications
Indications
Contraindications
Peritonitis
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Sepsis
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None
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Preoperative Investigations/Preparation for the Procedure
Analysis of abdominal secretion in the drain tube (bilirubin, amylase, lipase)
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Physical examination
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Abdominal ultrasound
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Computed tomography (CT)
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Procedure
Access
e abdominal cavity is opened through the previous incision.
If the dehiscence is small or barely visible, an omental ap is performed and the area well
drained (. Fig. 34.1). For some patients primary suture of the duodenum might be performed.
is is usually hand-sewn, although some surgeons prefer the stapler technique.
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_34, © Springer-Verlag Berlin Heidelberg 2016
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Section II • Esophagus, Stomach, and Duodenum
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. Fig.34.1
If technically feasible, an end-to-side duodenojejunostomy may be performed using single-layered
sutures.
If the duodenum is opened widely and the wall is edematous, a primary closure is usually
unsuccessful because the sutures will not last. Here it is suggested to insert a Malecot catheter into
the leak, which may be xed using a purse-string suture.
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23
. Fig.34.2
e catheter shall be completely covered by the greater omentum and externalized using a separate incision. Most stulas will close spontaneously aer 3 to 4weeks. An alternative is to cover
the leak by a jejunal loop using the Roux-en-Y technique either as a serosal patch or a formal
duodeno-jejunostomy.
Chapter • Management of the Duodenal Stump
Most protection from the catastrophic sequelae associated with the occurrence of duodenal
leakage is provided by temporary biliary diversion (large-bore T-tube into the common bile duct)
and covering the leak by a jejunal loop using the Roux-en-Y technique. e duodenojejunostomy
can be done in an end-to-side or side-to-side manner.
Wide intraperitoneal peri-duodenal drainage is necessary because all of these dierent forms
of repair of a duodenal stump leak are at risk for leading to a recurrent leak.
Late suture dehiscences will present usually 2weeks aer (distal) gastrectomy. is course is
less dramatic, because postsurgical adhesions lead to a contained leak. e presentation can be
either by fever, pain, or drainage out of the wound. By using total parenteral nutrition as well as
antibiotics, the stula will close spontaneously. If a collection is visible on CT and the patient is
symptomatic, the interventional placement of a drain, such as a Sonnenberg catheter, for optimized drainage of the duodenal uid is necessary (
. Fig. 34.3).
. Fig.34.3
Standard Postoperative Investigations
Daily check of the abdominal drainage
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Postoperative Complications
Recurrent duodenal stump leak or leak at the site of diodenojejunostomy
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Peritonitis
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Sepsis
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Pancreatitis
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Fistula formation
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Wound infection
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Tricks of the Senior Surgeon
Tissue should not be too edematous. Therefore the indication for some form of intervention,
-
such as re-laparotomy or percutaneous drainage, should be immediately undertaken once
duodenal stump leak has been diagnosed.
All surgeons know that these patients can be very ill and aggressive intervention is necessary
-
without delay. In extremely rare situations, a partial pancreatiduodenectomy might even be
necessary but only in life savings circumstances.
Operations for Morbid Obesity
Stefan Wolter, Jakob R. Izbicki, Oliver Mann, Markus Weber, Markus K. Müller, Michael G. Sarr
e prevalence of obesity has increased dramatically over the past several decades worldwide
and is currently reaching epidemic proportions. In the United States, two thirds of individuals
are considered overweight. One in ve Americans is currently obese. Morbid obesity, dened as
body mass index (BMI) > 40 kg/m
ated with many diseases responsible for a high prevalence of morbidity and mortality, such as
insulin-resistant diabetes mellitus, hypertension, coronary artery disease, hyperlipidemia, and
sleep apnea. ese direct weight-related complications eventuate in enormous health care costs.
e only evidence-based approach to substantial and sustainable weight loss in patients with
severe obesity is bariatric surgery.
Current bariatric surgical procedures are divided into restrictive, malabsorptive, and combined procedures.
Restrictive procedures aim to decrease the volume of oral intake. ese include laparoscopic
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adjustable gastric banding (LAGB), sleeve gastrectomy (SG), and vertical banded gastro-
plasty (VBG).
Malabsorptive procedures are designed to decrease protein and caloric absorption by de-
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creasing the eective absorptive surface for digestion and/or absorption. e most com-
mon procedures currently are biliopancreatic diversion (BPD) and duodenal switch with a
biliopancreatic diversion (BPD/DS).
Combined procedures utilize both a restrictive and a selective malabsorptive anatomy and
-
involve primarily the Roux-en-Y gastric bypass (RYGB) (the malabsorptive eect correlates
with length of Roux limb).
2
or BMI > 35 kg/m2 with weight-related morbidity, is associ-
Most of these procedures lead to a change in secretion of several gut hormones which inuence
eating behavior and insulin secretion. e metabolic eect of these procedures appears to play a
major role in the remission of co-morbidities.
e advantages of laparoscopic surgery, especially in these obese patients, which involve
shorter recovery time and fewer abdominal wound complications have led to widespread use of
minimal access approaches in bariatric surgery.
is chapter addresses the most commonly performed bariatric procedures, focusing on the
most important ones: Roux-en-Y gastric bypass (.
adjustable gastric banding (.
long-term weight loss in severely obese patients. Sleeve gastrectomy gained popularity more recently
in the eld of bariatric surgery, because this procedure is technically less demanding than RYGB.
Use of adjustable gastric banding in the United States and in Europe has declined tremendously.
Biliopancreatic diversion (Scopinaro procedure) (. Fig. 35.1d) and biliopancreatic diversion
with duodenal switch (BPD/DS) (.
remission of co-morbidities, but because they are malabsorptive procedures close follow-up regarding malnutrition is mandatory.
Vertical banded gastroplasty (VBG) is described because more and more patients require revisional surgery aer VBG (. Fig. 35.1 f). Because use of an articial band in this anatomic region
leads to complications, it has become less attractive as a primary procedure over the past decade;
indeed, few centers still perform this form of operative gastroplasty.
Although several other procedures have been described in bariatric surgery, the above mentioned
are considered the standard procedure in bariatric surgery. Gastric electrical stimulation or “mini”
gastric bypass, ileojejunal transposition, as well as endoscopic procedures like the duodeno-jejunal
Fig. 35.1c
). RYGB has been best documented to produce and maintain
Fig. 35.1e
Fig. 35.1a
) provide excellent weight loss and high rates of
), sleeve gastrectomy (.
Fig. 35.1b
), and
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_35, © Springer-Verlag Berlin Heidelberg 2016
Section II • Esophagus, Stomach, and Duodenum
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bypass liner (Endobarrier; GI Dynamics; Lexington, MA, USA), need to prove their long-term eciency and safety in larger studies at high-volume bariatric centers before they can be adopted widely.
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Indications
Contraindications
. Fig.35.1
Indications and Contraindications
Patients with ineective dietary attempts for weight control and
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BMI > 40 kg/m2 or
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BMI > 35 kg/m2 with weight-related comorbidity
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Age < 16 and > 60years (these are relative contraindications)
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Obesity history < 3 years
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Unacceptable operative risk
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Active gastric or duodenal ulcer
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Active inammatory bowel disease
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Moderate/severe portal hypertension
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Pregnancy
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Untreated endocrine disorders
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Unstable severe psychiatric disorders (psychosis, uncontrolled depression, active substance
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abuse)
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Chapter • Operations for Morbid Obesity
Relative contraindications
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Preoperative Investigations/Preparation for the Procedure
Clinical
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Laboratory
Lack of family/social support
Borderline personality disorder
Physical examination (abdominal hernia, former abdominal surgery)
Phenotype of obesity: androgenic (central obesity) versus gynecoid (peripheral obesity)
(note: male/androgene phenotype and BMI > 50 are associated with increased pre- and
perioperative morbidity)
Electrocardiography (ECG), pulmonary function tests (if necessary), sleep study if symp-
toms suggest sleep apnea, and detailed cardiac evaluation if necessary (echocardiography,
functional cardiac scintigraphy)
Nutritional and metabolic parameters
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Hormonal parameters
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Upper GI examinations
Gastroscopy in selected patients, esophageal manometry in patients with gastroesophageal
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reux disease if a restrictive procedure is to be performed (gastric banding, sleeve gastrec-
tomy)
Radiology: upper GI studies for reoperative surgery and especially aer failed gastric band-
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ing (reux, esophageal dysmotility, pouch dilation, band erosion?)
Anthropometry/body composition (optional)
Bioimpedance analysis
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Calorimetry
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Psychologic evaluation
Exclude psychosis (rare), severe uncontrolled depression, active substance abuse, or border-
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line personality disorder
Establish psychiatric care if necessary
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Procedures
Roux-en-Y gastric bypass
RYGB is the most commonly performed bariatric procedure worldwide. e eect of the RYGB
consists of restriction, selective malabsorption, and hormonal changes. Most commonly, an antecolic, antegastric route is used. e anastomosis technique can be circular or linear stapled construction. We describe the circular stapled (21/25) technique for the gastro-jejunal anastomosis,
but a linear stapler or a hand-sewn technique can be used as well.
Section II • Esophagus, Stomach, and Duodenum
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Step1
Positioning of the patient and access
e patient is placed in the lithotomy position in steep reverse Trendelenburg tilt with arms positioned upwards. e operating surgeon stands between the legs, rst assistant on the le, and
second on the right side of the patient. Two monitors are placed at the head of the bed. Aerwards,
seven trocars are inserted (. Fig. 35.2):
1. One 5 mm in the midline distal to the xiphoid for the liver retractor
2. One 10/12 mm on the right in the mid-clavicular line 10 cm caudal to the costal arch for the
linear cutter, grasper, and Ultracision shears (Ethicon; Cincinnati, OH, USA)
3. One 10/12 mm in the midline 15 cm caudal to the xiphoid for the optic port
4. One 10/12 mm on the le in the mid-clavicular line just distal to the costal arch for the linear
cutter, grasper, needle holder, and Ultracision
5. One 10/12 mm on the le in the mid-clavicular line 15 cm caudal to the costal arch for the
linear cutter, grasper, needle holder, and Ultracision
6. One 5 mm on the right in the mid-clavicular line 15 cm caudal to the costal arch for the grasper
and Ultracision
7. One 5 mm on the le in the extended anterior axillary line for the grasper
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. Fig.35.2
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Chapter • Operations for Morbid Obesity
Step2
Division of stomach and creation of proximal gastric pouch
e le lobe of the liver is retracted with a liver retractor inserted in the upper 5 mm midline
port. On occasion, a paddle liver retractor may be necessary, requiring insertion via a right upper
abdominal 12 mm port. Using the Ultracision shears, a window is created 3–4 cm distal to the
esophagogastric junction along the lesser curvature close to the gastric wall to avoid injury to the
vagus nerves.
e stomach is then transected using a linear stapler device (blue/purple cartridge, 3.5-mm
staples). e stapler device is rst applied transversely and then vertically heading up to the angle
of His until the stomach is completely divided. e dissection of the fat pad at the angle of His
before transection is not always necessary, but it may help in dicult exposures and is necessary
when there is a large fat pad. To ensure a small proximal gastric pouch of 20 mL, a calibration
tube/balloon lled with 20-mL saline can help dene the site of the transection line (
Be certain, however, to remove any nasogastric tube.
. Fig. 35.3).
. Fig.35.3