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Fig. 10 Creation of a
gastrojejunostomy
following subtotal
gastrectomy (A alimentary
limb, B gastric pouch)
Fig. 11 Completed
gastrojejunostomy (A liver,
B gastric pouch, C
alimentary limb)
E. Chuang et al.
2.4.2 Laparoscopic Total Gastrectomy
1. To begin the surgery, the surgeon performs a complete omentectomy that extends
from the hepatic exure to the inferior pole of the spleen and enters the omental
bursa (Fig.12). In patients with gastric cancer, the surgeon may perform a splenectomy. Following this, distal gastric dissection is initiated.
2. First, the surgeon identies and ligates the right gastroepiploic and gastric ves-
sels at their origin. It is then necessary to kocherize and divide the duodenum
using a linear stapler (Fig.13). The stapler is red twice, once on the pylorus and
once 1–2cm distal to the pylorus on the duodenum (Fig.2). After transecting the
stomach distally, the assistant retracts the stomach upward and anteriorly.
3. Adhesions between the posterior gastric wall and the peritoneum overlying the
pancreas could be seen and should be removed. This approach optimizes visualization of the celiac axis and the left gastric artery. The left gastric artery should
be ligated and divided at its origin (Fig.14).
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Fig. 12 Omentum
dissected away from
transverse colon (A
omentum, B colon)
Fig. 13 Division of the
duodenum with endoscopic
linear stapler (A liver, B
falciform ligament, C
antrum)
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Fig. 14 Left gastric artery
identied and transected
with vascular stapler load
(A caudate lobe of liver, B
left gastric artery)
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E. Chuang et al.
4. The esophagus is mobilized, starting by opening the gastrohepatic ligament
(Fig.15). At this time, the surgeon must check for a replaced left hepatic artery.
If the artery is present, it must be ligated and divided. Once the right crus is
identied, the phrenoesophageal ligament is incised (Fig.16). This begins the
mediastinal dissection, which is carried circumferentially towards the left crus
using blunt dissection. Once a retro-esophageal window is made, the esophagogastric junction is encircled with a Penrose drain for retraction (Fig.17). The
mobilization should be carried as high into the mediastinum as possible to gain
intra-abdominal esophageal length. Once the hiatal dissection is completed, the
surgeon will identify the vagus nerves and perform a bilateral truncal vagotomy.
5. The case continues with a Roux-en-Y reconstruction. The jejuojejunostomy and
closure of the mesenteric defect are done using similar techniques as the one
described above for a subtotal gastrectomy. The length of the limbs vary per
surgeon preference, but in general the biliopancreatic limb is approximately
Fig. 15 Gastrohepatic
ligament incised (A liver, B
gastrohepatic ligament)
Fig. 16 Right crus
dissection. Begin to
mobilize esophagus (A
caudate lobe of liver, B
right crus, C esophagus)
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Fig. 17 Esophagus
following posterior tunnel.
360° control obtained and
caudad retraction applied
to penrose (A caudate lobe
of liver, B right crus, C
penrose drain around GE
junction, D stomach)
Fig. 18 Division of the
esophagus; note preplaced
stay sutures at 3 and 9
o’clock position to
maintain intra-abdominal
esophagus length (A
transected proximal
esophagus, B stay suture)
219
30cm in length and the alimentary limb is at least 60cm in length to prevent
bile reux.
6. Then to the left of the middle colic artery, a 3cm incision is made in the avascu-
lar portion of the transverse mesocolon to pass the stapled end of the jejunum
through the incision up to the esophagus. In order to prevent herniation through
the mesenteric defect, it is necessary to suture the mesenteric defect to the jejunal wall.
7. The surgeon then proceeds to choose a site on esophagus wall to divide, at least
6cm away from the proximal margin of tumor. Prior to transection, two stay
sutures are placed at the 3 and 9 o’clock positions to prevent the esophagus from
retracting into the chest. The esophagus is transected with a linear stapler
(Fig.18). Alternatively, it can be occluded with umbilical tape. To remove the
specimen, one can extend the 10mm port incision to up to 5 cm, and insert a
hand-assisted port. It is sent for a frozen section of both margins to conrm negative margins prior to the reconstruction.
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8. Esophagojejunostomies are commonly performed using one of three approaches:
end-to-side hand-sewn, circular stapled, or linear stapled. In the circular stapled
technique, the alimentary jejunal limb is laid adjacent to the stapled end of the
esophagus and the blind end is opened. The anvil is passed trans-orally, and the
stapler is passed trans-abdominally and into the cut end of the alimentary end.
The stapler and anvil are mated through the wall of the jejunum and the anastomosis is created (Fig.19). The remaining jejunal stump is then resected with a
linear stapler (Fig.20). Stay sutures are placed on either side of the anastomosis
to relieve tension. A nasogastric tube is passed carefully through the anastomosis
and a leak test is then performed (Fig.21).
Complications
In both subtotal and total gastrectomy, reconstruction is often required. The complications of gastrectomy are dependent on a multitude of factors including extent of
gastrectomy and the chosen method of reconstruction. There are two broad
Fig. 19 Esophagojejunostomy created with circular
stapler after passing anvil
via transoral route (A
esophagus, B mated
stapler, C jejunum)
Fig. 20 Completion of the
esophagojejunostomy with
transection of the jejunal
stump (A alimentary limb,
B esophagojejunostomy, C
jejunal stump)
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Fig. 21 Completed
esophagojejunostomy—
nal aspect (A caudate lobe
of liver, B esophagus, C
jejunum)
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categories of complications following gastrectomy, those involving the anastomosis
and those involving dysmotility. Related to the anastomosis, there can be a leak,
stricture, obstruction, afferent and efferent loop syndrome, jejunal intussusception,
internal hernia, and marginal ulcer. Related to dysmotility, there can be rapid transit,
dumping syndrome (early and late), postvagotomy diarrhea, slow transit, gastric
stasis, bile reux, alkaline gastritis, roux stasis syndrome and gallstone formation.
After subtotal gastrectomy, a Billroth I reconstruction creates an anastomosis
between the remaining stomach to the duodenal stump in an end to end fashion.
This conguration leads to higher rates of retrograde biliary reux into the gastric
remnant which can cause alkaline gastritis. Dumping syndrome is also a concern as
stomach contents move rapidly through the remnant.
Alternatively, a Billroth II creates an anastomosis between the remaining stomach and a loop of proximal jejunum in an end to side fashion, thereby bypassing the
duodenum, and creating an afferent limb from the duodenum and efferent limb distally. Billroth II decreases the anastomotic tension as well as incidence of bile reux
and dumping, however, due to bypassing the duodenum, Billroth II can lead to malabsorption especially of fat-soluble vitamins. Due to susceptibility to scarring at the
gastrojejunal anastomosis, a stricture may also form. Esophagitis may also be a
complication.
The Roux-en-Y has lower rates of biliary reux compared to Billroth I and
II.However, there are concerns for dumping and Roux stasis syndrome due to gastric atony from transection of the jejunum. Long term complications with the remnant include marginal ulcer, remnant cancer, and nutritional deciencies.
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3 Gastrointestinal Stromal Tumors (GISTs)
3.1 Perioperative Work-Up
The initial work up of the GIST is dependent upon its size. For GISTs smaller than
2cm, EUS-FNAB or EUS-core needle biopsy can guide management. If there are
no high-risk features, then surveillance should sufce. For small GISTs with highrisk features, a complete resection should be planned. In terms of imaging, GISTs
smaller than 2cm require CT abdomen/pelvis with contrast or MRI abdomen pelvis
with contrast. For larger GISTs, the same imaging is ordered with the addition of a
CXR or CT chest to assess for distant metastasis.
GISTs can also be placed into three broad categories after initial screening that
is then used to guide treatment. Those that are 1 resectable with minimal morbidity
should undergo complete surgical resection; those that are 2 resectable with signicant morbidity or are 3. unresectable should complete neoadjuvant therapy, biopsy,
molecular testing and risk stratication.
3.2 Nonoperative Management
The main treatment modality when it comes to nonoperative management for GISTs
is treatment with a tyrosine kinase inhibitor (TKI), most commonly imatinib, and
close follow-up with imaging. Efcacy is tracked through PET/CT after starting
TKI and diagnostic abdomen/pelvic CT or MRI with contrast every 2–3months.
Imaging frequency is based on patient response to treatment.
3.3 Indications forOperative Management
Operative management for GISTs generally have two goals in mind: with curative
intent for primary gastric GISTs or with palliative intent for more advanced disease.
Factors to be considered prior to surgery are size, site, and invasiveness. GISTs that
have invaded into adjacent organs would require en bloc resection to achieve negative margins, however GISTs rarely metastasize via lymphatic channels, so lymphadenectomy is not usually indicated unless there is a suspicious node in the vicinity.
Recent advancements in minimally invasive surgery have allowed surgeons to resect
GISTs laparoscopically with similar oncologic outcomes. Figures 3 and 4 show
possible resection and repair approaches for GISTs.
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3.3.1 Technique
Laparoscopic Gastric Wedge Resection
1. Gastric lesions far from the gastroesophageal junction and the pylorus can be
resected using laparoscopic stapled wedge gastric resections. However, during
surgery, it is essential to avoid manipulating the tumor, particularly for more
extensive lesions, to prevent tumor rupture. A preoperative gastroesophageal
endoscopy can help locate lesions and facilitate a targeted dissection, thereby
helping to minimize the risk of incomplete tumor removal. It is also essential to
thoroughly assess the surrounding tissue with intraoperative endoscopy to identify any suspicious areas and ensure the surgeon has removed the entire
tumor burden.
2. A laparoscopic linear stapler, designed for thicker gastric tissue, removes the
wedge of gastric tissue, including the tumor. Seromuscular stay sutures can be
used proximal and distal to the lesion to lift the anterior gastric wall for resection
(Fig.22). These sutures help to reposition the specimen margins while using the
stapler. Ultrasonic dissector or electrocautery can be used for more extensive
lesions. Closure of the gastrotomy can be accomplished by either a stapled closure or running suture (Fig.23).
3. Lesions on the posterior surface can be more difcult to resect. Techniques for
posterior lesions include total mobilization of the greater curve with elevation
and cephalad retraction on the stomach to expose the posterior gastric wall. This
is followed by resection techniques similar to those used for anterior lesions.
Alternatively, an anterior gastrotomy can be created over the endoscopically
localized lesion. An intraluminal staple line can be used for full-thickness resection of the tumor with the assistance of stay sutures placed through the gastrotomy. Closure of the anterior gastric incision follows. Depending on their
preference, the surgeon may oversew the staple line.
Fig. 22 A potential
laparoscopic approach to
GIST removal on the lesser
curvature of the stomach
using stay sutures
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Fig. 23 A potential
laparoscopic suture closure
approach of the stomach
after removal of GIST
from lesser curvature of
the stomach
E. Chuang et al.
4. By using intraoperative endoscopy, it is helpful to conrm complete resection
and ensure that the gastric lumen is not narrowed during surgery. A postoperative
endoscopy can help ensure staple line integrity.
3.3.2 Postoperative Management
The patient should be admitted and monitored postoperatively for complications,
including bleeding, leak, or infection. The patient should also be provided with
appropriate pain management and education regarding lifestyle modications.
In general, the size and viability of the gastric remnant is to be considered when
determining postoperative diet. Post-gastrectomy patients should eat small, frequent
meals that are high in protein and low in carbohydrates to avoid worsening dumping. Vitamin and electrolyte supplementation should also be considered.
Postgastrectomy patients will need vitamin B12 supplementation, as patients with
Billroth II and Roux-en-Y may need to supplement fat soluble vitamins. Calcium
and iron can be supplemented on a case-by-case basis.
A leak from either staple line or anastomoses usually arises within the rst 7 to
10days. If a leak is suspected, a CT abdomen with oral contrast or Upper GI study
should be obtained. Once conrmed, patients should be started on broad- spectrum
antibiotics. Further management includes percutaneous drainage if the leak is contained and the patient is stable. If the patient is unstable or the leak is not contained,
a return to the operating room for washout/drainage and revision of the anastomosis
is warranted. A duodenal stump leak is one of the more serious complications following Billroth II or Roux-en-Y procedure. In this case, the surgeon may also opt
for inserting a tube duodenostomy.
There is a paucity of randomized trials regarding postgastrectomy surveillance,
however consensus-based guidelines from NCCN indicate that monitoring for
nutritional deciencies is key. Close follow-up 2–3 times in the rst 2years, 1–2
times up to 5years, and then annually is generally sufcient.
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In terms of imaging, CT chest/abdomen/pelvis is indicated based on extent of
disease burden. For late stage tumors that required neoadjuvant or adjuvant therapy,
CT chest/abdomen/pelvis 1–2 times for the rst 2years is indicated then annually
for up to 5years.
Some clinicians will check tumor markers, especially CEA. However this is controversial as there is no data to suggest that this contributes to improved overall
survival. For patients who underwent a partial gastrectomy, surveillance endoscopy
is performed 1–2 times a year for the rst 2years.
4 Conclusions
Developments within the last decade have enabled surgeons to treat gastric malignancies through minimally invasive means both safely and effectively. Given the
advantages in terms of surgeon ergonomics and patient recovery, it should be anticipated that more surgeons will elect to perform oncologic gastric resections laparoscopically and robotically.
Acknowledgement This chapter has preserved sections from a previous edition entitled “Gastric
and Duodenal Surgery” written by Patrick J. Shabino MD, Jad Khoraki MD, and Guilherme
M.Campos MD, FACS.
Disclosures The authors are accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are appropriately investigated and
resolved. The authors have no conicts of interest or nancial ties to disclose.
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