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Minimally Invasive Treatment ofUlcer
https://t.me/med1917
Disease: Laparoscopic Graham Patch,
Laparoscopic Vagotomy andAntrectomy
ChristianAdkisson andDavidWeithorn
1 Indications
The treatment of peptic ulcer disease (PUD) has profoundly changed with the discovery of H. pylori and acid suppression medications. Despite these major advances
in treatment of PUD, the annual incidence of complicated PUD (bleeding, perforation, ulcer penetration, and gastric outlet obstruction) is still common at 71 cases per
100,000 individuals. Laparoscopic Graham patch has become the preferred treatment modality over the open surgical approach for small perforated duodenal ulcers
due to lower mortality, decreased wound infections, improved pain control, and
shorter hospital stay [1–3]. The main contraindications to the laparoscopic approach
are inability to tolerate pneumoperitoneum and ongoing intraoperative hemodynamic instability.
Prior to medical advancements, PUD was often treated denitively with truncal
vagotomy and antrectomy. Though infrequently performed now, a select cohort of
patients who are either NSAID dependent, unable to take proton pump inhibitors,
have severe refractory disease despite optimal medical therapy, or have gastric outlet obstruction would benet from vagotomy with antrectomy. The major advantages to performing an antrectomy are denitively ruling out malignancy, relieving
gastric outlet obstruction, and removing all gastrin secreting G cells. However,
antrectomy patients experience more postoperative side effects such as dumping,
diarrhea, delayed gastric emptying, and early satiety. Alternative operations that
avoid these side effects are the highly selective vagotomy or truncal vagotomy with
pyloroplasty.
C. Adkisson (*) · D. Weithorn
Monteore Medical Center, Bronx, NY, USA
e-mail: christian.adkisson@einsteinmed.edu; daweitho@monteore.org
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_19
227© The Author(s), under exclusive license to Springer Nature
228
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C. Adkisson and D. Weithorn
2 Preoperative Preparations
Patients presenting with perforated peptic ulcers should be treated following the
surviving sepsis guidelines [4]: broad spectrum antibiotics, aggressive intravenous
hydration with crystalloid uid, foley placement for accurate urine output, and
nasogastric decompression. Following adequate resuscitation, the patient should be
taken to the operating room for denitive source control [5].
Patients that present for elective antrectomy with vagotomy in the setting of gastric outlet obstruction will need correction of any electrolyte derangements preoperatively. In cases of severe malnutrition, preoperative nutritional support should be
administered prior to proceeding with surgery.
3 Positioning
The patient is placed in the supine position with arms out. Use of a footboard is
recommended. The split-leg (French) position is also suitable for these operations.
4 Description oftheProcedure
4.1 Laparoscopic Graham Patch
The abdomen should be safely entered as per surgeon preference. Insufation to
15mmHg with CO2 is performed as tolerated. Three additional ports will be inserted
(Fig.1). A Nathanson liver retractor can also be used for better exposure. All spilled
enteric contents are then suctioned free from the peritoneum. The stomach and duodenum are carefully inspected. Simultaneous upper endoscopy may facilitate identication of the ulcer. When the perforated ulcer is identied, it should be roughly
measured as ulcers >2cm require more complex repairs. Attempts at primary closure of perforated duodenal ulcers should be avoided as the edges are often friable
leading to suture pulling through the tissue and further enlarging the perforation.
Additionally, primary closure risks luminal narrowing in a likely already scarred
segment of intestine.
A healthy tongue of omentum is then created and mobilized using a bipolar
energy device. This is brought up to the ulcer in a tension free manner. The omental
patch is secured to the ulcer in a similar fashion to that popularized by Roscoe
Graham using three interrupted 2-0 nonabsorbable or slowly absorbable braided
sutures through healthy duodenum (Fig.2). This author often uses three different
colored sutures for easier identication while tying. Use of absorbable barbed suture
is also popular and obviates the need for knot tying. The sutures are tied intracorporeally to adequately oppose the omentum to the ulcer without strangulation (Fig.3).
RL
Minimally Invasive Treatment of Ulcer Disease: Laparoscopic Graham Patch…
https://t.me/med1917
Fig. 1 Port placement for
laparoscopic graham patch:
white (primary surgeon
working ports), red
(camera port), and gray
(Nathanson retractor). An
additional left sided port
can be placed for assistant
retraction
Fig. 2 Perforated
duodenal ulcer. Suture
placement depicted by gray
circles
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Fig. 3 Completed Graham
patch
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C. Adkisson and D. Weithorn
A leak test is performed with an upper endoscopy. After completion of a satisfactory
repair, the entire abdomen and pelvis is thoroughly irrigated and suctioned to
remove any residual enteric spillage. Finally, a 19Fr round drain is placed adjacent
to the Graham patch repair and exiting out of the right lateral port site. The drain is
secured in place with a nylon suture and all remaining port sites are closed with a
subcuticular absorbable suture and skin glue.
4.2 Laparoscopic Truncal Vagotomy andAntrectomy
The port placement is similar to the laparoscopic Graham patch apart from upsizing
one of the working ports to accommodate a laparoscopic stapler. Identication of
the anterior vagal trunk is achieved after opening the gastrohepatic ligament and
clearing the peritoneum overlying the abdominal esophagus. The esophagus will
need to be mobilized 4–5cm proximally. The anterior vagus nerve is dissected free
(Fig. 4) and clipped and divided at approximately 4 cm proximal to the gastroesophageal junction (GEJ). A small portion (2cm) is resected and sent to pathology
for conrmation of neural tissue and to prevent neuroregeneration. The posterior
trunk is then identied after opening the phrenoesophageal ligament at the level of
the right crus. Similarly, this is divided 4cm above the GEJ, and a segment is sent
to pathology.
Selective vagotomies are performed to theoretically decrease the incidence of
postvagotomy diarrhea and gallbladder stasis by dividing only the gastric innervation and sparing the input to the gallbladder and intestine. The procedure is performed similarly to the truncal vagotomy except that the anterior vagus is divided
distal to the takeoff of the hepatic branches and the posterior vagus is divided distal
to the takeoff of the celiac branches. However, studies fail to show a signicant difference in postoperative side effects compared to truncal vagotomies and it still
Fig. 4 Dissection of the
anterior vagus nerve
(arrows) at the level of the
hiatus
Minimally Invasive Treatment of Ulcer Disease: Laparoscopic Graham Patch…
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231
requires a drainage procedure such as an antrectomy or pyloromyotomy. It is therefore not a preferred procedure. A highly selective vagotomy (or parietal cell vagotomy) is the third option for refractory peptic ulcer disease. It is technically more
demanding, as it involves transecting the proximal anterior and posterior nerves of
Latarjet and sparing the innervation to the antrum and pylorus, i.e. the “crow’s feet.”
It has been shown to have a higher recurrence rate of pre-pyloric and pyloric ulcer
disease, so is also not favorable for complicated PUD [6, 7].
When performing the antrectomy, the right gastric and right gastroepiploic arteries are then identied and ligated at the level of the incisura. The stomach is divided
at this point with a laparoscopic thick tissue staple load. The stapled end of the
antrum is retracted medially. The antrum is freed from the gastrocolic and gastrohepatic ligaments. Careful dissection is continued to the rst portion of the duodenum.
The duodenum is divided with laparoscopic linear staple load. Gastrointestinal continuity is obtained with a Billroth I or II reconstruction. The specimen is removed
and sent to pathology. The staple lines are reinspected for hemostasis and signs of
bile staining (from the duodenal stump) prior to abdominal closure.
Alternatively, a Heineke–Mikulicz pyloroplasty can be performed as a drainage
procedure rather than antrectomy in patients without gastric outlet obstruction. A
full thickness gastrotomy is made and carried through the pylorus longitudinally
(Fig.5) onto the rst portion of the duodenum. The stomach is then closed transversely in two layers, rst with full thickness bites (Fig.6) followed by a lembert
second layer. This author prefers slowly absorbable 2-0 barbed suture for both layers. It is helpful to place an interrupted stitch at both apices of the incision to retract
the pyloromyotomy transversely while closing. Routine Kocherization of the duodenum is not required, but may be necessary in select cases to take tension off of the
transverse closure.
Fig. 5 Longitudinal full
thickness opening of
pylorus extending to the
rst portion of the
duodenum
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Fig. 6 The pyloromyotomy is closed
transversely in two layers
C. Adkisson and D. Weithorn
5 Postoperative Care
5.1 Laparoscopic Graham Patch
Postoperatively, patients remain NPO with nasogastric decompression. Broad spectrum antibiotics are continued for 5days postoperatively. Patients are also empirically treated for H. pylori. The nasogastric tube is removed upon return of bowel
function or other clinical parameters. 24h following resumption of a normal diet the
drain is removed provided the output and consistency remains benign. Upper gastrointestinal uoroscopic studies should be performed selectively on patients with
clinical signs of a postoperative leak, as routine use prolongs hospital stay without
signicant increase in leak detection [8]. Lifelong avoidance of NSAIDs and smoking should be encouraged with all patients to minimize ulcer recurrence.
5.2 Laparoscopic Vagotomy andAntrectomy
Postoperatively, electrolytes should be closely monitored and replaced as those
patients with gastric outlet obstruction are at high risk for refeeding syndrome.
References
1. Chan KS, etal. A systematic review and meta-analysis comparing postoperative outcomes of
laparoscopic versus open omental patch repair of perforated peptic ulcer. J Trauma Acute Care
Surg. 2023;94(1):E1–E13.
2. Katkhouda N, etal. Laparoscopic repair of perforated duodenal ulcers: outcome and efcacy in
30 consecutive patients. Arch Surg. 1999;134(8):845–50.
Minimally Invasive Treatment of Ulcer Disease: Laparoscopic Graham Patch…
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3. Murad MF, et al. Laparoscopy: a better approach for perforated duodenal ulcer. Cureus.
2020;12(10):e10953.
4. Evans L, etal. Surviving sepsis campaign: international guidelines for management of sepsis
and septic shock 2021. Crit Care Med. 2021;49(11):E1063–143.
5. Tarasconi A, etal. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg
Surg. 2020;15(1):3.
6. Selking O, Krause U, Nilsson F, Thorén L.Parietal cell vagotomy and truncal vagotomy as treat-
ment of duodenal ulcer. A prospective randomized trial. Acta Chir Scand. 1981;147(7):561–7.
7. Jordan PH Jr, Thornby J.Should it be parietal cell vagotomy or selective vagotomy-antrectomy
for treatment of duodenal ulcer? A progress report. Ann Surg. 1987;205(5):572–90.
8. Poris S, etal. Routine versus selective upper gastrointestinal contrast series after omental patch
repair for gastric or duodenal perforation. Surg Endosc. 2018;32(1):400–4.
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Esophagectomy
https://t.me/med1917
MichaelJureller, JohnJay, andDhireshRohanJeyarajah
1 Introduction
An excellent chapter on the technique of esophagectomy was authored in the previous edition of the Illustrative Handbook of General Surgery by Drs. Ryan Macke
and Guilhermo Campos [1]. Much of their work warrants perseveration. We have
added some updates in the perioperative treatment as well as our technique of transhiatal esophagectomy and colon interposition grafting.
Esophagectomy is considered by many to be of the most complex and technically challenging gastrointestinal operations performed today. Resection of the
esophagus and proximal stomach followed by reconstruction to reestablish gastrointestinal continuity with a gastric pull-up or other conduit (colon or jejunal interposition) is a complex, multi-step operation that requires considerable attention to
detail. It is not only the operative technique which drives patient outcomes, but also
the preoperative preparation and postoperative inpatient management which is
linked to morbidity and rescue of the patient when needed. An understanding of the
surgical anatomy of the esophagus as it courses through the neck, chest, and
M. Jureller (*)
Division of General Surgery, Department of Surgery, NewYork University Long Island, New
York University Langone Medical Center, Mineola, NY, USA
e-mail: michael.jureller@nyulangne.org
J. Jay
Texas Cardiothoracic Surgery, Dallas, TX, USA
e-mail: johnjay@mhd.com
D. R. Jeyarajah
Division of General Surgery, Department of Surgery, Texas Christian University School of
Medicine and Methodist Richardson Medical Center, Richardson, TX, USA
e-mail: rohanjeyarajah@mhd.com
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_20
235© The Author(s), under exclusive license to Springer Nature
236
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abdomen is critical, as well as knowledge of the functional changes that occur with
this radical change in anatomy.
Esophagectomy is associated with signicant risk of morbidity and mortality. In
1941, Ochsner and Debakey reported a staggering mortality rate of 72% in one of
the earliest, large series of esophageal resections [2]. Fortunately, with improvements in surgical and anaesthetic technique, patient selection, nutritional support,
and critical care, mortality rates have declined signicantly. A review of 46,692
esophagectomies performed between 1980 and 1988 reported a decrease in mortality to 13% [3]. A hospital volume relationship has also been established, with mortality rates reported as high as 23.1% in “low-volume” centers and as low as 8.1%
in “high-volume” centers [4]. More recently, in 2009 an analysis of 2315 esophagectomies registered in the Society of Thoracic Surgeons’ General Thoracic
Database reported a mortality rate of 2.7% for patients treated primarily at tertiary
referral centers [5]. Minimally invasive approaches to esophagectomy have been
developed in hopes of further improving outcomes. Luketich and colleagues
reported a mortality rate of only 0.9% in a series of 1011 patients selected for laparoscopic and thoracoscopic esophagectomy [6].
Postoperative morbidity rates of 30–60% have been reported following esophagectomy [7]. The most common major complications are pulmonary in nature,
occurring in approximately 20–40% of patients, including pneumonia, empyema,
and respiratory failure [7]. Anastomotic leaks occur in roughly 10–20% of cases,
with varying degrees of severity and resulting morbidity [7, 8]. Other less common
major complications include pulmonary embolism, myocardial infarction, chylothorax, vocal cord palsy, gastric outlet obstruction and gastric conduit ischemic
complications. Common minor complications include supraventricular arrhythmias
and wound infections. Anastomotic strictures, delayed gastric emptying, and dumping syndrome are complications that occur in the late postoperative period. A technically sound operation, as well as attentive postoperative care and patient education
are crucial in order to minimize the risk of post-esophagectomy complications.
M. Jureller et al.
2 Indications
Esophagectomy is most commonly performed for the treatment of esophageal cancer. End stage achalasia, caustic ingestion injury are other benign indications.
Invasive adenocarcinoma and squamous cell carcinoma of the middle and distal
esophagus without evidence of metastatic disease are standard indications for
esophageal resection. Patients with evidence of locoregional nodal metastases,
tumors invading the muscularis propria (T2), and tumors invading into the periesophageal adventitia (T3) are typically offered neoadjuvant chemoradiation therapy prior to resection. Tumors invading surrounding structures (T4) that can be
completely resected, such as those invading the diaphragm, may also be considered
for resection following neoadjuvant therapy. Barrett’s esophagus with high-grade
dysplasia (HGD) was previously considered an indication for esophagectomy, as
Esophagectomy
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many older series reported presence of invasive cancer in the resected specimen in
as many as 50% of patients initially thought to only have HGD.However, with
improvements in endoscopic and imaging technology, endomucosal resection
(EMR) and/or radiofrequency ablation is now preferred over resection if the lesion
can be completely removed with negative margins [9]. In many instances, mucosal
(T1a) lesions are being considered for EMR and endoscopic submucosal resection
with acceptable resection margins and post-procedure disease free intervals [9–12].
Multi-focal HGD within a long segment of Barrett’s esophagus and HGD not amenable to complete endomucosal resection or ablation can be considered for esophagectomy given the increased risk for occult invasive carcinoma within the areas of
dysplasia. Esophagectomy may also be considered for palliation of unresectable
patients who are unable to tolerate oral/enteral intake or for those treated with denitive chemoradiation therapy that subsequently present with local recurrence.
However, only a select few are able to tolerate a procedure of this magnitude given
their debilitated state and higher risk of morbidity and mortality for what is commonly referred to as “salvage esophagectomy” [13]. Other less invasive therapies,
such esophageal stenting and photodynamic therapy, are often better options for this
patient population.
Though much less common, esophagectomy may be considered for the management of severe benign esophageal disease, such as end-stage achalasia, multiple
failed prior anti-reux procedures, strictures not amenable to dilation, and unrepairable esophageal perforations or those associated with underlying esophageal pathology (stricture, end-stage achalasia) [14]. The basic approach to esophagectomy
remains the same with the exception of omitting the celiac and mediastinal lymph
node dissection that is critical in patients undergoing resection for malignant
disease.
237
3 Preoperative Evaluation
Preoperative work-up should include a physiologic assessment of the patient to
determine their candidacy for resection, including cardiac risk stratication and
selective pulmonary function testing (i.e., heavy smokers, known chronic pulmonary disease). All cases of suspected cancer should have tissue diagnosis obtained
by biopsy with upper endoscopy. The proximal and distal extent of tumor, extent of
Barrett’s esophagus, and presence of other pathology should be noted. Signicant
extension of tumor beyond the cardia of the stomach may require a gastrectomy for
complete resection and colon interposition for reconstruction. Contrasted CT of the
chest, abdomen, and pelvis as well as a CT-PET scan. The use of endoscopic ultrasonography for staging is controversial [15, 16]. Lesions causing symptomatic dysphagia at typically at greater T2 which would require neoadjuvant therapy. Lesions
without adenopathy on cross-sectional imaging would be better targeted with endoscopic ultrasound to evaluate if the patient is a candidate for endoscopic resection or
upfront surgery rather than neoadjuvant therapy. The choice of neoadjuvant regimen
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