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■ ExaminethelessercurvatureofthestomachtoidentifythenerveofLatarjet (FIG12).

■ Dissect6to7cmproximaltothepylorusalongthelessercurvatureofthe stomachattheincisuraangularis.Itiskeytoleavetheterminalbranchesof thenerve,referredtoas“crow’sfoot,”tomaintaininnervationtotheantrum andpylorus(FIG13).

■ Dividethelesseromentumfromthelessercurvefromtheincisuraangularisand continuetodividethevagalbranchesto6cmproximaltotheGEjunction. Stayinsidethemainvagalbraches.

■

Clampanddivideneurovascularbranchesalongthelessercurveascloseto thestomachaspossibletoavoidinjurytothenerveofLatarjet(FIG14).

■ Thereisananteriorandposteriorbundleandtheyshouldbedivided separately.

■ InvertthelessercurvatureofthestomachwithinterruptedLembertsutures.

HemostasisandClosure

■ Midlineisclosedinusualstandardfashion.

■ Laparoscopicportscloseinusualstandardfashion,withfascialclosureforport sitesgreaterthan5mm.

PEARLSANDPITFALLS

Indications ■InpatientswithevidenceofactiveH.

pyloriinfection,treatmentoftheulcer

complicationandantihelicobactertherapy maybesufficient.

■WhentheoperativeindicationisGI

bleeding,thesurgeonshouldverifyifthe bleedingsourceisinalocationassociated withahighacidstatesuchasthe duodenumorprepyloricstomach.

Exposure ■Takecautionwhenencirclingthe

esophagusanddissectingthevagusoffof theesophagustopreventinjury.

■Avoidtheuseofcauterywhendissecting

thevagalfibersawayfromthe esophagealsurface.

Vagotomy ■Tenpercentofpatientswillhavemore

thanoneanteriororposteriorvagal trunks;caremustbetakentolookfor additionalfibersafterdivisionofthefirst trunk.

■Alwayssendasectionoftheexcised

vagaltrunktopathologytoverifythat nervoustissuewasexcised.

■Mostulcerreoccurrencesresultfrom

incompletevagotomy.

■Caretoresectabovethecriminalnerveof

Grassi(FIG15)

■Injurytothoracicductintransthoracic

approach

Drainage procedure

■Adrainageprocedure,apyloroplasty,

gastrojejunostomy,orantrectomyshould alwaysbecombinedwithatruncal

vagotomyasuptoone-thirdofpatients willdevelopgastricstasisaftervagotomy alone.

Paraesophageal herniation

■Inspecttheesophagealhiatusatthe

conclusionoftheproceduretoverifythat aniatrogenicparaesophagealherniahas notbeencreated.

POSTOPERATIVECARE

■ Nasogastricsuctionmaybeusedintheearlypostoperativeperiod.Inpatient whohasundergonegastricdrainageprocedureorperforationrepair, postoperativeileusmaylastaslongas7to10days.

■ Consistentwithotherforegutsurgery,dietadvancementisastolerated.

■ Intolerancetodietshouldpromptinvestigationfordelayedgastricemptying.

■ Inpatientsoperatedonforperforatedulcers,broad-spectrumantibiotictherapy includingantifungalagentsshouldbeadministeredpostoperatively.

■ PatientswhoarefoundtobeH.pyloripositiveshouldreceive10to14daysof antibiotictherapydirectedatH.pylorieradication.Eradicationshouldbe confirmedbyrepeattesting.

■ Patientsoperatedonforbleedingshouldbecarefullymonitoredforrebleeding forupto96hours.

■ PatientschronicallyusingNSAIDSoraspirinproductsshouldbecounseledto avoidfurtheruseofthesemedications.Patientswhoaremedicallyunableto discontinuethesedrugsshouldbestartedonaPPI.

■

Transthoracicpatientsshouldbemonitoredwithdailychestradiographsuntilthe chesttubeisremovedappropriately.

OUTCOMES

■

Vagotomy

■

Truncalvagotomyhasdemonstrated80%reductioninbasalacidsecretion.

■ Truncalvagotomyhasthelowestreoccurrencerates(1%to10%)buthavethe highestmorbidity(20%to25%)andmortality(0.5%to2%).

8,9

Ulcer recurrenceratesalsovarybasedondrainageprocedure,withbestresults fromtotalvagotomywithantrectomy.

■ Commonpostoperativemorbidityincludesdiarrhea(10%to25%),dumping syndrome(10%to20%),andbilerefluxgastritis(2%).

8,9

■ Vagal-mediatedreceptiverelaxationofthestomachisabolished;theremaybe morerapidemptyingofliquidsandsolids.

■

HSV

■ Lowermortalityandmorbidityincludingdiarrheaanddumpingsyndrome (1%to5%).

■ Higherulcerrecurrencerates,greaterthan10%at5years.

■ Vagal-mediatedreceptiverelaxationofthestomachisabolished,and therefore,thereismorerapidemptyingofliquids.However,with preservationofantruminnervation,emptyingofsolidsisunaffected.

COMPLICATIONS

■ Esophagealperforation

■ Bleeding

■ Incompletevagotomy—failuretoidentifyaccessoryvagusnerves.Vagusmust betakenproximaltothecriminalnerveofGrassi,thefirstgastricbranchof theposteriorvagus.

■ Delayedgastricemptying

■ Dumpingsyndrome

■ Pleuraleffusion

REFERENCES

1.NgEK,LamYH,SungJJ,etal.EradicationofHelicobacterpyloripreventsrecurrenceofulcer aftersimpleclosureofduodenalulcerperforation:randomizedcontrolledtrial.AnnSurg. 2000;231(2):153–158.

2.WangYR,RichterJE,DempseyDT.Trendsandoutcomesofhospitalizationsforpepticulcer diseaseintheUnitedStates,1993to2006.AnnSurg.2010;251(1):51.

3.LagooJ,PappasTN,PerezA.Arelicorstillrelevant:thenarrowingroleforvagotomyinthe treatmentofpepticulcerdisease.AmJSurg.2014;207(1):120–126.

4.RamakrishnanK,SalinasRC.Pepticulcerdisease.AmFamPhys.2007;76:1005–1012.

5.SchroderVT,PappasTN,VaslefSN,etal.Vagotomy/drainageissuperiortolocaloversewin patientswhorequireemergencysurgeryforbleedingpepticulcers[publishedonlineaheadofprint December23,2013].AnnSurg.

6.SkandalakisJE,RoweJSJr,GraySW,etal.Identificationofvagalstructuresattheesophageal hiatus.Surgery.1974;75(2):233–237.

7.AshleySW,EvoyD,DalyJM.Stomach.In:SchwartzSI,ed.PrinciplesofSurgery.7thed.New York,NY:McGraw-Hill;1999:1181.

8.YeoCJ,McFaddenDW,PembertonJH,etal.Shackelford’sSurgeryoftheAlimentaryTract.7th ed.Philadelphia,PA:ElsevierHealthSciences;2012:720–730.

9.LeeCJ,SimeoneDM.Gastriculcer.In:GeneralSurgery:PrinciplesandInternationalPractice. 2nded.London,UnitedKingdom:Springer;2009:539–548.

Chapter17

DrainageProcedures: Pyloromyotomy, Pyloroplasty, Gastrojejunostomy



GeorgeA.SarosiJr.

DEFINITION

■ Drainageprocedures,ormoreproperlygastricdrainageprocedures,areavariety ofsurgicalapproachesusedtoeitherrenderincompetentorbypassthe pylorus.Drainageproceduresareoftenperformedinconjunctionwith proceduresthatinterruptvagalinnervationofthepylorus,andthepurposeis tofacilitategastricdrainage.Originallyperformedinconjunctionwitha truncalvagotomyforthetreatmentofpepticulcerdisease,drainage proceduresarealsoperformedtofacilitategastricemptyingwhenthestomach isusedasanesophagealreplacementandoccasionallytoaddresspoorgastric emptyinginpatientswhohaveundergonefundoplicationorparaesophageal herniarepair.Gastrojejunostomyisalsofrequentlyusedtotreatduodenalor gastricoutletobstruction.

DIFFERENTIALDIAGNOSIS

■ Inpatientswhohaveundergonepriorgastroesophageal(GE)junctionsurgery, thedifferentialdiagnosisforabdominalbloatingincludesvisceral hypersensitivity(irritablebowelsyndrome[IBS]),gastroparesis,postsurgical delayedgastricemptyingsecondarytovagalinjury,paraesophagealherniation

ofthefundoplicationorportionsofthestomach,andovereatingorexcess consumptionofinappropriatefoodssuchascarbonatedbeverages.

■ Inpatientswhohaveundergoneesophagealreplacementwithagastricconduit, thedifferentialdiagnosisofdysphagia,earlysatiety,orregurgitationof undigestedfoodsincludesanastomoticstructure,aninadequate-sizedhiatal opening,torsionoftheconduit,paraesophagealhernia,andcompetent pylorus.

PATIENTHISTORYANDPHYSICALFINDINGS

■ Dependingontheindicationforadrainageprocedure,certainhistoricalelements andphysicalfindingsshouldbesought.

■ Forpatientswithpepticulcerdisease,thedurationofsymptomsandanyprior treatmentofpepticulcerdiseaseshouldbesought.Inaddition,knowledge ofthepatients’HelicobacterpyloristatusandpriorH.pyloritreatmentis important.Finally,ahistoryofuseofnonsteroidalantiinflammatorydrugs (NSAIDs)oraspirinproductsshouldbesought.

■ Inpatientswithapriorhistoryofpepticulcerdiseasewhoareundergoing surgicaltreatmentofableedingulcer,ahistoryofpriorulcerdisease shouldalertthesurgeontothepossibilityofencounteringascarredand possiblyfibroticduodenum.

■ PatientsknowntobeH.pyloripositivewhohavenothadtreatmentfor theirH.pylorimaynotrequireanacid-reducingprocedureatthetimeof surgicalbleedingcontrol.Simpleligationofthebleedingsitemaybe sufficient.

■ PatientswithasignificanthistoryofNSAIDoraspirinproductuseareata significantriskofrecurrentulcersandmustbecounseledtoavoidall theseproductsinthefuture.

■ Forpatientsundergoingdrainageproceduresafteresophagealreplacement withagastricconduit,patientsshouldbequestionedcarefullyabouttheir symptoms.Patientswithpoorgastricdrainagewilldescribeearlysatiety, bloating,regurgitation,oremesisofundigestedfood.Patientswith anastomoticstricturestypicallywilldescribedysphagia.

■ Forpatientsundergoingorwhohaveundergoneafundoplication,ahistoryof postprandialabdominalpain,bloating,orearlysatietyshouldbesought,as thiscanbeasymptomofpoorgastricemptying,whichcanbeconfirmed withagastricemptyingstudy.

IMAGINGANDOTHERDIAGNOSTICSTUDIES

■ Inpatientsundergoingemergencyoperationsforuppergastrointestinal hemorrhage,allpatientsshouldundergoesophagogastroduodenoscopy(EGD) priortooperationwithanattemptatendoscopichemostasis.Theoperating surgeonshouldmakeeveryefforttobepresentduringtheendoscopy,as accurateanatomicinformationregardingthelocationoftheulcerwill facilitatetheoperation.

■ Inpatientssuspectedofhavingpooremptyingoftheirgastricconduitafter esophagealreplacement,gastricemptyingstudiesareoflimiteduseduetothe alteredanatomyandthelackofreferencevaluesforemptying.Theauthorhas usedEGDandbotulinumtoxininjectionasadiagnostictestforpatientswith pooremptyingoftheconduit.1Thosewhohaveanimprovementinsymptoms havebeenofferedsurgicaldrainageprocedures.

■ Inpatientswithpriorfundoplicationorparaesophagealherniarepairsuspected ofhavingdelayedgastricemptying,nuclearmedicinegastricemptying studiesarehelpfulinidentifyingpatientswhocouldbenefitfromadrainage procedure.Hamricketal.,2inalargeseriesofrevisionalparaesophageal herniapatients,usedaT1/2emptyingtimeof90minutesasanindicationfor

theadditionofagastricdrainageprocedurewithgoodresults.Alternatively, EGDandbotulinumtoxininjectionofthepyloruscanalsobeusedasa diagnosticstudy.

SURGICALMANAGEMENT

PreoperativePlanning

■ Patientsundergoingdrainageprocedureswillhavepoorgastricemptyingand willbeatriskforaspirationduringinductionofanesthesia.Forelective procedures,patientsshouldbeplacedonaclearliquiddiet24hourspriorto surgeryandmadeNPOthenightbeforetheprocedure.Patientsundergoing emergencysurgeryforpepticulcerbleedingwillhaveastomachfullofblood andareatsignificantriskofaspiration.Wheneverfeasible,rapidsequence inductionshouldbeused.Antibioticprophylaxiswith1to2gofcefazolinis thestandardapproach;clindamycinplusafluoroquinoloneoraminoglycoside istheappropriatechoiceforthosepatientswithallergiestocefazolin.When performinganemergencyoperationforbleeding,thesurgeonshouldensure thatbloodiscrossmatchedandavailable.Forlaparoscopicprocedures,having theabilitytoperformintraoperativeEGDcanfacilitatetheidentificationof thepylorusandbleedingsourceindifficultcases.

Positioning

■ Foropendrainageprocedures,thepatientispositionedinthesupineposition withbotharmsextended.Spaceisleftonthepatient’sleftsidetoattacha BuchwalterorOmniretractortothebedrail.Duringthesurgicalprocedure, thepatientwilloftenbeplacedinreverseTrendelenburgtofacilitateexposure oftheupperabdominalorgans.Inalaparoscopicapproach,thesameposition isused,butafootboardandsafetystrapshouldalsobeaddedtopreventthe patientfromslidingwhensteepreverseTrendelenburgpositionisused.

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