Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_1050_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

23 Мб

Скачать

☆

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 4647 / 5047 48 49 50 > Следующая >>>

LAPAROSCOPICPYLOROPLASTY

PortPlacementandLiverRetraction

■ Weuseastandardfour-trocarapproachforgastricprocedures,witha5-mmport intheleftupperquadrant,asecond5-mmtrocarjusttotheleftofthe umbilicus,a12-mmtrocarattheleveloftheumbilicusinthemidclavicular line,anda5-mmtrocarintherightupperquadrant.ANathansonliver retractorisplacedtoelevatetheleftlobeoftheliver(FIG11).

IdentificationofthePylorusandPyloricIncision

■ ThepylorusisidentifiedeithervisuallyorbyperforminganEGDwithCO

insufflation.Placinga3-0silkseromuscularstaysutureatthesuperiorand inferioredgeoftheduodenumatthelevelofthepyloruswillfacilitatetherest oftheoperation.Beginningroughly2cmproximaltothepylorusonthe

gastricantrum,incisethegastricwall,enterthelumen,andextendthe incisiondistallyparalleltothelongaxisofthebowelacrossthepylorusonto theduodenumtoatotaldistanceofroughly5cmusingtheelectrosurgical deviceoranultrasonicdissector(FIG12).

ClosureofthePyloroplasty

■ Theassistantgraspsthesuperiorstaysutureandappliescranialandleftward tractiontoconvertthelongitudinalincisionintoatransverselyoriented closure.Thesurgeonthenbeginsatthesuperioraspectoftheduodenumand beginstheclosure.Theeasiestmethodisarunningclosurewith3-0or2-0 silkorpolyglycolicsuture.Thesurgeonshouldrunthissuturetowardthe inferioraspectoftheduodenumstoppingabouttwo-thirdsofthewaydown. Alaparoscopicclipisplacedonthesuturetomaintaintensionwhilethe surgeonfocusesontheloweraspectoftheclosure.Asecondsutureisthen runfromtheinferioredgeofthepyloroplastytothemiddleandtiedtothe uppersutureafterfirstremovingtheclipfromthesuture.Theassistantcan facilitatethesuturinganglesbyretractingtheinferiorstaysuturecaudaland rightward.Analternativeapproachistoperformaninterruptedclosure.This

allowsformoreprecisesutureplacementbutrequiresmoreintracorporeal knottying(FIG13).Withaninterruptedclosure,alternatingsuturesfromthe eitherendandtyingafterplacingeachsutureallowsforprecisesuture placement.Thelastsuturewillbeplacedblindly,butiftheassistantapplies cranialtractiononthetailofthesuturejustsuperiortothelastone,itreduces thelikelihoodofback-wallingtheduodenum.Methylenebluecanbeplaced intothedistalstomachviatheEGDscopetoensurethepyloroplastyclosure iswatertight.

OmentalPatch

■ Theauthorthencoversthecompletedpyloroplastysuturelinewitha vascularizedpedicleofomentum,whichissecuredinplacebytyingthe superiorandinferiorstaysuturesoverthepedicleinthefashionofaGraham patch.Thisiseasiertoperformandlesslikelytonarrowthepyloricoutlet

thanasecondlayerofseromuscularsutures.

LAPAROSCOPICGASTROJEJUNOSTOMY

PortPlacement

■ Weuseastandardfour-trocarapproachformostgastricprocedures,witha5-mm portintheleftupperquadrant,asecond5-mmtrocarjusttotheleftofthe umbilicus,a12-mmtrocarattheleveloftheumbilicusinthemidclavicular line,anda12-mmtrocarintherightupperquadrant.ANathansonliver retractorissometimesplacedtoelevatetheleftlobeoftheliverandfacilitate exposureoftheanteriorandinferiorgastricwall(FIG11).

PreparationoftheStomachandIdentificationofProximalJejunum

■ First,identifythepylorusbyeitherpalpationwithagrasperorbyperformingan intraoperativeEGD.Identifyapoint5cmproximaltothepylorus,andthen selectasectionofthejejunum15to30cmdistaltotheligamentofTreitz, whichwilleasilyreachthedistalstomachwithouttensioninanantecolic fashion.

ConstructionoftheAnastomosis

■ Astapledside-to-sidegastrojejunostomyisthenconstructedinanisoperistaltic fashionbyaligningthedistalportionofthesmallbowelwiththepyloricside ofthestomach.Placementoftwointerrupted2-0silkseromuscularsutures betweenthegreatercurvatureofthestomachandthesmallbowel6cmapart servestoalignthebowelforthestapledanastomosis.Usingthe electrosurgicaldevice,anenterotomyismadeinthestomachandsmallbowel (FIG14).A60-mmEndoGIAstaplerisinsertedviathemostlateralright sideportandfiredtoconstructtheanastomosis(FIG15A).Ablueorgreen loadofthestaplerdeviceshouldbeuseddependingonthethicknessofthe stomach.Thecommonenterotomyisthenclosedusingtwo3-0polyglycolic

acidsuturesineitherarunningfashionoraninterruptedfashionasdescribed forpyloroplasty(FIG15B).Asecondlayerofseromuscular3-0silkLembert suturesisplacedtocompletetheclosureofthecommonenterotomy.

PEARLSANDPITFALLS

Indications ■Whenperformingadrainageprocedurefordelayed

gastricemptyingwithafundoplication, documentationofpooremptyingwithagastric emptyingstudyisstronglyrecommendedpriorto surgery.

■WhenoperatingforGIbleeding,beingpresentatthe

initialendoscopytoseetheprecisebleeding locationwillhelpavoidhavingtomakean excessivelylargepyloroplastyincision.

Pyloroplastyincision ■Incisionslongerthan7or8cmaredifficulttoclose

inaHeineke-Mikuliczfashionwithoutnarrowing thepyloriclumenandmayrequireaFinneyclosure.

Kochermanuever ■Isnotalwaysnecessarywithashortpyloroplasty

andaHeineke-Mikuliczclosurebutisalways requiredwithaFinneyclosure

Pyloromyotomy ■Isveryhardtoperformwithoutmucosalperforation

inthesettingofanyduodenalinflammation.Ifa significantmucosaperforationoccursduring pyloromyotomy,thesafestapproachistoconvertto pyloroplasty.

Gastrojejunostomy ■Predisposestomarginalulcerationifavagotomyis

notperformed.Patientsundergoing gastrojejunostomydrainagewithoutvagotomywill requirelifetimeprotonpumpinhibitortherapy.

■Inthesettingofapriorgastricoutletobstruction,a

prolongedperiodofdelayedgastricemptyingmay beencountereddespiteanadequateanastomotic lumen.

POSTOPERATIVECARE

■ Mostpatientswillrequirenasogastricdecompressionfor24to48hoursaftera drainageprocedure.

OUTCOMES

■

Whenperformedinconjunctionwithfundoplicationinpatientswithdelayed gastricemptying,80%ofpatientsreportanimprovementinbloating symptoms.

■ Theincidenceofdiarrheareportedwhenpyloroplastyisperformedin conjunctionwithfundoplicationinthesettingofdelayedgastricemptyingis reportedtobeashighas25%.

■ Theincidenceofclinicallysignificantdumpingsyndromeafterdrainage proceduresislessthan10%.

COMPLICATIONS

■ Leakfromsutureorstapleline

■ Delayedgastricemptying

■ Surgicalsiteinfection

■ Dumpingsyndrome

■ Diarrhea

■ Duodenogastricrefluxisquiterareafterpyloroplasty.

■ Bilerefluxgastritisfollowinggastrojejunostomy

REFERENCES

1.ReddymasuSC,SinghS,SankulaR,etal.Endoscopicpyloricinjectionofbotulinumtoxin-Afor

thetreatmentofpostvagotomygastroparesis.AmJMedSci.2009;337:161–164.

2.HamrickMC,DavisSS,ChiruvellaA,etal.Incidenceofdelayedgastricemptyingassociated

withrevisionallaparoscopicparaesophagealherniarepair.JGastrointestSurg.2013;17:213–217.

3.MasqusiS,VelanovichV.Pyloroplastywithfundoplicationinthetreatmentofcombined

gastroesophagealrefluxdiseaseandbloating.WorldJSurg.2007;31:332–336.

4.KhajancheeYS,DunstCM,SwanstromLL.OutcomesofNissenfundoplicationinpatientswith

gastroesophagealrefluxdiseaseanddelayedgastricemptying.ArchSurg.2009;144:823–828.

5.TackJ,ArtsJ,CaenepeelP,etal.Pathophysiology,diagnosisandmanagementofpostoperative

dumpingsyndrome.NatRevGastroenterolHepatol.2009;6:583–590.

Chapter18

Antrectomy



J.SpencerLilesJohnD.Christein

DEFINITION

■ Bystrictdefinition,antrectomyreferstoremovalofthegastrin-secretingportion ofthestomachandwhencombinedwithavagotomyresultsinan85% reductioningastricacidsecretion.

1,2

Inthe1960sand1970s,antrectomywith orwithoutvagotomywasroutinelyperformedfortreatmentofbenigngastric andduodenalulcersbut,duetopharmacologicdevelopmentsinreducingacid secretionandelucidationoftheroleofHelicobacterpyloriinulcer development,isnowrarelyperformedforulcerdisease.

3,4

■ Today,thetermantrectomyislooselyappliedtoanydistalgastricresectionand isindicatedinrecurrentorpersistentgastriculcerstoruleoutmalignancy, complicatedpepticulcerdisease(i.e.,obstruction,hemorrhage,perforation), andforresectionofcertainneoplasmsoftheantrumandpyloricchannel (Table1).

■ Whenanantrectomyisperformedforcomplicatedpepticulcerdisease,a vagotomymaybeincludedtoreducethechanceofanastomoticulcer formationinpatientswhoarenotcandidatesforH.pyloritreatmentand lifelongprotonpumpinhibitortherapyduetounreliability,noncompliance,or medicationsideeffects.

5,6

■ Antrectomyisnamedbythetypeofgastrointestinal(GI)anastomosis performed.

■

BillrothIprocedure—antrectomyandgastroduodenostomy

■

BillrothIIprocedure—antrectomyandgastrojejunostomy

■ AmodificationoftheBillrothIIprocedurethatinvolvesa gastrojejunostomyviaaRouxlimbandisknownasaRoux-en-Y gastrojejunostomy

DIFFERENTIALDIAGNOSIS

■ Complicatedpepticulcerdiseaseanddistalgastricneoplasms,bothbenignand malignant,accountforthevastmajorityoftheantralresectionsperformed today.Thesediagnoseswillbediscussedseparately.

■ Pepticulcerdisease

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 4647 / 5047 48 49 50 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202624 Мб0Книга_1045_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1047_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1048_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1049_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202642 Мб0Книга_105_библиотеки_им_акад_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1050_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1052_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1053_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1054_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1056_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1057_Библиотеки_им_академика_М_И_Перельмана.pdf