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 46 47 4849 / 5049 50 > Следующая >>>

■ Divisionoftheduodenumvariesbasedonthetypeofreconstructionplanned. TheduodenumisdividedbetweenPottsclampsforaBillrothIprocedurein ordertofacilitatethegastroduodenalanastomosis.Ifpossible,astapling deviceshouldbeusedtodividetheduodenuminaBillrothIIprocedure.

RECONSTRUCTION:GASTRODUODENOSTOMY (BILLROTHI)

■ IfaBillrothIanastomosisisplanned,aKochermaneuverisneededtomobilize theduodenum.

■ Theduodenumistransecteddistaltothediseasedareabutproximaltothe ampullabetweenPottsclamps,andthespecimenishandedoffthesterilefield (FIG9).Itisessentialthatallgastricantrumberesectedtopreventpersistent ulcerdiseasefromretainedgastricantrum.Ifthereisquestion,afrozen sectioncanbesenttoconfirmduodenaltissueattheresectionline.

■ Atthispoint,onecangaugethemobilityofthestomach,andiflimited,the attachmentsofthefundustothebaseofthediaphragmcanbedividedalong withthegastrosplenicligamenttakingcaretopreservetheleftgastroepiploic vessels.Thisfurthermobilizationshouldallowforatension-free gastroduodenalanastomosis.Ifthereisconcernabouttheabilitytoperforma tension-freeanastomosisduetodifficultymobilizingtheduodenumorthe stomach,thenaBillrothIIprocedureshouldbeperformed.

■ ForaBillrothIprocedure,theduodenalstumpisclearedofadjacentadipose tissueforroughly1.5-cmdistanceinpreparationforanend-to-end anastomosis.Thisanastomosisisconstructedinstandardtwo-layerfashion. Silk3-0seromuscular“stay”suturesareplacedattheendsoftheanastomosis toapproximatetheduodenumtotheinferioraspectofthegastricstapleline andtheposteriorlayeriscompletedwithinterrupted3-0silkseromuscular sutures.Next,theinferiorportionofthegastricstaplelineisremovedusing electrocauteryforalengththatcorrelateswiththewidthoftheduodenal stump.Tworunning3-0polydioxanone(PDS)suturesareusedfortheinner layerandananteriorlayerofinterrupted3-0silkseromuscularsutures completestheanastomosis.Theremaininggastricstaplelinecanbe

oversewedwithinterrupted3-0silksutures(FIG10).

RECONSTRUCTION:GASTROJEJUNOSTOMY(BILLROTH II)

■ Inperformingagastrojejunostomy,thegastricstaplelineisoversewedwith interrupted3-0silksutures.

■ Next,theduodenumisdivideddistaltoanydiseasewithastaplingdevice.Ifitis notpossibletofitastaplerintothisplane,theduodenumcanbedividedwith electrocauteryandclosedwitharunning3-0PDS.Tobuttressthisclosure,30silkfull-thicknesssuturescanbeplacedandleftuntied.Omentumcanbe mobilizedandlooselysecuredinplaceovertheclosurewiththesilksuture ends.

■ Wepreferentiallyperformanisoperistaltic,retrocolicgastrojejunostomy, althoughanantecolicanastomosisiswidelyaccepted.Inthesettingof malignancy,anantecolicapproachmaybefavoredasconcernexiststhat progressionofdiseaseandfuturediffusemesentericlymphadenopathymay obstructaretrocolicanastomosis.Theanastomosisshouldbeperformedas closetotheligamentofTreitzaspossible(usually10to15cm),allowingfor atension-freeanastomosistominimizetheriskofdevelopingafferentlimb syndrome.

■

Althoughwepreferastapledanastomosis,bothstapledandhand-sewn techniquesarewidelyacceptedwithsimilarrateofpostoperative complications.A45-mmstapledgastrojejunalanastomosisisformedby creatingaposteriorwallgastrotomyandanantimesentericenterotomy.Care istakentoensurethattheanastomosisisawayfromthepriorgastricstaple lineontheposteriorwallofthestomach.Thecommonenterotomyisthen closedwitha3-0PDSfull-thicknesslayerandanoverlyinglayerof interrupted3-0silksutures(FIG11).Interrupted3-0silksuturesarethen usedtoclosethecolonicmesenterydefecttopreventbowelherniation(FIG

12).

PEARLSANDPITFALLS

Indication ■Today,thereisnoroleforantrectomyintreatmentof

noncomplicatedpepticulcerdisease.

■Avastmajorityofpepticulcerscomplicatedby

hemorrhageorperforationcanbecontrolledwith lessinvasiveprocedures.

Operativeplanning ■Preoperativeendoscopyisessentialtoevaluatefor

thescopeofdiseaseandtoallowbiopsyof persistentgastriculcerstoruleoutmalignancy.

■Inthesettingofmalignancy,preoperativestagingis

warrantedandamoreextensive,oncologic resectionmaybeindicated.

Laparotomy ■Priortoextensivedissection,theextentofdisease

shouldbegaugedtodeterminetheoperativeplan andfeasibilityofaBillrothIanastomosis.

Gastricmobilization ■Withmobilizationofthegreatercurvature,the

middlecolicveinisatriskofinjury.Caudaltraction onthetransversecolonduringdissectioncanhelp preventaninadvertentinjury.

Duodenaltransection ■Greatcareshouldbetakentonotfractureorinjure

theheadofthepancreas,whichcanbeclosely adherentduetochronicinflammation.

■Ifthecommonbileductisdifficulttoidentify,a

cholecystectomycanbeperformedandacatheter canbeplacedinthecysticduct.Palpationofthe cathetercanaidinsafelyidentifyingtheportal structuresduringdissectionoftheduodenum.

Reconstruction ■BillrothIandIIproceduresareperformedwith

acceptablepostoperativemorbidity.

■ABillrothIIanastomosisshouldbeperformedif

thereisconcernaboutmobilityoftheduodenumor thestomach.

■Ashortafferentlimb(10to15cmfromtheligament

ofTreitz)canhelpminimizethelikelihoodof significantpostoperativecomplications.

POSTOPERATIVECARE

■ Unlessconcerningcomorbiditiesexist,patientscanbemonitoredonthehospital floor/ward.Anasogastrictubeispositionedintraoperativelyintheproximal stomachandtypicallycanberemovedonpostoperativeday(POD)1.Thereis noroleforpostoperativeantibioticprophylaxis.Unlesscontraindicated,all patientsreceivechemicalprophylaxisfordeepveinthrombosisandare encouragedtoambulateonPOD1andbeginpulmonarytoiletwithincentive spirometry.Thereisnoconvincingevidenceforroutinelyplacingabdominal drainsafterBillrothIandBillrothIIprocedures.IfthereisconcernfortheGI anastomosisoradequateclosureoftheduodenalstump,aclosedsuction abdominaldraincanbeplaced.OralintakeisreintroducedonPOD3and advancedastolerated.

OUTCOMES

■ Seriousmorbidityfrompostgastrectomysyndromesdevelopsin3%to5%of patients.

■ Thirty-daymortalityforuncomplicatedgastriculcerdiseaseis1%to2%and increasesinemergencysettings.

COMPLICATIONS

■ Afteranantrectomy,short-termcomplicationsincludedelayedgastricemptying, anastomoticleak,bleeding,andpancreatitis.Long-termcomplicationsinclude thepostgastrectomysyndromes(describedbelow)andanastomoticstricture. Additionally,chronicanemia,neuropathy,andosteopeniacanresultfrom iron,copper,andcalciummalabsorptionduetobypassingoftheproximal smallbowelinaBillrothIIprocedure.

■

Postgastrectomysyndromes

■

Afferentloopsyndrome

■ Postprandialrightupperabdominalcolickypainthataccumulatesinbilious emesisthatalleviatesthepain

■ Resultsfromchronicdilation,obstruction,orstasisoftheduodenum (afferentlimb)afteraBillrothIIprocedure

■ RarelyoccursbutcanbecorrectedbyrevisionoftheBillrothII,conversion toaRoux-en-Yreconstruction,orperforminganafferenttoefferent bypass(Braunenteroenterostomy)

■ Refluxgastritis—Patientsreportepigastricburningpainresultingfromreflux ofbileintothestomach.Asexpected,bilerefluxismorecommonafter BillrothIandBillrothIIproceduresthanRoux-en-Yreconstructionandif severecanbetreatedbyconversiontoaRoux-en-Yreconstruction.

■ Dumping—Earlydumpingpresentsascrampyabdominalpainanddiarrhea shortlyaftereatingduetothelargehyperosmolarloadofsimplesugars whichquicklyenterthesmallbowelintheabsenceofapylorus.Late dumpingoccursroughly2hourspostprandialwiththesymptomsof hypoglycemialikelyduetoinsulinresponsetothelargesugarbolus. Dumpingoccursin5%ofpostgastrectomyandiscontrolledwithdiet modifications,andrarely,octreotideisgivenwithsuccessinsevereand refractorycases.

■ Retainedgastricantrum—IncompleteantrectomywithretainedGcellswithin theduodenalstumpcanresultinrecurrentulcerationfromcontinued intensegastrinsecretion.Exposureofthejejunumtohighlevelsofacid resultsinananastomoticormarginalulcer.Asodium99mtechnetiumscan identifiesantraltissueandreexcisionisneededforcompletesymptom relief.

REFERENCES

1.GlasgowRE,RollinsMD.Stomachandduodenum.In:NortonJA,BariePS,BollingerRR,etal,

eds.Surgery:BasicScienceandClinicalEvidence.2nded.NewYork,NY:Springer;2008:841–874.

2.GrayRJ,KellyKA.Pepticulcer.In:KellyKA,SarrM,HinderR,eds.MayoClinic

GastrointestinalSurgery.Philadelphia,PA:Saunders;2003:103–124.

3.ZittelTT,JehleEC,BeckerH.Surgicalmanagementofpepticulcerdiseasetoday—indication,

technique,andoutcome.LangenbecksArchSurg.2000;385:84–96.

4.BardhanKD,RoystonC.Time,change,andpepticulcerdiseaseinRotherdam,UK.DigLiver

Dis.2008;40(7):540–546.

5.LundellL.Acidsecretionandgastricsurgery.DigDis.2011;29(5):487–490.

6.LipofT,ShapiroD,KozolRA.Surgicalperspectivesinpepticulcerdiseaseandgastritis.WorldJ

Gastroenterol.2006;12(20):3248–3252.

7.DohertyGM,WayLW.Stomachandduodenum.In:DohertyGM,ed.CurrentDiagnosis&

Treatment:Surgery.13thed.NewYork,NY:McGraw-Hill;2010.

8.MulhollandMW.Gastroduodenalulceration.In:MulhollandMW,LillemoeKD,DohertyGM,et al,eds.Greenfield’sSurgery:ScientificPrinciplesandPractice.5thed.Philadelphia,PA:Lippincott Williams&Wilkins;2010.

9.HouW,SchubertML.Treatmentofgastriccarcinoids.CurrTreatOptionsGastroenterol. 2007;10(2):123–133.

10.ChassinJL,HenselmanC.Gastrectomy(antrectomy)forpepticulcer.In:ChassinJL, HenselmanC,eds.Chassin’sOperativeStrategyinGeneralSurgery:AnExpositiveAtlas.NewYork, NY:Springer-Verlag;1994.

11.SiewertJR,BummR.DistalgastrectomywithBillrothI,BillrothII,orRoux-Yreconstruction. In:FischerJE,BlandKI,eds.MasteryofSurgery.5thed.Philadelphia,PA:LippincottWilliams& Wilkins;2006:849–859.

12.BoltonJS,ConwayWCII.Postgastrectomysyndromes.SurgClinNAm.2011;91:1105–1122.

Chapter19

SubtotalGastrectomyfor Cancer



VikasDudeja,PatrickG.Jackson WaddahB.Al-Refaie

DEFINITION

■ Subtotalgastrectomyisremovalof70%to80%ofdistalstomach.Thisis performedwhenthenecessary5-to6-cmproximalmargincanbeobtained whilemaintainingagastricremnantofreasonablesize.

PATIENTHISTORYANDPHYSICALFINDINGS

Presentation

■ InUnitedStates,gastriccancerisoftendiagnosedatanadvancedstageand nearly65%ofpatientsharbornode-positivedisease.

1,2

Themostcommon symptomsareweightloss,anorexia,andearlysatiety.Someofthese symptomsoverlapwiththoseofbenignpepticulcerdisease.Patientswith distalgastriccancermaypresentwithsymptomsofgastricoutletobstruction, includingpostprandialvomitingandweightloss.Patientsmayalsopresent withprogressiveabdominaldistensionsecondarytomalignantascites.

■ Specialattentionshouldbepaidtoweightloss.Althoughthismayreflect metastaticdiseaseorgastricoutletobstruction,inpatientswithresectable disease,itsignifiesaneedforpreoperativenutritionaloptimization.

Specifically,patientswithmorethan10%weightlossareatincreasedrisk ofperioperativecomplications.

■ Attentiontopretherapyperformancestatusiscritical,asthiscorrelateswell withabilitytotoleratevariousoncologictherapiesincludingmajorsurgical resectionandsystemictherapy.

■ Patientspresentingwithgastricoutletobstructionmayhavedehydrationand electrolyteimbalances.Placementofanasogastric(NG)tube,volume replacement(initiallywithnormalsaline),andcorrectionofelectrolyte imbalanceisparamount.

PhysicalFindings

■ Mostpatientswithearlystagediseasewillhaveanormalphysicalexamination. However,signsofmalnutrition,cachexia,andjaundiceshouldbesought. Patientswithadvancedstagediseasemaypresentwithsupraclavicular lymphadenopathy,pleuraleffusion,abdominalmass,hepatomegaly,malignant ascites,ordropmetastasesinthecul-de-sacknownas“Blumer’sshelf.” Presenceofanyofthesephysicalfindingssuggestunresectability.

IMAGINGANDOTHERDIAGNOSTICSTUDIES

LaboratoryTests

■ Abaselinehemoglobinwillassesswhetherirondeficiencyanemiaispresent. Patient’srenalfunctionandhydrationstatusshouldbeassessedbymeasuring serumbloodureanitrogen(BUN)andcreatinineinpreparationforcrosssectionalimaging.Evaluationandcorrectionofabnormalitiesinelectrolytes areimportantinpatientswithgastricoutletobstruction.Serumalbuminand prealbuminareessentialtoolsforassessingnutritionalstatus.

DiagnosticStudiesandStagingEvaluation

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 4849 / 5049 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