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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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■ Theevaluationofanyuppergastrointestinal(GI)symptomatologybeginswith anupperGIendoscopy,especiallyifgastriccancerissuspected.Endoscopy provideshistopathologicdiagnosisaswellasguidancetowardthelocation andextentofthegastrictumor(FIG1A,B).Forexample,theendoscopist needstocommentonthelocationofthetumoraswellastherelationshipto thefirstportionoftheduodenum.Additionally,itisimportanttoexcludethe presenceoflinitisplasticabyinsufflatingthestomachandevaluatingits distensibility,aspatientswithlinitisplasticacarryahigherriskofmetastatic diseaseandamediansurvivalofapproximatelyonly14to16months.

■ Endoscopicultrasoundperformedatthetimeoforsubsequenttodiagnostic endoscopyprovidesthemostaccurateestimationofthetumordepth(Tstage) andneedlebiopsyofsurroundinglymphnodescanbeperformed.

■ Pretherapycross-sectionalimaging(contrastcomputedtomography[CT]scanor magneticresonanceimaging[MRI]ofabdomenandpelvis)isimportantto excludedistantmetastaticdiseasetotheliveroromentum(FIG2A).In patientswithproximalgastriccancer,theadditionofchestcross-sectional imagingishelpfultoexcludethepresenceofmetastasestothelung.The presenceofbulkyadenopathyaddsprognosticvaluebutshouldnotpreclude resectionunlessitisoutsidetheareaofresection,suchastheperiportalarea ormesentericvessels.Fewerthan15%ofpatientspresentwithlocally advanceddiseaseextendingtothepancreas.Inthesepatients,weperform staginglaparoscopytoexcludeM1diseaseandthenrecommendneoadjuvant

chemotherapy.

■ Positronemissiontomography(PET)/CTscanhasevolvedasanoninvasive radiographicstagingmodalitytoexcludethepresenceofmetastaticdisease (FIG2B).

■ Staginglaparoscopy:Duetothenaturalhistoryofgastriccancer,uptoathird ofpatientswhohavelocalizeddiseaseonstagingevaluationhaveunsuspected hepaticand/orperitonealdisease.4Thus,allpatientsshouldundergostaging laparoscopytodetect“subradiologic”disease.Staginglaparoscopyis typicallyperformedinareverseTNMfashion.Theoperatingsurgeonshould inspecttheintraabdominalcavityforpresenceofperitoneal,omental,or hepaticmetastases.Theadditionofperitonealwashingforcytologyisanarea ofdebate.

5,6

Itmayhaveaplaceinpatientsatriskofundeclaredmetastatic diseaseorsuboptimalperformancestatus,aspatientswithpositiveperitoneal cytologyhaveunfavorableoverallprognosis.6Intheabsenceofconcerning radiographicfeatures,staginglaparoscopyistypicallyperformedatthetime oftheintendedresection.

SURGICALMANAGEMENT

■ Margin-negativeresectionalongwithanadequatelymphadenectomyarethe mostcriticalcomponentsofthesurgicalresection.

PreoperativePlanning

■ Addressingpreoperativemalnutrition:Gastricoutletobstructioncausedby tumoraswellasanorexiaassociatedwithmalignancycontributeto malnutrition.Assuch,thesepatientsmaybenefitfromaplacementofa preoperativenasojejunaltubeandenteralnutrition.Inpatientspresentingwith malignantdistalgastricobstruction,anendoscopictranspyloricstentmay addressthegastricoutletobstructionandthushelpinoptimizingthenutrition. Staginglaparoscopyandplacementofafeedingjejunostomytubeisanother option.

■ Evaluationofthepatient’sfunctionalstatus:Acarefulreviewand optimizationofunderlyingcomorbidities(e.g.,cardiac,pulmonary,diabetes) andperformancestatusshouldbeperformed.Asubsetofhigh-riskindividuals maybenefitfrompreoperativeadmissiontooptimizethenutrition, electrolytesimbalance,andimproveperformancestatus(e.g.,physical therapy)inpreparationfortheoncologicresection.

■ Preoperativeantibiotics:Patientsshouldhavepreoperativefirst-orsecondgenerationcephalosporinspriortoincisiontoreducetheriskofwound infection.

■ Deepvenousthrombosis(DVT)prophylaxis:Allpatientsshouldhavea sequentialcompressiondeviceappliedduringtheprocedure.Useof subcutaneousheparin/low-molecular-weightheparinisinitiatedon postoperativeday1andcontinuedthroughoutthehospitalizationunless contraindicated.

Positioning

■ Thepatientisplacedinsupinepositionwithbotharmsoutat90degrees. Nipplestoupperthighshouldbepreppedanddrapedintheoperativefield.

TECHNIQUES

STAGINGLAPAROSCOPY

■ PneumoperitoneumiscreatedbyeitheropentechniqueorVeressneedle.A30degreescopeisinsertedattheumbilicus.Onetotwoadditional5-mmports onleftorrightsideoftheabdomenareneededforadditionalvisualization, grasping,andbiopsyofsuspicioustissue.Acompletesurveyoftheperitoneal cavityisperformed,includingundersurfaceofthediaphragm,liversurface, spleen,liningofperitonealcavity,pelvis,smallbowelsurface,andomentum, formetastaticdisease.Ifsuspiciousdiseaseisobserved,itissentforfrozen section.Inthesettingofbiopsy-provenperitonealdisease,gastrectomyshould notbeconsideredandnonsurgicaltreatmentsshouldbeinitiated.However, selectivepalliativesurgicalproceduresmaybeindicated,forexample,in bleedingorobstructingcancersthatcannotbepalliatedbyendoscopic procedures.Thesedecisionsneedtobeindividualizedbasedonthe performancestatusofthepatient,extentofmetastaticburden,andthe projectedsurvival.

■ Ifthestaginglaparoscopyisnegativeforperitonealspreadofthedisease, operativeresectionisperformed.

EXPLORATORYLAPAROTOMY

■ Abdomenisenteredthroughamidlineincisionextendingfromthexiphoid processtojustbelowtheumbilicus.Abilateralsubcostalincision,

approximately2cmbelowthecostalmargin,alsoprovidesgoodexposure. Duringentryintotheabdomen,thefalciformligamentshouldbepreservedas itcanbeusedtobuttresstheduodenalclosure.

■ Acarefulexplorationoftheperitonealcavityisperformedtoexcludepresence ofsubradiographicperitonealormetastaticdisease.Theliveriscarefully examinedforanysuspiciousnodules.

MOBILIZATIONOFTHEGREATERCURVATUREOFTHE STOMACH

■ Inthisstep,thetransversecolonisseparatedfromthegreateromentuminan avascularplane(FIG3).Thestomachandthegreateromentumarereflected superiorly,andthetransversecolonisreflectedinferiorly.Theplaneoffusion betweenthegreateromentumandthetransversemesocolonisidentifiedasa faintwhiteline.Thisplaneisincisedwithelectrocauterytoenterthelesser sac.Thisplaneisadvancedproximallyanddistallyalongthetransverse colon.

■

Thedissectionproceedstotheproximalgreatercurvatureofthestomachusing eitherclampsandtiesoranenergydevice,suchasHarmonic™or LigaSure™,todividetheshortgastricvessels.Whenperformingasubtotal gastrectomy,thisdissectionshouldstopatthebeginningoftheshortgastric vesselsasshortgastricarteriesprovidethebloodsupplytotheproximal gastricremnant.

DUODENALMOBILIZATIONAND TRANSECTION

■ Thehepaticflexureofthecolonismobilizedbydividingtheavascular attachmentoftherightcolontotheretroperitoneum.Theseparationofthe greateromentumfromthetransversemesocoloniscontinuedtothehepatic flexure.Thisexposesthegastrocolictrunk,whichisformedbytheconfluence ofrightgastroepiploicveinwithacolonicveinanddrainsintothesuperior mesentericvein(FIG4).Therightgastroepiploicveinisdividedatits junctionwiththegastrocolictrunk.Alternatively,thegastrocolictrunkcanbe dividedwithasinglefireofvascularstapler.Atthisstage,theright gastroepiploicarteryisdividedatitsoriginattheinfraduodenallevel.The infrapyloricnodes,locatedadjacenttotheoriginofgastroduodenalartery,are mobilizedwiththespecimen(FIG5).

■ Thelessercurvatureismobilizedbydividingthelesseromentumasclosetothe liveraspossible(FIG6).Ifareplacedoraccessorylefthepaticarteryis identified,itshouldbetemporarilyligated,andtheperfusionoftheleftlobe ofthelivershouldbeassessedpriortotransectingthevessel.Thedissection iscarrieddistallytotheportaltriad.Therightgastricarteryarisingfromthe commonhepaticarteryisdividedincludingthelymphatictissuewiththe specimen.Theduodenumiscircumferentiallydissectedabout2to3cmdistal tothepylorus,encircledwithaPenrosedrainanddividedwitheitherastapler orinbetweenstraightbowelclamps(FIG7).Careistakennottoinjurethe bileduct,hepaticartery,orportalveinwhenencirclingtheduodenum.The stapledduodenallineisoversewnwith3-0silkLembertsuturesandcanbe buttressedwiththefalciformligament(Moossa’spatch).However,inthe settingofextensiveinflammationaroundtheperiduodenalarea,consideration shouldbegiventodividingtheduodenalstumpinbetweentwostraightbowel clampsandsutureclosureoftheduodenalstump.

■ Thegastrectomyspecimen,nowdisconnecteddistally,isliftedupward.Theleft gastricarteryisidentified,sutureligated,anddividedatitsorigin(FIG8). Thelymph–areolartissuewiththeleftgastricarteryismobilizedwiththe specimen.

GASTRICTRANSECTION

■ Next,thestomachisdividedabout4to6cmproximaltothegastriccancer(FIG

9).OurpreferenceistouseseveralgreenloadsofaGIstapler.

■ Wesendtheresectedspecimeninseparatecontainersinthefollowingmanner: (1)stomachwithamarkingstitchonproximalend,(2)greateromentum,(3) infrapyloricnodalpacket,and(4)lessercurvaturenodalpacketwithalong stitchontheleftgastricartery.Theoperatingsurgeonshouldcommunicate withthepathologisttoorienthim/hertothespecimenandindicatethe proximalanddistalmarginsforfrozensectionassessment.

EXTENTOFLYMPHADENECTOMY

■ Theextentoflymphadenectomyinpatientswithoperablegastriccancerisan areaofcontroversy.

7,8

Toensureadequatelymphadenectomy,thegastric arteriesneedtobedividedattheirorigin.Wetypicallyperformapancreasandspleen-preservinglymphadenectomy.Thatis,takingtherightgastric artery,rightgastroepiploicartery,andleftgastricarteriesattheiroriginalong withceliacaxisnodaldissection.Weacknowledgethattheadditionofa celiacaxisdissectionisanareaofcontroversy.

RECONSTRUCTION

■ RestorationofGIcontinuitycanbeachievedbyperformingaBillrothIIloop gastrojejunostomyorRoux-en-Ygastrojejunostomy.OurpreferenceisRouxen-Ygastrojejunostomy.

■ Roux-en-Yreconstruction:Whileawaitingfrozensectiononthegastric margins,weproceedwiththereconstruction.Aloopofjejunumdistaltothe ligamentofTreitzthatreachesthestomachpouchwithouttensionis identified.Thejejunumisdividedatthispointwithabluegastrointestinal anastomosis(GIA)stapler.ThestaplelineontheendoftheRouxlimbis oversewnwith3-0silkstitchesinLembertfashion.TheRouxlimbneedsto beatleast40cm(i.e.,fromitsbeginningatthelevelofstomachtothe jejunojejunostomy).Adefectiscreatedinthetransversemesocolontotheleft ofthemiddlecolicvessels(FIG10).WethenconfirmthattheRouxlimbcan easilyreachthestomachwithouttensionwhenplacedintheretrocolic position.Ourpreferenceistofirstperformastapledside-to-sideanastomosis betweenthebiliopancreaticlimbandthejejunum.Ourrationalebehindthis orderofreconstructionistoallowforaneasierreconstructionofthis anastomosisawayfromthetransversemesocolondefect.Staysuturesare placedbetweenthebiliopancreaticlimbandthejejunum.Enterotomiesare madeinthebiliopancreaticlimbandthejejunum.OnelimboftheblueGIA staplerisintroducedintothebiliopancreaticlimbandtheotherinthe jejunum.Theblueloadisfiredandthecommonenterotomyisclosedeitherin

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