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N. Bayramov and N. Zeynalov
periampullary lesions intraoperatively evaluated
as non-resectable can be recommended in order
to prevent gastric obstruction in future.
15.3 Prophylactic Partial
Stomach-Partitioning
Gastrojejunostomy is a common method of surgical bypass for palliation in non-resectable malignant gastric outlet obstructions. However, in
30–50% of cases it results in a syndrome called
delayed gastric emptying, or gastric stasis presented by belching, vomiting, and intolerance to
oral feeding [5, 6]. Among methods of prevention
of delayed gastric emptying, there is a complete
or partial stomach-partitioning additionally to
gastrojejunostomy (Fig.15.1). In complete partitioning (Devine exclusion procedure) the distal
part of stomach is transected and closed, and in
partial partitioning (modied Devine exclusion)
2–3cm connecting bridge between the distal and
proximal parts of stomach is left for decompression and endoscopic interventions [7, 8].
Though there are no randomized studies about
the effect of gastrojejunostomy with stomachpartitioning to delayed gastric emptying, there
are many clinical observations and meta-analyses on this topic. Two meta-analyses conducted
in the recent years [9, 10] raised a special interest
by comparing gastrojejunostomy with complete
or partial stomach-partitioning and conventional
gastrojejunostomy. It has been shown that gastrojejunostomy with stomach-partitioning signicantly reduced the rate of postoperative gastric
stasis (11.6% vs. 43.6%), improved the oral feeding and tendency of life expectancy, and did not
increase the operation time and intraoperative
bleeding. Experience of laparoscopic implementation of these operations has been growing over
the past years [11, 12].
So, the meta-analysis of non-randomized
and cohort studies shows that in order to decline
the rate of delayed gastric emptying following
palliative gastrojejunostomy in patients with
non- resectable obstruction of gastric outlet gastrojejunostomy can be added by complete or partial stomach-partitioning.
15.4 Prophylactic Pyloric
Interventions
Pyloroplasty is a surgical procedure of transection
of pyloric sphincter. It is applied as a treatment
modality in pyloric stenosis, and as a prophylactic procedure to prevent spasm of pyloric sphincter and delayed gastric emptying which are the
complications after esophageal surgery [13].
Vagotomy, dislocation of stomach to the
negative pressure thorax, and imbalance of gastrointestinal hormones result in functional disorders in about half of the patients, more often
delayed gastric emptying (gastric stasis), duodenogastroesophageal reux, and dumping syndrome [14, 15].
Taking into account that the main cause of
delayed gastric emptying is the absence of relaxation of pylorus because of vagotomy, pyloroplasty is routinely applied in vagotomy for peptic
a b c
Fig. 15.1 (a) Gastrojejunostomy, (b) complete stomach partitioning and gastrojejunostomy, (c) partial stomach parti-
tioning and gastrojejunostomy
15 Prophylactic Surgery forBenign Diseases ofStomach andDuodenum
165
ulcer disease and intraoperative injuries of vagus
nerve (anti-reux procedures, hiatal hernia surgery, etc.). However in clinical practice the signicance of prophylactic pyloric interventions
during gastroplasty after esophagectomy is still a
subject for discussion.
Functional obstruction of stomach and according delayed gastric emptying are noted in 15–39%
cases after esophagectomy with gastroplasty [16],
there are also reports on decline of this rate for
the recent years because of wide application of
stomach tube [17, 18]. It is clinically presented by
early satiety, postprandial discomfort, dysphagia,
belching, and regurgitation; aspiration pneumonia
and reux esophagitis are possible complications.
Treatment includes diet, erythromycin which is
the agonist of motilin, and pyloric interventions
(pyloroplasty, pyloromyotomy, balloon dilatation,
botulinum injection) [14, 16].
In previous years, especially before 2007 randomized studies and meta-analyses showed that
pyloroplasty following esophagectomy signicantly reduced the rate of postoperative delayed
gastric emptying, but had no effect on rates of
pulmonary complications, leakage of anastomosis, and other results [19–21].
However, retrospective and systematic studies for the past decade show that pyloroplasty
does not signicantly change the rates of delayed
gastric emptying, reux esophagitis, pulmonary
complications, and anastomosis leakage [16, 22,
23]. Moreover, some studies report that pyloro-
plasty increases bile reux and operation time
[23]. It is quite difcult to explain the differences between these two groups of studies. Some
authors suggest that open surgery and procedure
with total stomach have been used before, while
minimally invasive methods and procedure with
gastric tube are being used for the recent years
[16]. That’s why there is a need for new randomized studies on minimally invasive esophagectomy and application of gastric tube [14, 16].
There is no common idea about the method of
pyloric drainage as well. Clinical studies showed
no signicant difference in efcacy of pyloroplasty,
pyloromyotomy, and botulinum injection [15].
Thus, prophylactic pyloroplasty for prevention of delayed gastric emptying seems reason-
able in cases of vagotomy and damage of vagus
nerve at surgery, but its signicance in case of
gastroplasty after esophagectomy remains disputable. In open surgery with total stomach reconstruction, pyloric interventions seem benecial.
However, pyloric interventions do not seem so
in procedures with gastric conduit which are
applied for the recent years—they increase the
bile reux. New multicenter randomized studies
are necessary to clarify these questions.
15.5 Vagotomy
Vagus nerve is the important regulator of secretion of gastric acid [13]. The main purpose of
transection of vagus nerve (vagotomy) is the
reduction of secretion of gastric acid to prevent
the relapse and complications of peptic ulcer.
This surgical procedure is rarely applied alone,
instead it is usually done together with gastric
drainage and resection operations. Vagotomy has
been widely used in surgical management of peptic ulcer disease before the era of H2 histamine
receptor blockers, proton pump inhibitors, and
anti-helicobacter therapy. Nowadays, the application of vagotomy slumped dramatically; it can
be applied according to the following indications:
ulcers resistant to conservative management,
complications of peptic ulcer disease (stenosis,
bleeding, perforation), and prevention of peptic
ulcer of gastroenteroanastomosis [24].
According to the level of transection, vagotomy can be truncal (vagus nerve is transected
at the level of esophagus), gastric or selective
(branches of vagus nerve to stomach are transected), and highly selective (branches of vagus
nerve to body of stomach are transected while
branches to antrum and pylorus are spared).
Vagotomy can be done by open surgery or laparoscopically [24].
15.6 Prophylactic Gastrostomy
Gastrostomy is a procedure for transabdominal
access to stomach. It can be done by surgical, percutaneous, endoscopic, and combined methods.
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N. Bayramov and N. Zeynalov
Gastrostomy is a treatment modality for patients
with difcult oral feeding (cancer of head, neck,
thorax, esophagus, brain injury) or for decompression of stomach (delayed gastric emptying, short
bowel syndrome). Indications to prophylactic gastrostomy are very limited, they include duodenal
injuries and large pyloric perforations in order to
provide a stomach decompression, and gastric volvulus in order to x the stomach [25].
15.7 Preoperative Ischemic
Conditioning oftheStomach
The ground of the idea of gastric conditioning
is the phenomenon of preparation of stomach to
ischemia before applying the esophagogastric
anastomosis in order to reduce the anastomosis
leakage risk. The most widely used method of
reconstruction after esophagectomy is esophagogastric anastomosis with gastric conduit. This
type of anastomosis is considered to be of high
risk of leakage. According to universally accepted
opinion and data of recently conducted sensitive
studies, the ischemia in the site of anastomosis is
one of the strongest risk factors for leakage [26].
Typical process of preparation of gastric conduit
includes the ligation of left gastric artery, short
gastric arteries, and sometimes right gastric artery,
remaining the blood supply of gastric conduit by
right gastroepiploic artery and submucosal vascular network. Studies show that this standard
mobilization results in more than 50% decrease
of perfusion of upper 20% of the stomach [27].
Experimental works revealed that acute hypoperfusion after partial devascularization results
in ischemic injury of the stomach after 3–5days.
After 10days the perfusion starts to recover, and
after 2–3weeks it is close to the initial perfusion
rate [28–30]. According to this phenomenon of
preparation to ischemia, the idea of “initial partial
devascularization of stomach, then waiting few
days for normalization of perfusion, then applying anastomosis” came out. By the way, this phenomenon is well known in plastic surgery; it is
widely used for staged skin grafting.
Currently, there are two methods of prepara-
tion of stomach tube to ischemia: embolization of
vessels and surgical ligation. In the rst modality,
an endovascular approach is used to embolize the
left gastric artery, and sometimes additionally the
right gastric artery; after 2weeks esophagectomy
is done and esophagogastric anastomosis applied
[31]. In the second modality, a laparoscopic
approach is used to ligate the left, right, and short
gastric arteries, and apply a feeding jejunostomy
if needed; then after 5–14 days the esophagectomy is done and esophagogastric anastomosis
applied [32].
Clinical studies give controversial outcomes
of the impact of ischemic conditioning to the rate
of anastomosis leakage. Some of studies report a
signicant reduction of the anastomosis leakage
after ischemic conditioning: 0–13% in cases with
conditioning vs. 16–46% in cases without conditioning [33–36]. Other clinical studies report that
in comparison with the control group the group
with ischemic conditioning shows a tendency to
reduction in anastomosis leakage rate without
statistical signicance: 8.5–26% vs. 7.6–21%
accordingly [32, 37, 38]. Systematic reviews,
meta-analyses, and randomized studies have
also not shown a signicant reduction of rate of
esophagogastric anastomosis leakage after ischemic conditioning [30, 39, 40].
The results of a randomized study dedicated
to this problem showed that the perfusion of both
ischemic conditioned and not conditioned stomach
conduit after dislocation to neck decreased 60% in
comparison with the normal rate, and the difference in perfusion between the groups was not statistically signicant [40]. This fact indicates a very
important role of dislocation to neck in reduction
of perfusion of stomach tube and can explain the
uselessness of ischemic conditioning. Some studies report that ischemic conditioning reduces the
severity of anastomosis leakage [37, 39].
Comparative analyses of methods of ischemic
conditioning do not reveal serious differences
between embolization and laparoscopic ligation
[39]. Along with this such disadvantages of ischemic conditioning like undergoing surgery twice,
expensiveness, and risk of complications are also
reported [30].
Thus, despite ischemic conditioning of stomach tube for reconstruction after esophagectomy
15 Prophylactic Surgery forBenign Diseases ofStomach andDuodenum
167
seems reasonable as per some fundamental and
clinical studies, many other studies report that
this approach does not reduce the rate of anastomosis leakage signicantly, limiting only with
a tendency to decrease the severity of leakage,
demands additional intervention and expenses,
and carries some risk of complications.
Considering this information the method of
ischemic conditioning of stomach conduit for
reconstruction after esophagectomy is currently
not recommended for wide application.
15.8 Gastroesophageal Reux
Disease (GERD)
GERD is the most common gastrointestinal disease; its incidence rate varies 2.5–33% among
world population [41]. This disease is presented
by signs related to reux of gastric content mainly
to esophagus, but also to mouth and lungs, clinically resulting in erosive esophagitis, non-erosive
reux, Barret’s esophagus, and extraesophageal
complications [42]. Contemporary management
of GERD encompasses conservative, surgical,
and endoluminal modalities. The main treatment modality is conservative management
which includes change of lifestyle (sleeping with
elevated bedhead, reduction of amount of each
food intake, weight loss) and drug therapy (proton pomp inhibitors (PPI), H2 histamine receptor blockers, antacids, etc.). However, in about
40% of patients conservative management does
not give sufcient response (refractory reux),
or side effects of pharmacotherapy arise [43].
Laparoscopic fundoplication is the main procedure in surgical management of GERD.Nissen
fundoplication (360°) and Toupet fundoplication (270°) are the most commonly used operations. Fundoplication gives sufcient effect in
those patients who show good outcome of PPI
treatment. Forty to eighty percent of patients
have to continue PPI treatment after fundoplication, and overall number of fundoplications
decreased for the recent years [44]. Nowadays,
fundoplication procedure is considered to be
the most effective approach in following cases:
side effects of drug treatment, patients refusing
from pharmacotherapy, large hiatal hernia, low
esophageal pH despite high dose PPI, sufcient
effect achieved only by continuous high dose of
PPI [42, 43]. Other surgical methods are magnetic ring (Linx™) and endoluminal procedures
(transoral incisionless fundoplication, Stretta
procedure) which are positioned as promising
alternative methods in refractory reux [43].
However, these new techniques need wide randomized investigations.
Another issue is the prevention of reux after
gastrointestinal surgery. Prophylactic fundoplication is routinely advised in myotomy due to achalasia and paraesophageal hernia surgery [45, 46].
So, conservative approach to management
of GERD (lifestyle change, PPI, H2 histamine
receptor blockers, antacids) is the main treatment modality at the moment; fundoplication is
applied according to indications, and promising
new surgical and endoluminal techniques need
thorough investigation.
15.9 Hiatal Hernia
Hiatal hernia is considered to be of quite prevalent pathologies; it is described as dislocation of
abdominal organs to the thoracic cavity through
hiatal foramen of diaphragm. According to content of hernia and place of gastroesophageal
junction, hiatal hernias are divided to sliding and
paraesophageal hernias, and also classied to 4
types:
• Sliding or type I hernia—gastroesophageal
junction is dislocated to thorax.
• Paraesophageal hernia is a complete hernia with
existing hernia sac; it can be in 3 variants:
– Type II—gastroesophageal junction does
not dislocate, gastric fundus herniates up;
this type is also called “pure” paraesophageal hernia.
– Type III—both gastroesophageal junction
and stomach are dislocated to thorax; this
type is also called “mixed” paraesophageal
hernia.
– Type IV—hernia content is presented by
stomach and other abdominal organs.
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N. Bayramov and N. Zeynalov
Most of hiatal hernias are sliding hernias
(95%), and most of paraesophageal hernias are
mixed hernias (type III) [47]. In the vast majority
of patients with sliding hernia, there are no symptoms, and those with symptoms are typically presented by signs of GERD.
Paraesophageal hernias most commonly
develop after surgery around the gastroesophageal junction. Despite many of such hernias are
asymptomatic, some patients complain of mild
gastrointestinal symptoms (epigastric pain, early
satiety, bloating, hiccups). Some paraesophageal hernias can complicate by gastric volvulus,
bleeding, strangulation, ileus, perforation, and
respiratory failure. Endoscopy, contrast X-ray
and CT are typically used for diagnosis of hiatal
hernia.
Approach to management is based on type
of hernia, symptoms, and complications.
Symptomatic sliding hernia is managed similarly
to GERD—initial treatment is conservative (lifestyle change, PPI, H2 receptor blockers, antacids),
second-line treatment is surgical or by other interventions [42]. Intervention is not recommended
in asymptomatic sliding hernia; however, prophylactic diaphragmatic crural repair is advised if
a bariatric procedure is done (sleeve gastrectomy,
Roux-en-Y bypass) [48]. Paraesophageal hernia
could be a subject to urgent, planned or prophylactic surgery. Complications (gastric volvulus,
bleeding, strangulation, ileus, perforation, respiratory failure) demand urgent surgery, and symptomatic cases without complication need planned
operation. Prophylactic intervention in patients
with asymptomatic paraesophageal hernia is controversial. Though some authors advocate prophylactic surgery, especially in large and type IV
hernias because of risk of complications [49], this
approach is not applied widely. The main steps
in surgical technique for paraesophageal hernia
are: moving the hernia content back to abdominal
cavity, dissection and removal of hernia sac, placing gastroesophageal junction back to abdomen,
fundoplication (total or partial), repair of hernia
ring, and xation of stomach [50]. This operation
can be done laparoscopically, by laparotomy or
thoracotomy. Sutures and mesh can be used for
repair of hernia ring. Types of mesh and indica-
tions to its application are not specied yet. Some
authors consider that repair with mesh reduces
the recurrence rate, so they advise its application
in most of such patients [50]. At the same time
other authors recommend a selective application of mesh, taking into account possible risks
of mesh-related complications [51]. The type
of mesh is another unspecied topic. According
to the general trend biological patch is the rst
choice, and absorbable and non-absorbable synthetic patch is the second choice [46, 52].
Thus, symptomatic and complicated hiatal
hernia is considered to be the indication to surgery. In asymptomatic cases, surgical repair is
indicated during bariatric procedures, large and
type IV hernias. The use of patch/mesh has not
been specied yet.
15.10 Reux Gastritis
Reux gastritis is a chemical gastritis occurring
because of regurgitation of duodenal or jejunal
content back to stomach. It usually develops
after surgical procedures resulting in dysfunction of pyloric sphincter, its removal or bypassing. Sometimes it can be a primary functional
disorder in patients without prior surgery. Reux
gastritis is clinically presented by pain and biliary vomiting. Conservative management (PPI,
antacids, astringents, prokinetics) is effective in
most cases. Surgery is indicated in refractory
cases with no effect of conservative treatment.
Main surgical procedures are Roux-en-Y gastric
resection, Braun anastomosis, isoperistaltic jejunal interposition, and duodenal switch [53].
15.11 Gastric Volvulus
Gastric volvulus is a rare pathology related to
rotation of stomach around its axis or the mesentery axis, can clinically progress in acute and
chronic (recurrent) types. Acute type is presented
by signs of complete gastric obstruction, leading to gastric necrosis and perforation in 1/3 of
patients, may result in high mortality (30–50%)
[53, 54]. Chronic type is presented by repeating
15 Prophylactic Surgery forBenign Diseases ofStomach andDuodenum
169
signs of gastric obstruction. Gastric volvulus can
be a primary pathology; however, in most cases it
is presented together with concomitant abdominal disorders, especially hiatal hernia and defects
of diaphragm (secondary volvulus). Acute volvulus is typically presented by acute pain, belching,
and impossibility of passage of nasogastric tube.
Signs of sepsis may arise in delayed cases. CT
plays the main role in diagnosis of gastric volvulus. Endoscopy is done in an operating room
for evaluation of changes of mucosa and decompression [53, 54]. First-line treatment in acute
volvulus is urgent stabilization of the patient
and surgery. Endoscopic, laparoscopic, and open
methods are used for management [55]. Urgent
gastric resection is indicated if signs of necrosis
of gastric wall are found at clinical examination,
CT, and endoscopy (sepsis, air in or around the
gastric wall, necrotic mucosa). If no such signs
are found, then operation of detorsion, decompression, and gastric xation (gastropexy) is
applied. Hernioplasty and fundoplication are
usually added in secondary volvulus. In order
to prepare high-risk surgical patients to intervention, the surgery can be postponed for few
days after successful endoscopic detorsion and
decompression if there are no signs of necrosis
of gastric wall.
Endoscopic percutaneous gastrostomy and
gastropexy can be applied in children [25].
Surgical xation of stomach can be done by
fundo-antral gastrostomy (Opelzer’s procedure),
gastroenterostomy, gastric resection, simple
gastropexy (suturing of stomach to abdominal
wall), and gastropexy with division of gastrocolic omentum (Tanner’s procedure). Though
less invasive laparoscopic gastropexy is reported
to have a high recurrence rate [54]. Prophylactic
gastropexy is recommended in chronic gastric
volvulus [53, 56].
15.12 Prophylactic Surgery
forDiverticula
Gastric diverticulum is one of the rarest pathologies; it is found at radiologic investigations at
0.04%, endoscopic investigation 0.01–0.11%,
and autopsies 0.02% rate [57]. Most of gastric
diverticula are congenital disorders with asymptomatic progression found occasionally at investigations. Symptomatic diverticula are presented
by non-specic gastrointestinal symptoms—
epigastric pain (18–30%), postprandial discomfort, early satiety, nausea, vomiting, halitosis,
anorexia, etc. [58, 59]. Gastric diverticulum may
result in complications like ulceration, bleeding,
perforation, and even malignant transformation.
Conventional approach to asymptomatic
diverticulum is observation, and to symptomatic or complicated diverticulum is management,
having laparoscopic resection as a rst choice.
Taking into account that diverticula greater than
4 cm are of high risk of complications, some
authors advise the resection of such diverticula
even if asymptomatic [60, 61].
It must be noted that the vast majority of scientic literature on gastric diverticula encompass
small series of patients and reviews. Elaboration
of common approach to small and asymptomatic
diverticula demands large series of long-term
studies.
Duodenum is the most common location of
gastrointestinal diverticula after colon; endoscopic investigations nd duodenal diverticula
in 4.7–13% cases [62]. Most of duodenal diverticula are asymptomatic, but in 10% cases may
be symptomatic, sometimes resulting in complications like perforation, bleeding, biliopancreatic obstruction, duodenal obstruction, and even
malignant transformation; some types of duodenal diverticula may complicate ERCP procedures
[63, 64]. Symptomatic and complicated duodenal
diverticula need conservative and surgical treatment [64–66]. Methods of surgery vary from
simple diverticulectomy to extensive procedures
like duodenal resection, duodenal exclusion, and
pancreaticoduodenal resection [63, 64].
Most of the authors do not recommend prophylactic interventions in duodenal diverticula
because of low risk of change to symptomatic
and complicated types, and high surgical risk
[64, 65]. However, this conclusion is based on
series with small number of patients, that’s why
studies with wide and large series of patients are
necessary.
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N. Bayramov and N. Zeynalov
15.13 Conclusion
– Prophylactic gastrojejunostomy can be
applied additionally to bilioenteric bypass in
periampullary lesions intraoperatively evaluated as non-resectable.
– Complete or partial stomach-partitioning can
be added to palliative gastrojejunostomy in
patients with non-resectable obstruction of
gastric outlet for prevention of delayed gastric
emptying.
– Prophylactic pyloroplasty for prevention of
delayed gastric emptying seems reasonable
in cases of vagotomy and damage of vagus
nerve at surgery, but its signicance in case
of gastroplasty after esophagectomy remains
disputable.
– Prophylactic vagotomy may be used for pre-
vention of peptic ulcer of gastroenteroanastomosis.
– Prophylactic gastrostomy may be reasonable
in duodenal injuries, large pyloric perforations, and gastric volvulus.
– Prophylactic ischemic conditioning of stom-
ach conduit for reconstruction after esophagectomy is currently not recommended to use
widely.
– Prophylactic anti-reux surgery is recom-
mended in Heller myotomy and paraesophageal hernia.
– Prophylactic surgery for GERD and sliding
hiatal hernia is advised during bariatric procedures, and in large and type IV hernias.
– Prophylactic Roux-en-Y, Braun, and duodenal
switch procedures are recommended for prevention of reux gastritis after gastroduodenal
surgery.
– Prophylactic gastropexy is indicated in
chronic gastric volvulus.
– Prophylactic surgery is recommended in large
(greater than 4 cm) gastric diverticula, and
not recommended in asymptomatic duodenal
diverticula.
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Prophylactic Surgery forSmall
Intestines
FaikYaylak andMustafaÖzsoy
16
16.1 Introduction
In this chapter, aim and rationale of prophylactic surgery for small intestines will be discussed.
Initially we will overview the types of prophylactic small intestinal surgery. In this overview, we
have classied the prophylactic small intestinal
surgeries according to aim and rationale. The primary aim of prophylactic small intestinal surgery
is to prevent loss of small intestinal integrity and
functions. The secondary type was dened those
surgical procedures where small intestines are
used to serve as an access point for gastrointestinal tract or to drain gastrointestinal secretions.
In addition, the role of minimal invasive surgery
techniques has been mentioned.
16.2 Overview ofProphylactic
Small Intestinal Surgery
The primary aim of prophylactic small intestinal
surgery is to prevent a further or future loss of
small intestinal anatomical and functional integrity. Hernia repair in an asymptomatic patient is
performed in selected patients to prevent intestinal strangulation related complications. In
addition, resection of an incidental Meckel’s
diverticulum may be performed with the intention of minimizing future diverticulum related
complications. Some other prophylactic surgical
procedures may involve small intestines to access
gastrointestinal system or to divert gastrointestinal secretions to feed or to prevent a gastrointestinal leak and related conditions. This chapter
will focus on these main domains of prophylactic
small intestinal surgery.
16.3 Types ofProphylactic
Surgeries forSmall
Intestines
Prophylactic surgeries for small intestines may be
F. Yaylak
Department of General Surgery, Kütahya Saglik
Bilimleri University, Kütahya, Turkey
e-mail: faik.yaylak@ksbu.edu.tr
M. Özsoy (*)
Department of General Surgery, AYBU University,
Ankara, Turkey
e-mail: mustafa.ozsoy@aybu.edu.tr
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_16
of mainly two types. The primary type of prophylactic surgeries for small intestines has intended to
protect small intestinal continuity and functional
integrity. This type of prophylactic surgeries may
also intend to prevent possible small intestinal
related complications such as bleeding, obstruction perforation, and even development of cancer.
173
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