clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer
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Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers |
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STEP 3 |
Braun’s anastomosis |
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Braun’s anatomosis is performed as distal as possible (>40cm) to avoid biliary reflux into the gastric remnant. Side-to-side jejunostomy is done either with single stitches, a running suture, or a stapler device (A, B, C).
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B |
C
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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Roux-en-Y Reconstruction |
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Procedure |
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STEP 1 |
Dissection of the jejunum |
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The ligament of Treitz is identified, and the jejunum is dissected about 40–50cm distal to |
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Treitz’ ligament (A). For convenience, a stapler device may be used. The blind end of the |
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distal part is closed using a running suture or single stitches. The distal loop is placed |
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side-to-side to the posterior wall of the gastric remnant without exerting any tension |
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on the mesentery. A retrocolic route is preferable. Before performing the anastomosis, |
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the serosa of the jejunal loop is fixed to the serosa of the gastric remnant over a distance |
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of 5–6cm, thus building the outer layer of the backward suture (B). |
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A
B
Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers |
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STEP 2 |
Gastrojejunostomy |
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The jejunal loop and the gastric wall are opened along the antimesenteric border using electrocautery, and the posterior part of the anastomosis is done with a running suture representing the inner layer, completed by a running inverting suture on the anterior part of the gastrojejunostomy.
However, single stitches in monolayer technique as well as the appliance of a stapler device are also adequate. The technique is similar to the gastrojejunostomy in the Billroth II reconstruction (STEP 2).
The dissected jejunal loop is anastomosed end-to-side to the distal part of the jejunum 40–50cm distal to the ligament of Treitz.
Postoperative Investigations
■The gastric tube should be kept until there are no further signs of gastric reflux or gastrointestinal atonia are present. Indwelling drains should be kept until enteral nutrition has been started.
Postoperative Complications
■Short term:
–Insufficiency of the gastrojejunostomy
–Insufficiency of the duodenal stump
–Acute pancreatitis, pancreatic fistula
–Early dumping syndrome
–Biliary stricture
■Long term:
–Biliary reflux
–Stricture of the gastrojejunostomy
–Stump carcinoma
–Late dumping syndrome
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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Local Excision in the Stomach |
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Introduction |
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Ulcers that do not respond to medical treatment, perforation, or bleeding require |
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surgical intervention. In bleeding, an endoscopic treatment is the firstline approach. |
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If bleeding cannot be controlled by endoscopic means, surgical excision is the therapy |
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of choice. |
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Local excision in the stomach is indicated when the extension of the ulcer allows for |
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readaption without exerting any tension on the anastomosis. |
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The test for Helicobacter pylori and the maintenance of antacid medication are |
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mandatory. Work-up includes gastrin testing and testing for elevated serum calcium |
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levels, both risk factors in complicated ulcers. |
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Indications and Contraindications |
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■ Endoscopically uncontrollable bleeding and perforation are indications. |
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Indications |
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for an emergency procedure. |
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Standard Preoperative Investigations
In Case of Bleeding
■Endoscopy with the identification of the bleeding site: active bleeding is identified by endoscopy or systemic hemoglobin values. Blood pressure and heart rate are recorded.
In Case of Suspected Perforation
■Standard X-ray of the abdomen in upright and left semiprone position
■Gas insufflation via a gastric tube may facilitate the diagnosis in conventional X-ray examination; in case of peritonism without direct evidence of free abdominal gas, a CT scan should be obtained.
■Especially in retroperitoneal perforation of the duodenum, free gas may not be seen in standard X-ray films.
Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers |
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Procedure in Perforated Gastric Ulcers |
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STEP 1 |
Exposure of the ulcerative lesion |
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The ulcerative lesion is completely exposed. In case of perforation of the posterior |
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gastric wall, the omentum of the stomach and of the colon is separated, and the omental |
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bursa is exposed (see “Subtotal Gastrectomy” STEP 1, Fig. B). |
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STEP 2 |
Excision of the ulcer |
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In case of chronic granulation, the wall of the ulcer is excised longitudally. |
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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STEP 3 |
Closure |
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The ulcer is closed in a crosswise technique by single layer stitches with an absorbable suture. (A, B).
A
B
Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers |
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STEP 1
STEP 2
STEP 3
Procedure in Bleeding Gastric Ulcers Refractory to Endoscopic Treatment
Gastrotomy and exposure of the bleeding site
In bleeding without perforation, gastrotomy is the exposure of choice. Use a longitudinal incision of the anterior gastric wall.
Isolation of the bleeding
In bleeding of the posterior gastric wall, verify that the source of bleeding might arise from an ulceration of the splenic artery. In this case, separate the artery at its origin and ligate it. Additional stitches placed around the ulcer wall on all four sides may help to control bleeding. The use of a non-absorbable suture is preferable. Collaterals maintain blood supply to the spleen, and splenectomy is not required.
Closure
Closure of the incision with the single layer technique.
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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Local Excision in the Duodenum |
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Introduction |
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In complicated duodenal ulcers, local excision is the therapy of choice. Depending on the localization and the extension, a duodenojejunostomy with a
Roux-en-Y reconstruction is indicated. Further, the gastroduodenal artery should be ligated in case of bleeding ulcers.
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Indications and Preoperative Investigations |
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■ These correspond to those in gastric ulcers and bleeding (see “Local Excision in the |
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Stomach” above). |
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Procedure in Complicated Duodenal Ulcers |
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Ventral Duodenal Wall |
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STEP 1 |
Exposure of the duodenum |
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The duodenum is completely exposed and opened longitudinally. |
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In case of perforation, the ulcerative lesion is excised. |
Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers |
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STEP 2 |
Closure of the incision |
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The incision is closed crosswise using single stitches. Kocher’s maneuver may lower the tension to the suture. Mind that the duodenal passage is not compromised. Depending on the extent of the excision, primary closure might not be advisable. In this case, a duodenojejunostomy is required using a Roux-en-Y reconstruction (A-1, A-2, A-3).
A-1
A-2
A-3
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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Posterior Duodenal Wall |
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STEP 1 |
Exposure of the duodenum |
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After exposing the duodenum, Kocher’s maneuver is performed, and the posterior wall |
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of the duodenum is completely exposed in case of perforation. In case of bleeding, the |
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anterior wall is opened, and single stitches are placed on all four sides of the ulcerative |
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lesion. |
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STEP 2 |
Excision of the ulcerative lesion |
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The ulceration is excised (see “Local Excision in the Stomach”, STEP 2). As a rule, |
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primary closure of the lesion may not be advisable, as mobilization of the posterior |
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duodenal wall is limited. Hence, a duodenojejunostomy is put in place. The gastro- |
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duodenal artery is exposed and ligated at its origin. In case of bleeding ulcers, this |
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step might be taken first, when the bleeding source has previously been identified in |
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gastroduodenoscopy. |