clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

There are two ways of performing the esophagojejunostomy, suturing either end-to-end or end-to-side. My preference is to use the latter because the end-to-end method carries an increased risk of compromising the circulation at the end of the jejunal loop. It is also easier to match the diameter of esophagus and jejunum in this way. The anastomosis is sutured by hand using a single-layer interrupted suture technique (lift anastomosis).

■An antimesenteric incision is made in the end of the jejunum, its length corresponding to the diameter of the esophagus. To avoid a blind loop syndrome, the incision is made close (1–2cm) to the end of the jejunum closed earlier by the staples and oversewn with a non-dissolvable running suture (A).

■Two corner sutures are inserted and lightly tensioned with Pean forceps. A further stitch is placed midway between the corner stitches on the posterior wall and the back line is completed using full-thickness mattress sutures (B).

A

B

C

D

E

F

At a point 50–60cm below the esophagojejunostomy, an end-to-side jejunojejunostomy is performed using a continuous extramucosal suture technique.

All openings in the mesentery are closed by monofilament suture.

Two drainages are placed behind the esophagojejunostomy and around the duodenal stump.

Standard Postoperative Investigations

■Hemoglobin

■Check daily for clinical signs of infection (anastomotic leak)

■Contrast study of esophagojejunostomy (day 6)

Postoperative Complications

■Short term:

–Intra-abdominal bleeding

–Subphrenic abscess

–Anastomotic leak

–Pancreatic fistula

–Duodenal stump leak

■Long term:

–Weight loss, decreasing nutritional status (reservoir capacity)

–Diarrhea

–Dumping syndrome

–Alkaline reflux

Tricks of the Senior Surgeon

■Ask the anesthesiologist not to introduce a gastric tube before having completed the backwall of the esophagojejunostomy. This may minimize the risk of esophagus spasm.

■Keep the dissection of the short gastric vessels closed to the great curvature of the stomach.

■Secure the duodenal stump (staples row) with a continuous suture.

■Use magnifying glasses to perform the lymphadenectomy.

Total Gastrectomy with Radical Systemic

Lymphadenectomy (Japanese Procedure)

Mitsuru Sasako

Introduction

Historically, total gastrectomy with radical lymphadenectomy included distal pancreatectomy and splenectomy and was favored by Brunschwig in 1948. Maruyama modified this procedure by preserving the distal pancreas, so-called pancreas preserving radical total gastrectomy. His initial report was published in Japanese in 1979. Initially he ligated both the splenic artery and vein near their origin, which often caused major congestion of the pancreas tail followed by massive necrosis. The first available English report was published in 1995 and described a modified technique of the original version. There he obtained the splenic vein up to the tip of the pancreas tail to preserve venous return.

The technique of pancreas preserving total gastrectomy with radical systemic lymphadenectomy (D2) by preserving the splenic artery and vein as far as the branching-off of the major pancreatic artery (Sasako’s modification) is described.

Indications and Contraindications

The transverse mesocolon is stretched by the second assistant. Dissection of the greater omentum together with the posterior wall of the omental bursa is performed.

It is compromised by two membranes, one continuing to the anterior pancreatic capsule and the other to the posterior duodenopancreatic fascia. Diathermy allows bloodless transection.

Following the right accessory vein, Henle’s surgical trunk can be found. The origin of the right gastroepiploic vein is ligated. Before going on to the third step, the dissection plane should be changed from the posterior to the anterior capsule of the pancreas.

By dissection of the anterior capsule of the pancreas towards the duodenum, the gastroduodenal artery appears on the anterior surface of the pancreas neck. Following this artery caudally, the origin of the right gastroepiploic artery can be found. After its ligation and division, the gastroduodenal artery should be followed cranially up

to the bifurcation of the common hepatic artery.