clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

After detachment of the greater omentum, the right gastroepiploic vessels are identified and secured with clips at the level of the duodenum. Mayo’s vein will locate the exact position of the pylorus. Identification of the pylorus can be facilitated by gentle palpation with a clamp in the postpyloric area. Care should be taken not to damage

the pancreatic parenchyma as this will result in pancreatitis. Sharp dissection at the posterior side of the postpyloric part of the duodenum creates space to introduce a 45-mm stapling device. A vessel loop can be used to facilitate safe insertion of the stapler. Prior to the closure of the stapler, care should be taken that the vessel loop and vascular clips are not included in the line of stapling (A).

The assistant retracts the liver to allow exposure of the smaller omentum. The gastrohepatic ligament is opened at the level of the hepatoduodenal ligament. The right gastric artery is transected using Ultracision (B). The assistant retracts the liver to allow exposure of the liver hilum. Following the common, proper, and left hepatic artery, the smaller omentum is freed, securing lymph nodes of the pyloric group up to the right pericardial group. This en bloc lymphadenectomy is part of a level D2 resection and

is optional. A replaced or aberrant left hepatic artery, originating from the left gastric artery, can be safely dealt with, using clips if necessary. Alternatively this lymphadenectomy can be done after transection of the stomach.

C

220 SECTION 2 Esophagus, Stomach and Duodenum

Postoperative Investigations

See chapter “Total Gastrectomy with Conventional Lymphadenectomy.”

Postoperative Complications

■Short term:

–Anastomotic insufficiency (including duodenal stump insufficiency)

–Acute pancreatitis

–Chylous ascites (particularly after R2 resection)

■Long term (all indications):

–Biliary gastritis (particularly after Billroth II reconstruction)

–Jejunal peptic ulcer disease

■Long term (in case of malignancy):

–Local recurrence (duodenal stump or resection line of stomach)

–Distant metastases

Tricks of the Senior Surgeon

■Instead of a vessel loop, a heavy resorbable suture can be used to force the stomach or duodenum into the endostapler. Even if this suture is included in the staple line, this will not compromise your anastomosis.

■In lean patients it is often possible to remove one of the 10to 12-mm trocars and directly introduce the 60-mm stapler or the retrieval bag, instead of using a 15-mm trocar.

■Suturing is best done with the scope in the middle and two needle holders on either side of the scope with a 60–90° angle between the two needle holders.

Gastroenterostomy

John Tsiaoussis, Gregory G. Tsiotos

Introduction

In this chapter both techniques for gastroenterostomy, the open and laparoscopic approaches, are described in patients with gastric outlet obstruction syndrome.

Indications and Contraindications

Preoperative Investigation/Preparation for the Procedure

A large-bore nasogastric tube is placed the day prior to the operation for gastric decompression and irrigation.

The patient’s water and electrolyte balance are corrected preoperatively.

The jejunal loop can be brought either anterior to the transverse colon (antecolic),

or through a window in the transverse mesocolon (retrocolic).Although a retrocolic gastrojejunostomy has been considered more prone to obstruction because of its closer proximity to an ever enlarging unresectable periampullary tumor, this has never proved true, especially since patient survival in this context rarely exceeds 6months. On the other hand, the retrocolic route allows more proximal placement of the jejunal stoma and smoother angles between afferent, efferent loops and stomach in both the coronal and the sagittal planes.

The window (wide enough to allow comfortable sliding of both afferent and efferent jejunal loops) is made in an avascular plane of the mesocolon left to the middle colic vessels. The ligament of Treitz is identified by lifting up the transverse colon, and the jejunal loop is brought up through the mesocolic window in apposition to the greater curvature (now free from omental vessels). The length of the afferent jejunal limb should not exceed 20cm.

The gastrojejunostomy can be placed either on the anterior (easier and thus preferable) or the posterior gastric wall; the latter has not proved superior in terms of gastric emptying. Then 3-0 silk traction seromuscular sutures are placed, taking into account that the incision in the jejunum will not be made exactly at the antimesenteric border, but at a level closer to its mesentery on the stomal side. This provides for more comfortable lining of the completed anastomosis without any undue angles in the transverse plane. At 5-mm intervals 3-0 silk interrupted seromuscular Lembert sutures are placed and tied to create the posterior outer suture line. Two incisions along the gastric and the jejunal apposite segments are then made. Although the gastric incision should be about 4cm, the jejunal incision should be a bit shorter, since it always tends to dilate and ends up being realistically longer than initially planned or thought to be.