gastric resection, reconstruction and post gastrectomy syndromes
TRANSCRIPT
Gastric Resection & Reconstruction
Dr SD Sanyal
GASTRIC RESECTION
History
• The earliest recorded operations on the stomach were performed for penetrating injuries
• Late 1800s: Experimental studies by Billroth confirmed the feasibility of removing the pylorus
• Rydygier 1881: First successful pylorectomy• Rydygier 1884 : First gastroenterostomy
History
• Billroth 1881: Performed the first successful pylorectomy – Duodenum anastomosed to the lesser curvature of the stomach and the greater curvature oversewn.
• Billroth 1885: Resection of a large pyloric carcinoma, using an anterior gastro-jejunostomy
Indications
1. Malignancy2. Peptic Ulcer Disease:
- Bleeding- Perforation- Obstruction- Failed medical therapy- Risk of malignancy
3. GIST
Gastric Resection• Special considerations:
1. Physiology of vagal innervation and gastric emptying2. Surface and vascular anatomy of the stomach3. Principles of reconstruction following resection ie.
Billroth I, Billroth II and Roux-en-Y configuration4. Principles of surgical stapling techniques and hand-
sewn suturing techniques5. Specific early and late postoperative complications
Gastric Resections
• Types:1. Wedge resections2. Gastrectomy:
- Antrectomy/Hemigastrectomy 35-50%- Partial 65%- Subtotal 80%- Near total 90%- Total/ Radical(D2)
Gastric Resection
• Pre operative evaluation and preparation:1. Endoscopy2. Imaging
- EUS- Computed Tomography
3. Comorbidities4. Nutritional status5. Pre-operative antibiotics6. DVT prophylaxis
Wedge Resection• Upper midline incision• Greater curvature lesions:
- Wedge resection with 2 cms free margin- Lesion within 2cms of Pylorus or GE jn
Consider conversion to formal resection
- Closure in 2 layers• Lesser curvature lesions:
- Mucosal approach- Possible sacrifice of one/ both nerves of Latarjet
Consider Pyloroplasty
- Possible sacrifice of Rt/Lt gastric arteries- Consider formal resection withBI/BII reconstruction
Resection
Repair: 2 layer
Antrectomy
• Removes Distal 35% of the stomach• Upper midline incision• Truncal vagotomy to be performed• Billroth I/II reconstruction• Distal margin: Flush beyond Pylorus• Proximal margins:
Lesser curvature : Incisura angularisGreater curvature: Termination of RGEA
Division of Greater Omentum
Lesser omentum Greater omentum
Distal Resection
Proximal Gastrectomy
Indications:- Ca involving the Cardia- GE jn lesions : Siewarts type I&II
• Disadvantages:- Alkaline reflux
Extent of Resection
Reconstruction
Sub-total & Near totalGastrectomy
Sub Total• Ca Pylorus• Ca Antrum• Primary Gastric Lymphoma• Extended Hemigastrectiomy
in princple• Removes upto 80% of
stomach
Near Total• Roux stasis syndrome• Gastroparesis • Ca body of stomach• Lymphoma• Removes upto 90% of
stomach
Sub-total & Near totalGastrectomy
• Special considerations:1. Chevron incision2. Left gastric artery is always ligated3. Division of branches of LGEA & Short gastrics after
defining the limit of resection4. Cuff of gastric wall(1-2cms) to be left back in Near
total gastrectomy5. 1to 2 upper branches of Short gastrics to be left
back in Near total gastrectomy6. Extended lymphadenectomy: D2 resection
Total gastrectomy• Indication: Carcinoma stomach• Aims:
- Clear esophageal and duodenal margins- Clearance of local and regional lymph nodes- Clearance of lymph nodal basins along Left gastric, RGEA and Short gastrics- En bloc removal of stomach and omentum- Removal of lymphoid tissue over pancreatic capsule- D2 lymphadenectomy
• Reconstruction:- Roux en Y with direct Esophagoenterostomy- Jejunal pouch
Total gastresctomy: Extent of resection
Division of Gastrocolic ligament
Division of Duodenum
Exposure of Lesser Sac
Division of Left Gastric
Esophageal transection
Lymph node zones
Lymph Node Stations
Gastric Reconstruction
Reconstruction Techniques
1. Billroth I2. Billroth II3. Roux en Y technique
Billroth I
• Gastric remnant anastomosed to Duodenum• Advantages:
1. Restoring the normal GI continuity2. Leaving specialised duodenal mucosa next to the gastric mucosa3. Avoiding problems with the afferent and efferent loops4. Easier performance of Endoscopy and ERCP5. Decreased incidence of carcinoma in the stomach remnant
Laparotomy
Billroth I
Stomach Remnant
Gastroduodenostomy
Variations of Billroth I
A. Billroth (1881) B. Billroth (1881) C. Kocher (1890) D. Kutscha-Lissberg (1925)
E. v. Haberer (1920) F. v. Haberer (1920), Finney (1923) G. Winkelbauer (1927) H. Schoemaker (1911) I. Harkins, Nyhus (1960
Posterior Serosal layer
Mucosal layer
Anterior Mucosal & Seromuscular layers
Stapled technique
Billroth II
• Indication:- Prevention of undue tension on the anastomosis secondary to scarring
• Points to consider:- Stapled vs Hand sewn closure of duodenum- Antecolic vs Retrocolic position of the Jejunal loop- Length of the Afferent limb
Variations A. Billroth II
B. Kronelin C. von Eiselberg D. BraunE. Roux F. Roux-en-Y G. Ploy and Reichel H. Finsterer-Hofmeister I. Balfour J. Moynihan K. Tanner
Gastric resection
Retrocolic window
Two layer anastomosis
Closure of Retrocolic window
Stapled technique
Roux-en-Y reconstruction
Division of Jejunum
Anastomosis
Anastomosis
Anastomosis
Completed Roux-en-Y
Post Gastrectomy Syndromes
Types
3 main types:
1.Gastric reservoir dysfunction 2. Vagal denervation 3. Aberrations in surgical
reconstruction
Gastric Reservoir Dysfunction
• Dumping Syndrome• Metabolic abnormalities
Dumping Syndrome
• Early Dumping• Late Dumping
Early Dumping 15 minutes to 1 hour after a meal.
Due to rapid release of hyperosmolar food into small bowel > rapid shift in extracellular fluid > systemic hypotension.
Loss of receptive stomach relaxation
Nausea, vomiting, epigastric fullness, abdominal cramping and diarrhea, palpitation, diaphoresis.
Relieved by lying down.
Late Dumping1 to 3 hours after a meal.
Carbohydrates absorbed quickly > blood sugar level rises > hyper-insulinemia and consequent hypoglycemia.
Fainting, tremor, prostration, decreased consciousness.
Relieved by food.
Management• CONSERVATIVE:
Low carbohydrate diet (prefer complex carbohydrate)
Small meal with solid and liquid food
Somatostatin analogues; Octreotide100 mcg IV 15-60 minutes before meal to slow transit time.
Alpha glucosidase inhibitor medication in late dumping
Anti Dumping Diet
Management
SURGICAL:Iso/anti peristaltic segment of jejunum
interposed between stomach and small bowel (10-20 cm)
Conversion to Roux-en-Y gastro-jejunostomy.
Conversion of Billroth II to Billroth I
Inter-positioned Isoperistaltic Jejunal loop(Henley)
Interpostioning of Anti-peristaltic jejunal loop
BII to BI
Metabolic abnormalitiesAnaemia: *Iron Deficiency( reduced absorption) *Pernicious anemia( reduced intrinsic factor) *Folate deficiency (malabsorption).
Metabolic Bone disease( decreased Vit.D & Ca absorption)
* Unexplained aches and pains in back or long bones *Rx : Ca and Vit D supplements
Vagal Denervation
Diarrhea
Gastroparesis
Gallstone
Diarrhoea
Uncontrolled bowel movements > increased stool frequency .
Conservative Rx : CholestyramineCodeineLoperamide
Surgical : 10 cm segment of reversed jejunal anastomosis placed 70-100 cm from ligament of Treitz .
Gastroparesis
• 50% of Pt have this syndrome• Most pts diagnosed if not taking adequate oral intake 7-14 days
post-op after gastric procedure• Symptoms: nausea, bloating, fullness, early satiety, vomiting• Gastric emptying studies( thin barium/ gastrograffin) – normal:
60% solid, 80% liquid clearance at 60 min.• Nuclear Medicine solid phase gastric emptying test-Gold
standard -> 50% solid-2Hrs >10% solid-4 Hrs
Acute Gastroparesis
Causes: • Metabolic/Neuronal
• Electrolytes – hypomagnesemia, hypokalemia• Endocrine – hypothyroidism, DM• Medications – opiates, anticholinergics, antidepressants
• Functional– Preoperative gastric outlet obstruction-affects contraction– Effects of truncal vagotomy – Stomal edema, adhesions, kinking, hematoma,
intussusception
Treatment
Conservative • NGT decompression• Prokinetic agents• Correction of
Electrolytes• patience
After failed treatment • Minimum of 3-4 wks
– No improvement – re-explore
– Look for mechanical causes
– Place feeding tube – jejunostomy
Chronic Gastroparesis
• Diagnosis of exclusion – rule out stricture, internal hernia, stomal edema, intussusception
• ~2% of patients after gastric surgery • Symptoms start later in the post-op period
Chronic Gastroparesis
Diagnosis• Symptoms – early satiety, nausea, vomiting,
postprandial bloating, hiccups, belching– Increase throughout the day
• Emesis of food ingested days earlier – pathognomonic
• Need UGI to rule out other syndromes
Treatment
Conservative treatment• Same as acute
gastroparesis• More emphasis
prokinetic agents
Surgical treatment• Resection of atonic
portion• Using a different type of
reconstruction• Only total gastrectomy
may be curative• Gastric pacing
?-Low/High Frequency
Gall Stones
Division of hepatic branches of anterior Vagal trunk.
Gallbladder dysmotilitySurgery indicated only if
pathological.No indication for prophylactic
cholecystectomy.
Aberrations in Surgical Reconstruction
Alkaline reflux gastritisAfferent and efferent loop obstructionRoux syndrome
Alkaline Reflux GastritisReflux of alkaline secretions into gastric
remnant.Billroth II>IManifests after 1yrReflux symptoms: epigastric pain, bilious
vomitingDiagnosis:
- Clinical + evidence of bile reflux on endoscopy- Bernstein Test- 24 hr pH monitoring
Alkaline Reflux Gastritis
Medical management:- PPI- Cholestyramine- UDCA
Braun’s procedureRoux en Y Gastro- jejunostomy with
afferent limb measuring at least 40cm.
Alkaline Reflux Gastritis
Alkaline Reflux Gastritis
Afferent & Efferent loops
Afferent loop syndrome
More commonAcute<ChronicExclusively with B IIRetrocolic > Antecolic Afferent loop > 40cmsGJ anastomosis above the retrocolic windowSymptoms:- Severe postprandial epigastric pain(30-60 mins)- projectile vomiting
Avoid excess length of afferent loopRelease trapped loop.Mgt is always surgical
Efferent loop syndrome Less commonD/D: Gastroparesis, Alkaline reflux gastritis, Roux limb
syndromeSymptoms:
- Epigastric pain- Nausea/vomiting- Relief on vomiting
Internal herniation of efferent limb behind the anastomosis
Surgical management
Roux SyndromeDisruption of normal myoelectric patternSymptom complex characterized by:
- chronic postprandial epigastric pain- fullness- vomiting after Roux-en-Y reconstruction
Post Vagotomy gastric atony. Medical treatment is successful in only about
half of cases: Prokinetic drugsSurgical :remove most or all of the gastric
remnant is usually successful.
Uncut Roux Loop
Thank You