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Kurien Slide 2: My sincere thanks to….. Christopher J. K. Bulstrode Norman S. Williams P. Ronan O’ Connell Topics will be discussed under.. : Topics will be discussed under.. Anatomy of stomach Types of Gastrectomy Indications Procedure with Reconstruction Complications ANATOMY : ANATOMY Vascular supply: Arterial supply to stomach. L Inf Ph, Left inferior phrenic artery. SG, Short gastric artery. LGE, Left gastroepiploic artery. RGE, Right gastroepiploic artery. S, Splenic artery. GP, Great pancreatic artery. Inf P, Inferior pancreatic artery. PD, Pancreaticoduodenal artery. DP, Dorsal pancreatic artery. GD, Gastroduodenal artery. RG, Right gastric artery. H, Hepatic artery. CT, Celiac trunk. LG, Left gastric artery. Post G, Posterior gastric artery Anatomy of Stomach : Anatomy of Stomach Slide 7: Blood Supply Slide 8: Arterial supply to greater omentum Slide 9: Venous system Slide 10: Lymphatic Drainage Slide 11: Lymphatic Drainage Slide 13: CLASSIFIES 18 LN REGIONS INTO 4 N CATEGORIES DEPENDING UPON THE RELATIONSHIP TO THE PRIMARY TUMOR AND ANATOMIC LOCATION. MOST PERIGASTRIC LN’s (NODAL STATIONS 1-6) – group 1. LYMPH NODES SITUATED ALONG PROXIMAL LEFT GASTRIC A (STATION 7), COMMON HEPATIC A (8), CELIAC AXIS (9) , SPLENIC A(11), PROPER HEPATIC A (12)- group 2. PARAAORTIC LN (16)- group 3 Slide 15: Based upon lymph node groups N1 to N4 (japanese) D0?removes no lymph node group D1?removes N1 group,including greater and lesser omenta. station 1 to 6 D2?removes N2 group en bloc with stomach includes station 1 to 9 (+/- 10,11) D3?removes N3 group + pancreas + spleen At present D2 DISSECTION gives NO SURVIVAL ADVANTAGE Slide 16: Nerve supply Intrinsic supply: Myenteric plexus of Auerbach & submucosal plexus of Meissner Extrinsic supply: Vagal nerves – both afferent( sensory) and efferent Efferent: receptive relaxation, stimulation of gastric motility, secretory function Sympathetic : Coeliac ganglia Slide 17: Vagal innervation of the stomach. The line of division for truncal vagotomy is shown and is above the hepatic and celiac branches of the left and right vagus nerves, respectively. The line of division for selective vagotomy is shown and occurs below the hepatic and celiac branches. Slide 18: Dotted line represents the line of dissection for parietal cell or highly selective vagotomy. Note that the last major branches of the nerve are left intact and that the dissection begins 7 cm from the pylorus. At the gastroesophageal junction, the dissection is well away from the origin of the hepatic branches of the left vagus Slide 19: Anatomic and Surgical History of the Stomach Billroth, Gussenbauer, Winiwarter (1874-6) Billroth I - Distal gastric resection with anastomosis of stomach and duodenum (developed in dogs) Billroth II - Anastomosis of stomach to jejunum through transverse mesocolon Billroth, Wölfler 1881 First successful resection on human patient Mikulicz-Radecki 1887 Performed successful pylorectomy for pyloric stenosis Billroth Clinic 1890 41 gastric resections for cancer, 19 successful (46.5%) Braun 1893 Described jejunojejunostomy as routine addition to gastrojejunostomy Eiselsberg 1895 Divided stomach proximal to cancer and performed gastrojejunal anastomosis (antral exclusion) Levels of Resection : Levels of Resection Slide 21: INDICATIONS Peptic Ulcer Disease Gastric Carcinoma Gastric Tumors Slide 22: Peptic Ulcer Disease Duodenal Ulcer Intractable: parietal cell vagotomy Bleeding: truncal vagotomy with pyloroplasty and oversewing of bleeding vessel Perforation: patch closure with treatment of H. pylori with or without parietal cell vagotomy Obstruction: rule out malignancy and parietal cell vagotomy with gastrojejunostomy Gastric Ulcer Intractable Type I: distal gastrectomy with Billroth I Type II or III: distal gastrectomy with truncal vagotomy Bleeding Type I: distal gastrectomy with Billroth I Type II or III: distal gastrectomy with truncal vagotomy Perforated Type I, stable: distal gastrectomy with Billroth I Type I, unstable: biopsy, patch, and treatment for H. pylori Type II or III: patch closure with treatment of H. pylori Obstruction: rule out malignancy and antrectomy with vagotomy Type IV: depends on ulcer size, distance from the gastroesophageal junction, and degree of surrounding inflammation Giant gastric ulcers: distal gastrectomy, with vagotomy reserved for type II and III gastric ulcers Principles of surgery in CA stomach : Principles of surgery in CA stomach Distal(body/antrum)?partial distal gastrectomy Proximal(cardia)?total gastrectomy Splenectomy?avoid if possible Consider placing a feeding jejunostomy tube Prefer >5cm proximal and distal margins. D0 lymphadenectomy,min 15 LNs should be evaluated . R status : R status Tumor status after resection R0 - microscopically margin negative resection R1 - removal of all macroscopic diseases R2 - gross residual disease Slide 25: PROCEDURE Slide 26: Wedge resection of stomach Slide 27: BILLROTH-I HEMIGASTRECTOMY Slide 28: Kocherization of duodenum after identifying the middle colic vessels Slide 29: Mobilization of the splenic flexure and release of omentum from the transverse colon Slide 30: Site of resection of the stomach Slide 31: Hemostatic sutures Slide 32: Gastric opening should be approximately 2.5 to 3 cm wide Direct end-to-end anastomosis with the duodenum Slide 33: Anastomosis Slide 34: Vascular pedicles on the gastric side are anchored to the ligated right gastric pedicle along the top surface of the duodenum Slide 35: BILLROTH –I Modifications Slide 37: BILLROTH II HEMIGASTRECTOMY (POLYA) Slide 38: The antrum is resected as in a Billroth I operation. The distal portion of the resection line is excised Slide 39: The jejunal segment, located 10 to 20 cm beyond the ligament of Treitz, is brought through a window in the retrocolic mesentery Slide 40: The gastrojejunal anastomosis is constructed in two layers Slide 41: Retrocolic window in the mesentery is closed in order to avoid herniation of other viscera. The mesentery is linked to gastric wall, positioning the anastomosis below the closure Slide 42: BILLROTH-II Modifications Slide 44: BILLROTH-II Roux-en-Y modification Slide 45: Polya modification Slide 46: SUBTOTAL GASTRECTOMY Slide 48: Extent and fixation of the tumor mass by exploring the lesser omental cavity through an opening made in the relatively avascular gastrohepatic ligament Slide 49: Kocherization of duodenum Slide 50: CBD is identified & preserved Slide 51: Gauze tape is brought up through an avascular space along the greater curvature and is used for traction Slide 52: Gastrocolic ligament is ligated close to the greater curvature Slide 54: Sacrifice of the left gastroepiploic artery and one or two of the short gastric arteries in the gastrosplenic ligament. The nutrition of the remaining fundus of the stomach depends upon the remaining short gastric arteries Slide 55: Cutting the splenocolic ligament for mobilizing the greater curvature Slide 56: right gastroepiploic vessels should be carefully isolated from the surrounding fat and securely ligated over the duodenum Slide 57: Most medial portion of the hepatoduodenal ligament, which includes the right gastric artery, is divided Slide 58: Transfixing silk traction sutures are applied to the superior and inferior borders of the duodenum adjacent to its retained blood supply. Pylorus is freed Slide 59: Clamps applied Slide 60: Ligation of the small vascular attachments between duodenum and pancreas must be carried out without damaging the gastroduodenal artery Slide 61: Duodenal clamps removed Slide 62: Duodenal stump closed in 2layers Slide 63: Anterior wall of duodenum to capsule of pancreas Slide 64: Gastrohepatic ligament dissection Slide 65: If not radical – Left gastric gastric vessels maintained Slide 69: Left gastric artery as far away from the lesser curvature as possible Slide 71: Clamped applied over the stomach Slide 72: TOTAL GASTRECTOMY Slide 74: At least 2.5 to 3 cm of duodenum distal to the pyloric veins should be resected Slide 75: Palpation of posterior aspect of stomach Slide 76: Free mobility of the growth without involvement of fixation to the underlying pancreas or major vessels, especially in the region of the left gastric vessels Slide 77: The right gastroepiploic vessels are doubly ligated as far away from the interior surface of the duodenum as possible, to ensure removal of the infrapyloric lymph nodes and adjacent fat Slide 78: Right gastric vessels along the superior margin of the first part of the duodenum are isolated by blunt dissection and doubly ligated some distance from the duodenal wall Slide 79: Duodenum is divided Slide 80: Duodenum should be freed from the adjacent pancreas, especially inferiorly, where a few vessels may enter the wall of the duodenum Slide 81: Avascular suspensory ligament is cut, Lt. lobe of liver examined and folded upwards Slide 82: Uppermost portion of the gastrohepatic ligament, which includes a branch of the inferior phrenic vessel, is isolated by blunt dissection Slide 83: Left gastric vessels are isolated from adjacent tissues Slide 84: Wall of the esophagus can be lightly anchored to the crus of the diaphragm on both sides, as well as anteriorly and posteriorly and also to approximate the crus of the diaphragm Slide 85: Prevent fraying of the muscle layers by fixing the mucosa to the muscle coats proximal to the point of division Slide 87: Oesophagus is then divided between this suture line and the gastric wall Slide 88: Arcades of blood vessels of jejunum defined Slide 89: Two or more arcades of blood vessels are divided and a short segment of devascularized intestine resected if needed Slide 90: If E-S anastamosis ,then end of jejunum is closed Slide 91: Opening of Mesocolon Slide 92: Row of interrupted 00 silk sutures is placed to approximate the jejunum to the diaphragm on either side of the esophagus Slide 94: Jejunum opened Slide 95: Layer of interrupted silk sutures is used to close the mucosal layer, starting at either end of the jejunal incision with angle sutures Slide 96: Interrupted Connell-type sutures closing the anterior mucosal layer Jejunum is anchored to the diaphragm, the wall of the esophagus, and the mucosa of the esophagus, a three-layered closure is provided Slide 97: Peritoneum, which has been initially incised to divide the vagus nerve and mobilize the esophagus, is brought down to cover the anastomosis and anchored with interrupted silk sutures to the jejunum Slide 98: Mesentery is anchored to the posterior parietal wall Slide 99: Open end of the proximal jejunum anastomosed at an appropriate point in the jejunum) with two layers and the opening into the mesentery beneath the anastomosis is closed with interrupted sutures to prevent herniation Slide 100: COMPLETED Roux-en Y Anastamosis Slide 102: Post Total Gastrectomy Reconstructions A, Roux-en-Y. B, Henley jejunal interposition. C, Omega gastrojejunostomy Slide 103: Ulm Pouch COMPLICATIONS : COMPLICATIONS Total Gastrectomy Postoperative: Leakage from the anastamosis Leakage from the duodenal stump Secondary hemorrhage Long term complications: Reduced capacity No dumping or diarrhea Nutritional deficiency: Vit B12 supplementation POST GASTRECTOMY SYNDROMES : POST GASTRECTOMY SYNDROMES Post operative Complications: Bleeding, Infection , Delayed Gastric Emptying Physiological derangements: Psychological component Conservative management should be tried in all and re-operation avoided as far as possible Slide 106: SECONDARY TO GASTRIC RESECTION Dumping Syndrome Early Dumping: 20-30minutes GI & CVS symptoms Rapid passage of hypertonic food Gastric emptying scan Dietary measures; Octreotide Operative : Interposition of iso/anti peristaltic jejunal loop, long loop Roux-en-Y anastomosis Slide 107: Late Dumping: 2-3hrs after ingestion of food Rapid gastric emptying Insulin like shock Frequent small meals, pectin, acarbose Antiperistaltic jejunal loop interposition Slide 108: Metabolic disturbances Iron deficiency & Vit B12 deficiency anaemia Impaired fat absorption Osteoporosis & Osteomalacia – Ca deficiency Slide 109: SECONDARY TO GASTRIC RECONSTRUCTION Afferent loop Syndrome Mechanical obstruction Long (>30cm) jejunal loop, antecolic anastomosis Acute and chronic obstruction Reoperation: Billroth II to Billroth I / Roux-en-Y anastamosis Slide 110: Efferent loop Obstruction Rare Herniation of efferent limb behind the anastomosis in a right to left fashion Operation: Reducing the hernia and closing the hernial space Slide 111: Alkaline reflux gastritis Medical treatment usually fails Surgery: Roux-en-Y gastrojejunostomy Retained Antrum Syndrome Recurrent Ulceration H2 receptor blockers or PPI eefective Billroth II to I may be necessary Slide 112: POST VAGOTOMY SYNDROMES Diarrhoea: Cholestyramine Gastric Atony: Metoclopramide Incomplete vagal transection: Recurrent ulceration Slide 113: Thank you You do not have the permission to view this presentation. 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