GASTRECTOMY 1

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GASTRECTOMY : 

GASTRECTOMY Presented by Dr Abdul basith Chaired by Prof John S. Kurien

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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

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Blood Supply

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Arterial supply to greater omentum

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Venous system

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Lymphatic Drainage

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Lymphatic Drainage

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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

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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

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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

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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.

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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

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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

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INDICATIONS Peptic Ulcer Disease Gastric Carcinoma Gastric Tumors

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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

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PROCEDURE

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Wedge resection of stomach

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BILLROTH-I HEMIGASTRECTOMY

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Kocherization of duodenum after identifying the middle colic vessels

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Mobilization of the splenic flexure and release of omentum from the transverse colon

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Site of resection of the stomach

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Hemostatic sutures

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Gastric opening should be approximately 2.5 to 3 cm wide Direct end-to-end anastomosis with the duodenum

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Anastomosis

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Vascular pedicles on the gastric side are anchored to the ligated right gastric pedicle along the top surface of the duodenum

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BILLROTH –I Modifications

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BILLROTH II HEMIGASTRECTOMY (POLYA)

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The antrum is resected as in a Billroth I operation. The distal portion of the resection line is excised

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The jejunal segment, located 10 to 20 cm beyond the ligament of Treitz, is brought through a window in the retrocolic mesentery

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The gastrojejunal anastomosis is constructed in two layers

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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

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BILLROTH-II Modifications

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BILLROTH-II Roux-en-Y modification

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Polya modification

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SUBTOTAL GASTRECTOMY

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Extent and fixation of the tumor mass by exploring the lesser omental cavity through an opening made in the relatively avascular gastrohepatic ligament

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Kocherization of duodenum

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CBD is identified & preserved

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Gauze tape is brought up through an avascular space along the greater curvature and is used for traction

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Gastrocolic ligament is ligated close to the greater curvature

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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

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Cutting the splenocolic ligament for mobilizing the greater curvature

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right gastroepiploic vessels should be carefully isolated from the surrounding fat and securely ligated over the duodenum

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Most medial portion of the hepatoduodenal ligament, which includes the right gastric artery, is divided

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Transfixing silk traction sutures are applied to the superior and inferior borders of the duodenum adjacent to its retained blood supply. Pylorus is freed

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Clamps applied

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Ligation of the small vascular attachments between duodenum and pancreas must be carried out without damaging the gastroduodenal artery

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Duodenal clamps removed

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Duodenal stump closed in 2layers

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Anterior wall of duodenum to capsule of pancreas

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Gastrohepatic ligament dissection

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If not radical – Left gastric gastric vessels maintained

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Left gastric artery as far away from the lesser curvature as possible

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Clamped applied over the stomach

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TOTAL GASTRECTOMY

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At least 2.5 to 3 cm of duodenum distal to the pyloric veins should be resected

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Palpation of posterior aspect of stomach

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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

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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

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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

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Duodenum is divided

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Duodenum should be freed from the adjacent pancreas, especially inferiorly, where a few vessels may enter the wall of the duodenum

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Avascular suspensory ligament is cut, Lt. lobe of liver examined and folded upwards

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Uppermost portion of the gastrohepatic ligament, which includes a branch of the inferior phrenic vessel, is isolated by blunt dissection

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Left gastric vessels are isolated from adjacent tissues

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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

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Prevent fraying of the muscle layers by fixing the mucosa to the muscle coats proximal to the point of division

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Oesophagus is then divided between this suture line and the gastric wall

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Arcades of blood vessels of jejunum defined

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Two or more arcades of blood vessels are divided and a short segment of devascularized intestine resected if needed

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If E-S anastamosis ,then end of jejunum is closed

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Opening of Mesocolon

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Row of interrupted 00 silk sutures is placed to approximate the jejunum to the diaphragm on either side of the esophagus

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Jejunum opened

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Layer of interrupted silk sutures is used to close the mucosal layer, starting at either end of the jejunal incision with angle sutures

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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

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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

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Mesentery is anchored to the posterior parietal wall

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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

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COMPLETED Roux-en Y Anastamosis

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Post Total Gastrectomy Reconstructions A, Roux-en-Y. B, Henley jejunal interposition. C, Omega gastrojejunostomy

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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

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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

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Late Dumping: 2-3hrs after ingestion of food Rapid gastric emptying Insulin like shock Frequent small meals, pectin, acarbose Antiperistaltic jejunal loop interposition

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Metabolic disturbances Iron deficiency & Vit B12 deficiency anaemia Impaired fat absorption Osteoporosis & Osteomalacia – Ca deficiency

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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

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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

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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

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POST VAGOTOMY SYNDROMES Diarrhoea: Cholestyramine Gastric Atony: Metoclopramide Incomplete vagal transection: Recurrent ulceration

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Thank you