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n r i U . s - & s 9 n 9 a r i i s h r e ta p . p vi Michael S. N ussbaunt

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MasterTechniques in Surgery Series Editor: Josef E. Fischer Also available in this series:

Breast Surgery Kirby I. Bland V. Suzanne Klimberg

Colon and Rectal Surgery: Abdominal Operations Steven D. Wexner James W. Fleshman

Colon and Rectal Surgery: Anorectal Operations Steven D. Wexner James W. Fleshman

Esophageal Surgery James D. Luketich

Hepatobiliary and Pancreatic Surgery Keith D. Lillemoe William R. Jarnagin

Hernia Daniel B. Jones

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Edited by

Series Editor

n Josef E..iFischer, r MD U s - & s 9 n 9 a r i i s h r e ta p . p vi

Michael S. Nussbaum, MD, FACS Professor and Chair, Department of Surgery University of Florida College of MedicineJacksonville Jacksonville, Florida

William V. McDermott Professor of Surgery Harvard Medical School Chair, Department of Surgery Beth Israel Deaconess Medical Center, Emeritus Boston, Massachusetts

Illustrations by: BodyScientific Intemational, uc. Anne Rains, Ara:ins illustration, Inc. Sara Krause, MFA, cMI

I

• Wolters Kluwer Lippincott Williams & Wilkins Health Philadelphia • Baltimore • New York • London Buenos Aires • Hong Kong • Sydney • Tokyo

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© 2013 by LIPPINCOTT WILLIAMS t. WILKINS, a WOLTKKS KLUWER business Two Commerce Square 2001 Market Street Phlladelphia, PA 19103 USA LWW.com

All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright.

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Ubrary of Congress Cataloging-in-Publication Data Gastric surgery I edited by MichaelS. Nussbaum. p.; em.- (Master techniques in surgery) Includes bibliographical references and index. ISBN 978-1-4511-1297-9 (hardback) I. Nussbaum, Michael S. II. Series: Master techniques in surgery. [DNLM: 1. Stomach-surgery. 2. Gastrectomy-methods. 3. Gastroplasty-methods. 4. Laparoscopy-methods. 5. Peptic fficer-surgery. 6. Vagotomy, 'Iruncal-methods. WI 380] 817.5'53-dc23

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Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 6383030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300.

Visit Lippincott Williams lie Wilkins on the Internet: at LWW.com. Lippincott Williams lie Wilkins customer service representatives are available from 8:30 am to 6 pm, EST.

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Dedication

He who combines the knowledge of physiology and surgery, in addition to the artistic side of his subject, reaches the highest ideal in medicine. -Christian Albert Theodor Billroth This book is dedicated to the three most important women in my life. My wife, Dr. Sue Nussbaum, inspires me daily with her wisdom and passion for always doing what is right. My wonderful and gifted daughters Jaclyn and Rachel thoroughly amaze me with their talents and creativity.

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Contributors

Wasef Abu-Jaish. MD. FACS

Markus W. Bichler. MD

Assistant Professor of Surgery Department of Surgery Minimally Invasive and Bariatric Surgery Fletcher Allen Health Care University of Vermont College of Medicine Burlington, Vermont

Professor and Chair Department of General, Visceral and Transplantation Surgery University of Heidelberg Heidelberg, Germany

Bestoun H. Ahmed, MD. FRCS Assistant Professor Department of Surgery University of Florida College of Medicine-Jacksonville Jacksonville, Florida

J. Wasley Alaxandar. MD. SeD. FACS Professor Emeritus Department of Surgery Director Emeritus, Transplantation Division Director Emeritus, Center for Surgical Weight Loss University of Cincinnati Medical Center Cincinnati, Ohio

Stan lay W. Ash lay. MD Frank Sawyer Professor of Surgery Chief Medical Officer Division of General and Gastrointestinal Surgery Department of Surgery Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts

Kavin E. Behrns. MD Edward R. Woodward Professor and Chairman Department of Surgery University of Florida Gainesville, Florida

Kfir Ban-David. MD. FACS Assistant Professor of Surgery Chief, Minimally Invasive, Gastroesophageal, and Bariatric Surgery Service Department of Surgery College of Medicine University of Florida Gainesville, Florida

Edward C. Borrazzo. MD Attending Surgeon Department of Surgery Fletcher Allen Health Care Associate Professor of Surgery University of Vermont College of Medicine Burlington, Vermont

Angal M. Caban. MD Assistant Professor Department of Surgery University of Florida Gainesville, Florida

Kayur Chavda. MD Fellow, Minimally Invasive Surgery Department of Surgery University of Florida College of Medicine-Jacksonville Jacksonville, Florida

Thomas E. Clancy. MD Assistant Professor of Surgery Division of Surgical Oncology Department of Surgery Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts

Danial T. Dampsay. MD. MBA Chief of Gastrointestinal Surgery Assistant Director of Perioperative Services Hospital of the University of Pennsylvania Professor of Surgery, University of Pennsylvania Philadelphia, Pennsylvania

Mark Alan Dobbertien. DO, FACS Fellow, Minimally Invasive Surgery Department of Surgery University of Florida College of Medicine-Jacksonville Jacksonville, Florida

E. Christopher Ellison. MD. FACS Associate Vice-President Health Sciences and Vice-Dean for Clinical Affairs Chair, Ohio State University Physicians Board Robert M. Zollinger Professor and Chair Department of Surgery Ohio State University Medical Center Columbus, Ohio

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Contributors

Jameson Forster, MD, FACS, FRCSC Professor Department of Surgery University of Kansas Medical Center Kansas City, Kansas

David W. Marcar, MD Chairman and Professor Department of Surgery University of Nebraska Medical Center Omaha, Nebraska

Matthew R. Goede, MD Assistant Professor of Surgery Division of Gastrointestinal and Minimally Invasive Surgery Department of Surgery University of Nebraska Medical Center Omaha, Nebraska

Thomas A. Miller, MD Ammons Distinguished Professor of Surgery Department of Surgery Virginia Commonwealth University School of Medicine Chief of General Surgery Hunter Holmes McGuire Veterans Affairs Medical Center Richmond, Virginia

Eric S. Hungnass, MD, FACS Assistant Professor of Surgery Division of Gastrointestinal and Oncologic Surgery Department of Surgery Feinberg School of Medicine Northwestern University Chicago, Illinois

Michael W. Mulholland, MD, PhD Professor of Surgery and Chair Department of Surgery University of Michigan Medical School Ann Arbor, Michigan

Mustafa Hussain, MD Assistant Professor of Surgery Minimally Invasive GI and Bariatric Surgery University of Chicago Medical Center Chicago, Illinois

Vladimir Neychev, MD, PhD Chief Surgery Resident Department of Surgery Danbury Hospital Danbury, Connecticut

Woo Jin Hyung, MD, PhD Associate Professor of Department of Surgery Director of Robot and Minimally Invasive Surgery Center Yonsei University College of Medicine Seoul, South Korea

Ninh T. Nguyen, MD, FACS Professor of Surgery and Chief Division of Gastrointestinal Surgery University of California Irvine Medical Center Orange, California

Namir Kalkhouda, MD, FACS Professor of Surgery Vice Chairman, Clinical Affairs Director, Bariatric Surgery Program Keck School of Medicine University of Southern California Los Angeles, California

Michael S. Nussbaum, MD, FACS Professor and Chair Department of Surgery University of Florida College of Medicine-Jacksonville Jacksonville, Florida

John C. Lipham. MD Chief, Division of Upper GI and General Surgery Associate Professor of Surgery Department of Surgery Keck Medical Center of USC University of Southern California Los Angeles, California Andrew M. Lowy, MD Professor of Surgery Chief, Division of Surgical Oncology Moores Cancer Center University of California San Diego San Diego, California David W. McFadden, MD, MBA Professor and Chairman Department of Surgery University of Vermont Surgeon-in-Chief Fletcher Allen Health Care Burlington, Vermont

Kazutaka Obama, MD, PhD Assistant Professor Department of Gastrointerological Surgery Kyoto University Hospital Kyoto, Japan Brant K. Oelschlager, MD Byers Endowed Professor of Esophageal Research Chief of Gastrointestinal Surgery Department of Surgery University of Washington Seattle, Washington Rebecca P. Petersen, MD, MSc Assistant Professor Division of General Surgery Department of Surgery University of Washington Seattle, Washington

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Contributors Melisse S. Phillips. MD Assistant Professor Division of General Surgery Department of Surgery University of Tennessee Health Science Center Knoxville, Tennessee Alfons Pomp. MD. FACS. FRCSC Leon C. Hirsch Professor Vice Chairman, Department of Surgery Chief, Section of Laparoscopic and Bariatric Surgery NewYork-Presbyterian Hospital Weill Medical College of Cornell University New York, New York

Jlffrey L. Polsky. MD Oliver H. Payne Professor and Chairman, Department of Surgery University Hospitals Case Medical Center Case Western Reserve University Cleveland, Ohio Mitchell C. Posner. MD. FACS Thomas D. Jones Professor and Vice-Chairman Chief, Section of General Surgery and Surgical Oncology University of Chicago Medicine Knoxville, Tennessee Aurora D. Pryor. MD, FACS Division Chief General Surgery, Durham Regional Hospital Associate Professor of Surgery Division of General Surgery Department of Surgery Duke University Medical Center Durham, North Carolina

K. Roggln, MD Associate Professor of Surgery and Cancer Research Program Director, General Surgery Residency Program Department of Surgery, Surgical Oncology University of Chicago Medical Center Chicago, Illinois Raul J. Rosenthal, MD, FACS, FASMBS Professor of Surgery and Chairman Department of General Surgery Section of Minimally Invasive Surgery Bariatric and Metabolic Institute Program Director Fellowship in Minimally Invasive Surgery Cleveland Clinic Florida Weston, Florida Alai A. Saber. MD, FACS Associate Professor of Surgery Case Western Reserve University School of Medicine Director of Bariatric and Metabolic Surgery University Hospitals Case Medical Center Surgical Director, Bariatric Surgery, Metabolic and Nutrition Center University Hospitals Digestive Health Institute Cleveland, Ohio

George A. Sarosi Jr. MD Associate Professor of Surgery Surgery Residency Program Director Robert H. Hux, MD, Professor of Surgery University of Florida College of Medicine NF/SG VA Medical Center Gainesville, Florida Mlchaal G. Sarr. MD Consultant Gastroenterology Research Unit, Division of Gastroenterologic and General Surgery, Department of Surgery James C. Masson Professor of Surgery Mayo Clinic Rochester, Minnesota Je11nia F. Savas. MD Associate Professor of Surgery Department of Surgery Virginia Commonwealth University School of Medicine Chief of Surgery Hunter Holmes McGuire Veterans Affairs Medical Center Richmond, Virginia Bruce Schinner. MD Stephen H. Watts Professor of Surgery University of Virginia Health System Charlottesville, Virginia Carol E.H. Scott-Conner. MD. PhD. MBA Professor of Surgery University of Iowa Carver College of Medicine Iowa City, Iowa Su1il Sllanna. MD Assistant Professor Department of Surgery University of Florida College of Medicine-Jacksonville Jacksonville, Florida Brian R. Smith, MD, FACS. FASMBS Assistant Professor of Surgery Associate Residency Program Director Division of Gastrointestinal Surgery University of California Irvine Medical Center Long Beach, California Hal11 J. Salin. MD Department of Surgery Sharp Grossmont Hospital La Mesa, California Vivian E. Strong. MD. FACS Associate Attending Surgeon Memorial Sloan-Kettering Cancer Center Associate Professor of Surgery Weill Medical College of Cornell University New York, New York

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Contributors

Ranian Sudan, MD Vice Chair Surgical Education Associate Professor of Surgery and Psychiatry Department of Surgery Duke University Medical Center Durham, North Carolina Hop S. Tran Cao, MD Research Fellow Department of Surgery University of California San Diego San Diego, California Richard H. Turnaga, MD Professor and Chairman Department of Surgery University of Arkansas for Medical Sciences Little Rock, Arkansas Cannina Volpa, MD, FACS Associate Professor of Surgery Chief, Division of Surgical Oncology Department of Surgery University of Florida College of Medicine-Jacksonville Jacksonville, Florida

R. Matthew Walsh, MD Professor of Surgery and Chairman Department of General Surgery Case Western University Lerner College of Medicine Rich Family Distinguished Chair of Digestive Diseases Cleveland Clinic Foundation Cleveland, Ohio Thilo Welsch, MD Assistant Professor Department of General, Visceral and Transplantation Surgery University of Heidelberg Heidelberg, Germany Yanghaa Woo, MD Instructor of Clinical Surgery Division of GI/Endocrine Surgery Department of Surgery Columbia University College of Physicians and Surgeons New York, New York Joarg Zahatnar, MD, MMM Assistant Professor of Surgery Division of Upper GI and General Surgery Department of Surgery Keck School of Medicine of USC University of Southern California Los Angeles, California

Series Preface

This series of mini-atlases, of which this is the fourth, is an outgrowth of MasteiY of SurgelJ'. As the series editor, I have been involved with MasteiY of SurgelJ' since the third edition, when I joined two greats of American surgery Lloyd Nyhus and Robert Baker who were the editors at that time. At that time, in addition to Mastery of SurgelJ', which really was, almost in its entirety, an excellent atlas of how to do operations, atlases were common and some quality atlases which existed at that time by Dr. John Madden of New York, Dr. Robert Zollinger of Ohio State, and two other atlases, with which the reader may be less familiar with is a superb atlas by Professor Pietro Valdoni, Professor of Surgery at the University of Rome, who ran ten operating rooms simultaneously, and as the Italians like to point out to me, a physician to three popes. One famous surgeon said to me, what can you say about Professor Valdoni: "Professor Valdoni said to three popes, 'take a deep breath,' and they each took a deep breath." This superb atlas, which is not well known, was translated by my partner, when I was on the staff at Mass General Hospital, Dr. George Nardi from Italian. Another superb atlas was that by Dr. Robert Ritchie Linton, an early vascular surgeon whose atlas was of very high quality. However, atlases fell out of style, and in the fourth and fifth edition of MastelJ' of SurgelJ', we added more chapters that were "textbooky" types of chapters to increase access to the increasing knowledge base of surgery. However, atlases seem to have gone out of favor somewhat. In discussing with Brian Brown and others of Lippincott, as well as some of the editors who have taken on the responsibility of each of these miniatlases, it seemed that we could build on our experience with Mastery of SurgelJ' by having individual books which were atlases of 400 to 450 pages of high quality, each featuring a particular anatomical part of what was surgery and put together an atlas of operations of a sharply circumscribed area. This we have accomplished and all of us are highly indebted to a group of high-quality editors who will have created superb mini-atlases in these sharply circumscribed areas. Why the return of the atlas? Is it possible that the knowledge base is somewhat more extensive with more variations on the various types of procedures, that as we learn more about the biochemistry, physiology, genetics, and pathophysiology in these different areas, there have gotten to be a variation on the types of procedures that we do on patients in these areas. This increase in knowledge base has occurred simultaneously when the amount of time available for training physicians-and especially surgeons-has been diminished and continues to do so. While I understand the hypothesis that brought the 80-hour work week upon us, and that limits the time that we have for instruction, and I believe that it is well intentioned, but I still ask the question: Is the patient better served by a somewhat fatigued resident who has been at the operation, and knows what the surgeon and what he or she is worried about, or a comparatively fresh resident who has never seen the patient before? I do not know, but I tend to come down on the side that familiarity with the patient is perhaps more important. And what about the errors of hand off, which seem to be more of an intrinsic issue with the hand off which we are not able to really remedy entirely rather than poor intentions. This series of mini-atlases is an attempt to help fill the voids of inadequate time for training. We are indebted to the individual editors who have taken on this responsibility and to the authors who have volunteered to share their knowledge and experience in putting together what we hope will be a superb series. Inspired by their

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Series Preface

experience of teaching residents and medical students, a high calling, matched only by their devotion and superb care they have given to thousands of patients. It is an honor to serve as the series editor for this outstanding group of mini-atlases, which we hope will convey the experiences of an excellent group of editors and authors to the benefit of students, residents, and their future patients in an era in which time for education seems to be increasingly limited. Putting a book together, especially a series of books, is not easy, and I wish to acknowledge the production staff at Lippincott, Wolters Kluwer's including Brian Brown, Julia Seto, Brendan Huffman, and many others, and my personal staff in the office who include Edie Burbank-Schmitt, Ingrid Johnson, Abigail Smith, and Jere Cooper. None of this would have been possible without them. Josef E. Fischer, MD, FACS Boston, Massachusetts

Preface

It is a most gratifying sign of the rapid progress of our time that our best text-books

become antiquated so quickly. -Christian Albert Theodor Billroth

When I was an intern at the University of Cincinnati, Master Techniques in Surgery series editor Dr. Josef Fischer was the chairman of the department. Every Monday afternoon we had Professor's Hour with Dr. Fischer where we would present cases to him and he would use the opportunity to teach us the nuances of surgical care that is exemplified in this series. One day, early in that year, one of the chief residents presented a case of giant duodenal ulcer; an entity that was new to me. Near the end of the session, Dr. Fischer asked for a resident volunteer to review the Cincinnati experience with giant duodenal ulcer. Fellow resident Mark Schusterman and I volunteered and thus began my academic career as a gastrointestinal surgeon. 1 Flash forward 30 years and I am now a department chair, holding my own Professor's Hour on Monday afternoons. Once again I find myself completing a project for Dr. Fischer related to gastric surgery as both editor and author in Master Techniques in Surgery: Gastric Surgery (see Chapter 14. Operation for Giant Duodenal Ulcer). I trained during the era when gastric operations were common. Peptic ulcer and the inherent complications were frequent problems that we faced on a daily basis. The training opportunities for residents in gastric surgery have diminished over the ensuing years due to the advent of antisecretory therapy, the discovery of helicobacter pylori, and advances in therapeutic endoscopy. However, as this volume exemplifies, benign and malignant gastroduodenal disease continues to provide challenges to the practicing surgeon. A thorough knowledge of the various approaches and techniques are essential components in anyone's armamentarium. Further confounding these issues are the growing opportunities to apply minimally invasive approaches in certain circumstances. To be a complete gastric surgeon, one must be comfortable with both minimally invasive and open approaches, depending upon the underlying situation. In this text, where appropriate, we detail both the open and minimally invasive approaches, including laparoscopic as well as robotic applications. The objective of the Master Techniques in Surgery series is to provide authoritative descriptions and illustrations of the management of each theme. This volume serves to supplement and augment the other resources available to surgeons-in-training as well as practicing surgeons faced with gastroduodenal pathology. The authors represent a truly global expertise in this field and they address the many operations and approaches in the management of benign, functional, and malignant gastric pathology. Master Techniques in Surgery: Gastric Surgery is intended to provide detail and clarity in the approaches to very specific diagnoses and procedures. Each chapter makes liberal use of color illustrations and photographs to elucidate important anatomical relationships and key operative steps. Further, the book comes with an associated Web site with fully searchable text and procedural videos. This volume should be useful for comprehensive review as well as a ready preoperative resource in preparation for specific gastric operations. 1

Nussbau.m, M.S., Schustarman, M.A.: Management of giant duodenal ulcer. Am. J. Surg.

1985;199:357-361.

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Preface

Once again, I am indebted to my mentor and colleague, Josef Fischer, for asking me to take on this task and allowing me to contribute as the editor of this important volume in the Master Techniques in Surgery series. Under Dr. Fischer's stewardship, Mastery of Surgery continues to withstand the test of time as an essential resource for any serious student of surgery. The Master Techniques in Surgery series will certainly add to that predominance as both an enhancement as well as an amplification of the body of knowledge on the subject matter. Finally I want to thank Brian Brown and Editorial Product Manager Brendan Huffman at Lippincott, Williams & Wilkins as well as Associate Project Manager Ruchira Gupta at Aptara, Inc. for all of their insight, diligence, and support of this project. Their help and advice was invaluable to all of the authors and me. This has been a true labor of love and I hope that you find the book to be enlightening, informative, and enjoyable. MichaelS. Nussbaum, MD, FACS Professor and Chair Department of Surgery University of Florida College of Medicine-Jacksonville May 2012

Contents

Contributors vii Series Preface xi Preface xiii

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PART 1: PROCEDURES FOR ULCER DISEASE 1

Truncal Vagotomy with Gastrojejunostomy 1 Richard H. Thrnage

2

Thun..Jal Vagotomy and Pyloroplasty 13 David W. McFadden, Edward C. Borrazzo, and Vladimir Neychev

3

Truncal Vagotomy with Antrectomy and Billroth I Reconstruction 23 Stanley W. Ashley and Thomas E. Clancy

4

Laparoscopic Truncal Vagotomy with Anb'ectomy and Billroth I Reconstruction 33 Aurora D. Pryor

5

Truncal Vagotomy with Antrectomy and Billroth IT Reconstruction 45 Michael W. Mulholland

6

Laparoscopic Truncal Vagotomy with Anuectomy and Billroth IT Reconstruction 61 Kfir Ben-David and George A. Sarosi Jr

7

Truncal Vagotomy with Antrectomy and Roux-En-Y Reconstruction 73 Kevin E. Behrns and Angel M. Caban

8

Proximal Gastric Vagotomy 89 Michael S. Nussbaum and Mark Alan Dobbertien

9

Laparoscopic Proximal Gastric Vagotomy

101

Namir Katkhouda and foerg Zehetner

10

Patch for Perforated Ulcer 109 David W. Mercer and Matthew R. Goede

11

Laparoscopic Patch of Perforated Duodenal Ulcer 115 Sunil Shanna and Bestoun H. Ahmed

12

Ligation Bleeding Ulcer, Vagotomy, Pyloroplasty 123 Eric S. Hungness

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Contents

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Ligation of Bleeding Ulcer, Antrectomy, Vagotomy, and Gastrojejunostomy 133 Bruce Schinner

14

Operation for Giant Duodenal Ulcer 147 Michael S. Nussbaum and Keyur Chavda

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PART II: PROCEDURES FOR NEOPLASTIC DISEASE

15

Distal Subtotal Gastrectomy and D1 Resection

153

K. Roggin and Mitchell C. Posner

16

Laparoscopic Subtotal Gastrectomy and D1 Resection 163 Namir Katkhouda, Helen]. Sohn, John C. Lipham, and ]oerg Zehetner

17

Subtotal Gastrectomy and D2 Resection 171 Cannine Volpe and Bestoun H. Ahmed

18

Laparoscopic Subtotal Gastrectomy and D2 Lymphadenectomy for Gastric Carcinoma 185 Vivian E. Strong

19

Total Gastrectomy and Esophagojejunostomy 195 Andrew M. Lowy and Hop S. Tran Gao

20

Laparoscopic Total Gastrectomy and Esophagojejunostomy 207 Brant K. Oelschlager and Rebecca P. Petersen

21

Robot-assisted Gastrectomy with Lymph Node Dissection for Gastric Cancer 219 Woo fin Hyung, Yanghee Woo, and Kazutaka Obama

22

Laparoscopic Resection of Gastrointestinal Stromal Tumors

229

R. Matthew Walsh

23

Surgery for Gastrinoma 239 E. Christopher Ellison

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PART III: OPERATIONS FOR POSTGASTRECTOMY

SYNDROMES

24

Bile (Alkaline) Reflux Gastritis

253

Daniel T. Dempsey

25

Dumping Syndrome 263 Thomas A. Miller and Jeannie F. Savas

26

Surgical Management of the Afferent Limb Syndrome

267

Carol E.H. Scott-Conner

27

The Raux Stasis Syndrome: Diagnosis, Treatment, and Prevention 275 Michael G. Sarr

Contents

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PART IV: BARIATRIC 28

Open Bariatric Operations

283

J. Wesley Alexander

29

Laparoscopic Roux-en-Y Gastric Bypass

295

Alfons Pomp and Mustafa Hussain

30

Laparoscopic Sleeve Gastrectomy Technique 311 Raul J. Rosenthal and Wasef Abu-Jaish

31

Laparoscopic Adjustable Gastric Banding

327

Ninh T. Nguyen and Brian R. Smith 32

Robot-assisted Laparoscopic Biliopancreatic Diversion with Duodenal Switch 337 Ranjan Sudan

33

Single-Incision Laparoscopic Bariatric Surgery

345

Sunil Shanna and Alan A. Saber

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PART V: OTHER GASTRIC OPERATIONS 34

Open and Laparoscopic Procedures for SMA Syndrome

359

Markus W. Buchler and Thilo Welsch

35

Gastrostomy: Endoscopic, Laparoscopic, and Open

365

Jeffrey L. Ponsky and Melissa S. Phillips 36

Gastric Electrical Stimulation for Chronic Gastroparesis 375 Jameson Forster

Index

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Praudurafar UlurDila-

1

Truncal Vagotomy with Gastrojejunostom y Richard H. Turnage

~ INDICATIONS/CONTRAINDICATIONS Indications Gastrojejunostomy is most commonly used to treat patients with gastric outlet obstruction (GOO) of whom nearly two-thirds will have malignancies of the distal stomach, pancreas, or duodenum. The most common benign causes of GOO are peptic ulcer disease (PUD), caustic strictures, and Crohn's disease. Less common benign etiologies include tuberculosis, chronic pancreatitis, benign gastric polyps, and Bouveret's syndrome (i.e., obstruction of the pylorus by a gallstone). Although not amenable to gastrojejunostomy, systemic medical diseases, most notably diabetes mellitus, are important causes of impaired gastric emptying. Complete resection is the treatment of choice for patients with upper gastrointestinal (UGI) malignancies. Unfortunately, locally advanced or metastatic disease precludes this approach in a significant percentage of these patients. Although non curative gastric resection is an important option for managing symptomatic patients with advanced gastric cancer, this approach is less often feasible for patients with advanced pancreatic cancer. Endoscopic stenting of malignant obstructions of the distal stomach and duodenum is an important option in managing patients with GOO who have relatively short life expectancies, such as those with metastatic disease or poor performance scores. Advances in imaging with multidetector computed tomography have significantly improved preoperative identification of patients with advanced disease such that gastrojejunostomy is now used most often for symptomatic patients with unresectable cancer for whom endoscopic stenting has been unsuccessful or patients who are unexpectedly found to have advanced disease during exploratory laparotomy for cure. PUD is the most common benign cause of mechanical GOO. Medical management combined with endoscopic balloon dilation results in durable relief of obstructive symptoms in about 70% of cases. This approach is particularly effective for patients with GOO due to Helicobacter pylori-associated ulcers. In contrast, NSAID-induced ulcers seldom resolve with nonoperative approaches. Young age, long duration of

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Part I Procedures for Ulcer Disease

symptoms, the need for repeated endoscopic balloon dilatations, and the continuous usa of NSAIDs predict the need for surgical management. Surgical approaches to patients with GOO from PUD include truncal vagotomy and antractomy or truncal vagotomy and a drainage procedure (either pyloroplasty or gastrojejunostomy). Truncal vagotomy and antrectomy has the lowest rate of recurrent ulcer disease. The magnitude of the operation and the consequent operative risk. necessitates other strategies in patients with significant medical comorbiditias as wall as those patients who are found intraoperatively to have significant inflammation and scarring of the distal stomach and duodenum. Truncal vagotomy and pyloroplasty is suitable for patients with minimal intlammation or deformity of the pylorus or proximal duodenum, thareby parmitting a tension-free transverse closure of the pylorus. Unfortunately, this is often not the case, making truncal vagotomy and gastrojejunostomy (TV &: GJ) the best option. Lastly, the ingestion of strong acidic solutions causes strictures in the prepyloric region of the stomach leading to GOO. Kochhar at al. have described excellent shortand intermediate-term outcomes with endoscopic balloon dilation of caustic-induced gastric strictures. Others have managed these patients with distal gastrectomy. Thus, gastrojejunostomy is reserved for those patients with prepyloric strictures who have failed endoscopic balloon dilation and are poor operative candidates for distal gastrectomy.

Contraindication• The principal contraindications to the performance of a TV &: GJ are technical. If a truncal vagotomy is required in a patient who has had a previous operation in the esophageal hiatus (e.g., fundoplication or prior vagotomy), a thoracoscopic approach to vagotomy may be preferable to allow dissection in tissue planes free from scarring and intlammation. In patients with ulcer disease or other benign causes of GOO, the enlarged stomach makes the performance of a tension-free gastrojejunostomy relatively straightforward. However, peritoneal metastases in patients with gastric or periampullary cancers may causa foreshortening of the small bowel mesentery, rendering it d:ifticult to achieve a tension-free anastomosis between the stomach and the jejunum.

V

PREOPERATIVE PLANNING

The initial management of a patient with GOO consists of intravascular volume and electrolyte resuscitation, nutritional repletion, and identification of the underlying cause of the obstruction. Significant intravascular volume depletion and electrolyte abnormalities, especially hyponatremia, hypokalemia, and hypochloremia, are common and are readily corrected by the intravenous infusion of a normal salina solution with potassium chloride. The loss of gastric secretions from persistent vomiting may also cause a significant metabolic alkalosis which will correct with the administration of normal salina and potassium chloride. Gastric aspiration via a nasogastric (NG) tuba will decompress the dilated atonic stomach and improve the patient's abdominal discomfort, nausea, and vomiting. The intravenous administration of a proton pump inhibitor will reduce gastric acid secretion, and the administration of total parenteral nutrition via a central venous catheter will begin to correct the patient's calorie and protein deficits. After resuscitating the patient, esophagogastroduodenostomy should be performed to determine the etiology of the obstruction. An ulcer or mass in the stomach or a suspicious lesion in the duodenum necessitates endoscopic biopsy. Biopsy of the gastric mucosa will document the presence of Helicobacter pylori-eradication of which will facilitate healing of benign ulcers and in many casas relieve the patient's obstruction. If a malignancy is identified or if endoscopy is indeterminate, computed tomography will characterize the lesion by determining its size, relationship to surrounding structures, and the presence or absence of visceral metastases.

Chapter 1 Truncal Vagotomy with Gastrojejunostomy

~ SURGERY Patients should receive a prophylactic dose of antibiotics intravenously 30 to 60 minutes prior to the incision. It is the author's preference to use cefoxitin in those patients who are not beta lactam allergic. Subcutaneous injection of 5,000 units of heparin sulfate administered preoperatively will reduce the risk of postoperative pulmonary embolism. The risk of aspiration during the induction of anesthesia and intubation may be diminished by the evacuation of gastric contents via the NG tube and posterior pressure on the cricoid cartilage.

Positioning TV 1: GJ may be performed by either a laparoscopic or an open approach. Depending on the surgical approach, the patient can be placed in the supine or lithotomy position. For minimally invasive gastric approaches, if the patient is in a supine position, the operating surgeon stands on the right side of the patient while the assistant is on the contralateral side. If the lithotomy position is used, the surgeon stands between the legs. The patient is secured to the table with two safety straps, a foot board, and all of their bony prominences are well padded. For an open approach the patient is placed in the supine position with the head of the operating table elevated to facilitate exposure of the organs within the upper abdomen. The lower chest and entire abdomen is prepped with a chlorhexidine-alcohol solution and then draped with sterile towels and sheets.

Technique The open approach will be presented in detail, but, ultimately, the same operative steps are generally true for a laparoscopic approach (for details on placement of laparoscopic trocars and specific techniques see Chapters 4, 6, and 7). When the laparoscopic approach to this procedure is used, a low threshold for conversion to an open procedure should exist when visualization of important structures are impaired. Standing on the patient's right side, the surgeon makes an upper midline incision from the xiphoid to the umbilicus. The incision is extended through the subcutaneous tissue and linea alba until the peritoneal cavity is entered. The ligamentum teres is ligated with 2-0 silk and divided and the falciform ligament is released from the anterior abdominal wall. The abdominal cavity is carefully explored and then attention is directed to the upper abdomen. In patients with GOO from ulcer disease, the location of the ulcer, extent of infiammation, and the patient's general medical condition will influence the choice of gastric resection versus a drainage procedure. For patients with malignancies, the first steps of the operation are to determine the resectability of the tumor and document the presence or absence of peritoneal or visceral metastases. The ability to mobilize an adequate length of jejunum for the performance of a tension-free gastrojejunostomy is ascertained at this time. Truncal Vagotomy A self-retaining abdominal wall retractor is placed to allow lateral retraction of the rectus abdom:inis muscles and anterior and superior retraction of the costal margins. The left lobe of the liver is mobilized by incising the avascular left triangular ligament with an electrocautery. This is facilitated by downward traction on the left lobe of the liver with the right hand while the index finger is placed behind the triangular ligament to protect the underlying structures. The triangular ligament is incised from lateral to medial until the left lobe of the liver can be folded upon itself thereby exposing the underlying gastroesophageal junction. The liver is covered with a moist laparotomy sponge and a Harrington-type blade for the self-retaining abdominal wall retractor is used to hold the left lobe of the liver to the patient's right side. In a laparoscopic approach the triangular ligament is left intact and the lateral segment of the left lobe of the liver is elevated with a self-reta:in:ing retractor such as a Nathanson retractor.

3

4

Part I Procedures for Ulcer Disease

figure 1.1 Transversa incision af the peritoneum and phranoasophagaal ligament to expose the underlying intra-abdominal esophagus and esophageal hiatus.

The peritoneum overlying the distal esophagus is grasped with DaBakey forceps and incised perpendicular to the long axis of the esophagus with Metzenbaum. scissors or the electrocautery. The peritoneum and the underlying phrenoesophagealligament are incised sufliciently to allow identification and mobilization of the esophagus (Fig. 1.1). This will usually include opening the medial most aspect of the gastrohepatic ligament on the right. The left gastric artery and its esophageal branch are left undisturbed. It is not necessary to divide the short gastric vessels on the left. By opening the incised peritoneum and phrenoasophagaal ligament, the surgeon is able to free the distal 5 or 6 em of the esophagus from the surrounding tissues by blunt dissection with his/her index finger. Once completed, the esophagus may be encircled with the index finger passed from the patient's left side to the right (Fig. 1.2). The esophagus with the NG tuba is felt anterior to the surgeon's finger and the abdominal aorta is appreciated posterior. A l-inch Penrose drain is then passed behind the esophagus to enc:ircle it. Downward and slight anterior traction on the esophagus using the Penrose drain will facilitate blunt dissection of the distal 8 to 10 em of esophagus from surrounding soft tissue, thus exposing the right crus of the diaphragm and the tissue lateral and posterior to the esophagus. figure 1.Z Mobilization of tile distal 5 to ll em af esophagus from the soft tissue af the esophageal hiatus by passing the surgeon's index finger from the left to the right side of tile esophagus.

Chapter 1 Truncal Vagotomy with Gastrojejunostomy figure 1.3 Identification of the left vagus narva on the anterior surface of the esophagus, just to the right of the midline. The narva is clipped with a medium stainless steal clip and then divided.

Identification of the vagus nerves is accomplished by passing the tip of the index finger over the anterior surface of the esophagus while placing downward traction on the Penrose drain. The vagus nerve fibers will present as tense, wire-like structures passing parallel to the long axis of the esophagus; the nerve fibers have been likened to "banjo strings." In addition to the larger left and right vagus nerves, there are often multiple smaller nerve fibers traversing the surface of the esophagus and the esophageal hiatus. In an anatomic study of the vagus nerve at the esophageal hiatus, Skandalakis et al. found four or more vagal t.runb in 12% of their dissections. The left vagus nerve is usually found on the anterior surface of the esophagus just to the right of the midline. A left truncal vagotomy is performed by lifting the nerve off the surface of the esophagus with a nerve hook. or a long right angle clamp. It is freed of surrounding soft tissue for a distance of 5 to 6 em with long Metzanbaum scissors. The proximal most portion of the nerve is then clipped with a medium stainless steel surgical clip and divided at the upper margin of the dissection just distal to the clip. The distal portion of the nerve is grasped and than clipped and divided 2 to 3 em from the cut proximal margin (Fig. 1.3). The right vagus nerve can be found by lifting the esophagus anteriorly while maintaining downward traction on the encircling Penrose drain. Although the nerve may be found on the posterior surface of the esophagus, it is mora commonly displaced posteriorly during the process of mobilizing the distal esophagus. In this case, the nerve is found to the right of the midline resting against the posterior wall of the esophageal hiatus, anterior to the aorta. The right vagus nerve is resected as described for the left vagus by elevating the nerve trunk., applying a surgical clip to the proximal-most portion of the nerve, and then excising a 2 to 3 em section of the nerve (Fig. 1.4). The right and left vagal trunks are sent for histologic confirmation. With the right and left vagal nerve trunks divided, a careful search for additional nerve fibers is undertaken. This is best accomplished by downward traction on the Penrose drain and careful palpation of the anterior and posterior surfaces of the esophagus. The distal 5 to 6 em of the esophagus and the surrounding tissue must be ca.ra.fully inspected to identify and divide any small nerve fibers that may have branched from the vagal trunks in the chest, such as "the criminal nerve of Grassi" which arises from the right vagal trunk. to innervate a portion of the posterior gastric fundus. The Penrose drain is then removed and the esophagus allowed to fall back toward the esophageal hiatus. The operative field is then carefully inspected for bleeding which is readily controlled with the electrocautery. The incised peritoneum and phrenoesophagealligament are not reapproximated.

5

6

Part I Procedures for Ulcer Disease

figur• 1.4 Identification of the right vagus nerve posterior to the esophagus on the right side af the esophageal hiatus.

Gastrojejunostomy The gastrojejunostomy may be constructed on either the anterior or the posterior surface of the distal stomach. The optimal site will be infiuenced by the amount of scarring and deformity in the distal stomach or duodenum in patients with benign strictures and by the location of the tumor in patients with malignancies. There is no evidence that anterior, antecolic gastrojejunostomy is superior to posterior, retrocolic gastrojejunostomy or vice versa. The easier anterior gastrojejunostomy is most commonly performed and hence it is this anastomosis that is described.

Hand-sewn. Anterior or Antecolic Gastrojejunostomy With the self-retaining abdominal wall retractor in place, the greater omentum and transverse colon are elevated to reveal the ligament of Treitz just to the left of the midline at the base of the transverse mesocolon. The proximal jejunum is brought onto the anterior surface of the stomach and oriented such that the afferent limb is adjacent to the body of the stomach and the efferent limb is juxtaposed to the distal stomach. The length of the aHerent limb should be as short as possible to reduce the risk of afferent limb obstruction. The surgeon must be careful to avoid twisting of the bowel or placing tension on the anastomosis. Stay sutures of 3-0 silk are placed through the seromuscular layers of the stomach and the jejunum at the proximal and distal ends of the anastomosis, about 8 em apart from one another. The ends of these sutures are secured with a hemostat and brought out the left and right side of the operative field. This maneuver orients the anastomosis horizontally allowing the surgeon to sew toward himself or herself. The back row of the anastomosis is constructed by placing interrupted 3-0 silk Lambert sutures through the serosa and muscularis of the juxtaposed stomach and the jejunum about 8 mm behind the planned gastrotomy and enterotomy. The sutures extend from the right stay suture to the left and are placed about 8 mm apart from one another. The sutures are tied after the entire row has been placed. The middle suture is not cut at this time but left long to aid in the placement of the inner postarior row of sutures. The full thickness of the stomach is then incised with the electrocautery parallel to and 8 mm from the back row of silk sutures. Fluid within the stomach is aspirated and a matching incision is made through the adjacent jejunal wall. The gastrotomy and jejunotomy should be approximately 1 centimeter shorter than the site of the silk stay sutures (Fig. 1.5).

Chapter 1 Truncal Vagotomy with Gastrojejunostomy Figur• 1.5 Construction of the outer layer of the back wall of an anterior or antecolic gastrojejunostomy using interrupted 3-0 silk Lambert sutures.

7

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-a jiJ u

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0.

The inner layer of the anastomosis is constructed by sewing the juxtaposed gastric and jejunal walls together with two running, spiral sutures of 3-0 polyglycolic acid. The sutures are started at the midpoint of the back wall of the anastomosis and continued around the corners until the front wall is closed. The stitch is placed about 4 to 5 mm from the cut-edge of the bowel and incorporates the full-thickness of the gastric and jejunal walls. Elevating the serosal edge of the jejunum (or stomach) with DeBakey forceps 1 em from the site of the planned stitch will help to incorporate all the layers of the bowel in the stitch. At the corner of the anastomosis, slightly more serosa than mucosa is included in the stitch to facilitate the invagination of the mucosa within the lumen of the anastomosis. As each stitch is placed, the edges of the anastomosis are gently drawn together. Ultimately, the inner layer of the anastomosis is completed and only the seromuscular edges of the stomach and the jejunum are visible (Fig. 1.6). The front wall of the anastomosis is now completed by placing interrupted seromuscular Lambert sutures of 3-0 silk between the gastric and the jejunal walls. These stitches are placed several millimeters from the inner layer of the anastomosis Fit•• 1.G Construction of the inner layer of the back wall of anterior gastrojejunostomy using a continuous 3.(1 polyglycolic acid suture placed through all layers of the juxtaposed stomach and jejunum.

8

Part I Procedures for Ulcer Disease Figur• 1.7 Construction of the outer layer of the front wall of the anterior gastrojejunostomy using interrupted 3..Q silk Lembert sutures placed 7 to 8 mm from one another. This row of sutures should comphrtely bury the comphrted inner layer of the anasto· mosis.

and about 7 to 8 mm apart. This layer should bury the inner layer from view (Fig. 1.7). The comers of the anastomosis can be completed by either tying the stay sutures or by placing a new Lambert stitch in each comer to completely cover the inner layer of the

anastomosis. The lumen of the anastomosis should be readily palpable either through the gastric or the jejunal wall. The operative field is inspected for evidence of bleeding or injury and the self-retaining retractor is removed. The linea alba is closed using a running suture of no. 1 polydioxanone, and the skin is closed with a skin stapler.

Stapled, Anterior Gastrojejunostomy The orientation of the stomach and jejunum and the placement of the 3·0 silk stay

sutures at the corner of the proposed anastomosis is as described earlier. A small gastrotomy and jejunotomy are made about 1 em from the stay suture at the proxi· mal corner of the anastomosis. One limb of a 60-mm linear stapling device (endoscopic linear stapler in laparoscopic) is inserted into the jejunum and the other limb figure 1.1 ConstJuction of anterior gastrojejunostomy using a GIA 60 stapler inserted through a small gastrotomy and matching enterotomy. Stay stitches of 3-0 silk are placed at the proximal and distal margins of the proposed anastomosis.

Chapter 1 Truncal Vagotomy with Gastrojejunostomy figure U Completion of the stapled anterior gastrojejunostomy by closing the insertion site of the GIA stapler using a TA 30 stapler.

9

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is inserted into the stomach. The device is locked and the site inspected to ensure that no tissue other than the stomach and jejunum is included within the stapler (Fig. 1.8). The stapler is then fired and removed from the operative field. The staple line is then carefully inspected for bleeding. Exposure of the staple line can be facilitated by gentle retraction with the long arm of an Army-Navy retractor. Bleeding from the staple line can be controlled with either the electrocautery or the placement of a 4-0 polyglycolic acid suture. The remaining defect in the anastomosis is grasped with several Allis clamps and a TA-30 or TA-50 stapler is aligned behind the clamps (endoscopic linear stapler or intracorporeal interrupted sutures in laparoscopic approaches). TheTA stapler is then fired and the redundant tissue is excised with the scalpel before removing the stapler. The staple line is inspected for bleeding which is controlled with the electrocautery or a 4-0 polyglycolic acid suture (Fig. 1.9).

POSTOPERATIVE MANAGEMENT Most patients undergoing a TV & GJ may be safely managed in the general surgical ward. Intravenous fluid administration with an isotonic solution for the first 24 hours will maintain a normal intravascular volume. Generally patients will mobilize their third-spaced fiuids on postoperative day 3 and the infusion of 5o/o dextrose/0.45o/o sodium chloride solution will allow the maintenance of normal intravascular volume until the patient is able to resume oral intake. Antibiotics are not administered postoperatively unless thera is clinical evidence of infection. Urine output may be a useful guide to the patient's volume status in the first day or two postoperatively; thereafter, the catheter is removed. The NG tube is removed when the output is less than 300 mL per 8-hour period. If the patient is nauseated or has a distended abdomen the tube is left in place for a longer period of time. As described subsequently, poor gastric emptying is a relatively common early complication necessitating longer periods of NG aspiration. A clear liquid diet is started when the NG tube has been ramoved and the patient is passing flatus. If liquids ara tolerated for 24 hours, the patient is allowed a regular diet and the parenteral nutrition is stopped.

10

Part I Procedures tor Ulcer Disease

Adequate pain management is an important part of the postoperative care of these patients. The upper abdominal location of the incision is painful especially when the patient takes deep breaths. Poor pain relief will diminish inspiratory volume and promote the development of atelectasis and pneumonia. Patient-controlled analgesia (PCA) with morphine, hydromorphone, or meperidine provides excellent pain relief. The epigastric location of the incision makes the usa of postoperative epidural analgesia less useful. The patient is instructed in the use of an incentive spirometer preoperatively, and it is used throughout the patient's postoperative course to reduce atelectasis and minimize the risk. of pneumonia. Subcutaneous heparin injections, also started preoperatively, are continued in the postoperative period to minimize the risk. of pulmonary emboli. The patient is ambulated on the first postoperative day and daily thereafter. If a tnmcal vagotomy has not bean performed, the patient should receive a proton pump inhibitor intravenously in the early postoperative period and than orally as he or she tolerates a diet.

. ) COMPLICATIONS The incidence of intraoperative complications during TV 8t GJ is low with the most common being hemorrhage from a retraction injury to the liver or spleen during the performance of the vagotomy or injury to the middle colic vein during the gastrojejunostomy. Bleeding from the liver may be avoided by careful mobilization of the left lobe and gentle retraction. Bleeding from the spleen necessitating splenectomy can be minimized by avoiding traction on the short gastric vessels or spleen. The early postoperative complications of gastrojejunostomy for treating patients with benign or malignant GOO are shown in Tabla 1.1. With the exception of the study by Kim et al., most of the patients in these studies underwent gastrojejunostomy alone, without truncal vagotomy. Overall, the rate of complications following gastrojejunostomy is relatively high, ranging from 22.7 to 62.5% (median= 32%). Most complications ware relatively minor, although wound infections, delayed gastric emptying, and

T A B L E 1. 1

~Complications of Gastrojejunostomy for Gastric Outlet Obstruction in Patients with Benign or

Mahgnant Diseases

Study Deli1n Retrospective comparison of Lap TV+ GJ vs. Open 1V + GJ in patientJ with PUD with GOD, patientJ accrued between 1999 and 2005 Retrospective review of patientJ with Crohn's disease and duodenal obstruction, patientJ accrued between 1995 and 2006 Retrospective review of GJ in patients with pancreatic cancer with GOD 166 patientst and without GOD 1447 patienat, patientJ accrued between 1996 and 2010 Prospective comparison HJ alone in patients with pancreatic cancer with GOD IHJ + GJ) and without GOD IHJ alone), patientJ accrued between 1992 and 1995 Single-center randomized trial, GJ vs. no GJ in patientJ with unresectable pancreatic cancer without GOD, patients accrued between 1994 and 1998 Muhicenter, randomized trial of GJ vs. stent for patienta with GOD from UGI cancers, patienta accrued between 2006 and 2008 Prospective, randomized trial of HP + GJ vs. HJ alone for patients with advanced periampullary cancers without evidence of GDD at presentation, patientaaccrued between 19911and 2002

Iampi• Size

......ity Rate(%t

Ma..idity Rate

8

62.5

11

36

513

1.6

36.7

44

9

22.7

44

32

18

33

36

3

31

Camplil:atiana Delayed gastric emptying l50%t; atelectasis l12.5%t GJ leakl9%) GJ bleeding 19%) Early SBD 19%) Wound infections 14.3%) Pleural effusion l2.5%t Cholangitis 12%) Delayed gastric emptying l11%t Wound infection 19%) Intra-abdominal abscess l4.5%t Cholangitis 19%) Wound infection 15%) Delayed gastric emptying 12%) Delayed gastric emptying 111%) Wound infection 15%) UTII5%) Delayed gastric emptying 111%) Cardiac complicational11%) Wound infection 18%)

Lip TV+ GJ, laparoscopic truncal vagotomy and gartrojejunOftomy; Open TV+ GJ, vuncal vagotomy and gartrojejunommy performed 1hrough a laparotomy; GOO, gartric olltlet obn'uc:lion; PUO, peptic: ulcer dillean; GJ, gmrojejunortomy; HJ, hepltlljejunortomy.

11

Chapter 1 Truncal Vagotomy with Gastrojejunostomy

anastomotic leak or intra-abdominal abscess occur with significant frequencies. The 30-d.ay mortality rate associated with this operation ranged from 0 to 9% (median = 0). Long-term complications specific to TV 8t GJ may be categorized as physiologic or mechanical. The physiologic complications include delayed gastric emptying, early satiety and weight loss, cholelithiasis, chronic diarrhea, dumping syndrome, and iron and calcium malabsorption resulting in anemia and osteoporosis, respectively. Patients in whom vagotomy was not performed or those in whom the vagotomy was incomplete are at risk for peptic ulceration of the jejunal side of the anastomosis. This condition is termed marginal ulceration and may cause life-threatening GI hemonhage or obstruction of the anastomosis. In patients undergoing gastrojejunostomy without vagotomy this complication is prevented by the administration of proton pump inhibitors or hista.mine-2 receptor antagonists. The mechanical complications of this procedure include obstruction of the afferent or efferent limb, stenosis or kinking of the anastomosis, and small bowel obstruction.

3

RESULTS

The results of performing a gastrojejunostomy for patients with benign or malignant GOO are shown in Table 1.2. As alluded to in the previous paragraph, delayed gastric emptying in the early postoperative period is a significant problem associated with this procedure. The median time to tolerating a diet is 8.15 days (range= 4.4 to 8.5 days). The median length of hospitalization is 12.2 days (range =8 to 21 days). The advantage of gastrojejunostomy over the placement of endoscopic stents or endoscopic dilation is a very low rate of persistent or recurrent GOO requiring remedial therapy. The median rate of patients requiring reoperation for either persistent or recunent GOO is Oo/o (range = 0 to 5% and 0 to 16.7%, respectively). Of those patients undergoing gastrojejunostomy for malignant GOO the median survival was 3.8 months (range= 2.1 to 7.2 months).

StudyD•ign Retrospective camparison of Lap lV + GJ vs. Open TV+ GJ in patients with PUD with GOO, patients accrued between 1999 and 2005 Retraspective review at patients with Crahn's disease and duadenal abstructian, patients accrued between 1995 and

Sample Size

lengthli H-.iblliZAdian

limeta Diet(dap)

Persi•entiOO/ Reaperatian (iiJII)

Recu~rent

1100(%)

SurvMII

21

8.5

n/a

11

12.2

4.4

9

n/a

513

8

n/a

3.1

6ma

44

21.5

8.3

4.8ma

44

8.5

n/a

8.3ma

8

(d~~ys)

2i116

Retraspective review at GJ in patients with pancreatic cancer with GOD 166 patients) and withaut GOD 1447 patients), patients accrued between 19911and 2010 Prospective cam parison, HJ alone in patients with pancreatic cancer with GOO IHJ + GJ) and without GOO IHJ alane), patients accrued between 1992 and 1995 Single-center randomized trial, GJ vs. na GJ in patients with unreaectable pancreatic cancer withaut 600, patients accrued between 1994 and 1998 Multicenter, randomized trial af GJ vs. stent for patients with GOO tram UGI cancers, patients accrued between 2006 and2008 Prospective, randomized trial of HP+ GJ vs. HJ alone for patients with advanced periampullary cancers without evidence af GOO at presentatian, patients accrued between 1998 and 2002

18

15

8

16.7

5

2.6ma

36

11

n/a

5.5

7.2ma

l.tp TV+ GJ,Iaparonopic truncal vagotomy and gntrajejunoatamy; Open TV+ GJ, truncal vagotomy and ganajejunartamy performed tllraugh a laparotomy; GOO, guttie autlet obatrurian; PUD, peptic ulcer disene; GJ, gartrajejunoatamy; HJ, hepatojejunoatomy.

12

Part I Procedures tor Ulcer Disease

~ CONCLUSIONS TV 8t GJ is used to manage patients with GOO from PUD who have not responded to medical management and endoscopic dilation. Gastrojejunostomy (without vagotomy) is used to treat patients with UGI malignancies and impending or actual GOO who are discovered during exploratory laparotomy to have advanced or unresectable disease. Technically the operation is relatively straightforward requiring access to the esophageal hiatus and the ability to create a tension-free anastomosis between the stomach and the proximal jejunum. Early postoperative morbidity rates are relatively high when compared to the significance of these patients' underlying illness and other medical comorbidities. Delayed gastric emptying is a common complication prolonging hospital stay. Patients who undergo gastrojejunostomy without vagotomy require acid suppression to prevant marginal ulcers.

Recommended References and Readings Allanthrelcrislmao. N, Parthasare.thy G, Kate V. Clu:onic co:n:osiva injuries of the stomach - a single UDit experience of 109 patiBilts ovar thirty yea:rs. World J Surg. 2010;34:758-764. Boylan JJ, Gre.dz:ka JI. Long-tarm :results of eildoscopic balloon dilatatiOil for gastric outlet obstruction. Dig Dis Sci. 1999;44:1883188f:l. Cberian PT, Cherian S, Singh P. L011g-term follow-up of patieilts with gastric outlet obstructi011 :related to peptic ulcar disease treated with endoscopic balloon dilation and drug therapy. CGstrointest Bndosc. 2007;66:491-497. Gibson JB, Behrman SW, Fabian TC, et al. Gaslrlc outlet obstruction :resulting from peptic ulcer disease :requiring surgical intervention is infrequently associated with Helicobacter pylori infection. JAm Coli Surg. 2000;191:32-37. Jelll'Ilillk SM, Steyerbe:rg EW, van Hooft JE, et al. Su:rgical gastrofejunostomy or endoscopic stent placement fa:r the palliation of malignant gaslrlc outlet obst:ructl.on (SUSTENT study): a multicenter randomized t:rial. Castrointest Bndosc. 2010;71:490499. Jeurnink SM, Steyerberg HW, Vieggaa:r FP, et al. Predictors of SUJ'o vival in patients with malignant gaslrlc outlet obstruction: a patient a:riented decision approach for palliative t:reatment. Dig Liver Dis. 2011;43:548-552. JeumiDk SM, van Eijck CHJ, Steyerberg EW, et al. Steilt varsus ga.strojejUDostomy for the palliati011 of gastric outlet obstructi011: a systematic review. BMC Gastroenterology. 2007;7:18-28. Kim 8-M, Song J, Oh SJ, at al. Compa:rison of laparoscopic truncal vagotomy with gastrojejunostomy and opeil surgery in peptic pyloric steilosis. Surg E:ndosc. 2009;23:1326-1330.

Kneue:rtz PJ, Cunningham SC, Cameron JL, et al. Palliative su:rgl.cal management of patients with unresectable pancreatic adenocaJ'o cinoma: t:rends and lessons learned from a la:rge, single institution experience. J CGstrointest Sw:g. 2011;15:1917-1927. Kocbha:r R, Kochha:r S. Endoscopic balloon dilation for benign gast:ric outlet obstruction in adults. World 1 CGstrointest Bndosc. 2010;16:29-35. Kochba:r R, PoomachiW.d:ra KS, Dutta U, at al. Ea:rly endoscopic ballo011 dilation in caustic-induced gastric injury. Castrointest Endosc. 2010;71:737-744. Lillemoe KD, Ca:maron JL, Ha:rdacre JM, et al. Is p:rophylactic gastrojejunostomy indicated for unresectable periampullary cancar? a p:rospectiva :randomized trial. Ann Surg. 1999;230:322-330. Shapi:ro M, G:rssnstein AJ, Bym J, et al. Surgical managameilt and outcomes of patients with duodenal C:rolm's disease. JAm Call Surg. 2008;207:36-42. Shone DN, Nikoomanash P, Smith-Meek MM, at al. Malignancy is tha most comm011 cause of gastric outlet obstructi011 in tha ara. ofH2 blockers. Am J CGstroenterol. 1995;90:1769-1770. Shy:r Y-M, Su C-H, Wu C-W, at al. Prospective study of gastric outlet obstruction in umesectable perlampullary adenoca:rdnoma. World I Surg. 2000;Z4:60-65. Skandalakis JE, Rowe JS, Gray SW, et al. ldentiilcation of vagal structu:res at the esophageal hiatus. Surgery; 1974;75:233-240. Sa:reide K, Sarr MG, Sa:reide JA. Pyla:roplasty for benign gaslrlc outlet obstruction - indications and techniques. Scand 1 Surg. 2006;95:11-16. Van Heek NT, De Cast:ro SMM, van Eifck CH, et al. The need fa:r a prophylactic gastrofefunostomy for unresectable perlampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of Ufe. Ann Sw:g. 2003;238:894-905.

2

Truncal Vagotomy and Pyloroplasty David W. McFadden, Edward C. Borrazzo, and Vladimir Neychev

Introduction The word vagotomy technically means vagal nerve transection, thus interrupting sensory and motor impulses to the stomach and gastrointestinal tract. However, a 1- to 2-cm section of each nerve is usually resected. Although the proper term for resection should be "vagectomy," vagotomy is the much more commonly used term (Fig. 2.1). Its purpose is the elimination of direct cholinergic stimulation of gastric acid secretion. Vagal fibers innervate the stomach and play a major role in the cephalic phase of gastric acid secretion by their release of acetylcholine, which stimulates acid secretion from the parietal cell. The distal portion of the anterior and posterior vagal trunks also sends motor branches to the antrum and pylorus. The celiac branch of the posterior vagus stimulates small intestine motility as well. Gastric motility is affected by the antral and pyloric branches of the vagus that stimulate peristaltic activity of the antrum and pyloric relaxation. The vagus also stimulates receptive relaxation of the fundus, resulting in accommodating intake with no corresponding pressure increase. Vagotomy results in a 75% decrease in basal acid secretion and a 50% decrease in maximum acid output Additionally, due to the loss of reflex relaxation of the gastric fundus, increased gastric capacity after eating is attended by a rise in pressure, resulting in rapid emptying of liquids. Vagotomy also disturbs distal stomach motility, resulting in difficulty in emptying solids. Because of these changes, approximately 20% to 30o/o of vagotomy patients develop gastric atony, which may lead to stasis and chronic abdominal pain and distention. Hence, it is surgical dogma that after truncal vagotomy patients require a "drainage" procedure to offset the nonrelaxing, obstructing pylorus. Although four kinds of vagotomy have been described in the surgical literature-truncal, selective, highly selective, and supradiaphragmatic-truncal and highly selective vagotomy are generally used to treat peptic ulcer disease. Selective and supradiaphragmatic vagotomies are rarely used. In Dragstedt's initial and seminal series of truncal vagotomy for the treatment of duodenal ulcer disease in 1943, nearly one-third of his patients experienced postoperative nausea, vomiting, and distention. His subsequent investigations revealed that truncal vagotomy denervated the antrum and pylorus resulting in a functional gastric

13

14

Part I Procedures tor Ulcer Disease

Figur• 2.1 Schematic of truncal vagotumy. Both branches of the vagus nerve are ligated betwaan clips.

outlet obstruction. It became apparent that a "drainage" procedure was necessary to avoid the symptoms of gastric stasis. Therefore, any patient who undergoes truncal, selective, or supradiaphragmatic vagotomy should undergo a drainage procedure to facilitate gastric emptying. Drainage procedures can be divided into two categories: pyloroplasties and gastrojejunostomy. Pyloroplasty is the favored approach as it maintains the original anatomy, is simple, and is accompanied by less bile reflux than gastrojejunostomy. Currently over 90o/o of all drainage procedures are variations of pyloroplasty. Pyloroplasty was originally described independently by two surgeons, Heineke and Mikulicz, in 1888, decades before its routine application for drainage after vagotomy. The Heineke-Mikulicz (HM) pyloroplasty is popular because it is technically uncomplicated, widely applicable, and associated with few complications. In children with pyloric stenosis, pyloromyotomy is usually performed, leaving the mucosa intact This approach in adults is often unsuccessful as the duodenal mucosa is more adherent to the muscle layer and the intestinal lumen is often entered during the myotomy.

Management Three different types of pyloroplasty have been described. Truncal vagotomy and pyloroplasty is a relatively simple procedure, but there are some nuances that will prevent recurrences and complications. It can be performed laparoscopically or with

Chapter 2 Truncal Vagotomy and Pyloroplasty

open surgical technique. Indications most often include persistent ulcer disease refractory to medical therapy.

Vagotomy Exposure is through an upper midline incision for the open technique or with fi.va trocars positioned in a similar way as for any laparoscopic foregut operation (see Figs. 2.1 and 2.2). First, attention is turned toward the gastroesophageal junction. We u.sa a Thompson retractor to elevate the left lateral segment of the liver when performing surgery laparoscopically, or a Bookwalter or Omni retractor for open surgery. For open surgery, the left triangular ligament is incised u.sing cautery to allow medial retraction of the left lateral segment of the liver. This step is not necessary in the laparoscopic approach since the liver is elevated in a cephalad direction to attain access to the diaphragm hiatus. The gastrohepatic ligament is divided. Also, division of the superior attachments of the gastrosplenic ligament makes encircling the esophagus easier. The esophagus is than encircled with a Penrose drain for retraction. The crura are separated from the esophagus, and the asophagophranic ligament is incised to expose the anterior esophagus. This step is especially important in patients with hiatal hernia. Occasionally, the gastroesophageal fat pad must be dissected if prominent, exposing the GE junction anteriorly. Again, if the lower esophagus is exposed in the mediastinum, the vagotomy may be performed superior to the GE junction fat pad. Attention is then turned toward the anterior branch of the vagus nerve (Fig. 2.2). It is easily found traversing from left to right at the distal esophagus. Dissection of the adventitia off the anterior esophagus allows exposure of the anterior vagus nerve, which can be lifted with the help of a right-angled dissector. A short length is dissected, clips are placed proximally and distally, and a segment of the nerve is resected with scissors if clips are used. Otherwise u.sa of ultrasonic anergy facilitates ligation. If any concern exists that the resected tissue is not the vagus narva, this small segment of tissue can be sent to pathology for frozen section to confirm nerve. Next, the esophagus is retracted, usually anteriorly and toward thalaft, exposing the posterior esophagus. Since it is larger than the anterior branch, the posterior vagu.s nerve is usually easier to find and dissect oH the esophagu.s (Fig. 2.3). Similar to the anterior vagus, the posterior branch is hooked with a right-angled dissector, clipped,

Figura 2.2 Anterior vagotomy. The esophagus is encircled with a Pen· rosa drain for ratraction. The asopha· gaal fat pad is ratractad inferiorly and the adventitia of the esophagus is cleared. The vagus nerve is dissected off the esophagus and a segment is ligated batwaen clips or, as in this case, using ultrasonic shears.

15

16

Part I Procedures tor Ulcer Disease Figur• 2.3 Posterior vagotomy. The esophagus is retracted anteriorly, and the vagus nerve is dissected. This image depicts the ligation of the posterior vagus nerve using ultra· sonic energy.

and ligated and a portion of the nerve is resected. The Penrose drain and liver retraction are then released, and attention is turned toward the pylorus. Remember, additional vagal trunb are present in nearly 20% of patients and must be identified and transected.

Pyloroplasty There are several methods for performing pyloroplasty. The most common is the HIM pyloroplasty (Fig. 2.4). First, a Kocher maneuver is performed, mobilizing the duodenum from its retroperitoneal attachments. This ultimately helps take tension off the suture line. The pyloric muscle is easily palpated between the surgeon's thumb and index finger. Stay sutures of 3-0 silk are placed with a seromuscular bite through the pylorus just superior and inferior to the anterior aspect of the pylorus. A longitudinal incision is made in between the two stay sutures using a needle-tip electrocautery pencil or ultrasonic energy source. Care is taken to avoid making the incision longer than necessary to prevent tension on the suture line. We recommend extending it between 1 and 2 centimeters past the pyloric muscle proximally and distally (Fig. 2.5). The stay sutures are distracted, and the suture line is closed transversely (Fig. 2.6). Many different methods exist for closing the pyloroplasty, including single-layer suture closure (with or without imbricating stitch), double-layer closure, or even stapled closure. We prefer a single-layer closure with interrupted 3-0 silk sutures using a Gambee stitch to imbricate the suture line, opposing serosa to serosa (Fig. 2.7). This allows secure closure without narrowing the lumen. Care is taken to avoid missing the mucosa, especially at the comers of the suture line as the pylorus is pushed away from the serosa by the large, thick sphincter muscle layer. If the pyloroplasty is performed laparoscopically, we prefer to use a free needle as opposed to automated suture systems for accurate needle placement. We start from the comers and work. toward the middle of the suture line. If possible, the last three sutures should be tied only after all sutures are placed to facilitate assurance of mucosal bites in each stitch. The suture line can be tested by occluding the duodenum and instilling 500 to 1,000 mL of methylene blue down the orogastric tube. Omentum can be placed overlying the suture line and sutured in place if there is any concern regarding suture line integrity. Another very quick and easy way of performing the HM pyloroplasty is with a stapling device. This is much easier to perform using open rather than laparoscopic

Chapter 2 Truncal Vagotomy and Pyloroplasty

17

Figure Z.4 Schematic af HeinekeMikulicz pyloroplasty. The pylorus is incised longitudinally and closed transversely.

18

Part I Procedures for Ulcer Disease Figure Z.S Pylorus incised and opened. Stay sutures are placed at each corner tD hold the pylorus open.

figur• 2.6 Pylorus pulled open prior to elos ure. Tlle pylorus is in eised completely from the prepyloric region into the duodenum.

figure 2.7 Pylorus closed transversely and defunctionalized.

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a.ld, aod thla ......1q.. rollohly ldmt!S..tho mld!blo fuclo aod Ha.eo olbo !J> oltnot!o,. wboD ~ ~ h.mo l>Gt boon p-.od. no.. m!dltno l5uda II ladoocl ~y Ill d!.o m!dbno to .-..!cl ~of d!.o ocnlluoooo of tlu> IIIILollor ma ~.,. ....... ,.,...... '!bs ~ lid 111 oh.aply ......,"""" aod tho pcalopol>ld .,111ofull-ottho.........!, ..-.a!JilJ>;a.,., whm ~ Tl>o ~D- to:oolutpolllo 1m: f»r boUor _..,.of tlu> oooploopol b!llu. A ~1 opat>p Ia plocod ldM-ol and partolltttto tho oplool> ID-rmy t«b6101> OD tho tlr!l6 m!nfml!dn& tht !I'd afipl01ll4!J>Iw:l'. AMlf--lnln&

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150

Part I Procedures for Ulcer Disease

Figwa 14.1 (A) Nissen closure. This method, oftun employed whan the duodenum is scarred to tha pancreatic capsule, is per· formed by first transecting the duodenum. The duodenal stump is than sutured to tha pancreatic capsule or duodenal wall left in place on tha pancreatic capsula. (B) Bancroft closure. In this method of duodenal stump closure, tha stomach is transacted 3 to 4 em pro.ximal to tha pylorus, whara tissue is lass fibrotic. Tha antral mucosa in tha duodenal stump is then dissected away from tha submucosa beyond tha pylorus and into tha duodenum. This is sacurad with a purse-string suture, and tha seromuscular layer is closed ovar the stump.

removed. A purse-string suture is then used to close the pylorus from inside; then the submucosa and the muscularis layers of the prepyloric stomach are used to reinforce the closure of the duodenal stump (Fig. 14.1B). An important principle is preservation of the distal antral blood supply because necrosis of the stump is a risk. with this procedure. Either of these closure techniques can be combined with duodenostomy tube decompression. When emergency surgery is required for continuing hemorrhage from a duodenal ulcer, it is common practice to oversaw the bleeding ulcer and at the same time perform a vagotomy and pyloroplasty. But in the case of a GDU, where the blood may be coming directly from the gastroduodenal or pancreaticoduodenal artery, this approach is insufficient and carries a high risk of recurrent bleeding. Truncal vagotomy and either pyloroplasty or gastrojejunostomy should be avoided. The ulcer must be separated from the duodenum and the blood supply to the ulcer must be appropriately ligated. Lapa.roscopic approaches for gastroduodenal disease are well established. The minimally invasive approach allows for the possible benefits of less pain, less wound complications, and shorter hospital stay (see Chapter 2 for laparoscopic vagotomy,

Chapter 14 Operation for Giant Duodenal Ulcer

151

antrectomy, and Billroth I and Chapter 4 for laparoscopic vagotomy, antrectomy, and Billroth However, because of chronic inflammation around the ulcer area and S\11"rounding organs, the laparoscopic approach is sometime difficult when treating GDU. The sw:geon should be prepared to convert to an open approach if duodenal inflammation makes it difficult to perform a safe and expeditious resection.

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Historically, the two key features of GDU disease were the difficulties in prompt diagnosis and the failures of medical management. The advent and widespread use of endoscopy has made prompt diagnosis of GDU more accurate and easy to obtain. Once a diagnosis has been made, initiation of therapy can begin. Uncontrolled hemorrhage, perforation, and unstable patients should undergo prompt opemtive management with vagotomy and antrectomy. Stable patients may be safely treated initially with medication. However, close observation and repeat endoscopic evaluation is essential in the successful medical management of these patients. Furthermore, a malignant etiology may be more common than previously suspected, and liberal use of endoscopic biopsies are warranted in the setting of GDU, particularly those with nodular-appearing edges. Due to evolving endoscopic and medical therapies, the management of GDUs has changed. What was once a disease that was difficult to diagnose and managed solely with surgical intervention has become one easily diagnosed and potentially treated medically. It is of utmost importance that physicians recognize GDUs as being different than their standard-sized counterparts and that we continue to further our understanding of this entity.

Recommended References and Readings Agrawal NM, Campbell DR, Safdi MA, et al. Superiority of lan8o· p:razole vs :ranitidine 1n healing nonsteroidal anti-inflammatory drug-associated gastric ulcers: :results of a double-blind, rand· o:I!Wed, mullicenter study. NSAID·Associated Gastric Ulcar Study Group. Arch Intern Msd. 2000;160:145~1461. Bader JP, Delchier JC. Clinical efficacy of pantoprazole oompa:red with ranitidine. Aliment Pharmacal Ther. 1994;8(Suppl 1): 47-52. Bancroft FW. A modificalion of the Devine ope:alion of pyloric exclusion for duodenal ulcer. Am J Surg. 1932;16:223-230. BaiLDett JM. Modified Bancroft procedure for the duodenal stump. Arch SUrg. 1972;104:21~222. Brdic.zka JG. Das Grosse ulcus duodeni in rontgenblld. Fort!Chr Ceb Bontgenstr. 1931;44:177-181. Burch JM, Cox CL, Feliciano DV, at al. Managemsnt of the difficult duodenal stump. Am J Surg. 1991;162:523-524. Collen MJ, Santoro MJ, Chen YK. Giant duodenal ulcer. Evaluation of bue.l ad.d output, nonsteroidal antllnflammatory drug use, and ulcer complications. Dig Dis Sci. 1994;39:1113-1116. Fischar DR, Nussbaum MS, Pritts TA, st al. Use of omeprazole in. the management of giant duodenal uloer: Results of a prospec· live study. Surge.ry. 1998;128:843-649.

Gustavsson S, Kelly KA, Hench VS, et al. Giant gastric and duodenal ulcers: a populati.on-ba.sed study with a comparison to nongiant ulcers. World J Surg. 1987;11:333-338. jaszewski R, Crane SA, Cid AA. Giant duodenal ulcers. Successful healiDg with medical therapy. Dig Dis Sci. 1983;28:486-489. Klammer TW, Mahr MM. Giant duodenal ulcer: a dangarous variant of a common illness. Am J Surg. 1978;135:760..762. Mislilis SP, Wiot JF, Nedelman SH. Giant duodenal ulcer. Ann Intern Med. 1983;59:155-184. Newton EB, Versl.and MR, Sepe TE. Giant duodenal ulcers. World J Gastroenterol. 2008;14:4995-4999. Nussbaum MS, Schusterman MA. Management of giant duodenal ulcer. Am J Surg. 1985;149:357-361. Rathl P, Pa:rikh S, Kal:ro RH. Giant duodenal ul.ci!!r: a new look at a variant of a common illness. Indian J Castroenterol. 1996;15: 33-34. Walan A, Bader JP, Classen M, et al. Effect of omeprazole and ranitidine on ulcer healing and :relapse rates in palients with benign gastric ulcar. N E:ngl J Med. 1989;320:8~75. Yeomans ND, Thla.ssay Z, Juhasz L, et al. A comparison of omeprazola with ranitidina for ulcers associated with nonstaroidal anliinflammatory drugs. Acid Suppression 'IM.al: Ranitidine versus Omeprazole for NSAID·Associated Ulcar 'D:eatment (ASTRONAUT) Study Group. N EncJ J Med. 1998;338:71~726.

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15

Distal Subtotal Gastrectomy and Dl Resection K. Roggin and Mitchell C. Posner

INDICATIONS/CONTRAINDICATIONS Gastric adenocarcinoma is the fourth most common malignancy and the second leading cause of death worldwide annually. In the United States, it remains a relatively rare cancer (in 2010, approximately 22,000 new cases were diagnosed). Gastric carcinoma is associated with chronic exposures to environmental carcinogens (Helicobacter pylori, nitrosamines, tobacco exposure), inO.ammatory conditions of the stomach (atrophic gastritis), pernicious anemia, blood type A, and less commonly, genetic mutations in the E-cadherin gene, CDH-1 (hereditary diffuse gastric cancer). The relatively poor overall survival reported in most Western series is likely influenced by the high percentage of patients who are diagnosed with locally advanced or metastatic disease. Symptoms remain nonspecific early in the course of the disease, but advanced tumors can cause GI hemorrhage, gastric outlet obstruction, and profound weight loss. Curative treatment requires an appropriate gastrectomy with adequate regional lymphadenectomy. Peri- or postoperative treatment with chemotherapy and/or radiation has been shown to reduce recurrence and improve survival. Thmor location, clinical stage of disease, and patient performance status influence the decision to perform a subtotal versus total gastrectomy. Lymphatic metastases should be treated with an appropriate lymphadenectomy for optimallocoregional control of disease. Early-stage cancers may be cured by complete endoscopic mucosal resection (e.g. , Tla cancers) or surgical gastrectomy; chemotherapy and/or radiation are effective adjuvant treatments that have been associated with improved disease-free and overall survival in stage IT and III disease. Optimal management should be individualized with the input of a multidisciplinary tumor board. Two treatment paradigms are accepted as standards of care: Perioperative chemotherapy using EOX (Epirubicin-Oxaliplati.n-Capecitabine) or equivalent chemotherapy for three cycles (nine weeks) before and after radical gastrectomy (MAGIC trial regimen). • Subtotal or total gastrectomy followed by chemotherapy and external beam radiation (McDonald regimen, SWOG 0116).

153

154

Part II Procedures tor Neoplastic Disease

V

PREOPERATIVE PLANNING

NCCN guidelines (www.nccn.org) suggest a comprehensive staging workup for patients with resectable gastric cancer. • Comprehensive history and physical examination • Complete upper endoscopy defining the location of the tumor within the stomach, extent of intragastric spread, end relationship of the cancer to the gastroesophageal junction. • All biopsies should be reviewed by a dedicated GI pathologist to determine the histologic subtype (intestinal, Lauren's diffuse type, signet ring cell adenocarcinoma, adenosquamous carcinoma) and degree of differentiation. • Endoscopic ultrasonography should be considered in select patients who are candidates for neoadjuvant chemotherapy protocols. This modality is accurate at assessing the depth (T stage) of invasion, presence of metastatic regional lymphadenopathy, and distant metastatic disease to the liver or peritoneal cavity (liver metastases, peritoneal implants, and/or ascites). • Contrast-enhanced, triphasic (pre-, arterial-weighted, and portovenous phases) multirow detector computed tomography of the chest, abdomen, and pelvis. • Positron-emission tomography (PET scans) remains an experimental diagnostic staging modality in gastric adenocarcinomas, as only two-thirds of these mucin-producing or signet ring adenocarcinomas have the ability to concentrate the radiotracer fiuorodeoxyglucose. PET-CT fusion scanning has been reported to improve the diagnostic accuracy compared with either CT or PET scans alone. • Staging laparoscopy ±peritoneal washings (cytology) should be considered in patients with ~T3 or node-positive cancers: as many as 20 to 30o/o of patients with negative radiographic and endoscopic imaging will have occult Mt or stage IV disease on laparoscopy. • Peritoneal cytology appears to be an independent predictor associated with death from gastric adenocarcinoma.

\9 SURGERY Complete surgical resection of gastric cancers is the only treatment modality associated with long-term survival. The tumor stage, location, and performance status of the patient infiuence the optimal type of resection (subtotal vs. total gastrectomy). Two randomized prospective trials have shown that the estimated overall survival after distal subtotal gastrectomy is equivalent to total gastrectomy for distal gastric cancers. Total gastrectomy is associated with higher postoperative complication rates, more frequent concomitant splenectomy, and longer inpatient length of stay. In addition, it is often associated with significant long-term protein-calorie malnutrition and functional impairment. Proximal gastrectomy has not been rigorously compared with total gastrectomy, but it offers a reasonable alternative to total gastrectomy for cancers of the cardia and gastroesophageal junction (GED. In general, this procedure has a higher frequency of recalcitrant postoperative biliary reflux. Radical gastrectomy requires a comprehensive understanding of the arterial supply of the stomach and duodenum (Fig. 15.1), lymphatic drainage basins, and physiologic consequences of decreasing the volume of the gastric reservoir. The optimal extent of regional lymphadenectomy remains controversial. Two landmark-randomized controlled trials failed to show a short-term survival benefit with D2 lymphadenectomy. Results from both a recent trial by Wu et al. and a 15-year re-analysis of the Dutch gastric cancer trial suggest a small absolute survival benefit for patients who were treated with extended lymphadenectomy (>Dl). Operative principles include the following: • Complete laparoscopic and open assessment of occult, sub-radiographic metastases to the liver, peritoneal cavity, adrenal glands, and distant lymphatic basins.

Cllaptar 15 Distal Subtotal Gastrectomy and 01 Resection

155

figur• 15.1 Arterial supply to stomach and duodenum. LGA, laft gastric artery; SA, splenic artery; CHA, common hepatic artery; PHA, proper hepatic artery; LHA, laft hepatic artery; RHA, right hepatic artery; RGA, right gastric artery; GDA, gastroduodenal artery; RGEA, right gastroepiploic artery; IGEA, gastroepiploic artery.

• Complete resection of the primary tumor with at least 5-cm proximal and distal margins. • Appropriate regional lymphadenectomy as indicated by the location of the primary tumor (proximal, middle, and distal stomach) and stage of disease. In the absence of clinical lymphadenopathy in the D2 drainage basiDS (celiac axis distribution), a complete D1lymphadenectomy may be sufficient treatment. Resecting at least 15 lymph nodes appears to eDSure adequate staging accuracy. • D1 lymphadenectomy involves removal of the perigastric lymph nodes along the lesser curvature (stations 1, 3, and 5) and greater curvature (stetioDS 2, 4, and 6) (Fig. 15.2). • D2 lymphadenectomy extends the lymphatic sampling to all of the lymph nodes around the celiac axis and its named vessels (stations 7-11). • Gross and histologic intraoperative mSigin assessment. • Reconstruction of GI tract continuity with appropriate conduit to maximize function and reduce the incidence of postgastrectomy syndromes.

Operative Positioning and Setup Patients are positioned on the operating room table in the supine position with appropriate padding. Sequential compression devices and a single dose of 5,000 units of subcutaneous heparin are administered prior to induction of anesthesia to reduce the incidence of perioperative thromboembolic events. An oro- or nasogastric tube and Foley catheter are placed into their respective locatioDS after the patient has been sedated and successfully intubated. Complete pharmacologic neuromuscular blockade is essential to maximize operative exposure and minimize incision length. Broad-spectrum antibiotics covering gastric flora (e.g., second-generation cephalosporins) are given intravenously

156

Part II Procedures tor Neoplastic Disease

Figwa 15.2 01 lymphadenectomy

stations.

1. Rlttrt cardiac nodes 2. Left cardiac nodes 3. Lesser curvature nodes 4s. Left gastroepiploic nodes, Short gastric nodes 4d. Right gastroepiploic nodes 5. Suprapylorlc nodes 6. lnfrapyloric nodes

within 1 hour prior to the incision; antibiotics 81'8 routinely re-dosed within one-half life (generally 4 to 6 hours) if needed. The patient's left arm is usually padded and tucked to facilitate the placement of the retractor arm. The skin is prepared with a chlorhexidine solution and allowed several minutes to completely dry before draping the patient. An antibiotic-impregnated impermeable barrier is placed on the abdominal skin.

Operative Technique Diagnostic Laparoscopy All patients with gastric cancer operation require complete operative staging prior to resection. A formal diagnostic laparoscopy is performed to rule out radiologically occult metastatic disease. Generally, two trocars ere used: a 12-mm supraumbilical incision for the Hasson port and a 5-mm port in the subcostal position along the left midclavicular line. The peritoneal cavity should be systematically explored to identify intrahepatic metastases, peritoneal carcinomatosis, drop metastases (i.e., I lh.e elo - - 4swice. 'l'ha mlaoondnler, p:oulu •PI""""""' of 1M~"'""'"""' Ia nl!-.flb I of 1ho oxlnlli.opellc bllo cl- nu. p.lllociu.oclaa llllocy l.t lclecotiBocl mel. -eel. • 'l'b.a .,...111 m.ab!HaHan !lllod. mel. :a.ot l!wl-.al\y l:ojwocl. Tl>o -~~~~ lo dlt!docl.olttQs 1ho opleb!o bllum- II'"Ol..,.. toba to •"'ld copoulo! 1:1oc1!011 lll!miM to 1la opleoD "'oploa!G ~. • 'l'b.a u...t p.wtzll:: ....!a ""' dlt!ded up to lite lim>l of Ills lfLIIdc fw>dna 1LIID,t !he

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Bariatric

28

Open Bariatric Operations J. Wesley Alexander

~ INDICATIONS/CONTRAINDICATIONS During the past two decades, there has been a major increase in the number of laparoscopic bariatric procedures compared to open procedures for the surgical treatment of morbid obesity. The advantages of the laparoscopic procedures have been improved cosmesis (lack of a long scar), a slightly decreased mortality rate (approximately 0.2% vs. 0 .4% related somewhat to patient selection and characteristics) and a reduction in postoperative incisional hernias. However, the laparoscopic procedures have an increased leak rate, a higher rate of bleeding and small bowel obstruction and an increase in costs. The amount of long-term weight loss is similar for open vs. laparoscopic procedures as is improvement in co-morbidities and quality of life. The selection of open vs. laparoscopic procedures depends in large part upon the experience of the surgeon and the desire of the patient However, additional consideration for open procedures should be made in patients who are extremely obese (e.g., BMI >60), have had previous gastric procedures or prior operations in the central subdiaphragmatic region or with the need for additional intraabdominal operations or revision of prior bariatric procedures. Furthermore, there is sometimes a need for conversion of a laparoscopic to an open procedure. Therefore, it is mandatory that anyone who does laparoscopic bariatric procedures be qualified to do open procedures as well. This chapter will discuss gastric bypass, biliopancreatic diversion, sleeve gastrectomy and revisions, but not various types of gastric banding as nearly all of these are done laparoscopically. Indications for bariatric surgery should follow guidelines by the NIH and ASMBS which generally include a BMI >40 or >35 with significant co-morbidities. Untreated coronary artery stenosis needs correction before any major surgical procedure, but hypertension, cardiovascular disease, severe sleep apnea, severe diabetes, advanced renal disease and thromboembolic disease should not themselves prevent the performance of needed bariatric surgery.

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V

PREOPERATIVE PLANNING

• In patients who have had prior gastrointestinal surgery, obtaining end reviewing the operative report is essential. • In patients who have had prior bariatric procedures, an upper GI series and endoscopy are needed. • Preoperative endoscopy should be done in patients who have a history of reflux disease. • Some surgeons perform preoperative evaluations for the presence of H. pylori, but this is unnecessary in patients who have no history of reO.ux symptoms or ulcer disease. • Preoperative weight loss has been mandated in some programs to reduce liver size, but is unnecessary in open procedures. • To reduce skin organisms, the patient should shower with chlorhexidine the night before as well as the morning of operation. • A laxative is given the night before operation. • Preoperative oral neomyc:in/metronida.zole is helpful in reducing both gastric and intestinal organisms. • All patients should undergo psychiatric evaluation, nutritional counseling, and physical therapy counseling preoperatively. • All patients should attend support groups preoperatively.

S

SURGERY

Positioning • Patient must be placed supine on the operating table being careful to avoid any pressure points to prevent rhabdomyolysis. • Place both arms out being careful to prevent any stretch on the brachial plexus.

Management of the Incision and Prevention of Wound Infection • All patients should receive preoperative systemic antibiotics. Cefazolin is used widely for this. The initial dose should be basad on weight, giving 2 grams for patients under 300 pounds and 3 grams for patients weighing more than this, approximately 30 minutes before incision. A repeat dose should be given approximately 3 hours later in lengthy operations. • For skin preparation, scrubbing with a sponge saturated with 70% alcohol is used to remove grease, desquamated skin, dirt, and debri. After this dries, paint the skin with DuraPrep11• Wait until it dries completely and then apply Ioban11• Press firmly over the site of the incision since this has a pressure-sensitive adhesive, and lifting of the IobanQII from the skin edge will result in an increased incidence in wound infection. Evacuate all trapped bubbles. If the Ioban11 adheres wall to the skin edges, there is no possibility of contamination from the skin. • Make the incision from the xiphoid to just above the umbilicus. Incise the subcutaneous fat with a kn:i.fa rather than electrocautery to minimize tissue damage. Electrocautery can be used to spot coagulate bleeders. Make the fascial incision in the center of the linea alba without cleaning off any of the attached fat. • Closure of the fascia at the end of the operation should be done with a running #2 Prolena starting at each end and tying the sutures together somewhere in the middle with six square tightly tied knots. The ends of the suture should be cut short to avoid sharp points. To avoid the "cheese cloth" type of hernias, the bites into the fascia should be placed approximately 1 em from the edge and 1 em apart, making certain not to pull the sutures excessively tight It might seem intuitive to take larger bites into the fascia, but this actually increases tension at spots where the fascia is not as strong and promotes the development of the "cheese cloth" hernias.

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0!do--.!&~ I a - !ll6350 pounds. In patients with sleep apnea, CPAP or BiPAP is used routinely. Nasal 0 2 is given to all patients to maintain 0 2 sat >92. Incentive spirometers are used in all patients. Ambulation is encouraged the day of operation and is mandatory by the next morning. The more the patient walks, the quicker will be the recovery. Clear liquids, 30 mL/hr, are offered by mouth the day of operation and a pureed diet is offered the first postoperative day with solid food being given after four weeks. Pain control can be achieved by standard approaches. Urinary catheter should be removed on the first postoperative day unless the patient is unable to ambulate. Ulcer prophylaxis should be given using a proton pump inhibitor for at least 6 months. If the patient has been on beta blockers, these should be continued during the time of operation and afterward. The large majority of patients can be discharged after 48 hours. Removal of the Hemovac is done just before discharge. Patients who live more than a one-hour drive from the hospital, and/or have additional medical problems that require continued hospitalization (such as renal failure requiring dialysis), will be kept for a longer period of time.

Complications Numerous complications can occur in both the early and late postoperative periods. Atelectasis is one of the more common early complications. The primary prevention for this is early ambulation and the use of an incentive spirometer. Pneumonia is much less common but sometimes cannot be easily distinguished from atelectasis. Antibiotic therapy is indicated if pneumonia is likely. Thromboembolism can be fatal. If a pulmonary embolism is suspected, a CT scan or pulmonary angiogram should be done so that appropriate therapy can be instituted promptly. A duplex scan of the lower extremities is sometimes helpful. Placement of a vena caval filter is infrequently indicated. Bleeding occurs in 1 o/o to 4o/o of patients but is less common after open procedures. This can be from anastomotic sites, sites of surgical dissection or from ulcers. A thorough workup should include endoscopy, coagulation profiles and sometimes tagged red cell studies or angiography. On rare occasions, bleeding is associated with lesions in the excluded stomach so if no other cause is found, a transgastric endoscopy can be done, either open or laparoscopically. Death from bleeding is rare in the absence of a severe coagulopathy. A leak can occur from any of the procedures where the GI tract is opened, but they are less common with open procedures when all staple lines are oversewn. In general, detection measures using drain placement or upper GI contrast studies are not done routinely with open procedures. Most leaks from the stomach can be treated without reoperation. Wound infection is reported in 3o/o to 25o/o of patients. In general, the incidence of abdominal wound infection is approximately five times higher in obese patients than

Chapter 21 Open Bariatric Operations

• • • • • •

293

in nonobese patients. With the use of appropriate means to prevent wound infection 88 described earlier, (use of an incise drape, proper preparation of the skin, systemic antibiotics just before the incision in doses which are appropriate for morbidly obese patients with redosing as necessary, use of monofilament rather than multifilament sutures, running sutures rather than interrupted sutures, and the administration of antibiotics into the wound for a short period of time), the incidence of infection can be reduced to 40 kglm2 • BMI > 35 kglm2 with a comorbidity (e.g., diabetes, hypertension, obstructive sleep apnea.) • Failed attempts at nonsurgical weight loss

Contraindication• • • • •

BMI < 35 kg/m2 (unless under IRB-approved protocol) Inability to comply with postoperative follow-up High anesthetic risk Hostile abdomen: Extensive foregut surgery or extensive small-bowel adhesions

V

PREOPERATIVE PLANNING

A thorough history and physical examination should be obtained. History should include pertinent information regarding dietary habits and diet history. There should be documentation of attempts at nonsurgical means of weight loss. Generally, counseling by a registered dietician is warranted to establish this. Ally preoperative vitamin or mineral deficiencies (e.g., vitamin D, iron) should be treated. Comorbidities should be elucidated and risk stratification and optimization should be undertaken before general anesthesia. This may include stress echocardiograms, pulmonary function tests, and sleep studies. Many patients present for operation with previously undiagnosed diabetes or sleep apnea. These and other newly diagnosed conditions should be optimized prior to surgery. Patients are assessed for hypercoagulable states and history of venous thromboembolism (VTE). Some patients, particularly supel\-super morbidly obese patients, may require a preoperative inferior vena cava (IVC) filter. Upper endoscopy should be performed to evaluate the stomach for pathology prior to bypass. If Helicobacter pylori is present, it should be treated prior to sw:gary to reduce the risk of postoperative ulcers and stricture. Notation of a hiatus hernia should be made; an upper GI series may be helpful for this. If significant hernia is present, it should be repaired at the time of surgery in order to prevent the creation of a large gastric pouch. Patients should not be active smokers, as this not only leads to postoperative pulmonary complications but also increases the risk.

Chaptar 2:9 Laparoscopic Roux-en·Y Gastric Bypass

of later ulcer formation. Psychiatric evaluation should also be performed both to diagnose and optimize any pre-existing pathology and to assess patient's ability to cope and comply with postsurgical life and follow-up. Pertinent points in the physical examination include abdominal fat distribution. Patient's who are "apple" shape or android tend to be more challenging to operate on than "pear" shape or gynecoid patients. Notation of prior abdominal surgery, scars, and hernias should be made. Skin folds should be examined for extensive fungal infection or cellulitis. Lower extremity edema, particularly asymmetric edema, may portend an underlying deep venous thrombosis (DVT), and this should be evaluated. The ability to ambulate and "clear a chair" should be assessed. Immobile patients are at significantly higher risk of postoperative complications. Some surgeons require their patients to undergo a strict low-calorie, low-carbohydrate diet (e.g., Optifast) in the weeks leading up to surgery. The thinking here is not absolute weight loss per se, but the hopes it will reduce the size of the liver and amount of visceral fat. This makes access to the hiatus easier and safer and allows for easier manipulation of the mesentery. This may be partl.cularly useful in higher BMI patients. Some surgeons also use this as a "test" to determine whether the patients have the willpower to comply with postoperative dietary restrictions. Generally, we do not feel that this is necessary or appropriate. Certainly patients should not be actively gaining weight in the weeks leading up to surgery, and such behavior should be discouraged. Immediately prior to surgery all patients should receive appropriate antibiotic prophylaxis to limit wound infection. This is particularly the case when using transoral anvil and EEA stapling device. In addition, patients should have appropriate VTE prophylaxis. There have not been adequate studies to determine the best means of VTE prophylaxis in this patient population and it must be weighed against the risk of postoperative bleeding. There is unlikely to be such a study given the large number of patients required to measure differences. Generally, all patients should walk to the operating room if possible and ambulate hours after surgery. All patients should wear pneumatic compression devices prior, during, and after surgery while in bed. It is also generally recommend that some chemoprophylaxis be utilized. We administer 5,000 units of subcutaneous heparin prior to surgery and continue it every 12 or 8 hours. Low-molecular weight heparin administered in low doses may also be appropriate.

Preoperative Assessment • Nutritional assessment: Diet history, expectations after surgery, and optimization of nutritional deficiencies • Medical evaluation and optimization: Treat uncontrolled blood sugars, cardiac evaluation, assess for risk of VTE, diagnose and treat sleep apnea, and assess ambulatory status • Endoscopy: Evaluation of pre-existing pathology and treatment of H. pylori • Psychiatric: Diagnose and treat underlying psychiatric conditions if present Assess for patient compliance and identify maladaptive behaviors • Abdominal assessment: Predict the likelihood of successfully completing a Iaparoscopic gastric bypass • Preoperative diet: Reduce liver size and intra-abdominal fat • Preoperative antibiotics and VTE prophylaxis as appropriate

(g SURGICAL TECHNIQUE • Pertinent Anatomy: Surgeons undertaking laparoscopic gastric bypass should be well versed in foregut anatomy. Identification of the gastroesophageal junction and the anatomy of the angle of His is necessary to safely create the gastric pouch. The surgeon should be comfortable around the hiatus of the diaphragm and able to repair a hiatus hernia. The spleen lies at the superior extent of the dissection when creating the gastric pouch and may be injured during the process. The pancreas

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Part IV Bariatric

and splenic vessels run in the retroperitoneum behind the stomach. Injury here can result in bleeding or postoperative pancreatitis or fistula. Preservation of the left gastric artery and the lesser curve vasculature ensures blood supply to the gastric pouch. Identification of the ligament of Treitz is crucial in appropriately making the Roux-en-Y jejunal limbs. Generally, it can be located by its fixed attachment to the transverse colon mesentery. Often, the inferior mesenteric vein is seen just to the patient's left of the fourth portion of the duodenum as it exits the transverse colon mesentery. Appropriately orienting the proximal and distal ends of the bowel is crucial when reconnecting bowel segments and creating the gastroj ejunos tom y. Patient positioning and equipment: The operating room table should have the capability to withstand 800 lbs and should have split leg capabilities with right angle foot board attachments and have the ability to undergo steep reverse Trendelenburg. We prefer the Alphastar table (Maquet, Rastatt, Germany). Intubating the morbidly obese patient can be a challenge for the untrained anesthesiologist and having a dedicated bariatric team is ideal. Placing a "bump" or a "wedge" under the patient's upper back can facilitate intubation and pull away flesh from the upper chest that can hinder manipulation of the patient's airway. Once intubated, the patient should have all pressure points protected with foam padding. The arms should be out to the sides, just shy of 90 degrees. Care must be taken to assure that the arms are not hyperextended in both the cephalo-caudal and the anterior-posterior direction. French Position: The patient is in split leg with all pressure points protected and each leg secured to boards with circumferential bandages or tape. The operating surgeon is between the legs. The first assistant stands to the patient's right and is a dedicated camera driver and liver retractor. A second assistant is on the left and assists with retraction. The scrub technician stands on the patient's left. A single high-definition screen should be positioned above the patient's head at eye level. Alternatively, the surgeon can stand on the patient's right with the camera driver between the legs. American Position: The patient is supine with legs together. Right angle foot supports are still necessary for steep reverse Trendelenburg. The surgeon stands to the patient's right and the first assistant on the left. The scrub technician stands on either the left or the right. 'IWo high-definition screens are required over each of the patient's shoulders. A second assistant is generally not required. Trocar placement: Peritoneal access can be quite challenging in the obese patient. Several techniques have been described. We feel the safest method is to cut-down at the umbilicus. This site can serve as an optical port and all subsequent ports are placed under direct vision. Other techniques include the blind insertion of a Veress needle to establish pneumoperitoneum with blind placement of the first trocar and optical nonbladed trocar placement. If these techniques are used, it is generally recommended that they be placed in the left upper quadrant at the midclavicular line close to the costal margin. Our preferred trocar scheme is to have a 10-mm optical trocar in the umbilicus and a 10-mm optical trocar in the epigastrium which enters at the base of the falciform. A 12-mm trocar in the subxiphoid position is used for dissecting and stapling the gastric pouch and creation of the jejunojejunostomy. A second 12-mm trocar in the left upper quadrant is used for stapling the gastric pouch and is later expanded to introduce the EEA stapler to create the gastrojejunostomy. A 5-mm trocar in the left anterior axillary line is used by the second assistant and a 10-mm trocar in the right upper quadrant is used for a fan liver retractor and serves as an optical port during the creation of jejunojejunostomy. A fixed Nathanson or Genzyme liver retractor can be inserted through a separate 5-mm incision as an alternative. Alternative techniques have been described and are valid and can be tailored to the surgeon's preference and patient habitus. We have found this to be the most reproducible across a wide range of patient sizes and the most ergonomic. The abdomen should be insuffiated to 15 mm Hg. At times 20 mm Hg may be necessary to enhance visualization.

Chapter 29 Laparoscopic Roux-en-Y Gastric Bypass

Two insuftlators are useful in maintaining pneumoperitoneum, especially if suction is used. The surgeon and anesthesia team should be aware of hemodynamic and respiratory alterations during insuffiations. • Abdominal survey: Assess the abdoman for feasibility of gastric bypass. Any unexpected anatomy or adhesions should be evaluated. Most important to successful completion of gastric bypass is the ability to expose the diaphragm and angle of His. If the left lobe of the liver is too large to retract or fatty and friable, creation of the gastric pouch maybe too difficult or dangerous. In this case, the surgeon may decide to abort the case and subject the patient to a low-calorie diet, convert the procedure to sleeve gastrectomy or a two-staged gastric bypass. • Creation of the gastric pouch: We prefer to start with the creation of the gastric pouch and creation of the gastrojejunostomy, as this is the most challenging part of the case. Others feel that creation of the Roux limb first is more appropriate. • Dissection of the angle of His: The patient should be in maximal reverse Trendelenburg. The first assistant retracts the liver exposing the gastroesophageal (GE) junction, gastric fundus, and diaphragm. The second assistant retracts the fundus of the stomach caudally and to the patient's left with an atraumatic grasper. The surgeon retracts the fat pad overlying the GE junction to the patient's right with his or her left hand via the subxiphoid trocar. With a hook. electrocautery or ultrasonic dissector, in the right hand via thalaft upper quadrant port, the angle of His is dissected free of the GE junction and off the left crus. Bulging of retroperitoneal fat through this space suggests adequate dissection. Care should be taken to avoid injury to the spleen. In case this dissection is difficult due to the size of the liver or patient habitus, it can be completed from behind the stomach after the first couple of staple firings. Freeing the angle of His marks the target of the staple line in creating the gastric pouch (Fig. 29.1). • Parigastric dissection: In order to perform the first staple firing, the gastric wall along the lesser curvature should be freed from the fat containing its blood supply. A spot is chosen about 5 em from the GE junction, which is generally between the second and third vessel on the lesser curvature. Soma surgeons prefer longer pouches in order to decrease tension off the gastro-jejunal (G-J) anastomosis. The neurovascular fat bundle is freed with combination of blunt and sharp dissection using blunt graspers alternating with judicious use of the ultrasonic shears to seal individual vessels,

Fig..• 29.1 Angle of His has been dissected. Perigastric window approxi· mately 5 em below GE junction ere· ated for firing of first stapler.

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Part IV Bariatric

taking care not to injure the gastric wall. The majority of the dissection is done with the surgeon's left hand via the subxiphoid trocar. The surgeon's right hand acts as a place holder and gently pushes the gastric wall away from the fat. The second assistant should retract the stomach at this point anteriorly to create adequate tension for dissection. Bleeding can make this dissection difficult and should be controlled quickly if occurs. Care must be made to not track. superiorly or inferiorly in the perigastric fat which can devascularize a larger portion of the stomach than necessary (Fig. 29.1).

• Stapling the pouch: Before beginning, it is important to confirm that the anesthesiologist has removed all tubes from the esophagus. The lesser sac is antered via the perigastric dissection. The surgeon's right hand holds the place open while a 45 mm x 3.5 mm stapler is inserted via the subxiphoid trocar. It is important that this first staple line is perpendicular to the lesser curvature. The subsequent staple firings are performed from the left upper quadrant 12-mm trocar aiming toward the left crus with the surgeon's left hand retracting the forming pouch to the patient's right. After the second staple firing, it may be necessary to free up posterior adhesions to the pancreas and dissect posterior gastric vessels. This can be done with the ultrasonic scalpel. The second assistant can grasp the posterior fundus and retract it to the patient's left. This results in a smaller pouch size. Generally, the pouch is created with one 45 mm x 3.5 :mm and two to three 60 :mm x 3.5 mm staplers. We prefer using stapling line buttressing material (Seamguard, Gore, Flagstaff AZ) for all except the first two staple lines in order to reduce bleeding. The resultant pouch is approximately 30 mL in volume. Once the pouch is created, the staple lines should be checked for completeness and hemostasis. The staple lines that do not have buttressing material on the remnant stomach can be over sewn to prevent bleeding from the excluded stomach (Figs. 29.1 and 29.2). • Tranaoral Anvil: A 25-mm EEA anvil can be sutured to an orogastric tube or the DST series EBA OrVil. (CovidienCovidien, Mansfield, MA) can be passed through the mouth into the gastric pouch. The anesthesiologist should be instructed that the tube end should anter the mouth and pass with ease. The anvil should be guided into the mouth with the convex end up toward the hard palate. It does get hung up on the hard palate and behind the arytenoids. A jaw thrust can facilitate passage

Figur• 29.2 Stapling completed toward angla of His dissection.

Chapter 29 Laparoscopic Roux-en-Y Gastric Bypass Figur• 2.!1.3 Tra nso raJ passa 11 a of anvil into gastric pouch.

into the esophagus. The tip of the tube should be visible against the staple line. It can be guided into place by the surgeon's graspers. Ideally it should be on the patient's left side of the first staple line or the junction of the first and second staple line. A small gastrotomy is created with the ultrasonic shears just big enough to allow passage of the tube. The tube is gently withdrawn from the gastric pouch while the anesthesiologist assists in guiding the anvil into the mouth. No resistance should be felt while traction is applied to the tube. If resistance is encountered, it is generally in the places described above. If the anvil gets caught in the esophagus, an endoscope should be passed to evaluate the site of obstruction or to help push the anvil into position. The tuba is withdrawn out of the body. It is not sterile at this time and should be manipulated with clamps or towels. 'Iraction should be stopped when the white cuff of the anvil is seen. The sutures to the tube are cut and the tube is passed off the field. The anvil should fit snuggly in the gastrotomy. If it is gaping open, then a purse string suture around the device should be applied (Figs. 29.3 and 29.4). AltBl'llatiw techniq1UI: The anvil of an BEA can be placed into the stomach via a separate gastrotomy prior to complete transection of the gastric pouch from the remnant stomach. The gastrotomy is stapled closed and the anvil is pulled through a small hole in the pouch. Craation of ltoax limb: The camera is placed in the umbilical port and the patient is placed in a level position. The end of the omentum is identified and grasped by the surgeon's left hand and the second assistant The omentum is then split in a line headed toward the left phrenic vessels (Fig. 29.5). Care must be taken to make note of the location of the transversa colon to avoid injury. Once two leaves of omentum are created, they can be tucked away on each side. The transverse colon is rolled cephalad and the ligament of 'Ireitz is identified. The first assistant can aid in retracting the colon with the liver retractor. The surgeon runs the bowel for 75 to 100 em from the ligament The bowel can be tucked away in the left upper quadrant The second assistant grasps the proximal end of the bowel and the surgeon's left hand is

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figur. 2U Transoral passage of aiiYil into gastric pouch.

on the distal and (the future site of gastrojejunostomy). The bowel is held tightly while a blunt dissector such as a 10-mm right angle is used to dissect a space between the bowel and mesentery. A 45 mm x 2.5 mm stapler with buttress material is used to tr8D8ect the bowel. It is important to maintain orientation of which are the prox· im.al and distal ends of the bowel (Fig. 29.6). • Gutrojejunostomy with the EEA: The staple line on the distal end (being held by the surgeon's left hand, on the patient's right) is opened using ultrasonic shears. Once open, the distal end is distinct from the proximal end, and the ends of the

Figure Z9.5 Division af greater omentum.

Cllapter 29 Lap~rascopic Roux-an-Y Gastric Bypass

303

Rgur• 29.1 Craation of Roux limb.

bowel can be let go. The left upper quadrant 12-mm port is enlarged to about 2.5 em and the subcutaneous and muscle layers are spread using a large Kelly clamp. The hole should allow passage of two fingers which can further spread the opening. The BEA stapler should ba wrapped in a disposable camera bag secured to the shaft with a Stari-strip. This allows for subsequent removal of the stapler without contaminating the abdominal wound. The stapler is placed through the abdominal wall. This can be challenging, and it is helpful to use the curve of the instrument. Once inside the abdomen, the surgeon grasps the open and of the bowel at the 10 o'clock position while the second assistant holds open the staple line. They work together to guide the stapler into the bowel. It is important to allow the bowel to accommodate the stapler so it is does not tear. Here again, the curve of the stapler can be used to facilitate this process. The stapler is placed curve down, and once in the bowel, it can be flipped upward to keep the bowel on the stapler and the graspers can be taken off. The patient is returned to the reverse Trendelenburg position and the Rou:x limb is brought up to the gastric pouch containing the anvil. The spike of the EBA is brought out to reveal the orange stripe. The first assistant's liver retractor can help hold the bowel tightly over the stapler. The liver is retracted to reveal the anvil and pouch. The anvil is grasped with a 10-mm right angle clamp with the surgeon's left hand from the sub.xiphoid position while the right hand drives the EBA and Rou:x limb toward the anvil anterior to the transverse colon and remnant stom.a ch (antecolic, antegastric). As the anvil and stapler are married, ensure that there is no .kinking or folding of the bowel that can serve as an obstruction. Confirm there is no fat or remnant stomach that is being caught in the stapler. The "green" line appearing on the stapler signifies a complete union of the stapler. It should be fired, with an audible "click" heard. The stapler is opened and removed from the small bowel. A gentle rotation can aid in this. The stapler should be withdrawn from the body by undoing the Steri-strip on the shaft and pulling the bag over the device and then out of the body. The 12-mm trocar can be replaced with the addition of towel clamps to maintain pneumoperitoneum. The corners of the anastomosis can be reinforced with 2-0 Vicryl sutures. The anastomosis is inspected from inside the small bowel for completion and bleeding. Bleeding sites should be sutured from the outside of the anastomosis. Once satisfactory, the open end of the bowel is stapled closed

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Part IV Bariatric

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with a 60 :mm x 2.5 mm load with buttressing material. When doing this, it is critical to make sure the mesenteric end of the bowel is within the staple line. The end of the bowel should be removed from the body. The anastomosis can be tested by passage of an orogastric tube and instillation of methylene blue or with an endoscope and insuffiations of air. If leak is encountered, sutures can be used to oversaw the area in question (Figs. 29.7-29.9). • Jejunojejnnoatomy: With the camara in the umbilical port, the surgeon runs the Roux limb from the anastomosis for 150 em. The cut end of the biliopancreatic limb is identified and approximated to the site of anastomosis. Some surgeons suture the two together, but we find this unnecessary. An entarotomy is made on each side with the ultrasonic shears on the antimesentaric surface. The surgeon now moves to the patient's right side and the camera is placed in the right upper quadrant 10-:mm. trocar site. A 60 mm x 2.5 mm. stapler is introduced via the 12-:mm. subxiphoid incision, and the surgeon manipulates the bowel on either end of the stapler. Once on the stapler, the bowel and the stapler are raised anteriorly to allow the mesentaries to align. The stapler is fired and withdrawn from the body. The staple line is examined for bleeding. The enterotomy is closed with two layers of permanent suture in a running fashion. Alternatively, the entarotomy can be stapled closed. It is important to ligur• 29.8 Creation of jejunojejunostomy.

Chapter 29 Laparoscopic Roux-en-Y Gastric Bypass

figure 29.9 Completed antecolic-antegasttic Roux-en-Y gasttic bypass.

take note not to nSITow the anastomosis during this step. A stitch is placed in the crotch of anastomosis (Fig. 29.8). • Closure of mesenteric defects: The jejunojejunostomy defect can be closed as a continuation of the outer layer of the enterotomy or with a separate permanent suture and is done from the patient's right side. It is important to include a bite of serosa to prevent the closure from opening once the patient loses weight. Closure of Peterson's defect (between the Roux limb and transverse colon mesentery) is performed from between the patient's legs. It may be necessary to place another 5-mm trocar in the patient's left lower quadrant to perform this closure ergonomically. The closure is performed with permanent suture from the base of the defect to the level of the transverse colon. Again, it is important to include bites of serosa in the closure. TheRoux limb should be flipped to the patient's right side after closure of this defect. And propar orientation of the limbs is coofi.rmed one last time. We do not feel it is necessary to routinely leave a drain (Fig. 29.9). • Closure: We close all10· or 12-:mm. trocar sites with 0 Vicryl figure of eight transfascial sutures using a suture passer. The site of the EEA stapler may require mora than one suture. The umbilical site can be closed this way or from the outside. We prefer prolene suture at the umbilicus. All wounds are irrigated and closed with running absorbable subcuticular suture.

Alternate Techniques • Gaatrojejnnostomy: • Hand-sewn: A two-layered anastomosis can be performed between the Roux limb and the gastric pouch with absorbable 2.0 or 3.0 sutures. This can be performed with a free needle or an Endostich (Covi.dien, Mansfield, MA) device. Advantages (compared to EEA) include decreased cost, lower rate of postoperative ulcars, strictures, and lower wound infection rate. Disadvantages include longer operative times, greater skill in suturing, and greater variability in size of anastomosis. No diHerence in long-term weight loss or leak rate is noted in the literature.

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• Li:near stapler: This is generally performed with an outer layer of hand-sutured

anastomosis, followed by a linear stapler, and the enterotomy is either sutured or stapled closed. Advantages (compared to EEA) include decreased wound infection rate and decreased cost Disadvantages: Requires suturing skills and variable size of anastomosis. No difference in leak has been shown. • Retroc:olic versus antecolic Roux limb: The Roux limb can be passed in front of or through the mesocolon. In addition, if retrocolic, it can be ante- or retrogastric. We prefer an antecolic approach, as described. Advantages of a retrocolic approach are as follows: potentially decreased tension on the gastrojejunal anastomosis and no division of the omentum is necessary. Disadvantages include potential diffi. culty in dissection through the mesocolon, bleeding in the mesocolon, need to close the defect in the mesocolon, and highar rate of internal hernia through this space.

POSTOPERATIVE MANAGEMENT After extubation, the patient should be transferred to a bed capable of withstanding the weight of bariatric patient. Hospital staff should be protected against injury when transferring patients with the assistance of hover technology air mattress transfer systems if possible. After discharge criteria from the post-anesthesia care unit are met, the patient should be transferred to a fioor that is familiar with bariatric patients and surgery. Routine use of monitored settings is not necessary, unless the patient has significant obstructive sleep apnea or cardiovascular disease. The patient is maintained NPO for the first 24 hours, with IV fiuid, urinary catheter in place with an IV dilaudid PCA supplemented by ketorolac. The patient should ambulate on the evening of surgery, have compression devices in place when in bed, and have 5000 units of subcutaneous heparin administered every 8 to 12 hours to prevent VTE. Incentive spirometry and chest therapy is also necessary to prevent atelectasis and pneumonia. On post operative day 1, a contrast upper gastrointestinal series is obtained to evaluate for patency of anastomosis. Some canters forgo this study if there are no clinical signs of leak. Clear liquids are initiated, and the urinary catheter is removed. On postoperative day 2, if the patient continues to tolerate liquids, the IV is discontinued, oral medications are initiated and the diet is advanced to puree. Most patients can be discharged on the afternoon or evening of postoperative day 2. Patients stay on a pureed diet for 2 weeb after surgery and slowly transition to more formed food over the next month. Patients should take a proton pump inhibitor, multivitamin fortified with iron, calcium, and vitamin D. Patients are also instructed to take about 70 grams of protein a day, generally in the form of shakes in the first few weeb following surgery. Interface with specialized dieticians are crucial in maintaining postoperative patient health and nutrition.

)

CO:MPLICATIONS

Several early and late complications are possible after laparoscopic Roux-en-Y gastric bypass (LRYGB). The overall rates of serious complications is usually less than 5o/o in most series, and generally lower than that of open gastric bypass, particular in the area of wound and pulmonary complications. • Anutomotic leak: Probably the most dreaded complication, it generally occurs less than 3% of the time in most large series by experienced surgeons and is rare after the surgeon's first hundred cases, stressing the significance of the learning curve. Tachycardia, fever, low urine output, and elevated WBC are all signs of a leak.

Chapter 29 Laparoscopic Roux-en-Y Gastric Bypass

• •

Stable patients should undergo imaging by contrast examination or CT scan. If patients are unstable or doubt exists as to the diagnosis, there should be no hesitation in proceeding to the operating room for diagnostic laparoscopy. Leab are not limited to the gastrojejunal anastomosis but can occur in the pouch, the remnant stomach, and the jejunojejunostomy. A leak should be suspected if a patient deteriorates in the setting of a normal upper GI series that may not evaluate soma of these othar sites. Managing early leaks generally means raoperation and direct suture repair, drainage, and distal feeding tube. Delayed leaks may be managed by percutaneous drain placement and feeding tube placement. Oral feeds should be bald for several weeks to allow the leak. to heal, and an upper GI demonstrates patency without leak. VTE: Pulmonary embolus is a significant source of perioperative fatality in this population. As discussed earlier, all measures should be made to prevent DVT, including screening of high-risk individuals, early ambulation, and mechanical and chemical prophylaxis and IVC filter in the highest risk. individuals. If suspected, patients should ba anticoagulated, and a CT pulmonary angiogram should ba obtained. PE and gastrointestinal leak can often have the same symptoms (tachycardia and hypoxia). If one is suspected, both should be ruled out. Bleeding: Can occur in up to 5% of casas and can be intra-abdominal or intraluminal. Staple lines are a frequent cause of bleeding and absorbable buttressing can reduce the incidence of bleeding. If bleeding occurs, it may be necessary to hold nonsteroidal anti-infiammatory drugs and VTE prophylaxis. Endoscopy and ra-operation to oversaw staple lines may ba necessary to control bleeding. Later formation of marginal ulcers or formation of gastrogastric fistula can be a source of gastrointestinal bleeding. Smokers and those with untreated H. pylori are at higher risk of ulcer formation. Stricture: This can also occur in 3% to 5% of casas. Emesis and intolerance to oral intake in the first few months after surgery may suggest stricture formation at the GJ anastomosis. It can generally be managed with outpatient endoscopic dilation, unless the patient is severely dehydrated. Two to three balloon dilations are usually necessary. Patients with untreated H. pylori are at higher risk. of stricture. Thera is also a slightly higher stricture rate using the EEA stapler to form the anastomosis, particularly the 21-mm. EEA. Internal hernia: One of the few complications that occur more frequently after laparoscopic bypass as opposed to open surgery, probably due to less adhesion formation. Closure of the mesenteric defects and use of antecolic Rou:x limb has reduced the incidence of this complication. It can present with chronic or acute pain, vomiting or acutely with signs of ischemic bowel The presentation may ba insidious as the herniated bowel is usually the excluded segment so vomiting may not be present. If suspected and the patient is stable, a CT scan should be ordered. Dilated bowel, dilated gastric remnant, or "swirling" of the mesentery suggests internal hernia. If the CT is negative and symptoms persist, diagnostic laparoscopy should be undertaken. Nutritional complications: The majority of gastric bypass patients can have normal vitamin and micronutrient levels when adequate supplementation is administered. Patients are, however, at risk of iron, vitamin D, calcium, and vitamin B12 deficiency. Other deficiencies can occur but are rarer. Protein calorie malnutrition is generally not seen, unless there are very poor diet choices or a distal gastric bypass has been performed. Patient compliance with long-term follow-up is critical in preventing deficiencies.

3

RESULTS

• Safety: Despite the multiple potential complications that can exist in this relatively high-risk. population, with this rather complex surgery, the overall major complication

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at high volume is generally less than 5% with a mortality less than 0.5%. Patients with a history of VTE, sleep apnea, and higher BMis are at increased risk of complication and death. • Weight loss: In terms of weight loss, many large series of laparoscopic gastric bypass with about 2-year follow-up have demonstrated that the average percent excess weight loss (%EWL) ranges from 60% to 80%. Ten-year data available on gastric bypass from the Swedish obesity study suggests that weight loss is maintained over a long period of time and that gastric bypass is superior to other solely restrictive mechanisms of bariatric surgery. • Comorbidities: Resolution of comorbidities is frequent and dramatic after gastric bypass. Meta-analysis of all published series of laparoscopic gastric bypass (and other bariatric procedure) by Buchwald demonstrated that diabetes resolves or improved in 86% of subjects. Hypertension improves in 78.5% of patients. These patients can frequently be free of medications. Eighty-five percent of patients with obstructive sleep apnea had resolution and were able to come oH CPAP. Lipid profile improvement is seen in 93o/o of patients. In addition, patients can also see improvement in GERD, asthma, infertility, stress urinary incontinence, osteoarthritis, normal pressure hydrocephalus, and mood. • Overall survival: Perhaps most significantly, gastric bypass is associated with an increase in overall survival of obese patients. In a study comparing patients having undergone gastric bypass with matched obese patients obtaining a drivers license, not undergoing surgery with 7 year follow-up, there was a 40% reduction in death noted. While not a randomized study, the findings highly suggest a survival benefit from having undergone surgery. The reduction in mortslity was primarily due to decreased cardiovascular disease.

~ CONCLUSIONS • Obesity is a prevalent and growing health problem with few adequate long-term solutions. • Surgical weight loss is currently the most effective means of weight loss for morbidly obese individuals. That is, those with a BMI > 40 kg/m2 or BMI > 35 kg/m2 and a comorbidity. • Patients should be appropriately educated prior to surgery, have demonstrated inability to lose weight by other means, and be of reasonable risk. to undergo surgery. • Preoperative evaluation and preparation can be extensive and involve multiple specialists including nutritionists, psychiatrists, cardiologists, sleep specialists, gastroenterologists, and endocrinologists. • Laparoscopic Roux-en-Y gastric bypass is a complex and technically demanding procedure and surgeon and institution volume has been shown to reduce complications. • Operating room equipment and postoperative care units should be customized to address the need of bariatric patients. • Several variations of technique have been described in performing gastric bypass: • Position: French vs. American • Order of steps: Proximal first vs. distal first • TYPe of anastomosis: Circular stapled, linear stapled, or hand-sewn • Position ofRoux limb: Ants-colic vs. retro-colic (can be retro or ants-gastric) • Common themes: Small restrictive gastric pouch (approximately 30 ml); approximately 2 em anastomosis, bypassed bowel of varying lengths, closure of mesenteric defects. • Postoperative care aims to have patients ambulate early and prevent VTE, identify early leaks, and feed patients as early as possible and have them return to an ambulatory l:ifestyle. • Various complications are possible, but overall rate of major complications is low, with most complications being treatable. • Weight loss after LRYGB is significant and durable, is associated with profound and frequent resolution of comorbidities, and is associated with increased overall survival.

30

Laparoscopic Sleeve Gastrectomy Technique Raul J. Rosenthal and Wasef Abu-Jaish

~ INDICATIONS AND CONTRAINDICATIONS The morbid obesity epidemic continues to spread throughout industrialized nations. Bariatric surgery continues to be the only proven method to achieve sustained weight loss in the majority of patients. Currently, the four most common bariatric operations in the United States are Raux-an-Y gastric bypass (RYGB), adjustable gastric band (LAGB),laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion with duodenal switch (BPD-DS). These operations are now performed laparoscopically at most bariatric centers. The adoption oflaparoscopic techniques has led to a dramatic increase in the annual number of bariatric procedures performed. Sleeve gastrectomy (SG), a relatively now surgical approach, was initially conceived as a restrictive component of the BPD-DS in the era of open bariatric surgery. With the advent of minimally invasive surgery in the late 1980s, LSG has been proposed as a step procedure in high-risk patients, followed by a second step RYGB or BPD-DS, and, recently, as a stand-alone bariatric approach. When evaluating a potential patient for bariatric surgery, a multidisciplinary team should be used. This team includes a dietitian and a mental health professional who are familiar with bariatric surgery. Their purpose is to obtain past dietary and behavioral eating history, discuss postoperative dietary expectations, and decide whether the individual is an appropriate candidate for this type of operation. Support for the surgery from family members and friends is important If the team believes that the patient is not appropriate for the procedure, then consideration should be given to nonoperative medical management with appropriate counseling. Since the National Institutes of Health (Nnl) Consensus Conference convened in 1991, surgical approaches have been identified as the best course of treatment for patients with clinically severe obesity, who have a body mass index (BMI) of at least 35 kg/m2 and associated comorbid conditions. In most institutions, LRYGB, LAGB, and LSG are offered to all patients. Following tho NIH recommendations, most centers in the United States recommend LRYGB as the procedure of choice or gold standard in patients with a BMI over 40 kg/m1 with or without comorbidity. As the experience with LSG increases, attempts are being made to define indications for LSG as a first or final step. Most centers agree that there is

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Bariatric

Two-stage procedure First step in super-super morbidly obese patient First step to a nonbariatric second procedure

Single-stage procedure Fine I step in ASA IV morbidly obese patient Final step in poor candidate for LRYGB or BPD-DS Fine I step in extremes of age Fine I step in a high-risk stomach Patient preference/refusal to undergo anatomic rearrangement of their intestinal enetomy or placement of an implanted device Low BM I of 35--40 with comorbidity Final step in Crohn'llr'Celiac disease or UC BMI30-35withthe metabolic syndrome Other indications: liver cirrhosis. Dense adhesions of small bowel, expected complex colorectelsurgery in patients with diverticular disease, huge abdominal hernia, necessity to continue specific medications (immunosuppressant, anti-inflammatory)

Followed by RNYGB or BPD low BMI of35--40 Followed by hip replacement, recurrent incisional hernia, pull through procedure for ulcerative colitis, renaiJiiver transplantation Low EF, heart/liver/kidney transplant recipient Smoker Warfarin Adolescents Elderly ege :th.e rWt, af ""'Plli>8 CODOpHrolln,., tw:J. .. lseb,

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In thl.t nl!n!ooo taalm!qaM hal 10 potll· ~· mao!h. A pO!Ipll.al !mra...,.,. (IV) lin• 16 p)aoood orn.d o ....,.,__ _ coplaoloopo;I!D lledm'"'•""""' --...~ m! rmt!nnO......_ W•lion fowl.tl. tlool. do.> ....... - to- tll.o ollli ...... lD.II>OCICdlfoto- p!lll- .. dlloca

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pi-~ md poolop r. l""'!l""i ao.d dmpod Ill wwl•tad!. .wp:•lal!ll.Mt!cm ot tht p.l1:dA &adua (P'IaL 30.7 a:D 100), up to 15%. The reported leak, bleeding, and stricture rates are 2.2, 1.2, and 0.63%, respectively, for all studies reporting detailed complication data (n = 2367). Overall, the complication rate of LSG is equivalent to RYGB, BPD-DS, and LAGB with lass or absent nutritional complications, dumping syndrome, internal hernia, marginal ulcers, foraign body, and port access problems that plague more traditional bariatric operations.

3

RESULTS

The American Society for Metabolic and Bariatric Surgery, in its position statement, analyzed the published reports in the literature and concluded that LSG is a promising procedure for the surgical management of morbid obesity. Mora recently, a systematic review of the current literature reporting either complications or weight loss outcomes after LSG in adult human subjects has been completed. This review includes 36 studies, two randomized controlled trials, one nonrandomized matched cohort analysis, and 33 uncontrolled case sarles. Three ware multicenter trials while the remaining studies were from single institutions. These 36 studies report on a total of 2,570 patients. Intermediate-term follow-up is now reported in the literature with 3-, 4· and 5-year follow-up periods. The postoperative 30-day mortality rate is 0.19% in the published literature. The mean percentage EWL after SG was reported in 24 studies (n = 1662) and was 33o/o to 85%, with an overall mean EWL of 55.4%. The follow-up period for the weight loss data was 3 to 60 months. During the consensus section of the second annual International Consensus Summit for LSG (ICSSG) in 2009, the audience responded as follows: 1. There was enough evidence published to support the usa of LSG as a primary procedure to treat morbid obesity and indicated that it is on par with LAGB and RYGB, with a yes vote at 77%. 2. There is a perception among most bariatric surgeons that in order to achieve acceptable long-term weight loss, the bougie size should not be lSigar than 40Fr; however,

Chapter 3D Laparoscopic Sleeve Gastrectomy Technique

3. 4. 5.

6.

325

it has also been a concern that the lower the bougie size, the higher the incidence of staple line disruption. The responders reported postoperative occurrence of a high gastric leak in 1.5% and a lower gastric leak. in O.So/o. A total of 81.9% of the surgeons reported no conversions from a laparoscopic to an open SG. A total of 65.1 o/o of the surgeons reported that they reinforced the staple-line of the gastric tube: of these, 50.9o/o over-sew the staple line, 42.1% use a buttress on the staple line, and 7.0o/o do both, depending on the circumstances (e.g., a figure-of-eight stitch where each buttress meets). Nearly two thirds (64.1%) leave a drain, with 93.2% of these using a closed-suction (Blake/Jackson-Pratt) and 6.8% using a Penrose drain.

~ CONCLUSIONS LSG is rapidly gaining popularity as a primary, staged, and revisional operation for its proven safety, as well as short-term and midterm efficacy. It is a safe procedure with less short- and long-term morbidity, as well as negligible mortality when compared with other well-established operations. It is technically a simple operation, and it causes satisfactory weight loss along with resolution and/or improvement of comorbidities. There are still important questions that remain unanswered. What will the future of LSG look like? Will LSG replace any of the current procedures such as LA.GB7 Will the long-term results be superior or equivalent to the current procedures endorsed by CMS and American Society for Metabolic and Bariatric Surgery? LSG has clearly been demonstrated to be a safe and efficacious procedure in the treatment of morbid obesity. The most compelling argument that is positioning this procedure as superior to the current options is the lack of long-term complications. The difference in morbidity is significant when comparing the long-term follow-up of LSG to RYGB and LAGB. Currently, several new laparoscopic and endoscopic approaches, such as gastric imbrication, gastroplastias, balloons, and removable devices, are being tested under US FDA supervision. We hope that they may provide a better and less invasive option for weight loss and resolution of comorbidities than the current surgical approaches. However, it is too early to predict the efficacy and safety of these new procedures when implemented in clinical practice.

Recommended References and Readings Abu-Jaish W, Rosenthal RJ. Sleeve gastrectomy: A new sw:glcal approach for morbid obesity. Expert Rev Gartrosnterol Hepatol. ~010;4(1):101-119.

Akkary E, Duffy A, Bell R. Deciphering the sleeve: Technique, indications, efficacy, and safety of sleeve gastrectomy. Obes Surg. ~008;18(10):1323-13~9.

Brethausr SA, Hammel J, Schauer PR. Systematic review of sleeve gastrectomy as a stagillg and primary bariatric operati011. Surg Obes Relat Dis. 2009;5:469--475. Broglio F, Koetaveld PV, Benso A, et al. Ghrelin. secretion l.s i:nhib· ited by either somatostatin or cortl.statin in humans./ Clln Endocrinol Metab. 2002;87:4829-4832. Chousleb E, Szomatein S, Podkameni D, et al. Routine abdominal drains after laparoscopic Roux-en-Y gastric byp888: A retrospective review of 593 patients. Obes Surg. 2004;14:1203-1207. Clinical Issues Committee of the ASMBS. Updated position state· ment on sle8V8 gastrectomy as a bariatric procedw:e. Surg Obes

Rslat Dis. ~010;6:1-5.

Consten EC, Gagner M, Pomp A, et al. Decreased bleeding after lapuoscopic sleeve gastrectomy with or without duodena switch for morbid obesity using a stapled buttressed absorbable poly· mer membrane. Obes Surg. 2004;14(10):1360-1366. Croce E, Olmi S. Chiru:rgia del reflusso gastroesofageo UTET, Torino, ~006, p. 18.

Dallal RM, Mattar SG, Lord JL, at al. Results of laparoscopic gastric bypass in patients with cirrhosis. Obes Surg. ~004;14(1): 47-53. Dapri G, Ca.die're GB, llim.pens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: Prospectl.ve randomized clinical study compariDg three different techniques. Obtls Surg. ~010; 20(4):462--467 Deitel M, Crosby RD, Gagner M. The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25-2.7, 2001. Obes Surg. 2008;18:487-96. Frezza EE. Are we closer in finding the treatment for '!YPe n diabetes mellitus in morbid obesity - are the incretins the key to ., success? Obes Surg. 2004;14(1):99~1005. !!! Frezza HE. Laparoscopic vertical sleeve gastrectomy for morbid 41 oblllity. The future prOC1ldure of choice? Surg Today. 2007;37: m

:s..

~7~.281.

~

Frezza EE, Wachtsl MS, Chiriva-Intemati M. The multiple faces of t! glucegon-like peptide 1-obesity, appetite, and stress: What is tf next? A Review. Dig Dis Sci. 2007;52(3):643-649. F.ris RJ. Preoperative low energy diet diminishes IJver size. Obes

Sw:g.

2004;114:116~1170.

Gagner M, Deitel M, Kalberer TI., et al. The Second International Consensus Summit for sleeve gastrectomy, March 19 2.1, 2009. Sw:g Obes Relat Dis. 2009;5:476-85. Karam.anakos SN, Vagenas K, Kalfarentzos F, et al. Weight loss, appetite suppression, and changes in fasting and postprandial

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ghrelin and peptide-YY levels after Roux-en-Y gastric: bypass and sleeve gastrectomy: A prospec:tive, double blind study. Ann Surg. 2008;247(3):408--41 0. Livingston EH, Huerta S, Arthur D, et al. Male gender is a predic:tor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg. 2002;236:576-582. Meier JJ, Gallwitz B, Schmidt WE, et al. Glucagon-like peptide 1 as a regulator of food intake and body weight: Therapeutic perspectives. Bur J Phurmucol. 2002;440:269-279. National Institutes of Health. Gastrointestinal surgery for severe obesity. NIH Consens Statement. 1991;9(1):1-20. Norrelund H, Hansen TK, Orskov H, et al. Gbrelin immunoreac:tivity in human plasma is suppressed by somatostatin. Clin Endocrinol. 2002;57:539-546. Peterli R, Wi:ilnerhanssen B, Peters T, et al. Improvement in glucose metabolism after bariatric surgery: comparison of laparoscopic Roux-en-Y gastric: bypass and laparosc:opic sleeve gastrec:tomy: A prospec:tive randomized trial. Ann Surg. 2009;250(2):234-241. Ramos AC, Zundel N, Neto MG, et al. Human hybrid NOTES transvaginal sleeve gastrec:tomy: Initial experienc:e. Surg Obes Relut Dis. 2008;4:660-663.

Saber AA, El-Ghazaly TH, Dewoolkar AV, et al. Single-incision laparosc:opic sleeve gastrectomy versus conventional multiport laparoscopic sleeve gastrectomy: Technical considerations and strategic modific:ations. Surg Obes Relut Dis. 2010;6: 658-664.

Sc:hauer PR, Ikramuddin S, Gourash W, et al Outc:omes after laplil'oscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232(4):515-529.

Suzuki K, Prates JC, DiDio LJ. Incidence and surgic:al importanc:e of the posterior gastric artery. Ann Surg. 1978;187(2):134-136. Szomstein S, Arias F, Rosenthal RJ. How we do laparoscopic sleeve gastrec:tomy. Contemp Surg. 2008;64(3):126-130. Tucker 0, Szomstein S, Rosenthal R. Indic:ations for sleeve gastrec:tomy as a primary proc:edure for weight loss in the morbidly obese. J Gastrointest Surg. 2008;12:662-667. Yehoshua RT, Eidelman LA, Stein M, et al. Laparoscopic sleeve gastrec:tomy-volume and pressure assessment. Obes Surg. 2008; 18(9):1083-1088.

31

Laparoscopic Adjustable Gastric Banding Ninh T. Nguyen and Brian R. Smith

~ INDICATIONS AND CONTRAINDICATIONS In 1991, the National Institutes of Health Consansua Development Conference established the current indications for bariatric surgery which have remained in effect since that time. These guidelines recommend bariatric surgery for the following patients: Acceptable operative risks, well-informed and motivated Evaluated by a multidisciplinary team • Failure of established weight control programs • Body mass index (BMI) ~ 40 or ~ 35 with at least one high-risk, obesity-related comorbid condition The prominent obesity-related comorbid conditions include hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiomyopathy, and pseudotumor cerebri. Other common obesity-related comorbidities include gastroesophageal reflux, osteoarthritis, infertility, cholelithiasis, venous stasis, and urinary stress incontinence. With a large body of evidence supporting the efficacy of bariatric surgery in ameliorating the above comorbidities, debate over the role of bariatric surgery specifically to treat these conditions, more than the obesity, has begun. In February 2011, the FnA approved the expanded use of the Lap-Band (Allergan Inc., Irvine, CA, USA) for adults with obesity who have failed more conservative weight reduction alternatives and have a BMI of 30 to 40 with at least one obesity-related comorbid condition. Relative contraindications to bariatric surgery include the following: Alcohol or drug dependance Ongoing smoking Uncontrolled psychiatric disorders such as depression or schizophrenia Untreated, severe underlying psychiatric disorders, specifically depression and schizophrenia. • Inability to comprehend the requirements for postoperative nutritional and behavioral changes • Unacceptable cardiorespiratory risk (American Society of Anesthesiologists class IV) • End-stage hepatic disease

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The patients best suited for gastric band placement are those who have less weight to lose (BMI < 40), are willing to exercise regularly, and those willing to sign:ifi.cantly change their eating habits. Patients who tand to take-in high-calorie foods or those who graze continuously throughout the day are less well suited to gastric banding, as are those unable to perform regular exercise to augment the dietary restriction or those who live far anough from their surgeon to preclude regular band adjustments.

V

PREOPERATIVE PLANNING

Patients preparing for laparoscopic adjustable gastric banding (LAGB) require both preoperative medical evaluation as well as optimization prior to surgery. Medical clearance requires a comprehensive and thorough review of the patient's medical history, specifi.cally looking for factors which can predict an adverse outcome. Independent predictors of surgical moxbidity and mortality include age ~45 years, mala gender, BMI ~50 kg/m2, risk. for pulmonary embolism, and hypertension. Collectively, these clinical findings can be used to calculate Obesity Surgery Mortality Risk Score which has been validated at multiple institutions. Patients with 0 or 1 comorbidity are considered low risk. or class A with a 0.2% risk. of mortality. Those in class B have two or three comorbidities and are at intermediate risk of 1.2%. Class C patients are highest risk. and have four or five comorbidities with a corresponding mortality of 2.4o/o. BMI ~50 kg/m2 and cigarette smoking have also been shown to be associated with higher postoperative surgical moxbiditias. Basic preoperative work-up should include the following: • • • •

Comprehensive history and physical 12-lead EKG Basic blood chemistries, lipid profile, and nutritional panel Chest radiograph

The choice of operation for a particular patient must take into account several issues including patient's preference, surgeon's expertise, BMI, patient's metabolic conditions, and other associated com01:biditias. While gastric bypass is largely considered the most affective procedure at achieving long-term weight loss, it is also the most eHective at reducing the metabolic derangements of obesity, including diabetes, hypertension, and dyslipidemia. However, these benefits come with a slightly higher overall mortality rate. For gastric bypass, average 30-day mortality is 0.16%, compared with that of LAGB placement at 0.06%. For this reason, high-risk. patients, including older patients with more comorbidities, should be counseled with regards to the perioperative risks between gastric bypass and LAGB. The benefit of preoperative weight loss prior to bariatric surgery has bean debated. A recant randomized trial demonstrated that patients who achieve ~5% excess body weight loss (EBWL) prior to surgery had significantly lower weight and BMI and a higher EBWL at 1 year. The success of preoperative weight loss is felt to predict patients with the discipline and willingness to follow a healthy lifestyle that will ultimately translate to sustained long-term weight loss. As a result, many surgeons will place patients on one of many available forms of preoperative weight loss diet for 2 to 4 weeks prior to surgery, with a goal of 5o/o to 10o/o EBWL. Many forms of commercial dietary programs are available for these purposes, often consisting of a high-protein, low-fat, low-carbohydrate, predominately liquid diet. An additional benefit of this preoperative liquid diet is decreased liver size and density which makes manipulation of the left lobe of the liver easier during surgery.

e

SURGICAL PROCEDURE

All patients should receive routine deep venous thrombosis (DVT) chemoprophylaxis :immediately prior to arrival in the operating room, as initial development of DVT is felt to occur intraoperatively in this high-risk population. In addition, sequential compression

Cllaptar 3t

Laparoscopic Adjustable Gastric Banding

device is placed prior to anesthetic induction. Routine preoperative antibiotic prophylaxis is also indicated. A second-generation cephalosporin is adequate but typically requires increased dosing in morbidly obese patients. Thera are two adjustable gastric bands cmrently an the market, including the Lap-BandTM (Allergan Inc., Irvine, CA, USA) and the Reali.ze11 Band (Ethicon Endo-Surgery, Cincinnati, OH, USA). Regardless of which band is implanted, it is advisable to have a second band available for backup at the time of surgery in the event that one is contaminated or damaged at the time of implantation. Each band also has a separately packaged replacement port available as a stand-alone when necessary.

Patient Positioning Patient positioning is often dictated by surgeon's preference. Some surgeons prefer the French or lithotomy position. The main advantage of this position is access in between the patient's legs and inline trajectory of one's laparoscopic instruments. This centers the surgeon over the operative field and improves posture while minimizing shoulder fatigue. However, this position can be d:if6.cult and time consuming and places patients at risk for nerve injury if not positioned properly. Most surgeons have evolved to a completely supine position with arms outstretched on and secured to arm boards. For LAGB placement, supine positioning is recommended. A footboard is also recommended to minimize patient slippage inferiorly during reverse Trendelenburg positioning, as is an upper thigh strap to minimize lateral slippage during rotation of the patient All bolsters placed behind the patient's neck and/or shoulders by anesthesia to facilitate endotracheal intubation should be removed prior to initiation of surgery. A Foley catheter is optional. Routine cardiac noninvasive monitoring is essential. Invasive monitoring, including arterial and central venous catheters, is not routinely indicated and is only utilized in selected cases where such additional monitoring is necessary.

Technique Standard technique includes a five-trocar configmation (Fig. 31.1). Initial cannulation of the abdominal cavity with Veress needle is typically through the camera port, located Figure 31.1 Port placement for laparoacopic adjustable gastric banding.

Smm

Smm

e eamera

12mm

Q • 1'l mm

0 5mm

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in the left supraumbilical region. Upon insufllation to 15 mm Hg, the Veress is removed and a 15-mm b:ocar is inserted followed by camera coofi.:rmation of no visceral injury from anb:y. Subsequent 5-mm trocars are placed in the far left and right subcostal margins just above the viscera, along with right epigasb:ic (12 mm) and right upper quadrant (5 mm) trocars. The far right subcostal trocar secures a serpentine liver retractor for anterior retraction of the left lobe of the liver. Alternatively, the subxiphoid 5-mm trocar site can be used to accommodate a Nathanson liver reb:actor. The operating surgeon utilizes the epigasb:ic and right upper quadrant trocars while the assistant utilizes the left subcostal trocar and the laparoscope. The band is inserted through the 15-mm b:ocar, either utilizing a blunt grasper or specific band inb:oducars are commercially available for intra-abdominal placemant. Once the band is in the abdominal cavity, it can be placed in the left upper quadrant in preparation for placement. A small peritoneal window between the stomach and the diaphragm is dissected at the angle of His for eventual band passage. The gastrohepatic ligamant is then incised with thermal anergy and the right crus of the diaphragm exposed. The pars flaccid dissection begins immediately anterior to the base of the right crus and is initiated with thermal energy. Blunt dissection is then continued along the anterior decussation of both diaphragmatic crura which is avascular. A tunnel is created between the crura and the retroesopha.geal fat pad. One of several commercially available 10-mm. articulating band graspers is then passed through this tunnel and articulated and brought through the previously created window at the angle of His. The band is then secured to the band grasper, which is un-articulated and withdrawn through the tunnel, drawing the band around the gasb:ic cardia. The band is then disconnected from the band grasper and the tubing may need to be drawn through the buckle prior to closure, depending on the brand (Fig. 31.2). The band is then closed over the cardia using the buckle attached to the band (Fig. 31.3). Gastric plication of the body to the cardia to cover the band anteriorly is then performed with several interrupted sutures (Fig. 31.4). This plication, along with the pars fiaccida approach posteriorly, serves to discourage band slippage. Another plication suture is also placed on the medial aspect of the gastric cardia, immediately below the band to minimize the risk for slippage. The band tubing is then grasped and brought out to the 15-mm port site, taking great care to avoid abrupt angles upon exit through the fascia. The 15-mm port site is then closed utilizing a suture passing device, and a pocket in the subcutaneous tissue is created to accommodate the port. The suture tails of the fascia closure can be saved to secure the port to the fascia. Band tubing is then shortened to appropriate length and connected to the saline-fiushed port, again taking great care to avoid abrupt angles or redundancy in the tubing. The port is then secured to the fascia with the previous suture tails or with a commercially available securing device, which comes with the

Figure 31.2 Placement af adjustable gestJic bend using the pars flaccid approach.

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Laparoscopic Adjustable Gastric Banding

Figwa !t.3 Closure of the adjust· able gastric band.

Realize band. Soft tissue is closed over the port, followed by skin closure. All instruments and troc81'8 are than removed and closure of the 12-mm port site is optional at the surgeon's discretion. Port sites 81'8 then closed at the skin level.

POSTOPERATIVE MANAGE:MENT Patients without significant cardiac issues can be transferred to a ward bed. Cases where continuous monitoring may be indicated postoperatively include a significant cardiac history, any intraoperative cardiorespiratory issues, or severe obstructive sleep apnea. Higher-risk patients 81'8 admitted for overnight observation while lower-risk patients can be discharged on an ambulatory basis. Patients begin a diet of sugar-free clear liquids on the evening of the surgery. Ambulation also begins on the evening of surgery. Medication adjustments are vital, particularly in diabetic patients, and must take place immediately postoperatively. While each patient must be individualized, often utilizing half of the patient's preoperative dose of diabetic medications serves as an appropriate starting point after surgery. Diet is advanced to sugar-free full liquids upon discharge for the first 2 weeks postoperatively. Patients are then transitioned to pureed diet, soft foods, and finally a modified regular diet over the ensuing 6 weeks. Postoperatively, patients are counseled

Figura 31.4 Placement of anterior gastrogastric sutures to minimize postoperative slippage.

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regarding appropriate behavioral and dietary changes. Overall dietary guidelines include routine low-calorie, low-fat, and low-sugar food intake. Patients 81'8 encouraged to take in three small meals par day with healthy snacks in between and to eat slowly, stopping at the first sign of feeling full. Specific eHorts at protein intake at each meal are encouraged. Patients are counseled to take eight 8-ounce cups of water daily and should avoid taking beverages concurrently with meals. Carbonated beverages result in gas expansion of the small gastric pouch that lead to significant discomfort and hence should ba avoided. Vitamin and mineral supplementation is essential to avoid deficiencies in vitamins A, D, B1, B6, B12, calcium, and folate. As banding is not a malabsorptive procedure, these deficiencies are less pronounced yet not entirely absent, predominately due to dietary restrictions encouraged after surgery. As such, a daily multivitamin is usually adequate for most LAGB patients. Routine daily physical activity is encouraged, and participation in monthly bariatric support groups has been shown to result in significantly improved and sustained weight loss. Postoperative follow-up typically occurs at 1 weak, 1, 3, 6, 9, and 12 months, and then avery 4 months thereafter. Evaluation for late complications, behavioral counseling, and monitoring for nutritional deficiencies are the main goals of these routine visits. Band adjustments era the hallmark of progressive weight loss. The first band adjustment typically takes place beyond 4 weeks postoperatively, as the majority of wound healing has taken place by that time. In addition, the band usually provides adequate restriction upon placement, and only after several weeks of weight loss does the band become sufficiently loose to require adjustment to augment restriction. Adjustments 81'8 oflica-basad procedures and can ba done with or without fluoroscopic guidance. A long Huber needle is used to access the subcutaneous port with the port pinned between the fingers of the opposite hand. Local anesthetic is not indicated. It is recommended that all fluid in the band ba completely aspirated with each adjustment prior to infusion in order to ensure accuracy of the adjustment. Addition of fluid typically ranges between 0.5 and 1 mL of saline per adjustment, depending on the brand of band. Older bands had smaller reservoirs, requiring adjustments ranging from 0.1 to 0.5 mL. Alternatively, adjustments can ba performed under direct fluoroscopic imaging to visualize the amount of desired restriction basad on contrast retention and passage through the adjusted band. The authors find this unnecessary and cumbersome, but the practice is common in certain practices.

. ) C01\1PLICATIONS Complications after LAGB placement range from those that are perioperative, to late complications, to eventual band axplantation. Relatively low parioparativa complications rates range from 2.3% to 2.8% and lmgaly account for the good safety protila of LABG. These complications tend to include those issues related more to obesity and major surgery than to the band itself. They include pulmonary complications, wound infections, venous thromboembolism (VTE), postoperative hemorrhage, and band fai1Ul'9neak, each with a rate less than 1%. The most common late complication after LAGB remains prolapse/slippage (Fig. 31.5), occurring in approximately 3o/o of patients. This rate has decreased in recent years with adoption of the pars fl.accida technique and gastric plication over the band anteriorly, decreasing the posterior and anterior prolapsed rates, raspaclivaly. Band erosion occurs in 1% to 2% of patients and rarely causes significant morbidity. This process occurs slowly over time and often presents with a port infection as the herald sign. As the band erodes through the wall of the stomach, the serosa typically heals over the band, preventing leakage of gastric contents but permitting luminal infection to ascend along the tubing and eventually infect the pmt. Band removal is indicated once erosion is discovered. Port and tubing problems, including port inversion or kinking of the tube, can be as high as 4o/o at 5 years. Correction of these problems is often a local procedure. The most common indications for band explantation include band slippage, pouch dilation, gastric inlet obstruction (Fig. 31.6), band erosion, and inadequate weight loss. In a prospective multicenter trial, band removal rates due to slippage and pouch dilation

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Figwa !t.5 Upper gastrointestinal contrast study demonstrating band slippage. Note the horizontal plana af the band. A normal band should reside at a 30° angle from the horizontal plana on an AP film.

(5.3%), obstruction (4.6%), inadequate weight loss (3.5%), and erosion (1%) as well as other conditions (3.5%) totaled 18o/o of the patients within 5 years. Rates of band removal in other studies have been similar, ranging from 1.4% to 5.8%. Most complica-

tions from LAGB are not life-threatening, making this the operation of choice when patient comorbidities serve as a deterrent to the mora risky gastric sleeve or bypass. Mortality rates have been consistently low at 0.01 %. Figure 31.& Band obsttuction despim complete evacuation af all fluid from the band.

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Weight Loss Outcomes Bariatric surgery has bean shown repeatedly to be the most definitive and successful treatment for severe obesity compared to conventional medical therapy. Lifetime risk of death from extreme obesity is decreased by 35o/o in individuals who undergo bariatric surgery compared to control individuals. However, the safety of bariatric surgery has coma under increasing scrutiny since the early part of this century. Bariatric Centers of Excellence were developed by the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery, and many insurance carriers have followed by only covering bariatric surgery performed at these canters. The Leapfrog Group has added bariatric surgery to the growing list of procedures with improved mortality when performed at high-volume centers (>125 annual cases). LAGB has consistently yielded the lowest EBWL percentages of all bariatric operative procedures. A recent randomized controlled trial comparing gastric bypass to LAGB revealed a 41.8% EBWL at 2 years and 45.4% at 4 years. The same trial also revealed statistically better EBWL in those patients with B:Mlless than 50 kg/m2 compared to those whose preoperative BMI was above 50 kg/m2, suggesting LAGB is not ideal for the larger super morbidly obese. These results were consistent with another prospective randomized trial between the two d:iffarent band devices available. In this trial, those patients with preoperative EBW < 50 kg had a better postoperative weight loss at 2 years (55% EBWL) compared to larger patients with EBW >50 kg (44%: P= .004). These two studies provide evidence to help counsel super obese and larger patients away from LAGB and toward a more invasive procedure such as sleeve gastrectomy and gastric bypass. Other studies have demonstrated EBWL closer to 50% at 1 year. Improvement in obesity-related medical comorbidities has been shown to be similar to other weight loss procedures. However, results tend to be more time (and hence weight loss) dependant than with gastric bypass. Predictors of poor weight loss and/or failure, defined by either conversion to another procedure or < 20% EBWL at 4 years postoperatively, included male sex for those undergoing LABG. Overall failure rate in the randomized trial was 16.7% at 4 years for LAGB. The FDA) recently approved the Lap Band for use in patients with BMI ~ 30 and at least one obesity-related medical comorbidity. This approval represents the first formal US government movement toward expansion of surgery to patients with a lower BMI for the treatment of both obesity and the concomitant comorbidities.

~ CONCLUSIONS Of the standard bariatric operations currently available and widely covered by insurance, gastric banding remains the safest and second most commonly performed operation. However, such safety is traded for the lower long-term weight loss outcomes of the standard operations currently baing performed. Morbidity of gastric banding has bean largely overcome with improved techniques of surgery and adjusting the band. It appears that males are more likely to fail with LAGB as are the super obese. However, with the FDA lowering the B:Ml threshold recently for band placement to 30, bands will likely continue to play an integral role in the bariatric surgery lineup as the entry-level operation for the foreseeable future.

Recommended References and Readings Buchwald H, Avfdor Y, Braunwald E, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA. 2004;292:17241737. Buchwald H, Estok R, Fahrbach K, et al. fiends in mortality in bariatric surgery: A systematic review and meta-analysis. Surgery.

2007;142:821~32.

Buchwald H, Estok R, Fahrbach K, at al. Weight and type 2 diabetes after bariatric surgsry: Systematic review and meta-analysis. Am I Med. 2009;122:248-256.

Gravante G, Araco A, Araco F, at sl. IAparoscopic sdjustsbla gsstric b8lldings: A prospective 1'8.Ildomizad study of 400 operations parformed with 2 different dsvicas. Alch Surg. 2007;142:958-981. Hinojosa MW, Varels JE, Parikh D, at al. Nstional trends in usa and outcome of laparoscopic sdjustsbla gsstric banding. Surg Obes Relat Dis. 2009;5:150-155. llvingston EH, Langert J. The impact of age and Medicare status on barlatrlc surgical outcomes. Arch Surg. 2006;141:1115-1120. Martin LF, Smits GJ, Greenstein RJ. fieating morbid obesity with laparoscopic adjustable gastric banding. Am/Su~g. 2007;194:333343.

32 Robot-assisted Laparoscopic Biliopancreatic Diversion with Duodenal Switch

Ranjan Sudan

tb, INDICATIONS/CONTRAINDICATIONS The biliopancraatic diversion with duodenal switch (BPD/DS) has mora weight loss, but it is technically complex and has more malabsorptive side effects than the other bariatric operations. The fl.rst BPD/DS was performed by Hess in 1988 and is a modification of the original biliopancraatic diversion (BPD) described by Scopinaro. In the BPD/DS, a sleeve gastrectomy is performed and the pylorus is preserved. This modification is associated with reduced dumping, marginal ulcerations, diarrhea, and protein malnutrition compared to the Scopinaro operation. The first laparoscopic BPD/DS in humans was described in 2000, and the same year the first robot-assisted procedure was performed. While any patient with morbid obesity with a body mass index (BMI) of more than 40 kg/m2 or more than 35 kg/m 2 with comorbid medical conditions may be a candidate for a BPD/DS, those with severe diabetes, severe hypercholesterolemia, or higher BMI may benefit mora with the BPD/DS than other bariatric operations. It is also a good option for revisions from a previous failed restrictive operation such as a laparoscopic adjustable gastric band, a sleeve gastrectomy, or a vertical banded gastroplasty. Compliance with diet and micronutrient intake as well as lifestyle modification, and regular follow-up to monitor for vitamin deficiencies, will give the bast results. Contraindications for a BPD/DS are those for any bariatric operation such as unacceptable anesthetic risk or unresolved psychological issues, but more specifically those medical conditions in which a malabsorptive procedure is contraindicated such as Crohn's disease or end-stage liver disease.

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PREOPERATIVE PLANNING

Detailed clinical history and physical examination helps detect co-existing medical problems and guides further investigations such as cardiac achography, sleep apnea studies, and pulmonary evaluations. Suitable medical consultations are obtained on the

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basis of individual assessment of the patient to optimize their health prior to surgery. Routine laboratory investigations include a comprehensive metabolic panel, hemogram, thyroid tests, HbA1c, lipid pro6.le, and vitamin levels. Electrocardiograms and chest radiographs are also obtained. Nutritional deficiencies are easier to correct in patients prior to their undergoing a malabsorptive operation. Patients are also asked to update their screening mammograms, Papanicolaou's smears, and colonoscopy, as indicated for cancer screening. In addition, all patients undergo psychological and nutritional evaluations to assess their understanding of the lifestyle changes that are necessary for the success of a bariatric operation, ability to comply with medical instructions, rule out untreated psychiatric disorders or addictions and maladaptive eating behaviors.

6) SURGICAL TECHNIQUE Pertinent Anatomy In order to perform the sleeve gastrectomy and the duodenal switch, it is necessary to recognize the location of the pylorus and the gastroduodenal artery. The pylorus is thicker, has a slightly more pale appearance and is identified by the overlying vain of Mayo. The gastroduodenal artery lies posterior to the first part of the duodenum and provides a useful landmark where the first part of the duodenum is transected. Identifying the incisure is important to avoid narrowing the stomach tuba when performing the sleeve gastrectomy. The lesser sac is entered across from the incisura near the greater curvature of the stomach. By keeping the dissection close to the stomach, the gastroepiploic vessels are preserved, avoiding excessive bleeding. The gastrosplenic ligament is also thin in this location, facilitating division with an ultrasonic dissector. To prevent a delayed perforation of the stomach, transmission of thermal energy near the gastroesophageal junction is avoided when dividing the proximal short gastric vessels. The ileocecal valva is an important landmark because the bowel is measured and marked from it in order to create the distal anastomosis.

Positioning The patient is placed supine with the right arm by the patient's side. The left arm is placed on an arm board and can be extended to provide the operating surgeon with standing room by the patient's side, and the anesthesiologist sufficient access for intravenous lines and other monitoring devices, as needed. The extremities are suitably padded and protected to prevent pressure sores or a neuropathy. A Foley catheter is placed, but it is not necessary to place routine arterial catheters. The endotracheal tube is positioned with a low pro6.le, ensuring an adequate distance between the operating tabla and the anesthetic cart, to allow the robot to be brought in over the patient's right shoulder. A thermal blanket is used on the lower body so that it does not interfere with the operation. Thera are three phases of the operation, and the operating team changes its position in relationship to the patient in each phase. At the beginning of the operation, the team stands near the head of the patient and face toward the patient's feet. The surgeon is to the patient's left, the camera operator is in the middle, and the assistant is to the right. During this phase, the distal ilaoilaal anastomosis is performed, and an appendectomy is optional. In the second phase of the operation, the team moves to the patient's side and face toward the patient's head. The camera operator and surgeon are on the patient's left while the assistant is on the patient's right. During this phase of the operation, the sleeve gastrectomy, division of the duodenum, and placement of the alimentary limb in a ratrocolic position is completed. Many surgeons will also elect to perform a cholecystectomy in this phase.

Chapter 32 Robot-assistsd Laparoscopic Biliopancreatic Diversion with Duodenal Switch

In the last phase, the operating surgeon moves to the robotic console from where the robotic 8I'IDB and the camera are controlled, and the assistant moves to the patiant's left side.

Technique Pneumoperitoneum is obtained using a left upper quadrant Veress needle and the abdoman is entered in the midline, about 15 em inferior to the xiphoid, using a 12 mm optical trocar, and a zero-degree scope. Additional clear non-cutting trocars ara positioned in the anterior and :midclavicular lines as shown in Figure 32.1. All port sites are preinjected with a local anesthetic. The operation is divided into three major phases as outlined above:

Phase1 With the patient in Trendelenburg position and tilted to the left, the team stands near the patient's head and idantifies the ileocecal valva to perform the ilaoileal anastomosis, and an optional appandactomy. If the surgeon decides to perform an appendectomy, a 2.5 :mm leg-length stapler load is used to divide the base of the appendix, and its mesentery is divided close to the appendix to facilitate its removal from one of the ports. In order to perform the ileoilaal anastomosis, marking sutures are placed at 100 em and 250 em from the ileocecal valve (Fig. 32.2). The bowel is divided 250 em proximal to the ileocecal valve with a 2.5 :mm leg-length stapler and the mesentery is divided using the ultrasonic dissector. A two-inch piece of blue drain (non-latex sterile tourniquet) is attached to the stapled edge of the alimentary limb to facilitate its subsequent passage through the retrocolic tunnel. The distal ileoileal anastomosis is performed by making small enterotomies at the 100 em mark. on the common channel and near the stapled edge of the biliary limb (Fig. 32.3). A 60 mm long staple load with 2.5 mm lag-length is used to craata the sideto-side anastomosis. The enterotomy is closed with intra-corporeal suturing to prevent narrowing of bowel.

Figwe 32.1 Trocar placement Anterior axillary line

Midclavicular line

camera

OPom

part

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Figwa 32.2 Marking sutures are placed at 100 em and 250 em from the ileocecal valva.

The mesenteric defect between the biliary limb and the common channel is closed with a running permanent 2-0 suture.

Phase2 With the patient placed in steep ravarse-Trendelenburg position, the Nathanson liver retractor is inserted just to the left of the xiphoid and is used to elevate the liver. The falciform ligament may need to be divided or sutured to the anterior abdominal wall if it obscures visualization. This phase begins with a cholecystectomy. The cystic duct and artery are dissected, double clipped proximally, and single clipped distally before dividing. The gallbladder is taken off the liver bed by using cautery or ultrasonic dissectors and placed in an Figwa 32.3 Tha distal ileoileal anastomosis is performed by making small arrtarotomies at the 100 em mark on tha common channel and near the stapled edge of tha biliary limb.

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figur• 32A The greater cuJVature of the stomach is mobilized to about 4 em distal to the pylorus, and the duodenum is divided using 3.5 mm leg-length stapler load. The sleeve gastrectomy starts 5 em proximal to the pylorus.

endobag for retrieval later. The gallbladder may also ba left in place for later removal with the help of the robot in phase three. Next, the lesser sac is entered across from the incisure, near the greater curvature of the stomach. The greater curvature of the stomach is then mobilized to about 4 em distal to the pylorus, and the duodenum is divided using a 3.5 mm lag-length stapler load (Fig. 32.4). In order to position the stapler in this location, a window is created on the superior aspect of the duodenum, using a right angle clamp. The areolar tissue overlying the second part of the duodenum, where it turns to become the third part, is cleared to facilitate the retrocolic passage of the alimentary limb. The rest of the greater curvature of the stomach is then mobilized to the angle of His using the ultrasonic dissector. After completing the division of all of the short gastric vessels, the sleeve gastrectomy is performed by dividing the stomach about 5 em proximal to the pylorus. This part of the stomach is thick and at least 4.5 mm lag-length staples are used for the Initial two firings. Using a 45 mm long stapler cartridges makes it is easier to create a smooth curve so that there is no encroachment of the stomach luman toward the incisura. After the first two cartridges are fired, the rest of the stomach is divided using 3.5 mm lag-length, 60 mm long stapler cartridges with the intent to create a 150 to 250 mL stomach tube. An Allergan11 sizing tube is used as a guide to size the stomach pouch and can be used to insufflate the stomach with methylene blue to check for laab. After the stomach is resected, a long suture is secured to one of the ends on the specimen to facilitate its removal at the end of the operation. The staple lines may be reinforced with buttress material or suture, particularly if the stomach is thick or the integrity of the staple line is in question. Bleeding along the staple line can easily ba controlled with hamoclips. The patient is next taken out of the steep reverse Trendelenburg position, and the omentum is elevated to create a window in the transverse mesocolon. A blunt grasper or the ultrasonic dissector can be used to open the transversa mesocolon. Using the blue tubing as a handle, the alimentary limb is delivered through a reii'ocolic tunnel to the first portion of the duodenum where it is anchored to the proximal duodenum with a stay suture. The robot is then engaged in position to perform the duodenoileostomy.

Phase3 The robot is brought over the patient's right shoulder and the robotic camera is inserted through the umbilical port. The robotic insll'umant ports are inserted using a cannulain-cannula technique in the right anterior axillary, right midclavicular, and left midclavicular ports. A grasper in the right anterior axillary line port is used to retract the stay

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Figura !2.5 Two robotic needle drivers are used to perfonn a two-layer robot-sewn anastomosis.

suture and help align the bowel for suturing. Two robotic needle drivers are then brought in from the remaining robotic ports and used to perform a two-layer robot-sewn anastomosis (Fig. 32.5). First, the posterior seromuscular row is completed using running 2·0 braided nylon suture. Next, the bowel is opened using the robotic ultrasonic dissectors and a running full-thickness posterior row of 2-0 absorbable suture is placed and then continued anteriorly to close the bowel. The placement of seromuscular anterior layer of sutures completes the formation of the two-layer anastomosis. Methylene blue is insuffiated to check for leaks. The omentum is again lifted to identify the mesentery of the alimentary limb and close the defect between the alimentary limb mesentery and the retroperitoneum. A 2·0 permanent braided nylon is used to close this defect robotically completing the rearrangement of the bowel (Fig. 32.6). The robot is then disengaged and the gallbladder and stomach specimens are removed. Grasping the long suture attached to the stomach specimen helps retrieve it though the midline port-site. Usually, the port-site does not need to be dilated to retrieve the stomach specimen. Following the irrigation and suctioning of the right upper quadrant of the abdominal cavity, the absence of leaks is con&rmed and ports are removed. The skin incisions are closed with subcuticular absorbable suture. A drain is not placed routinely.

POSTOPERATIVE MANAGEMENT Patients are encouraged to ambulate early and the liberal use of incentive spirometry. Prophylactic doses of low-molecular weight heparin are used for the duration of the patient's hospital admission. A patient-controlled analgesic pump is used for pain control, and patients are given acetaminophen orally, as a scheduled dose, to reduce the need for narcotic medication. Due to the probability of gastroparasis, a liquid diet is initiated only after the patient passes natus. Over the ensuing weeks, the diet is gradually advanced to solid foods, and supplemented with vitamins and minerals. It is important to include the water-soluble analogues of fat-soluble vitamins for BPD/DS patients.

J

CO:MPLICATIONS

A leak may present with tachycardia, fever, and significant abdominal pain. It should be investigated radiographically or evan surgically, if needed. A pulmonary embolism may develop despite prophylactic anticoagulation and is often suspected in a dyspneic

Chapter 32 Robot-assistsd Laparoscopic Biliopancreatic Diversion with Duodenal Switch

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Figwa 32.6 The robot is used to create the duode· noileal anastomosis and close the defect between the alimentary limb mesentery and the ratroperitoneum. The orientation of the rearranged bowel is shown.

patient. Results of blood gas results end computerized tomographic angiogram confirm the diagnosis. Superficial or deep wound infections are infrequent and may need treatment with antibiotics or drainage. Bowel obstructions or vitamin deficiencies (particularly vitamin D) can develop long term.

~ RESULTS Patients lose more than 70% of their excess body weight long term, and the cure rate for diabetes type 2 is as high as 98o/o to 99o/o. Rates of resolution of other medical condition including hypertension, hypercholesterolemia, and sleep apnea are also high. Results of initial robotic BPD/DS series are available.

~ CONCLUSIONS The BPD/DS is a lass commonly performed but vary affective bariatri.c operation. By using the robot, a complex bariatri.c procedure can be performed safely with fewer ports and easier intracorporeal suturing.

Recommended References and Readings Aills L, Blankenship J, Buffington C, et al. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Helot Dis. 2008;4(5 Suppi):S73-S108. Hess DS, Hess DW, Oakley RS. The biHopancreatic diversion with the duodenal switch: Results beyond 10 years. Obes Surg. 2005; 15(3):408-416. Msrcaau P, Biron S, Hould FS, et sl. Duodsnsl switch: Long-term re&ults. Obss Surg. 2007;17(11):142.1-1430.

Ran CJ, Patterson E, Cagnsr M. Early results of laparoscopic biliopancraatic diversion with duodsnsl switch: A case series of 40 coll8scutivs patients. Obss Surg. 2.000;10(6):514-52.3; discussion 52.4. .g Scopinaro N, Cianetta E, Civallsri D, at sl. Bilio-p8llcrsatic bypass .~ for obesity: D. In.itfal experience in man. Br J Surg. 1979;66(9): ou lXI M~~ >_·· Sudan R, Purl V, Sudan D. Robotl.cally assisted biliary pancreatic diversion with a duodenal switch: A new technique. Surg ~ Endosc. 2007;21 (5):72~733.

33

Single-Incision Laparoscopic Bariatric Surgery Sunil Sharma and Alan A. Saber

~ INDICATIONS AND CONTRAINDICATIONS There is a growing trend toward surgical techniques that facilitate less abdominal trauma. This has the potential to complement and expand the benefits of traditional laparoscopic surgery that stems from less abdominal trauma, less postoperative pain, analgesia requirement, hospital stay, less scarring, and better cosmetic outcome. With the emergence of natural orifice translumenal endoscopic surgery, more attention has been directed toward the single-incision transumbilicallaparoscopic approach for minimally invasive surgery. Single-incision surgery brings together the cosmetic advantages of natural orifice translumenal endoscopic surgery and the familiarity of conventi.onallaparoscopic surgery. AB instruments become more O.exible, along with availability of multichannel ports, the single-incision approach could represent the future direction of minimally invasive surgery. The predetermined exclusion criteria for the single-incision bariatric approach includes patients who have undergone previous bariatric surgery, upper abdominal open surgery, or upper abdominal ventral hernia mesh repair and super-morbid obesity.

~ PREOPERATIVE PREPARATIONS As with any form of bariatric surgery the essential prerequisites before surgery are to attend a weight loss surgery information seminar, psychological evaluation and clearance, nutrition evaluation, medical evaluation, workup and clearance. We have found that by instructing all of our bariatric patients to consume a high-protein low-calorie liquid diet for 2 to 4 weeks before their scheduled surgery enables the liver to shrink, making its retraction more feasible. All patients should be involved in the decisionmaking process. They should receive a detailed description of the risks and benefits of all bariatric procedures.

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Deep vein thrombosis prophylaxis is achieved using anticoagulation, compression stockings, and lower extremity sequential compression devices. Preoperative intravenous antibiotic prophylaxis is administrated before making the slcin incision.

Operative Strategy and Technical Considerations The feasibility of the single-incision approach is enhanced when tailored according to each patient's body habitus. In patients with a relatively low BMI, peripheral obesity, a small liver, and a short umbilicus-xiphoid distance, we proceed with transumbilical single incision. In addition to the cosmetic advantages of a hidden intraumbilicalsingla incision, the umbilicus provides a safe zone for abdominal access while minimizing the torque effect of an obese patient's thick abdominal wall. In contrast, for patients with a much greater BMI, central obesity, a large liver, and a long umbilicus~ubxiphoid distance, we advance the single incision toward the epigastric area.

TAP Block The single-incision approach involves a single incision as opposed to multiple tiny incisions, scattered all over the abdomen in a standard laparoscopic operation. We take advantage of this situation by selectively blocking the nerves supplying the periumbilical area. This is achieved by ultrasound-guided transversus abdominis plane (TAP) block. When the block is performed correctly, the single incision stays relatively painfree, thereby reducing the requirement for narcotic analgesics and enabling for a faster recovery and earlier discharge from the hospital.

Anatomy The anterior abdominal wall (skin, muscles, parietal peritoneum) is innervated by the anterior rami of the lower six thoracic nerves (T7 to T12) and the first lumbar nerve (11). Terminal branches of these somatic nerves course through the lateral abdominal wall within a plana between the internal oblique and transversus abdominis muscles. This intermuscular plana is called the TAP. Injection of local anesthetic within the TAP can therefore potentially provide unilateral analgesia to the skin, muscles, and parietal peritoneum of the anterior abdominal wall (Fig. 33.1). Figw•l'11 Anatomy oftha abdominal wall.

~--External oblique ~++:-:--Transversus

abdominis -iF':-:--

Internal oblique

Cllaptar 33 Single-Incision Laparoscopic Bariatric Surgery Figwa 312 Ultrasound showing layers of the abdt:~minal wall.

Block Technique Scanning Technique 'illtrasound-guided TAP block: • Using ultrasound guidance, it is easy to identify the fascial plana between the internal oblique and the transversus abdominis muscles. • The patient is placed in a supine position exposing the costal margin and the iliac crest. • A linear, high-frequency transducer is recommended for this block. • After preparing the skin and transducer in sterile fashion, the transducer is placed in an axial (transverse) plane, above the iliac crest, and at the anterior axillary line. • The three muscular layers of the abdominal wall are identified as follows: the external oblique (most superficial), the internal oblique (most prominent), and the transversus abdominis muscles below it (Fig. 33.2). The terminal branches of the anterior rami are expected to lie within the TAP between internal oblique and the transverse abdominis muscles above the iliac crest. The peritoneal cavity lies deep to the transversus abdominis muscle layer and may be identified by the peristaltic movements of bowel loops.

Needle Insertion • A 120- to 150-mm 22G short beveled block. needle is inserted in-plana with the transducer, in an anterior-posterior direction Alternatively, a spinal needle may be used and connected to the syringe via short extension tubing. • The needle is inserted some distance away from the transducer. This permits a shallower needle trajectory and improves needle shaft and tip visualization. • In obese patients with protuberant abdomen, manual retraction of the abdominal wall by an assistant is a useful maneuver to facilitate needle insertion. • Accurate placement of the needle tip may be facilitated by "hydrodissection" of the appropriate plane. This is achieved by injection of a small amount of fluid (1 to 2 mL of saline or local anesthetic). • It is important to deposit local anesthetic deep to the fascial layer that separates the internal oblique and the transversus abdominis muscles. Local Anesthetic Injection • A total of 20 to 30 mL oflocal anesthetic (e.g., ropivacaine 0.5% to 0.75%) is injected into this plane on each side (Fig. 33.3).

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Figwa 313 Ultrasound-guided

TAP Block.

• Correct needle tip position and deposition of local anesthetic is indicated by the appearance of a hypoechoic fluid pocket immediately deep to the hyperechoic fascial plane below the internal oblique and above the transversus abdominis. If the needle tip is intramuscular, a pattern of fluid spread consistent with intramuscular fluid injection will be seen. • During local anesthetic injection, it is advisable to scan the abdomen cephalad and caudad to determine the extent of longitudinal spread. Medial and lateral scanning will determine the extent of horizontal spread.

Technical and Physical Challenges in Single-Incision Approach Lost Triangulation and Trocar Placement Stntagy Achieving adequate triangulation is a basic principle of traditionallaparoscopic surgery. Trocars could be directed from multiple points of entry, guiding instruments toward the target organ, where adequate manipulation could be achieved. (Fig. 33.4A) Operating through a single incision with only rigid instruments would be challenging, because the surgeon would either implement a coaxial positioning of instruments (Fig. 33.4B) or a "crossing" arrangement (Fig. 33.4C). In the coaxial technique, both instruments emerge through the umbilicus and are parallel to one another; thus, controlling both instruments outside the abdomen would pose a challenge, because the surgeon's hands would be at such close proximity. On the other hand, when rigid instruments are crossing, there would be a considerably more comfortable range of movement on the outside: however, on the inside, the left hand controls the right instrument, and vice versa, posing a challenge for first-time single-incision adopters. As the overall flexibility of the instruments increases, triangulation issues can be overcome without sacrificing external maneuverability. Flexible instruments have articulating shafts, steering the tip of the instrument toward the target organ and restoring lost triangulation. Thus, combining flexible and rigid instruments has resulted in a more comfortable configuration (Fig. 33.4D,E), increasing maneuverability and the feasibility of advanced surgical procedures using a single incision.

Conflict of Instruments Multiple instruments inserted at close proximity through a common port of entry produce an undesirable limitation of movement both inside and outside. Many advanced

Cllaptar 33 Single-Incision Laparoscopic Bariatric Surgery Fighting

Tip

A

B

c

D

E

Triangulation ccnventicnal

Coaxial

Crossing straight instruments

Crossing straight and flexible instruments

Crossing flexible instruments

Restore triangulation

laparoscapy

figur• 33.4 Conflict of instl'\lmentation and triangulation in single-incision laparoscopic surgery and trocar reduction. Reproduced with permission from Saber AA. Single incision laparoscopic surgery ISILS) and trocar reduction strategies fur bariatric procedures. Adapted from: Dietel M, Gagner M, Dixon JB, Himpans J, Madan AK, eds. Handbook of Obesity Surgery. Toronto: FD Communications Inc. 2010:19(H97.

procedures involve switching instruments and trocars more often, which could compromise the pneumoperitoneum. These challenges have led to the development of multichannel ports to avoid the clinching of laparoscopic instruments diverting from a common point. If multichannel ports are not available, it is necessary to insert three trocars through the same umbilical skin incision but with different fascial incisions at different levels in a triangular fashion. Using a flexible tip laparoscope minimizes the external conflict of instruments, because its cable exits through the instrument's back end, keeping it away from the operative field. Alldominal Wall ·rorque Effect• Utilizing the umbilicus (the thinnest part of abdominal wall) minimizes the torque effect on trocars inserted at such close proximity, providing a widar range of motion for the instruments and trocars in different directions. Howevar, in incisions away from the umbilicus, the "torque eHect" on trocars increases with the increasing thickness of the point of abdominal access, counteracting the movement of trocars and decreasing maneuverability. Umbilical Recession In super-obese patients a receded umbilicus can reduce the feasibility of the transumbilical approach, favoring the epigastric placement of trocars to ensure that the gastroesophageal junction is within the comfortable reach of the laparoscopic instruments. Retraction of Large Liver Bariatric patients have a higher incidence of fatty liver, potentially obscuring the operative field and presenting a challenge for the single-incision approach. Liver retraction can be achieved by internal retraction (i.e. sutures), external retraction (i.e. subxiphoid, transumbilical liver retractor), or using the mobilized portion of the stomach.

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Operative Technique for Single-Incision Sleeve Gastrectomy The patient is placed in a supine or split leg position. The surgeon stands either on the right side or between the legs of the patient with the assistant on the left. Both the location of the single incision and the method of liver retraction are tailored according to the operative strategy discussed in the previous sections. For the transumbilical approach, the deepest point in the umbilical scar is pulled up using Kocher graspers while applying subtle pressure on the abdominal wall to tent up the umbilical scar. A 2.5-cm intraumbilical skin incision is created and deepened to the linea alba. A fascial opening up to a length of 2 em is established. Larger incisions can result in a loose port, promoting gas leakage and an inadequate pneumoperitoneum. The SU.STM Port (Covidien, Norwalk, CT) is folded at its lower edge (opposite to the insufflator) and advanced under direct vision into the abdomen using a clamp. Once the bottom half of the port is introduced into the abdomen, the port is released. Two 5-mm trocars and one 15-mm trocar are introduced through the access channels. The pneumoperitoneum is initiated to a pressure of 15 mm Hg. A 5-mm flexible tip laparoscope is inserted. Using a 5-mm. LigaSureTM and 5-mm. flexible grasper, the greater curvature of the stomach is mobilized, beginning from a point 6 em proximal to the pylorus, staying close to the wall of the stomach, all the way up the greatar curvature to the angle of His, dividing both gastrocolic and gastrosplenic ligaments. This is followed by liver retraction, as detailed, according to each patient's body habitus and liver size (Fig. 33.5). It is important to identify and mobilize the angle of His, with exposure of the left crus of the diaphragm, to facilitate complete resection of the fundus. Ret.rogastric adhesions are taken down with the LigaSureTM. This allows complete mobilization of the stomach, eliminates any redundant posterior wall of the sleeve, and excludes the fundus from the gastric sleeve. Once the stomach is completely mobilized, a 34F orogastric tube is inserted orally, placed against the lesser curvature and through the pylorus. This calibrated size of the gastric sleeve prevents constriction at the gastroesophageal junction and incisura angularis and provides a uniform shape to the entire stomach. The gastric transection is started at a point 6 em proximal to the pylorus, leaving the antrum and preserving gastric emptying. A long laparoscopic roticulating 60-mm. XL endo-GIA stapler with green cartridge 4.8-mm staples and a synthetic absorbable buttressing material is inserted through the 15-mm trocar in a cephalad direction. The stapler is fired consecutively along the length of the orogastric tube until the

figure 33.5 Umbilical port, trocars, and liver retractor placement during single-incillion sleeve gallttectomy and adjustable gallttic band.

Cllaptar 33 Single-Incision Laparoscopic Bariatric Surgery Figu.. 33.& 0 pIii rative picture afta r

completion of single-incision slaava gastrectomy.

angle of His is reached. Care must be taken not to narrow the stomach at the incisura angularis. It is important to inspect the stomach anteriorly and posteriorly to ensure that there is no redundant posterior stomach. Approximately 80% of the stomach is separated. The entire staple line is inspected for bleeding and tested for leakage. Insuftlating air under saline and infusing methylene blue into the remaining stomach tests the integrity of the staple line. The resected stomach is extracted along with the sn.sTM Port without the need for an Endobag. The fascial defect of the port site is closed with a figure-of-eight 2-0 nonabsorbable suture to prevent port site hernia formation. The skin incision is closed with 4-0 absorbable suture in a subcuticular fashion (Fig. 33.6).

Technique far Single-Incision Adjustable Gastric Band The patient is placed in a supine position with the surgeon standing on the right side and the assistant standing on the left side of the patient. A 2.5-cm skin incision is placed intraumbilically. The incision should be large enough to accommodate the multichannel port and ultimately the subcutaneous access port for the adjustment of the gastric band. A safe entry to the abdomen with a 2-cm fascial incision is achieved using the open Hassan technique. The adjustable gastric band is inserted through the skin and the fascial defect into the abdominal cavity in an atraumatic fashion. A sn.sTM port is placed and three 5-mm very low-profile trocars are placed at different levels. Pneumoperitoneum is established. A 5-mm fiexible-tip laparoscope is used for visualization. The liver retractor is inserted either through the umbilical port or a 5-mm. subxiphoid skin puncture with no port placement, in a fashion similar to that of single-incision sleeve gastrectomy (Fig. 33.5). Using the endoflnger device, the phrenoesophagealligament is bluntly dissected at the angle of His exposing the apex of the left crus of the diaphragm; this represents the first landmark for the operation. Extensive dissection should be avoided to minimize the risk of slippage. A flexible grasper is used to elevate the lesser curve of the stomach. L-hook electrocautery is used to open the pars fiaccida of the gastrohepatic ligament exposing the right crus of the diaphragm. The peritoneum overlying the base of the right crus is incised using L-hook electrocautery. Next, an articulating 5-mm blunt grasper is used to develop the retrogastric tunnel. The instrument is passed gently without resistance from the base of the right crus to the apex of the left crus at the 0 of His (Fig. 33.7). This will achieve a 45-degree angulation of the band. The distal end of the band tubing is held securely by the grasper and is passed through the retrogastric tunnel by an articulating grasper allowing the band to be placed within the retrogastric tunnel. The band is wrapped around the proximal stomach creating a small gastric pouch and the buclde is locked.

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Part IV Bariatric Figur• 33.1 Operative strategy during single-incision laparoscopic adjustable gastric band placement. Note that the use of flexible blunt grasper facilitates retrogastric dissection.

The flappy part of the fundus below the band is then sutured to the pouch to imbricate the band. This is done using an endostitch device (Covidien) with a 2-0 nonabsorbable exira corporeal suture technique. The automated features of the endostitch device facilitate exira corporeal knot tying and overcome the challenges associated with the limited range of motion in the single-incision approach. It is important to make sure that the stomach is taken in each bite using seromuscular to seromuscular gaslrogastric sutures. A total of four interrupted anterior gaslrogastric sutures are placed to create the gastric plication necessary to reduce the risk of anterior slippage. Upon completion of the laparoscopic part, the band should be seen assuming a 45-degree tilt, with its buckle outside the anterior gastric wrap to minimize the risk of erosion. The single-incision port is removed, and the tubing is exteriorized through the single umbilical incision and attached to the subcutaneous access port. The fascial defect is closed to avoid postoperative herniation. Four 2-0 nonabsorbable sutures are used to secure the access port to the anterior rectus fascia; this is done to avoid the rotation and subsequent inaccessibility to the port. The skin incision is closed with 4-0 absorbable suture in a subcuticular fashion.

Operative Technique for Single-Incision Raux:-en-Y Gastric Bypass Patient Position The patient is placed in the supine position. The patient is properly strapped to the bed with a foot strap and appropriately cushioned on all the pressure points. After endotracheal intubation, a Foley catheter is inserted.

• TAP block: The TAP block is then performed in a sterile fashion as described. • Creating pneumoperitoneum: The surgeon stands on the right side with the assistant on the left. Pneumoperitoneum is created by inserting a 150-:mm. Veress needle through umbilicus or left subcostal area. We have experienced that this step is very helpful in planning skin incision, undercutting the fascia and entering the peritoneal cavity.

Cll1ptar 33 Single-Incision Laparoscopic Bariatric Surgery

Figwa 318 Umbilical incision.

• Incision: Both the location of the single incision and the method of liver retraction are tailored according to the operative strategy discussed in the previous sections. Our preferred incision is a 3-cm periumblical with small vertical extension as shown in Figure 33.8. About 10 mL of xylocaine is infiltrated at the umbilical site to evert the umbilicus. Skin incision is placed using a no. 15 blade, and then the subcutaneous fat is cut using electrocautery. The bulging peritoneum is opened by blunt dissection. Undercutting of fascia is performed to admit at least three fingers. • Insertion of port: We prefer using GelPOINTTM port (Applied Medical) for singleincision gastric bypass. The inner ring of the wound protector is first inserted into the abdominal cavity. It is then rolled in until it becomes snug to the skin (Fig. 33.9). The GelPOINT port is then prepared by inserting three 5-mm ports and one 12-mm port as shown in the figure. The port is then mounted over the wound protector and the pneumoperitoneum is created (Fig. 33.10). • Diagnostic laparoscopy: A 5-mm 45-degree angle scope is used to visualize the peritoneal cavity (Fig. 33.11). Alternatively a 5-mm flexible scope can also be used. If adhesions are seen, then lysis of adhesions is performed using the ultrasonic shears and also the liver size is assessed at this point. A snake retractor is used through a 5-mm port to retract the lateral segment of the left lobe of liver. Occasionally, a Nathanson retractor may be placed through a subxiphoid incision without a port if the liver is massively enlarged. • Creation of gastric pouch: The pars flaccida overlying the caudate lobe of the liver is entered by blunt dissection. The lesser sac tunnel is visualized under the left gastric vessel. Three firings of articulating GIA 60-mm blue cartridges are used to create the gastric pouch. The first stapler is fired almost horizontal, the second one

Figwe 319 Wound protector.

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Part IV Bariatric

Figw• 3:1.10 Galpoint port.

is vertical, and the last one is through the angle of His (Fig. 33.12) creating a 10· to 20-ml. gastric pouch. An Orovil™ (Covi.dien) tube is then passed by the anesthesi· ologist via the oral route. Using a point cautery the tuba is delivered out through the posterior wall of the pouch about 1 em away from the staple line. The tuba is then gently pulled until the anvil is seen projecting out through the gastric pouch. The tube is then detached from the anvil and pulled out • Creation of jejunojejunal anastomosis: We prefer doing an extra corporeal small bowel anastomosis as it significantly reduces the operating time. After identifying the ligament of Treitz, the jejunum is measured and transected at about 50 em distal from the ligament of Treitz using an endoscopic linear cutter stapler 60-mm white cartridge. The tip of the Roux limb is then undermined for 3 em using a harmonic scalpel. TheRoux limb is then measured for about 100 to 150 em. A stay suture is placed between the measured Roux limb and the tip of the biliopancreatic limb. The suture is cut long. The gelpoint port is then detached from the ring, desuffiating the peritoneal cavity. By pulling the stay suture the two jejunal limbs are delivered out. Enterotomies are made at the appropriate antimesenteric sites, and using a linear cutter 60-mm white cartridge a jejunojejunal anastomosis is created (Fig. 33.13). The enterotomy site is then closed by firing another 60-:mm. white cartridge (Fig. 33.14). Silk suture is used to close the mesenteric defect, and Brolin stitch is placed to pre· vent the kinking of Roux limb. The anastomosis is then placed back into the abdominal cavity. • Creation of gastrojejunal anastomosis: The tip of the Roux limb is identified. Without twisting the mesentery the tip is delivered out. The staple line is excised

Figur• 33.11 Diagnostic laparos·

copy.

Cll1ptar 33 Single-Incision Laparoscopic Bariatric Surgery

Fig..• 33.12 Creation af gastric pouch.

Fig..e 33.13 Extracorporeal jejunojejunal anastomosis.

figure 33.14 Closure of enterotomy.

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extracorporeally using electrocautery. A 25-mm EEA stapler is then passed through the gelpoint port and then introduced into the tip of the Rou.x limb. The spike of the stapler is then advanced to pierce the Rou.x limb at about 5 to 6 em from the tip. Under direct vision the Raux limb with the tip of the spike is placed into the peritoneal cavity and gelpoint port is mounted back. Pneumoperitoneum is re-established and the 45-degree angle scope is again introduced. A flexible grasper is introduced to hold the anvil. The spike is then aligned to the anvil under direct vision and locked. After ensuring that there is no tension or twisting of mesentery, the stapler is fired and the GJ anastomosis is created. The nonviable open portion of the tip of the Rou.x limb is excised using a linear cutter 60-mm stapler. The specimen is removed after placing it in a specimen retrieval bag. • Testing the anastomosis: EGD is performed to do the air leak test and check for any internal bleeding. Closure The fascial closure is done by no. 1 PDS suture. Dead space is obliterated by subcutaneous vicryl sutures and the skin is approximated by subcuticular stitches. Postoperative care Postoperative gastrografin swallow is obtained on the first postoperative day to rule out leaks and obstruction in case of sleeve gastrectomy or gastric bypass and in case of gastric band to confirm the appropriate position of the band with no obstruction or extravasation. Deep vein thrombosis prophylaxis is achieved using anticoagulation, compression stockings, and a sequential compression device. The patient is discharged once they are tolerating a full liquid diet, are hemodynamically stable, afebrile, ambulating, able to maintain hydration, and pain is managed appropriately with oral analgesics.

. ) C01\1PLICATIONS There have been very few minor early complications described: however, long-term data are required to rule out port site hernias, and weight regain.

3

RESULTS

The scarce data documenting the early intraoperative and postoperative experience with single-incision bariatric surgery have shown that single-incision sleeve gastrectomy, adjustable gastric banding, and gastric bypass procedures are feasible and associated with a reasonable degree of safety. Postoperative weight loss is similar to those occurring after conventional multipart laparoscopic procedures, for both sleeve gastrectomy (1) and adjustable gastric banding (2). More importantly, no major operative or perioperative complications have been reported. Regarding the benefits of the single-incision approach, in addition to the cosmetic advantage, the potential advantages might include a shorter hospital stay or a reduced need for analgesia. However, prospective randomized studies comparing multipart laparoscopic adjustable gastric banding, gastric bypass, and sleeve gastrectomy with their single-incision counterparts in large volumes with long-term follow-up are needed to confirm these initial results, identify the direct benefits, and assess the cost-effectiveness of the singleincision approach in broad detail.

Chapter 33 Single-Incision Laparoscopic Bariatric Surgery

357

t!!; CONCLUSIONS • The single-incision approach is a new emerging approach for bariatric surgery. • The approach is particularly attractive for procedures that require a 2- to 3-cm incision to insert the adjustable band and the port as in adjustable gastric banding or to retrieve a large specimen as in sleeve gastrectomy. • The single-incision approach has many potential advantages over the conventional laparoscopic approach, including less postoperative pain, less need for analgesia, and hospital stay. In addition it improves cosmesis and body images. • However, some technical challenges are encountered during single-incision bariatric procedures including lost triangulation, conflict of instruments, umbilical recession, and large fatty liver. • These could be overcome by using long flexible instrument, flexible tip scope, multichannel access ports, and liver retractor.

Recommended References and Readings Saber AA, El-Gha.zaly TH. Early experience with slngle-eccess tram· sumbllical laparoscopic adJustable gastric banding. Obes Surg. 2009;19(10):1442-1446.

Saber AA, El-Ghazaly TH, Elian A. Slngle-incislon transumbilical laparoscopic sleeve gasll1lctom.y. J Lllparosndosc Adv Surg Tech A. 2009;19(6):755-758.

Saber AA, El-Ghazaly TH, Elian A, et al. Slngle-indsion laparoscopic

sleeve gutrectmny versus conventional multipart laparoscopic

sleeve gastrectmny: Technical considerations and strategic modi· tlcaiions. Sw:g Obea Relat Dis. 2010;6(6):65~64. Saber AA, El-Ghazaly TH, Elian. A, et al. Singl~incision laparoscopic placement of adjustable gastric band versus conventional multiport laparoscopic gastric bandiDg: A comparative study. Am Surg. 2010;76(12):1328-1332. Tacchino RM, Greco F, Matera D, et al. Singl~incisionlaparoscopic gastric bypass for morbid obesity. Obss Surg. 2010;20(8):11541160.

Other Gastric Operations

34

Open and Laparoscopic Procedures for SMA Syndrome Markus W. Buchler and Thilo Welsch

~ INDICATIONS/CONTRAINDICATIONS The superior mesenteric artery syndrome (SMA syndrome or Wilkie's syndrome) is cawed by the compression of the third part of the duodenum in the angle between the aorta and the SMA (Figs. 34.1 and 34.2). The entity was first described by the Austrian professor Carl von Rokitansky in his anatomy textbook in 1842. Subsequently, Willie published the first comprehensive series of 75 patients in 1927 and his name has become a common eponym for the SMA syndrome. Symptoms arise from the duodenal compression and comprise chronic or acute postprandial epigastric pain, nausea, vomiting, anorexia, and weight loss. Frequently, predisposing medical conditions associated with catabolic states or rapid weight loss result in a decrease of the aortomesenteric angle and subsequent duodenal obstruction. External cast compression, anatomic variants, and surgical alteration of the anatomy following spine or gastrointestinal surgery (e.g., ileoanal pouch anastomosis) can also precipitate the syndrome (Table 34.1). Once radiologic studies have established SMA syndrome, first-line treatment is wually conservative with jejunal or parenteral nutrition for restoration of the aortomasenteric fat tissue. Nasogastric tuba placement for duodenal and gastric decompression and mobilization into the prone or left lateral decubitus position often is effective in the acute setting. If conservative management fails, surgical procedures are indicated and include open or laparoscopic duodenojejunostomy or duodenal mobilization and diversion of the ligament of 'lreitz (Strong's procedure). Surgical exploration is further indicated if the SMA syndrome is expected to be caused by vascular pathology or by local tumor growth that require surgical intervention. Indications for surgical treatment are as follows: • • • •

Failure of conservative treatment Longstanding disease with progressive weight loss and duodenal dilatation with stasis The need for surgery for the causative pathology Complicated peptic ulcer disease secondary to biliary stasis and reflux

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Part V Other Gastric Operations figur• 34.1 The SMA crosses the third part of the duodenum in the mesenteric root A high insertion of the ligament of Treitz at the duodenojejunal juncture can displace the duodenum cranially into the vascular angle formed by the SMA and the aorta. A. SMA; 8, third part of the duodenum; C, ligament ofTreitz. Adapted from Welsch T, Buchler MW, Kienle P. (2007~ Recaling superior mesentBric artery syndrome. Dig $urg. 24:

149-156.

~

PREOPERATIVE PLANNING

A detailed history (predisposing medical or surgical conditions, weight loss, epigastric pain, and conservative treatment strategies) and physical examination of the patient is mandatory in the preoperative setting. Patients who present with a history of characteristic symptoms suggesting SMA syndrome should undergo further radiographic studies figur• 34.2 The SMA leaves the aorta at an acute angle that is sustained by the left renal vein and the uncinate process of the pancreas embedded in retroperi· toneal fat and lymph tissue. A low aortomesenteric angle can lead to vascular compression of the duodenum. A, SMA; 8, aorta; C, third part of the duodenum; D, pancreas. Adapted from Welsch T, Buchler MW, Kienle P. 12007). Recalling superior mesenteric artery syndrome. Dig $urg. 24:

149-156.

Cllaptar

Opan and Laparoscopic Procedures for SMA Syndrome

,.................

Cancer Cerebral palsy Paraplegia Juvenle rheumataid arlhrtds Canlac cachexia Drugabun Trau11111 Bum injury Brain injury Multipla injuri11

Bariatric surgery Prar:tacolectamy and ileoanal pouch anaiiCDmolia Niaaen fundaplicatian Aortic aneurysm repair Spinal inatnJmentdon, acalalis surgery, ar body cll'llng

........, and CGngtnitlll .AII•••IIts High inser1ion of th a ligament of Treitz Intestinal malrotation, peritoneal adh11ion1 Law origin oftha SMA Increased lumbar lordosi• Intestinal malrotation

Lacal PadlalaiJ Anorexia narvosa Malab1orption

Neoplastic growth in 1he me1enblric root Dissecting aortic aneurysm

to establish the diagnosis. Upper gastrointestinal series, computed tomography (CT) scan or CT angiography, magnetic resonance (MR) angiography, conventional angiography, ultrasonography, and endoscopy have all been used for diagnosis. The following strict radiographic criteria have been established for diagnosis of the SMA syndrome by upper gastrointestinal series with contrast dye: (i) dilatation of the first and second parts of the duodenum, with or without gastric dilatation, (ii) abrupt vertical and oblique compression of the mucosal folds, (iii) antiperistaltic O.ow of contrast medium proximal to the obstruction, (iv) delay in transit of 4 to 6 hours through the gastroduodenal region, and (v) relief of obstruction in a prone, knee-chest or left lateral decubitus position. Contrast-enhanced CT scan additionally demonstrates the aortomesenteric angle, distance and fat tissue, obstruction of the duodenum and a potential culprit for compression, for example, local neoplasia or an aneurysm. Contrast-enhanced CT scan and MR imBging seem to be equivalent in evaluating the exact angle and distance and are recommended by the authors (Fig. 34.3). Criteria for diagnosis mainly result from angiography studies (the former "gold standard"). An aortomesenteric angle of less than 22 to 25 degrees and a distance of less than 8 mm correlated well with the symptoms of the SMA syndrome. Because of the superior information content and noninvasiveness, contrast-enhanced CT or MR angiography is more valuable if the cause for the SMA syndrome is unclear. In addition, upper gastrointestinal endoscopy should be performed to rule out intestinal intraluminal obstruction and gastric or duodenal ulcer disease that might be secondary to refiux or that might constitute a primary pathology mimicking SMA syndrome.

Figurt M.3 SMA l'flldrome in a 28-year-ald female after gastro.intestinal surgery. MR image demonstrating a moderately dilated sec and part of the duodenum (*) and campre11ion by 1he SMA l•rrowl. The aortomesenteric distance was measured at 7 mm. Adapted from Welsch T, Buchler MW, Kienle P. (2007). Recalling superior mesenteric artery syndrome. Dig SIIIJI. 24:145-156.

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Preoperative assessment: • Attempts of medical treatment failed or are contraindicated • Proper imaging with contrast-enhanced CT scan or :MR. angiography of the abdomen and endoscopy (to rule out intrinsic abnormality) for surgical planning • Optimize the patient's medical and nutritional status and nasogastric decompression

S

SURGERY

Several surgical approaches to resolve or bypass the SMA syndrome have been described: • gastrojejunostomy • open or laparoscopic duodenojejunostomy • open or laparoscopic duodenal mobilization by division of the ligament of Treitz (Strong's procedure) The first duodenojejunostomy for the SMA syndrome was done by Stavely in 1908 and has become the most frequent surgical procedure with a success rate of about 80%. Data reporting the outcome after different surgical procedures are historical. Lee et al. concluded after reviewing 146 cases operated after 1963 that duodenojejunostomy revealed the best results in severe cases and was significantly better compared to gastrojejunostomy and Strong's procedure. Today, laparoscopic procedures are increasingly performed, but studies comparing the outcome of laparoscopic duodenojejunostomy or duodenal mobilization are missing. In this chapter, the authors describe the open Strong's procedure and the laparoscopic duodenojejunostomy for SMA syndrome. For either approach, the patient should undergo preoperative gastric decompression through a nasogastric tube.

Positioning For the open Strong's procedure, the patient should be placed in a decubitus position. For the laparoscopic approach, the patient is placed in the lithotomy position with the legs extended in stirrups. The right arm is tucked at the patient's side. The operating surgeon stands between the legs, and the assistant stands to the patient's left side. Preoperative antibiotics are given 30 minutes prior to incision.

Laparoscapic Duodenajejunastomy Recent reports have demonstrated that laparoscopic duodenojejunostomy can be safely and successfully performed without duodenal mobilization (Kocher maneuver). In the presented laparoscopic approach, a duodenojejunal bypass is created anastomosing the dilated third part of the duodenum with a proximal jejunal loop. • A pneumoperitoneum is established and a 30-degree laparoscope is inserted through a 12-mm port near the umbilicus. The patient is placed in a 20-degree reverse Trendelenburg position. The surgeon operates through one right-handed 12-:mm. working trochar on the left side of the abdomen and one left-handed 5-mm port on the right abdomen. A third port (5-mm) is inserted in the left subcostal region and allows the assistant to retract the transverse colon cephalad. • Once the transverse colon is elevated the dilated third part of the duodenum is seen below the transverse mesocolon and the ligament of Treitz can be identified. Dissection of the visceral peritoneum and base of the transverse mesocolon over the distal second part of duodenum and third part proximal to the superior mesenteric vessels is performed with laparoscopic scissors. This exposes the duodenum just proximal to the site of obstruction. • A proximal jejunal loop 15 to 20 em from the ligament of Treitz is mobilized to the exposed duodenal segment and the most caudal part of the duodenum is identified for the creation of the side-to-side anastomosis. The two limbs were secured with two stay sutures of 2-0 Viccyl.

Cllaptar 34 Open and Laparoscopic Procedures for SMA Syndrome

Figwa 31.4 Laparoscopic duode· nojejunostomy. Tha transversa colon is elevated with tha assis· tant laparoscopic grasper. After incision of the mesocolon, tha dilatBd third part of tha duodenum lA) is clearly exposed. A proximal jejunal loop IB) is mobilized to the duodenum and the two limbs ara side-to-side anastomosed using an endoscopic stapler device. Compression of the duodenum is caused by the superior mesenteric artery IC).

• 'I'w'o small antimesenteric enterotomies are made with the hook cautery and gently dilated with an atraumatic grasper. The duodanojejunostomy is than performed using a 45-mm endoscopic gastrointestinal anastomotic (GIA) stapler (Fig. 34.4), and the remaining enterotomy is closed using a running 2·0 slowly absorbable suture. Finally, the abdomen is irrigated, a drain is positioned, and the trocars are removed.

Open Duodenal Mobilization by Division of the Ligament ofTreitz (Stong's Procedure) Strong first described the diversion of the ligament of 'll-eitz with mobilization of the transversa and ascending duodenum far caudal displa.cmnsnt of the duodenum. The advantages of this procedure are that it does not violate the bowel and thus is the less invasive, quicker, and safer procedure. It has been correlated with an earlier postoperative recovery. The disadvantages are that the procedure can be aggravated or impossible due to adhesions and that caudal displa.cmnsnt of the duodenum cannot always be a.cb:ieved because of interference with shart vessels from the inferior pancreaticoduodenal artery to the duodenum. In reoont years, Strong's procedure has also been performed laparoscopically. • An epigastric midline incision is made and the abdominal cavity is explored. • The ligament of Ti'eitz is identified and divided with the electrocautery. • Then the third part of the duodenum is completely mobilized from the mesenteric root This results in a caudolateral shift of the duodenum resolving the duodenal compression in the aortomesenteric angle. • No drain is placed and the abdomen is closed.

POSTOPERATIVE MANAGE:MENT After duodenojejunostomy, the nasogastrlc tube is left in situ initially. A swallow study with oral contrast dye is performed on the first postoperative day. In the absence of a leak ar a delay of the contrast dye passage through the anastomosis, a liquid diet is started. If liquid diet is well-tolerated, the nasogastrlc tube is removed. Patients are slowly advanced to pureed and solid diet as tolerated. Abdominal drains are generally removed on the second postoperative day.

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Postoperative hospital stay after laparoscopic procedures is usually short lasting about 4 to 5 days. Patients should be followed regularly in the outpatient clinic for 3 months to check. relief of symptoms and weight gain.

J COMPLICATIONS Postoperative complications are rare. In a systematic review, the morbidity rate was calculated to 7% with no mortality. Patients can present with delayed gastric emptying requiring prolonged decompression with a nasogastric tube. Further, leakage of the duodenojejunostomy is a critical complication, and early diagnosis of this complication through the swallow study should prompt surgical re-exploration.

~ RESULTS Symptom relief is usually achieved early after the surgical procedure and the surgical results are excellent. From 1978 to 2010, duodenojejunostomy is reported to be successful in almost 100% of the patients, although there are only small series or case reports published in the literature owing to the paucity of the entity. A contemporary comparison of the different surgical procedures is not available, but in the past, duodenajejunostomy was considered to be superior to Strong's procedure. However, Strong's procedure is indicated only in selected patients without long-lasting duodenal dilatation and is limited by the extent of duodenal mobilization.

~ CONCLUSIONS • SMA syndrome is a rare condition and is caused by the compression of the third part of the duodenum in the angle between the aorta and the SMA. • There are numerous conditions that can cause SMA syndrome including catabolic states, anatomic abnormalities, scoliosis, external cast compression, gastrointestinal operations. • Diagnosis is optimally confirmed through contrast-enhanced CT scan or MR angiography. • The first-line treatment approach of SMA syndrome is conservative aiming to restore the aortomesenteric angle for duodenal decompression through nutritional support • Surgery is indicated if medical treatment fails. • Historically, two major surgical approaches have bean described: duodenojejunostomy and duodenal mobilization (Strong's procedure). • Today, both procedures are increasingly performed laparoscopically with excellent results. The indications for Strong's procedure are limited, but duodenojejunostomy is the more invasive procedure. • Complications are rare, and the most critical complication following duodenojejunostomy is anastomotic leakage. Postoperative contrast study is therefore recommended early before advancing dietary intake.

Recommended References and Readings Fraser JD, St Peter SD, Hughes JH, at al. L8p81'08copic duodenojejUilostomy for suparior mesenteric artery syndrome. ]SLS. 2009; 13:254-259.

Lea CS, Mangla JC. Superior mesenteric artery compression syndrome. Am J Gastr08nterol. 1978;70:141-150. Musaud WZ. Laparoscopic management of superior mesenteric artery syndrome. Int Surg. 1995;80:322-327. Morris TC, Devitt PC, Thompson SK. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome-how I do it.

J Gastrointest Surg. 2009;13:1870-1873.

MUilene C, Knab M, Parag B. La.paroscopic duodenojejUilosto:my for superior mesenteric artery syndrome. Am Surg. 2010;76:321-3Z4.

Neri S, Signorelli SS, Mondati E, et al. Ultrasound imaging in diag· nosis of superior mesenteric artery syndrome. JIntern Med. 2005; 257:346-351.

Richardson WS, Surowiec WJ. Lapw:oscopic repair of superior masantaric artary syndrome. Am J Surg. 2001;181:377-378. StrODg EK. MechSILics of artariomesmtric duodenal obstruction md direct surgical. attack upon etiology. Ann Suz:. 1958;148:125-730. Unal B, Aktu A, Kamal C, et al. Superior mesenteric artery syndrome: CT md ultrasonography findings. Diagn Interv Radial. 2005;11:90-95.

Welsch T, Buchler MW, Kienle P. Recalling suparior mesenteric artery syndrome. Dig Surg. 2007;24:149-156. Wl.lkie DPD. Chronic duodenal ileus. Am JMed Sci. 1927;173:643649.

35

Gastrostomy: Endoscopic, Laparoscopic, and Open Jeffrey L. Ponsky and Melissa S. Phillips

~ INDICATIONS/CONTRAINDICATIONS The importance of nutritional support has been shown to decrease infectious complications, lead to better wound healing, and improve overall surgical outcomes. The most common approach for enteral access is through placement of a gastrostomy tube which can be placed through a percutaneous, laparoscopic, or open approach. Dysphagia and aspiration are common indications for gastrostomy tube placement and can result from multiple pathologies. Despite the approach taken, gastrostomy tube placement for nutritional support requires a functional gastrointestinal tract • Neurologic disease: This is the most frequently encountered indication for gastrostomy placement. Underlying neurologic pathology may range from an acute onset cerebrovascular event to those with a more slowly progressive process such as multiple sclerosis or amyotrophic lateral sclerosis. Additional indications may include severe dementia, hypoxic encephalopathy, and meningitis. Trauma: In addition to direct facial trauma, many people who undergo multisystem trauma require placement of a temporary gastrostomy for support during the recovery process. Patients with a high percentage of total body surface area burns may require supplemental nutritional support secondary to the induced state of catabolism. Aerodigestive malignancies: The indication for gastrostomy may be a direct result of the patient's primary malignancy, as would be the case in a nearly obstructing esophageal cancer or in dysphagia induced by a squamous cell carcinoma of the tongue. It may be, however, independent of the primary malignancy, being placed as a method for maintaining supplemental nutritional support during chemotherapy or to assure adequate caloric intake following a planned surgical resection. Pediatric indications: Pediatric patients have additional indications, such as congenital malformations, enzymatic deficiencies, or congenital neurologic syndromes. Examples of these conditions include tracheoesophageal fistulas, carebral palsy, and seizure disorders. • Decompression: Patients with unresectable malignant obstructions with a life expectancy greater than 4 weeks may be candidates for gastrostomy placament for decompression.

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Other indications include severe radiation enteritis, refractory gastroparesis, or for redirection of gastrointestinal flow, such as following a duodenal perforation. • Other indications: Gastrostomies have bean used for refeeding of bile in patients with malignant biliary obstruction or for administration of intolerable medications. In patients who are unable to meet their caloric needs, such as those with inflammatory bowel disease or cystic fibrosis, supplemental tube feed support may also be indicated. There are very few contraindications to gastrostomy tube placement although the approach for placement must be tailored to meet the specific needs of the patient. With the exception of a decompressive gastrostomy, an absolute contraindication for placement is a nonfunctioning gastrointestinal tract. Another specific contraindication is a limited life expectancy, generally accepted as less than 4 weeks. Patients in this situation should have a nasoenteric tuba placed for temporary need given the cost and risks of a mora permanent procedure. Patients with psychologically basad eating disorders should also have a full evaluation including ethics consult before an invasive procedure is undertaken. Any patient with clinical decompensation, including fever of unknown origin or generalized sepsis, should undergo work up of this condition and gastrostomy tube placement should be delayed. Generally speaking, the percutaneous approach for gastrostomy is preferred in all patients without a specific indication for laparoscopic or open placement • Percutaneous approach: Relative contraindications for the endoscopic approach include morbid obesity, massive ascites, portal hypertension, and a history of peritoneal dialysis. Anatomic variations, such as the presence of a hiatal hernia or previous operations, must be considered. These factors can be overcome in many circumstances by the use of a good technique and the skill level of the endoscopist. Any patient with peritonitis should not undergo a percutaneous approach to gastrostomy but should be treated with immediate surgical exploration. • Surgical approach: Laperoscopic or open gastrostomy is often reserved for patients who are not candidates for a percutaneous approach. This includes patients who have upper aerodigestive obstruction, commonly from malignancy, that does not allow the endoscope to pass. It may also be required for patients in whom there is a concern for interposed viscera (colon, liver, small bowel) between the gastric wall and the abdominal wall during a percutaneous attempt. In patients who have undergone a previous surgical intervention, an open approach may be required if significant intra-abdominal adhesions or postsurgical anatomy modifications fail to provide safe access to the stomach for gastrostomy tube placement.

V

PREOPERATIVE PLANNING

AB mentioned in the "Indications" section, each patient should undergo evaluation as to which type of gastrostomy tube will oHer the best benefit The level of invasiveness increases with the different approaches from percutaneous to laparoscopic to open. The most common approach taken is a percutaneous endoscopic gastrostomy (PEG) which can be performed under sedation in an endoscopy suite. All patients undergoing gastrostomy placement should have coagulation values and platelet levels checked. Subcutaneous heparin administration for deep venous thrombosis (DVT) prophylaxis is not a contraindication; however, full anticoagulation may need to be bald temporarily. Any patient requiring general anesthesia should have the risks of this evaluated and an appropriate evaluation, such as cardiac clearance or consultation for a difficult airway, performed. Any patient who has undergone previous surgical intervention should have evaluation to detail the postsurgical anatomy before undertaking gastrostomy placement Old operative notes should be obtained and will help with determining the best treatment approach. In patients who have undergone imaging of the abdomen for other reasons, these studies should be evaluated to assess for the feasibility of a percutaneous approach.

Chapter 35 Gastrostomy: Endoscopic, Laparoscopic, and Open

t9 SURGERY All patients undergoing gastrostomy placement should be prepared by fasting for 8 hours prior to the procedure. Infl'avenous access should be obtained in all patients. Patients should receive preprocedural antibiotics as this has been shown to decrease the risk for peristomal infection. Antibiotic coverage should be directed to s1dn tlora and should be administered within 30 minutes of the procedure.

Operative Technique for Percutaneous Endoscopic Gastrostomy Placement of a PEG was first described in 1980. Since its description, multiple modifications for placement have been developed. These can be broadly divided into procedures that infl'oduce the gastrostomy orally, such as the "pull" or "push" techniques, and those that introduce the gastrostomy through the abdominal wall under endoscopic guidance, such as the introducer technique. • Positioning and sedation: The patient is placed in the supine position and step-wise administration of intravenous medications, commonly a combination of narcotic and benzodia.zepine, is given until adequate sedation has been obtained. Patient factors may necessitate the use of general anesthesia and should be evaluated before the procedure is undertaken. • Upper endoscopy: Following the placement of a bite block, a standard gastroscope is passed through the mouth. The esophagus, stomach, and duodenum are then examined for any evidence of pathology. Specifically, one must take care to assure that there is no evidence of poor gastric emptying or of duodenal obstruction before PEG placement. • Site selection: Finding the appropriate site for PEG placement is important as poor technique in this step can lead to inadvertent viscus injury. Attempts should be made to identify fl'ansillumination of the gastroscope when viewing the external abdominal wall. Next, the abdominal wall should be palpated under endoscopic visualization, watching for a one-to-one movement of the abdominal wall with fingar indentation as seen by the gastroscope. Most important in the opinion of the authors is the use of the "safe tract" technique to confirm. placement (Fig. 35.1A). A syringe is filled with local anesthesia, available in most kits, and the needle is introduced through the anterior abdominal wall while negative pressure is applied to the syringe. Endoscopically, the expected site is carefully monitored for the presence of the needle (Fig. 35.1B). If air is aspirated before the needle is seen in the gastric lumen, significant concem for interposed viscera is present If this occurs, a new site should be selected. H the "safe tract" technique is unable to confirm a safe location, the percutaneous approach should be aborted and other techniques of gastrostomy considered. • Obtaining access: After an appropriate location has been chosen, an infl'oducer needle with a plastic catheter is infl'oduced through the anterior abdominal wall (Fig. 35.2A). This catheter is grasped using an endoscopic snare while the needle is removed (Fig. 35.2B). A guidewire is then passed through the catheter and the endoscopic snare is relocated onto the guidewire. The guidewire is then advanced through the abdominal wall while the snare, other end of the guidewire, and endoscope are removed through the patient's mouth. • "Pull" technique: The guidewire used in the "pull" PEG is soft and has a preformed loop at the mouth end. Once the guidewire has exited through the mouth, this loop is passed through the loop attached to the gastrostomy tube, forming a secure attachment. After application of a water-soluble lubricant, firm but gentle pressure is applied to the abdominal side of the guidewire as the gastrostomy tube is introduced through the mouth. The guidewire is used to advance the tube into the stomach and through the abdominal wall to the final position (Fig. 35.3). The guidewire is removed and the PEG is secured in place.

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Figura 35.1 Percutaneous gastrostomy: safe-tract technique for selecting a safe location. The axternal view {A) shows transmumi· nation and confirms lumen with visualization of air bubbles while the endoscopic view {B) confirms intragastric location of the needle simultaneous to air bubble appearance.

Figure 35.Z Percutaneous gastrostomy: access to the stomach. A cstheb!r-covered needle is introduced, the needle removed, end guidewire inserted from the external view {A) end from en endoscopic view (8}.

Chapter 35 Gastrostomy: Endoscopic, Laparoscopic, and Open Figwa 35.3 Percutaneous gastrostomy: introduction of the gastrostomy tuba. The tuba is inserted through the mouth, fol· lowed by the endoscope, and, in this case, the MpuiiM technique is used to pass the tuba through the anterior abdominal wall.

• "Push" technique: The guidawire used for the "push" PEG is longer and more firm than that used for the "pull" approach and does not have an associated preformed loop. The associated gastrostomy tube is also longer and more tapered than that used for the "pull" approach. The gastrostomy tube is fad over the mouth side of the guidewire. While tansion is held on both the mouth and the abdominal sides of the guidewire, the gastrostomy is advanced forward by applying gentle pressure to the bumper end. This allows the endoscopist to "push" the PEG through the abdominal wall from the mouth side. Once the bumper enters into the mouth, the endoscopist applies gentle traction to the abdominal side of the gastrostomy tube to align it into the final position. The guidawire is removed and the PEG is secured in place. • "Introducer" technique: In this approach, endoscopic visualization is maintained throughout the entire procedure, which is performed from the abdominal wall side. The use of percutaneously placed t-tag anchors may be placed to provide fixation of the anterior gastric wall to the abdominal wall. Access to the gastric lumen is obtained with an 16G needle and a guidewire inserted. The needle is removed and an incision is then made where the wire pierces the skin. Using Seldinger technique, a dilator with break-away sheath is introduced using a twisting motion to facilitate introduction into the stomach. Care must be taken to assure that the dilator follows the path of the wire and does cause a kink. Again, endoscopic visualization is essential to the safety of this procedure. The guidewire and dilator are then removed, leaving the break-away sheath in place. Through this, a balloon tip gastrostomy, or alternatively a Foley catheter, can then be introduced. The sheath is than removed and the PEG is secured in place. • Final touches: After the gastrostomy has bean placed, the scope can be reintroduced to confirm positioning of the bumper (Fig. 35.4A). Literature has supported that this second pass may not be necessary, but the authors routinely confirm placement endoscopically at the completion of the procedure. When securing the gastrostomy tube at the completion of the procedure, care must be taken to avoid undue tension on the tube as this can lead to increased risks of wound complications (Fig. 35.4B).

Operative Technique for Surgical Gastrostomy: Open and Laparoscopic Surgical gastrostomy is one of the earliest documented surgical procedures and was the gold standard for enteral access before the invention of the percutaneous approach. Operative gastrostomy still remains an important adjunct of care, as a significant number of patients are not candidates for PEG placement Open and laparoscopic approaches are available and will be detailed here.

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Figwa 35.4 Percutaneous gastrostomy: final gastrostomy placement Note the endoscopic view (A) shows good approximation of the internal bumper while the external view (B) allows for 2 to 3 mm of freedom to prevent local ischemia and erosion.

• Positioning and sedation/anesthesia: The patient is placed in the supine position. Open gastrostomy may be performed under local anesthesia with sedation or under general anesthesia. Laparoscopic approaches require general anesthesia for appropri· ate insufflation of the abdomen. The arms can be positioned perpendicularly to the torso on arm boards. • Stamm gastrostomy: This technique for gasb:ostomy placement involves the development of a serosal-lined channel from the gastric wall to abdominal wall. This technique requires that an indwelling gasb:ostomy tube be present. otherwise the gasb:ocutaneous tract will close, losing access to the stomach. Through a small vertical midline incision, the anterior wall of the stomach is identified and a location is chosen that will reach the anterior abdominal wall without undue tension. Two purse-string sutures are then placed, one inside the other, to define the boundaries of the gastrostomy enb:y site (Fig. 35.5A). The gasb:ostomy is then placed in the center of these two sutures and a gastrostomy tube inb:oduced through this incision (Fig. 35.5B). The authors prefer the use of a mushroom tip (dePezzar) catheter with a 20 to 24F diameter. The inner pursestring is tied, creating a secure closure around the gastrostomy tube, followed by the outer purse-string, which allows reinforcement of the gasb:ostomy tube by inverting it into the wall of the stomach (Fig. 35.5C). The external portion of the gastrostomy is then inserted (inside to outside) through the abdominal wall. The anterior gastric wall is secured to the abdominal wall using four absorbable sutures to encourage a mature gastrocutaneous tract The catheter is secured to the abdominal wall at the level of the skin and the laparotomy site is closed. • Janeway gasb:ostomy: This technique is based on the creation of a full thickness gastric tube to the anterior abdominal wall. The advantage of the Janeway approach is that a permanent, indwelling catheter is not required. The tract functions more as a small ostomy, allowing for intermittent access for feeding. The stomach is approached through a midline laparotomy. When compared to the Stamm approach, placement of a Janeway gasb:ostomy requires more extensive exposure of the stomach. The direction of the proposed gastric tube, either in the b:ansverse or oblique direction, is chosen and the stomach is elevated in that direction. Creation of the full thickness gasb:ic tube may be accomplished through firing of a commercially available stapling device with contained knife on an elevated piece from the anterior gastric wall (Fig. 35.6). This may also be performed as a hand-sewn approach if desired by the surgeon. This gasb:ic tube must be of adequate length to reach through the abdominal wall intact without undue tension. The gastric tube is passed through the rectus sheath, similar to placement of an ostomy. The midline laparotomy is closed and covered to prevent contamination. The tip of the gastric tube is then removed. The

Chapter 35 Gastrostomy: Endoscopic, Laparoscopic, and Open

371

Figure 35.5 Open Stemm gastrostomy: nate the double pursestting placement {A), the gasttostllmy tube insertion (8}, and the use af the sutures to invert the gastric wall (C).

gastrostomy tuba site is then matured, similar to an ostomy, using absorbable sutures. A straight tip gastrostomy or Foley catheter is placed for decompression until ileus improves. The catheter is then removed and inserted intermittently for feedings. • Laparoscopic Stamm gastrostomy: The most common laparoscopic approach is a modified Stamm gastrostomy. After general anesthesia, access to the abdominal cavity is obtained, usually with a trocar at the level of the umbilicus. One additional trocar, used as the working port for an atraumatic grasper, is placed in the right upper quadrant. The anterior gastric wall is grasped and, using the above criteria, a location is chosen for the gastrostomy. Using t-fasteners, the anterior gastric wall is then Figure 35.6 Open Janeway gastrostomy: nate the use af staples til create a full thickness gastric tube, which will function as an intubatable connection through the abdominal wall.

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secured to the abdominal wall. A 10-mm. skin incision is then made and a needle introduced into the gastric lumen through the abdominal wall at this incision. A guidawire is passed into the stomach and the tract is serially dilated using Seldinger technique. The gastrostomy tube is then introduced, confirming appropriate placement using the laparoscope. The tube is secured in place. The abdomen is desuffiated and the trocar sites closed. • Laparoscopic Janeway gastrostomy: Similar to the laparoscopic approach to Stamm gastrostomy, access to the abdomen is obtained with the camera port at the umbilicus and the working port in the right upper quadrant One additional12·mm port is placed in the left upper quadrant, allowing far the introduction of a commercially available stapling device. The anterior gastric wall is elevated and the directionality of the gastric tube is chosen. While this area is elevated, an articulating stapling device is used to create the full thickness gastric tube that will reach the abdominal wall without tension. Once created, an instrument through the left upper quadrant port is used to grasp the tip of the gastric tube, allowing it to exit through the abdominal wall without twisting. The abdomen is desuftlated and the trocar sites are closed in standard fashion. The tip of the gastric tube is then amputated and it is matured in the manner described above in the open section. The catheter is introduced and left in place until ileus resolves.

POSTOPERATIVE MANAGEMENT Gastrostomy tubes placed through a percutaneous approach may be used immediately for medications. Tube feeds can be initiated beginning 4 hours following the procedure. Surgically placed gastrostomy tubes, if straightforward, may be used according to these guidelines. Far more difficult cases or those requiring extensive lysis of adhesions, the initiation of tube feeds should be delayed until the concern far postoperative ileus has passed. All gastrostomy sites should be cleaned with soap and water and covered with dry gauze. Excessive tension on the gastrostomy tube should be avoided as this may increase wound complication rates or lead to conditions such as buried bumper syndrome, detailed below. These patients may have preexisting postoperative care needs related to the indication for gastrostomy tube placement, such as neurologic disease ar trauma, which should continue to be addressed.

, ) COMPLICATIONS • Wound complications: Wound problems are common following gastrostomy tube placement and most frequently consist of local skin irritation or small volume leakage around the tube. These can be treated conservatively, cleaning the site with soap and water daily and leaving open to air. True infectious complications, such as per· itubal abscess, are rare and may require incision and drainage far resolution. The risk far infectious complications can be reduced by making the skin incision 1 to 2 mm lSiger than the gastrostomy tube to allow for egress of bacteria. Avoiding tension on the tube can also decrease the risk for tissue ischemia and reduce wound complications. Excessive tension on the gastrostomy can lead to buried bumper syndrome, a situation in which the bumper erodes through the gastric wall into the abdominal wall. Finally, administration of prophylactic antibiotics that cover skin flora has also been shown to decrease the risk for infectious complications related to gastrostomy placement. After surgical gastrostomy, patients are also at risk for developing standard postoperative wound infections at the site of incision(s). • Clogging of the gastrostomy: Intraluminal obstruction of a gastrostomy is more common with smaller diameter tubes. Prevention is the key. Routine tap water flushes, especially following medication administration, will help maintain patency. If clogging

Chapter

Gastrostomy: Endoscopic, Laparoscopic, and Open

does develop, commercially available enzymatic products, hydrogen peroxide, or soda may help dissolve the obstruction. Clogged tubes that are not able to be opened may require removal and replacement. Thbe dislodgement: Early dislodgement is a complication that is more concerning after percutaneous approach, as surgical approaches provide direct fixation of the anterior stomach to the abdominal wall. Whether the gastrostomy was placed through surgical or percutaneoUB technique, an attempt may be made to replace the tube. 'I'hiB should be performed in an expedient manner as the tract may close spontaneoUBly within a few hours. A watel"-soluble contrast study should be UBed to con.ft.rm intragastric placement before the replaced tube is used. If the tube is unable to be replaced, a stable patient with a benign abdominal examination can be treated with gastric decompression, bowel rest, and antibiotics until a repeat gastrostomy tube can be placed. Any patient who develops fevers, pain, feeding intolerance, or an acute abdomen should undergo emergent laparotomy or laparoscopy. • Perforation: Inadvertent visceral injury is rare. Following good operative judgment and using the above-mentioned techniques for percutaneous site selection, including the safe tract approach, reduces the risk for unintended injury to surrounding organs. The endoscopic approach also carries a small risk of esophageal or gastric perforation, most commonly occurring at the level of the cricopharyngeUB. Sedation/anesthesia-related complications: As many as 10% of patients undergoing conscioUB sedation experience hypoxemia with desaturation, but this is most commonly transient and without residual effect. Close monitoring with prompt intervention is required to maintain good outcomes. General anesthesia is relatively safe but does carry rlsb of cardiovascular collapse, myocardial infarction, stroke, allergic reaction, and DVT formation. Rare complications: Rare cases of cancer seeding to the abdominal wall have been reported after endoscopic placement of gastrostomy in patients with aerodigestive malignancies. Use of a surgical approach or the percutaneous introducer technique can help eliminate this risk. Other complications include parotitis, abdominal cramping, osmolarity-related diarrhea, and nutritional deficiencies.

3

RESULTS

Results following gastrostomy placement are dependent on the original indication for enteral access, such as stroke, trauma, decompression for unresectable disease, or supplemental nutrition for catabolic states. The procedure and direct complications have only minor impact on overall outcome.

~ CONCLUSIONS Gastrostomy tube placement is a safe and a reliable way to provide enteral access to the gastrointestinal tract for a variety of different indications. Common indications for gastrostomy include neurologic disease, trauma, and malignancies of the head, neck, or esophagus. Gastrostomy placement may also be necessary for decompression in patients with unresectable malignancy or for refractory gastroparesis. Successful gastrostomy placement can be predicted in most patients and modifications in techniques can help overcome complicating factors, such as surgically altered anatomy, morbid obesity, ascites, or portal hypertension. Surgical indications for gastrostomy include the inability to pass a gastroscope secondary to obstruction, concern for inadvertent viscera interposition with failed "safe tract" technique, and postsurgical anatomy that precludes percutaneous gastrostomy. • Percutaneous approaches for gastrostomy include oral passage methods ("pull" and "push") and abdominal wall introducer methods. Patient-specific factors should be considered in the choice of the approach.

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The two main approaches to surgical gastrostomy include construction of a serosallined channel requiring indwelling catheter (the Stamm gastrostomy) or creation of a full thickness gastric tube that allows for intermitted catheterization for feeding (the Janeway gastrostomy). Either technique can be performed via an open or a laparoscopic approach. Complications from gastrostomy include wound complications, clogging, dislodgement, perforation, and those related to sedation. Good surgical technique, reducing tension on the gastrostomy, and routine catheter care will help decrease these risks. All patients should receive preprocedural antibiotics to decrease wound complications. Outcomes following gastrostomy are dependent on the indication for gastrostomy placement. The procedure and direct complications play only a minor role in overall recovery of the patient.

Recommended References and Readings Cappell M. Risk fac:tors and risk reduction of malignant seeding of the percutaneous endoscopic gastrostomy track from pharyngoesophageal malignancy: a review of all 44 known reported cases. Am J Gustroenterol. 2007;102(6):1307. DeLegge M. Enteral access-the foundation of feeding. JPEN J Purenter Enteral Nutr. 2001;25:58. Eisen GM, Baron TII, Dominitz JA, et al. American Society for Gastrointestinal Endoscopy: Role of endoscopy in enteral feeding. Gustrointest Endosc. 2002;55(7):794. Eisen GM, Baron TII, Dominitz JA, et al. American Society for Gastrointestinal Endoscopy: Complications in upper GI endoscopy. Gustrointest Endosc. 2002;55(7):784. Foutch P, Talbert G, Waring J, et al. Percutaneous endoscopic gastrostomy in patients with prior abdominal surgery: Virtues of the safe tract. Am J Gustroenterol. 1988;83:147. Gauderer MWL, Ponsky JL, Izant R. Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pediutr Surg. 1980;15:872. Holzman R, Cullen D, Eichhorn J, et al. Guidelines for sedation by nonanesthesiologists during diagnostic: and therapeutic procedures. J Clin Anesth. 1994;6:265.

Lipp A, Lusardi G. Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy. Cochrane Database Syst Rev. 2006;18:CD005571. Ljungdahl M, Sundbom M. Complication rate lower after percutaneous endoscopic gastrostomy than after surgical gastrostomy: A prospective, randomized trial. Surg Endosc. 2006;20:1248. Mazaki T, Ebisawa K. Enteral versus parenteral nutrition after gastrointestinal surgery: A systematic review and meta-analysis of randomized controlled trials in the English literature. J Gastrointest Surg. 2008;12(4):739. Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results ofa meta-analysis. Ann Surg. 1992;216(2): 172. Pofahl W, Ringold F. Management of early dislodgment of percutaneous endoscopic: gastrostomy tubes. Surg Lupurosc Endosc Percutan Tech. 1999;9(4):253. Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gustrointest Endosc. 1981;27:9. Russell T, Brotman M, Norris F. Percutaneous endoscopic gastrostomy: A new simplified and cost effective technique. Amer J Surg. 1984;148:132.

36

Gastric Electrical Stimulation for Chronic Gastroparesis Jameson Forster

tb, INDICATIONS/CONTRAINDICATIONS As a transplant surgeon who 13 years ago happened to become involved in placing gastric electrical stimulators for the treatment of gastroparesis, I have been impressed that the patients who suffer from this disease are as much psychologically impaired as they are nutritionally impaired. They are afraid of eating and scared to be anywhere but in a hospital bed: to later see these patients walking down the hospital hallway, well dressed, smiling, and engaged in life, all because they can now eat is astounding and gratifying. I have learned that being able to eat is an important part of being human. Gastroparetics suffers from nausea, vomiting, bloating, abdominal pain, weight loss, and early satiety. The disease is defined as having >10% of a standard meal remaining in the stomach after 4 hours. There needs to be an anatomically normal stomach, normal thyroid function, and no small bowel obstruction. The condition is frequently associated with diabetes mellitus of 20 years or more duration but may develop from unknown causes (idiopathically) or following abdominal surgery. Since the gastric electrical stimulator does not cause gastric contractions, I have felt that we should not use the term "pacemaker," even though the device resembles a cardiac pacemaker. To actually pace the stomach, one needs to use a pulse lasting 1,000-fold longer, which can only be accomplished with an external power source. A surgeon should not venture out alone in this endeavor but be an integral part of a multidisciplinary team that cares for these complicated patients. The other members should include gastroenterologists, with an interest in motility disorders, dietitians, psychologists, psychiatrists, pain specialists, and nurse practitioners. Conditions that often mimic gastroparesis but require a significantly different approach include rumination syndrome, conditioned vomiting, regurgitation, gallbladder dyskinesia, gastric outlet obstruction, and severe constipation. Medical treatment includes Erythromycin, Reglan, Domperidone, Tegaserod, Bethanechol, phenothiazin.es, ondansetron, tricyclic antidepressants, and antihistamines. Surgeons have previously played only a minor role, since any resections short of total gastrectomy have proven ineffective in promoting gastric emptying or reducing

375

376

Part V Other Gastric Operations

nausea and vomiting. Pyloroplasties, gastrostomies, and/or subtotal gastric resections do not help. A jejunostomy feeding tube may allow a malnourished patient to be safely fed without the expanse and risk associated with total parenteral nutrition (TPN).

V

PREOPERATIVE PLANNING

Patients should have recently documented normal esophagogastroduodenoscopy (EGD) and colonoscopy. An abdominal ultrasound should be obtained to rule out gallstones and a biliary scan with measurement of the gallbladder ejection fraction is appropriate, if there is a suggestion of biliary colic. Thyroid function studies are also required. Since postoperative infections are difficult to treat, prevention is the key. For patients with a history of infections, I suggest nasal swabs to make cartain MRSA is not present and treatment with Bactroban if positive. Showers with chlorhaxidine soap for a week prior to surgery are recommended. Ioban skin drapes are used during the operation so that neither the stimulator nor the electrodes come in contact with the skin; cefa.zolin as the preoperative intravenous antibiotic and for 24 hours postoperative is essential; a subcuticular closure with a running absoroable suture, dressed with dermabond, which seals and protects the skin from postsurgical infection, ends the case. Some patients may benefit from pyloroplasty, in an eHort to improve gastric emptying which is not improved by the stimulator; others who come to surgery severely malnourished are often supplemented by placement of a feeding jejunostomy. We have seen two early postoperative deaths in our series, for a mortality of about 1%, one elderly woman died from a pulmonary embolism and the other, also an elderly woman, died from a cardiovascular event. Morbidity includes no improvement in symptoms, migration of the device requiring reoperation, 10% incidence of :i.n.faction, and a limited (7 to 8 years) battery life requiring replacement

S

SURGERY

The patient is placed supine. After sufficient endotracheal anesthesia is established, nasogastric (NG) tube and Foley catheter are placed. Preoperative antibiotics are given and the lower chest and abdomen are prepped with chlorhexidine. The patient is draped using an Ioban Incise Drape. A small upper midline incision is made, approximately 5 em in length. Once in the abdomen, exploration is done. The stomach is identified and the pylorus is located. If there was a prior cholecystectomy, the pylorus is usually adherent to the gallbladder bed and needs to be mobilized. Only when the pylorus is freed, can one properly measure along the greater curvature. Using a plastic ruler, we measure along the greater curvature and mark the stomach at 9.5 and 10.5 em proximal to the pylorus, stretching the stomach as much as possible (Fig. 36.1). The Figura 3G.1 A plastic ruler is used

to measure 9.5 and 10.5 em proxi· mal to the pylorus.

Cll1pter 3& Gastric Electrical Stimulation for Chronic Gastroparesis Figure 3i.2 The needles are inserted tangentially 1ttrough 1tte gastric wall.

needles of each electrode are inserted tangentially through the gastric wall, radially inward, deep enough so that the needle is in the gastric muscle and not visible through the serosa. The two needles are placed a centimeter apart and coursing for at least a distance of 1 em within the muscle (Fig. 36.2). With an endoscope, the gastroenterologist verifies that the needles have not traversed the mucosa and are not visible within the gastric lumen. During the endoscopy, the NG is clamped to allow the stomach to be insufllated. With the ceiling lights off but the operating room lights on, the surgeon gently pushes against the needles to clearly locate them, identities that they are close to the incisura, and makes cartain the needles are not visible to the endoscopisl If the needles are far from the incisura or if the needles are visible from the lumen, they are removed, cleaned with Betadine, and reinserted. Once proper position of the needles is ascertained, the needles are pulled through the stomach wall and left dangling until the endoscopy is completed. The endoscope is passed into the duodenum and retroflexed in the stomach to complete the examination. While the endoscope is baing pulled out, care is taken to not also pull out the NG tube, which tends to stick to the sides of the endoscope. Once the endoscope is out, the stomach is decompressed using the NG tube. Both of the gastric electrodes are pulled into the gastric muscle wall by pulling on the monofilament, which is swadged onto the end of the electrode; this is safely done while the surgeon gently holds the stomach around the electrode (Fig. 36.3). Due to the slight difference in the diameter of the electrode and the monofilament, more force is needed to pull the electrodes into position than one would have thought; one feels a slight pop when the electrode gets into place. Once the electrode is in position, each anchor is sutured to the serosa with two interrupted stitches of 5-0 silk. Each monofilament is threaded through a plastic disk and two medium clips are placed to hold the monofilament to the disk.. Each disk. is stitched to the serosa with two sutures Figure 36.3 Each electtode is pulled into position.

m

378

Part V Other Gastric Operations Figure 36.4 The final appearance of the electrodes.

of 5-0 silk. (Fig. 36.4). An adequate-sized pocket is created on the right side of the incision, anterior to the rectus fascia, using electrocautery. The stimulator needs to be at a sufficient distance from the costal margin: so the pocket is often made lateral to the umbilicus while the incision is above the umbilicus. The electrodes are pulled into the pocket via a stab wound through the abdominal wall created with a tonsil clamp. The two electrodes are screwed into place on the stimulator. Either electrode can go into either track. The stimulator is interrogated and the load impedance is measured. The stimulator is sutured to the abdominal wall with three stitches of a 2-0 Ethibond suture. Two stitches are placed through the anterior rectus fascia and one of the plastic tracts and one stitch is placed through one tract and the abdominal wall and then through the abdominal wall and the second tract, being tied on top. The stimulator has to be positioned so that the writing is toward the skin, because only in that position can the interrogator change the settings of the stimulator. The pocket is closed with a running 3-0 PDS suture, bringing the edge of the subcutaneous fat to the top of the fascia. This suture separates the pocbt from the skin and hopefully prevents a wound infection from getting Figwe 36.5 This is the x-ray af one patient's abdomen after placement of the stimulator. The important issue is to note the distance between the end af an electrode and the first clip. In follow-up for worsening symptoms, one needs to re-examine that distance and if greatly increased, the electrode may have pulled out of the stomach.

Cllapter 3& Gastric Electrical Stimulation for Chronic Gastroparesis

into the pocket The stimulator is interrogated a second time and the load impedance rechecked. The fascia is closed with a running 0 PDS suture. The subcutaneous tissue is closed in two layers with interrupted 3·0 chromic sutures, and skin is closed with a running subcuticular 4-0 absorbable suture. The wound is dressed with dermabond.

POSTOPERATIVE MANAGE:MENT The stimulator is usually not activated until after the operation is completed and the electrocautery is no longer in use. The settings used initially are those that the device selects. Postoperatively, we advance the diet slowly. With placement of the stimulator and electrodes alone, the patients are kept NPO for the first 24 hours. Then they are advanced to clear sips the second day, clear liquids the third day, full liquids the fourth day, a soft mechanical diet the fifth day, and discharged on the sixth day. If the patient had a pyloroplasty, the NG is left in for the first day, and then the same schedule is followed, with discharge being on the seventh day. Once the patients are taking liquids, their preoperative madicatiom are resumed. The day after surgery the patients should get a flat and upright of the abdomen to establish the initial position of the electrodes relative to the medium clips, in order to allow for a check later on whether the electrodes had moved (Fig. 36.5). If a jejunostomy feeding tube had been placed, the tube is put to gravity for the first 24 hours. The next day feedings are started at 10 mL/hour of a 1 Kcal/mL formulation and are slowly advanced by 10 mL/hour every 6 hours until goal is reached. If the patient is severely malnourished, the rate may need to be advanced more slowly. Once the patient is eating sufficiently by mouth, the tube feedings are stopped. The tuba placed at surgery can be exchanged for a low-profile Mickey tuba at 2 weeks, if the patient needs to have small bowel access for the long term. Most patients will not need long-term access and the tube can be simply removed when both the patient and the gastroenterologist are comfortable doing so.

_.) COMPLICATIONS The majority of patients do very well and are seen by the surgeon only once postoperatively until 7 to 8 years later when their battery is running out and they need a new stimulator. Unfortunately, some patients have an inordinate number of problems. After placement of the stimulator and its activation, some patients feel better almost immediately; we feel we need to wait 3 months to see the maximum effect of the stimulator. When a patient's symptoms abruptly worsen, a flat and upright x-ray of the abdomen should be dane to make certain the electrodes have not pulled out of the stomach (Fig. 36.5) and the stimulator should be interrogated to make certain that the load impedance has not changed. An upper endoscopy should also be considered to verify that the electrodes have not eroded through the gastric wall and thus are visible from within the lumen. If a patient is found to have the electrodes visible in the stomach's lumen, we assume that the entire system is contaminated and the electrodes, the stimulator, and the plastic disks all have to be removed, cultures have to be taken, and the patient should be appropriately treated with antibiotics. Fluid collections around the stimulator need to be carefully aspirated and the fluid cultured. Not all such collections are infected; even if the cultures are negative, such patients need extended antibiotic therapy. Clearly, if there is infection in the pocket and around the stimulator, the stimulator, the electrodes, and the plastic disks are all removed. The pocket is left open and a wound vacuum assisted closure (VAC) device is used to help the healing process. Infections that do not clearly involve the system, even intra· abdominal abscesses, have been successfully treated without removing the device. When patients develop pain associated with the stimulator, the stimulator may be moving. Unfortunately, the stimulators have become detached from the rectus fascia due to trauma and abdominal wall movement; this has been seen in patients who lean over a tub in their job washing clothes and or in patients whose stimulator is too close

380

Part V Other Gastric Operations

to the right costal margin. The patients will complain that such stimulators flip or stand upright. If the stimulator has completely loosened, it can coil up the electrodes and pull out the electrodes from the stomach wall.

3

RESULTS

About 90% of the patients achieve more than a 50% reduction in Total Symptom Score. Patients with diabetic and postoperative gastroparesis seem to do better than those with idiopathic gastroparesis. Gastric emptying time was reduced at 6 months but not at a year. About 89% of jejunostomies were removed at 1 year. After placement of the stimulator, diabetic patients have improved HgbAtc.

+~ CONCLUSIONS 1. Gastroparesis is characterized by a dysfunctional stomach that no longer pushes food into the duodenum. 2. Treatment requires a team approach and relies on prokinetic medications. 3. The best surgical procedure is placement of a gastric electrical stimulator.

Recommended References and Readings Buckles DC, McCallum RW. Treatment of gastroparesis. Curr 7l'eat

Options Castroenterol. 2004;7:139-147.

Forster J, Sarosiek I, Delcore R, et al. Gastric pacing is a new surgical treatment for gastropares:l.s. Am J Surg. 2001;182:676-681. Forster J, Sarosiek I, Un Z, et al. Further experience with gulric stimulation to tr9e.t drug Nfrsctory gastroparssis. Am JSurg. 2003; 188:890-695. Hsjui RA, McCallum RW. 'D:satment of refractory gastroparnis: Gastric and jejunal tubes, botox, gastric electrical stimulati011, and surgary. Castrointfist Endosc Clin N Am. 2009;19:73-82. J011es MP, Maganti K. A systsme.tic NView of surgical tharapy for gastrop811!8i.s. Am J Gastroentwal. 2003;98:2122-2129. LiD. Z, Forster J, Sarosiek I, at al. 'D:satmsnt af ge.stroparssis with electrical stimulati011. Dig Dis Sci. 2003;48:837-848.

LiD. Z, Forster J, Sarosisk I, at al. 'D:satmsnt of diabetic ge.stroparssis by high-frequency gastric slsctrical stimule.tion. Diabf/tes Care. 2004;27:1071-107(1. Muaoka T, Tack J. Cutroparesis, Current C011cepts and Management. Cut Uver. 2009;3:166-173. McCallum RW, Lin Z, Forster J, et al. Cutric electrical stimulation improves outcomes of patients with gastroparesis for up to 10 years. Clin Castroenterol Hepatol. 2011;9:314-319. Parkman HP, Hasler WL, Fisher RS. American Castroenterologl.cal Assodati011: American Castroenterological Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology. 2004;124:1592-1(122. Touge.s G, Esker EY, Abell TL, at al. Assessment of gastric smptyiDg using e. low fe.t meal: Establishment of intsme.tional c011trol values. Am J Gastroentwal. 2000;95:1456-1482.

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Index Note: Page number followed by f and t indicates figure and table respectively.

A Abdominal pain giant duodenal ulcer and, 148 perforated peptic ulcers and, 109 Adenocarcinoma, gastric, 34-35, 153 Afferent limb syndrome, 182, 267-273 after Billroth II gastrectomy, 267 pathogenesis of, 267-268, 268f prevention of, 268-269, 269f surgical management, 269-273 conversion ofBillroth II to Billroth I, 273,273f conversion to Roux-en-Y reconstruction, 272f elective surgery, 270--271, 272f, 273,273f emergency surgery, 270, 271f jejuno-jejunostomy, 270, 271f preoperative planning, 269-270 uncut Raux-en-Y reconstruction, 272f AJCC TUmor Staging Manual, 184 Alkaline reflux gastritis, 30, 70. See also Bile reflux gastritis, operation for Allergan sizing tube, 341 Alloderm, 288 Alphastar table, 298 American College of Surgeons, 334 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP], 90 American Joint committee on cancer, 171 American Society for Metabolic and Bariatric Surgery, 324, 334 Antiulcer therapy, 115 Arterial supply, of stomach and duodenum and, 155f, 197f

B Bancroft procedure, 149-150, 150f Bariatric operations, open, 283-293 biliopancreatic diversion, 288, 290f cholecystectomy, 285 complications, 292-293 atelectasis, 292 bleeding, 292 gastrointestinal disturbances, 293 hypoglycemia, 293 intestinal obstruction, 293 kidney stones, 293 leak, 292 nutritional deficiencies, 293 pneumonia, 292 stenosis of gastrojejunal anastomosis, 293 thromboembolism, 292 ulcer formation, 293 wound infection, 292-293 duodenal switch, 288, 289f failed, revisionalsurgery for, 289-291 biliopancreatic diversion, 291

gastric bypass, 290, 291f horizontal gastroplasty, 289 jejunoileal bypass, 291 lap band, 291 sleeve gastrectomy, 291 vertical banded gastroplasty, 290,290f gastric bypass enteroenterostomy, creation of, 285-286,286f gastrointestinal anastomosis, creation of, 286-288, 287f pouch, creation of, 286, 287f sleeve gastrectomy, 288, 289f incision management and wound infection prevention, 284-285 indications/contraindications, 283 patient positioning, 284 postoperative management, 291-292 preoperative planning, 284 results, 293 skin preparation, 284 systemic antibiotics, preoperative, 284 Bariatric surgery, 327. See also specific type for weight loss, 295 Bile reflux gastritis, 253 differential diagnosis of, 253 operation for (See Bile reflux gastritis, operation for] primary, 253 secondary, 253 Bile reflux gastritis, operation for, 253-261 choice of, 254-255, 255t complications, 261 contraindications to, 253 indications for, 253 operative technique, 256-260 Braun enteroenterostomy, 256-257, 256f duodenal switch, 259-260, 260f gastric resection, 258-259 Henley jejunal interposition, 258, 259f positioning, 256 Roux-en-Y gastrojejunostomy, 257-258, 257f postoperative management, 260--261 preoperative planning, 253-255 results, 261 Biliopancreatic diversion, 288, 290f Biliopancreatic diversion with duodenal switch (BPD/DS], 337--443 complications, 342-343 indications/contraindications, 337 patient positioning, 338-339 pertinent anatomy, 338 postoperative management, 342 preoperative planning, 337-338 results, 343 surgical technique, 339-342 phase 1, 339-340, 340f phase 2, 340--341, 341f

phase 3, 341-342, 342f, 343f trocar placement, 339f Bleeding duodenal ulcer, surgical therapy for. See Ligation of bleeding ulcer, antrectomy, vagotomy, and gastrojejunostomy; Ligation of bleeding ulcer, vagotomy and pyloroplasty Boey score, 115 Bookwalter retractor, 91, 124, 197 Braun enteroenterostomy, 182, 183f, 256-257,256f British Medical Research council trial, 183 British surgical co-operative Group study, 204

c

Cefazolin, 90, 142, 284, 376 Celiac nerve, 93 Cellan-Jones repair, 111, 111f, 112f "Cheese cloth" hernias, 284 Cisapride, 280 c-KIT proto-oncogene, 229

D Da vinci• Surgical System, 180 Deep venous thrombosis (DVT], 215, 366 Delayed gastric emptying, 30, 86-87 Diet, postgastrectomy, 203 Distal gastrectomy, 36-38, 37f, 38f Distal subtotal gastrectomy and D1 resection, 153-162 complications after, 161-162 for gastric adenocarcinoma, 153 indications/contraindications, 153 postoperative management, 161 preoperative planning, 154 history and physical examination, 154 imaging, 154 staging laparoscopy and peritoneal washings, 154 upper endoscopy, 154 results, 162 surgery, 154-161 arterial supply of stomach and duodenum and, 155f Billroth II gastrojejunostomy, 159, 159f conclusion of procedure, 160--161 diagnostic laparoscopy, 156 distal subtotal gastrectomy reconstruction, 158-160, 158f-160f distal subtotal gastrectomy resection of stomach, 157-158 D1 lymphadenectomy stations, 156f exploratory laparotomy, 156 operative principles, 154-155, 156f positioning and setup, 155-156 reconstruction of gastric remnant, 158f Roux-en-Y gastrojejunostomy, 159, 160f tahir99 - UnitedVRG 381 vip.persianss.ir

382

Index

D1lymph node stations, 172f D2 lymph node stations, 172f Drainage procedures, 14 gastrojejunostomy, 14 pyloroplasty, 14 Dumping syndrome, 70, 86, 130, 181-182, 204. See also Dumping, treatment of Dumping, treatment of, 263-266 operative therapy, 264-265, 264f, 265f jejunal interposition operation, 264-265,264f Raux-en-Y gastrojejunostomy operation, 265,265f postoperative management, 265-266 preoperative preparation, 263-264 Duodenal switch, for primary enterogastric reflux,259-260,260f DuraPrep, 284 Dutch Gastric cancer trial, 183

E Echelon Endopath, 322 Efferent loop syndrome, 182-183 EndoGIA linear cutting stapler, 322 Endo-GIA stapler, 159 Endoscopic biopsy, 2 Endoscopic therapy, for bleeding duodenal ulcer, 143-144 failure of, 144 Endoscopic ultrasound (EUS) in gastric adenocarcinomas, 154, 164 GISTs, 230f Endostitch, 117 End-to-end anastomosis (EEA) stapler, 83, 83f, 84f Enseal devices, 94 Erythromycin, 280 Esophagogastroduodenoscopy (EGD), 149 Excess body weight loss (EBWL), 328

F Finney pyloroplasty, 19, 20f-22f

G Gastric adenocarcinoma, 153 risk factors for, 153 treatment for, 153 (See also specific technique) Gastric atony. See Delayed gastric emptying Gastric outlet obstruction (GOO) causes of, 1 from peptic ulcer disease, 1 surgical approaches to, 2 (See also Truncal vagotomy and gastrojejunostomy (TV & GJ)) Gastric pouch, creation of, 286, 287f Gastrin, 239 Gastrinoma, surgery for, 239-252 complications, 251 diagnosis of gastrinoma, 239 duodenal tumors duodenotomy, 248-249, 249f excision of duodenal tumors, 249, 249f, 250f intraoperative endoscopy, 248 equipment, 241 follow-up, 251-252 incision, 241 liver metastases management, 250-251 lymph nodes sampling in gastrinoma triangle, 250, 251f

pancreatic exposure and pancreatic tumors management dissection of neck of pancreas, 245f division of gastrosplenic ligament, 244f division of pancreas, 246f enucleation of pancreatic head gastrinoma, 248f exposure of pancreas, 241-243, 242f gastrinoma in head of pancreas, 247f isolation of splenic vain, 246f Kocherization of duodenum, 241, 242f mobilization of spleen and tail of pancreas, 244f resection of pancreatic tumors, 244-247,244f-248f splenic artery identification, 245f stapling splenic artery, 245f traction stitch in gastrinoma, 248f ultrasound of pancreas, 243, 243f patient positioning and preparation, 241 postoperative management, 251 preoperative planning, 239-240 steps in operative procedure, 240--241 Gastrinoma triangle, 240f Gastroenterostomy, creation of, 287f Gastroesophageal junction (GED tumors, 209 Gastrointestinal stromal tumors (GISTs), 34 Gastrointestinal stromal tumors, laparoscopic resection of, 229-238 complications, 237 hemorrhage, 237 inlet/outlet obstruction, 237 leak, 237 contraindications to, 229-230 indications for, 229 positioning, 232 postoperative management, 237 preoperative planning, 230-231 endoscopy equipment, 231 laparoscopic equipment, 231 results, 237-238 surgical objective, 231 techniques, 232 intragastric resection, 233-235, 234f-236f laparoscopic formal gastric resection, 235 laparoscopic wedge resections, 232, 232f, 233f robotic excision, 235-236, 236f Gastrojejunostomy, for gastric outlet obstruction treatment, 1 Gastroparesis, gastric electrical stimulation for, 375-380 complications, 379-380 indications/contraindications, 375-376 postoperative management, 379 preoperative planning, 376 results, 380 surgery, 376-379, 376f-378f Gastrostomy tube placement, 365-374 complications, 372-373 clogging of gastrostomy, 372-373 perforation, 373 rare, 373 sedation/anesthesia-related, 373 tube dislodgement, 373 wound, 372 contraindications to, 366 indications for, 365-366 aerodigestive malignancies, 365 decompression, 365-366 neurologic disease, 365 other, 366

pediatric indications, 365 trauma, 365 open and laparoscopic, 369-372, 371f Janeway gastrostomy, 370-371, 371f laparoscopic Janeway gastrostomy, 372 laparoscopic Stamm gastrostomy, 371-372 positioning and anesthesia, 370 Stamm gastrostomy, 370, 371f percutaneous, 367-369,368f-370f final gastrostomy placement, 369, 370f introducer technique, 369 obtaining access, 367, 368f positioning and sedation, 367 pull technique, 367, 369f push technique, 369 site selection, 367, 368f upper endoscopy, 367 postoperative management, 372 preoperative planning, 366 results, 373 GDU. See Giant duodenal ulcer (GDU] GelPOINT port, 353, 354f GIA linear stapler, 27 Giant duodenal ulcer (GDU), 147 diagnosis of, 148 H. pylori infection and, 147 medical treatment of, 148 NSAID use and, 147 presenting symptom, 148 surgical treatment of, 148-151 indications,148-149 operation, 149-151, 150f preoperative assessment, 149 GIA-type stapler, 136, 136f GISTs. See Gastrointestinal stromal tumors (GISTs) GOO. See Gastric outlet obstruction (GOO) Graham (omental] patch closure, 33 Graham patch, 111, 111f, 112

H Harmonic scalpel, 321 Heineke-Mikulicz (HM] pyloroplasty, 14, 16-19, 17f, 18f Helicobucter pylori, 2, 73, 296 Helicobucter pylori-associated ulcers, and G00,1 Hemovac, 285 Henley loop, 258, 259f HIDA, 270 Highly selective vagotomy. See Proximal gastric vagotomy (PGV) Horizontal gastroplasty, 289 Hypergastrinemia, 239

I Imatinib mesylate, 230 laban, 284 laban Incise drape, 376 Iron Intern, 102

JJaboulay pyloroplasty, 19 Japanese Research Society for Gastric cancer, 171, 172f Jejunoileal bypass, 291

K Ketorolac, 161 Kocher maneuver, laparoscopic, 37f

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Index

L Laparoscopic adjustable gastric banding (LAGB), 327-334 complications after, 332-333, 333f band obstruction, 333f band slippage, 333f indications and contraindication&, 327-328 operative technique, 328-331 band placement, 330f closure of adjustable gastric band, 331f patient positioning, 329 placement of anterior gastrogastric sutures, 331f port placement, 329f postoperative management, 331-332 band adjustments, 332 dietary guidelines, 331-332 postoperative follow-up, 332 preoperative planning, 328 weight loss outcomes, 334 Laparoscopic-.assisted distal gastrectomy (LADG), for early gastric cancer, 43t Laparoscopic patch of perforated duodenal ulcer, 115-120 complications, 120 indications/contraindications, 115 postoperative management, 119-120 preoperative planning, 116 results, 120 surgery alternative methods, 119 definitive ulcer surgery, 119 port site placement, 117f positioning, 116 technique,116-118, 117f-119f Laparoscopic posterior truncal vagotomy with anterior seromyotomy, 104-106, 104f-106f Laparoscopic proximal gastric vagotomy, 101-107 complications, 107 contraindications for, 101 indications for, 101 instrumentation, 102 laparoscopic PGV technique, 102-103, 103f patient positioning, 102 postoperative management, 106 preoperative planning, 101-102 results, 107 Taylor procedure, 104-106 anterior seromyotomy, 105-106, 105f, 106f hiatal dissection, 104 posterior truncal vagotomy, 104, 104f trocar placement, 102 Laparoscopic Roux-en-Y gastric bypass, 295-308 complications, 306-307 anastomotic leak, 306-307 bleeding, 307 internal hernia, 307 nutritional, 307 stricture, 307 VTE, 307 gastrojejunostomy hand-sewn, 305 linear stapler, 306 indications/contraindications, 295-296 postoperative management, 306 preoperative planning, 296-297 results, 307- 308 comorbidities, 308 overall survival, 308

safety, 307-308 weight loss, 306 retrocolic versus antecolic Roux limb, 306 su:rgical technique abdominal survey, 299 closure, 305 closure of mesenteric defects, 305, 305f creation of gastric pouch, 299 creation ofRoux limb, 301-302, 302f, 303f dissection of angle of His, 299, 299f equipment, 298 gastrojejunostomy with EEA, 302-304, 304f, 305f jejunojejunostomy, 304-305, 304f patient positioning, 298 perigastric dissection, 299-300 pertinent anatomy, 297-298 stapling pouch, 300, 3oof transoral anvil, 30D-301, 301f, 302f trocar placement, 298 Laparoscopic sleeve gastrectomy (LSG), 311-325,316f complications, 324 contraindications for, 313-314, 313t indications for, 311-313, 312t, 313t postoperative management, 323-324 preoperative planning, 314 results, 324-325 su:rgical technique, 314-323 dissection of short gastric vessel, 317f, 318f drain placement, 320f imbrication of staple line, 320f left crus of diaphragm, identification of, 318f liver retraction, 317f mechanism of action, 314-315 posterior dissection of stomach, 318f pylorus, identification of, 317f resected stomach, extraction of, 321f sleeve completed, 320f transoral insertion of bougie, 319f trocars placement, 316f vertical transaction of stomach, 319f Laparoscopic subtotal gastrectomy and D2 lymphadenectomy, 185-192 complications after early, 191- 192 late, 192 contraindication& for, 185- 186 indications for, 185 instrumentation and equipment, 186 Nathanson liver retractor placement, 188 operative technique greater curvature and pyloric mobilization, 188-190, 189f reconstruction with Roux-en-Y, 19D-191 right gastric vessels and lesser curvature mobilization and lymphadenectomy, 190 tumor localization and entry into lesser sac, 188, 188£, 189f patient positioning, 187-188, 187f postoperative care and follow-up, 191 preoperative planning/staging, 186 results, 192 surgery, 186- 191 trocar placement, 187, 187f Laparoscopic subtotal gastrectomy and D1 resection, 163-170 complications, 169-170 contraindication& for, 163- 164 indications for, 163 postoperative management, 169 preoperative planning, 164

383

results, 170 surgery, 164-169 alternative lesser curvature first technique, 167 01-lymphadenectomy, 167 greater curvature first technique, 165, 166f hand-sewn anastomosis, 167 intra-abdominal Billroth II reconstruction, 16Bf port placement, 164, 165f positioning, 164 specimen retrieval, 167 stapled anastomosis, 167-169, 168f Laparoscopic total gastrectomy (LTG), 207 complications, 215- 216, 216t contraindications for, 208t and esophagojejunostomy, 207-217 for gastric cancer, 207-208 indications for, 208t operating room set-up, 209, 210f patient positioning, 210 patient selection criteria for, 208, 208t postoperative management, 215 preoperative evaluation, 208, 209t results, 216-217, 217t technique, 21D-215 creation of esophagojejunostomy, 214f division of duodenum, 211f division of esophagus, 213, 213f division of left gastric vessels, 212, 212f mobilization of esophagus, 211-212, 212f omentectomy and duodenal division, 21D-211, 211f placement of jejunostomy feeding tube, 215 removal of specimen en bloc, 215 Roux-en-Y esophagojejunostomy anastomosis, 213-215, 214f, 215f trocar placement, 210, 211f treatment and procedure selection, 209 Laparoscopic truncal vagotomy with antrectomy and Billroth II reconstruction, 61-71 complications, 70 alkaline reflux gastritis, 70 dumping syndrome, 70 contraindications to, 61 indications for, 61-62 postoperative management, 70 preoperative planning, 62 results, 70-71 surgery, 62-69 closure of common gastrotomy and enterotomy defect, 67f completed anastomosis, 69f division of proximal duodenum, 66f division of right gastric vessels, 65f endoscopic evaluation of anastomosis, 69f excision of vagus nerve, 65f gastric resection using linear stapler, 66f gastrocolic omentum dissection, 63, 64f inversion of stapled and suture line, 68f jejunal loop sutured to transverse mesocolon defect, 69f jejunum apposed to posterior gastric wall, 67f jejunum in newly created gastric pouch, 67f ligation of right gastroepiploic vessels, 64f linear stapler's cartridge and anvil limbs insertion, 68f patient positioning, 62 transverse mesocolon window, 66f trocar and liver retractor placement, 63£

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384

Index

Laparosc:opic: tunc:al vagotomy with antrectomy and Billroth I rec:onsnuc:tion,33-43 c:omplic:ations, 42 indic:ations/c:ontraindic:ations, 33-35 adenocarcinoma, 34-35 c:arc:inoids, 34 gastrointestinal stromal tumors, 34 peptic: ulc:er disease, 33-34 patient positioning, 35, 35f port placement, 36, 36f postoperative management, 42 preoperative planning, 35 results, 42, 43t surgical technique, 36-42 Billroth I rec:onstruc:tion, 39-40, 40f-42f distal gastrectomy, 36-38, 37f-39f endoscopic: adjuncts use, 42 Koc:her maneuver, 37f vagotomy, 38-39, 39f, 40f Lap-Band,327,329 Leapfrog Group, 334 LigaSure, 94,288,350 Ligation of bleeding ulc:er, antrec:tomy, vagotomy, and gastrojejunostomy, 133-145 c:omplic:ations, 142-143 c:ontraindic:ations for, 134 indications for, 133-134 postoperative management, 14D-142 preoperative planning, 134-135 results, 143-145 surgical procedure, 135-140 antrec:tomy,136-137,136f, 137f gastrojejunostomy, 138-140, 139f-141f oversewing ofulc:er, 135-136, 135f, 136f trunc:al vagotomy, 137-138, 138f Ligation of bleeding ulc:er, vagotomy and pyloroplasty, 123-130 c:omplic:ations, 128, 130 dumping syndrome, 130 postvagotomy diarrhea, 130 rebleeding, 128 indications for, 123-124 postoperative management, 126 preoperative planning, 124 surgery duodenotomy and ligation of bleeding vessel, 125, 125f, 126f exposure,124-125 Heineke--Mikulic:z pyloroplasty, 125-127,126f positioning, 124 trunc:al vagotomy, 127-128, 127f-130f Linear stapler, 322 Linitis plastic:a, 195 Low-molecular weight heparin, 297 Lymph node dissection, for gastric: adenoc:arc:inoma, 171, 172f, 172t. See also Subtotal gastrectomy and D2 resection

M Mac:Donald trial, 186 MAGIC trial, 186, 209 Marginal ulc:eration, in gastrojejunostomy without vagotomy, 11 3-0 Maxon, 285 Medic:al Research c:ounc:il (MRC) trial, 184 Metoclopramide, 280 Multiple endoc:rine neoplasia type 1 (MEN1) syndrome, 239. See also Gastrinoma, surgery for

N Nasogastric: (NG) aspiration, 123 Nathanson Hook Liver Retractor, 102, 164 Nathanson retractor, 3, 63 National Institutes of Health Consensus of Conference on Obesity, 295, 327 Neuroendoc:rine carcinomas, 34 Nissen dosure, 149, 150f Noh procedure, for Roux stasis syndrome prevention,276,279f NSAID-induc:ed ulc:ers, 1-2

0 Obesity, 295 and surgic:al procedure for weight loss, 295, 311 (See also specific procedures) Obesity Surgery Mortality Risk Score, 328 Oc:treotide, 263 Omental pedicle flap, 111, 111f, 112f Omni retractor, 124, 156 OrVil,167-168,213

p Parietal cell vagotomy. See Proximal gastric vagotomy (PGV) Patient-controlled analgesia (PCA), 10, 203 Pectin, 263 Peptic: ulcer disease (PUD), 1, 23, 61-62 nuncal vagotomy for, 23-24, 33-34 (See also specific technique) Perforated peptic ulcers nonoperative management of,109 presentation, 109 use of patch for (See Perforated ulc:er, patch repair for) Perforated ulc:er, patch repair for, 109-114 complications, 113-114 intra-abdominal absc:ess, 114 persistent leak, 113-114 sepsis, 114 indic:ations/c:ontraindications, 109-110 postoperative management inpatient, 113 outpatient, 113 preoperative planning, 110 duodenal ulc:er, 110 gastric ulc:er, 110 results, 114 surgery opentechnique,110-111 operative pearls, 112-113 patc:h techniques, 111-112, 111f, 112f Perigastric: lymph nodes, groupings of, 172t PGV. See Proximal gastric: vagotomy (PGV) 3-0 Polydioxanone, 167f 4-0 Polyglycolic acid suture, 9 3-0 Polyglycolic: acid sutures, 7, 7f Port placement for laparoscopic adjustable gastric banding, 329f for laparoscopic: gastrectomy, 36, 36f, 165f Positron-emission tomography, in gastric adenocarcinomas, 154, 164 Posterior vagus nerve, locating of, 138, 138f Postgastrec:tomy syndromes, 86-87 Postvagotomy diarrhea, 86, 130 3-0 Prolene, 285 Proton pump inhibitor (PPI) therapy, 251 chronic: use of, 239 for giant duodenal ulcer, 148 for ulcer disease, 33 Proximal gastric vagotomy, open, 89-99

advantages of, 89 disadvantages of, 89 indications for, 89-90 postoperative management, 98 preoperative planning, 90 results and complications, 98-99 surgical techniques, 9D-98 abdominal dosure, 98 anesthesia and skin preparation, 91 anterior lesser omental dissection, 93-95,94f distal esophageal dissec:tion, 92-93, 92f, 93f exposure and exploration, 91 extended PGV, 97-98 incision, 91 lesser curvature closure, 96-97, 96f, 97f management of perforation and bleeding, 91-92 patient positioning, 9D-91 posterior lesser omental dissection, 95-96, 95f, 96f procedural steps in PGV, 92 seven areas of vagotomy, 97f Proximal gastric vagotomy (PGV) laparosc:opic, 101-107 open,89-99

R Realize Band, 329 Retrocolic placement, of gastrojejunostomy, 269 Rho-shaped limb, for Raux stasis syndrome prevention,278,279f Robot-assisted gastrectomy with lymph node dissection, 219-227 c:omplic:ations, 226 D2 LN dissection during distal subtotal gastrectomy, 221-224 exposure of left gastric: artery and skeletonization of splenic vessels, 223-224,224f five steps and associated anatomic landmarks, 221 hepatoduodenalligament and suprapanc:reatic dissec:tion, 222-223, 223f left side dissection of greater curvature, 221,222f lesser curvature dissection and proximal resection, 224 right side dissection of greater c:urvature,221-222,222f D2 lymphadenectomy during total gastrectomy, 224-225 spleen-preserving total gastrectomy, 224-225,225f total gastrectomy with splenectomy, 225 gastrointestinal reconstruction, 225 indications for, 219 intraoperative tumor localization, 221 liver retraction, 220 operating room configuration, 220 patient positioning and port placement, 220,221f pertinent anatomy, 220 postoperative management, 225 preoperative work-up, 220 results of, 226-227, 226t robot docking and preparation of operative field, 220, 221f Roux stasis syndrome, 87, 265, 275-281 clinical presentations, 276 diagnosis of, 277

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Index etiopathogenesis of, 276-277 patient complaints in, 275 prevention clinical studies, 278, 279f experimental studies, 278, 279f treatment, 277 clinical studies, 278, 280 medical, 28D-281

s

Salvage surgery, for bleeding duodenal ulcer, 145 Secretin provocative test, for gastrinoma, 239, 240f. See also Gastrinoma, surgery for Seromyotomy, suture for, 106f Serosal patch, 112 3-0 Silk Lambert sutures, 6, 7f SILS Port, 350, 351 Single-incision laparoscopic bariatric surgery, 345-357 block technique local anesthetic injection, 347-348, 348f needle insertion, 347 scanningtechnique,347,347f challenges in conflict of instruments, 348-349 lost triangulation and trocar placement strategy, 348, 349f retraction of large liver, 349 torque effect, 349 umbilical recession, 349 complications, 356 indications and contraindications, 345 preoperative preparations, 345-346 results, 356 single-incision adjustable gastric band, technique for, 351-352, 352f single-incision Roux-en-Y gastric bypass, technique for, 352-356, 353f-355f single-incision sleeve gastrectomy, technique for, 350-351, 350f, 351f TAP block, 346 abdominal wall anatomy, 346, 346f Sleeve gastrectomy (SG), 288, 289f, 291,311 Somatostatin analogues, 30, 70 Stomach, 196, 198f arterial supply of, 155f, 196, 197f Stress gastritis, 60 Subtotal gastrectomy and D2 resection, 171-184 complications after, 181-183 afferent loop syndrome, 182 dumping syndrome, 181-182 efferent loop syndrome, 182-183 indications/contraindications, 171-173 postoperative management, 181 preoperative planning and assessment, 173 results, 183-184 surgical therapy, 173-181 celiac axis dissection, 176, 176f completed Billroth II retrocolic gastrojejunostomy, 178f laparoscopic approach, 178-181, 180f lesser omentectomy, 175-176 ligation of right gastroepiploic vessels, 175f omentobursectomy, 174, 174f plane of dissection for complete lesser bursectomy, 175f positioning, 174 reconstruction,176-178,177f-179f

stapled gastrojejunostomy, 179f technique, 174-176 Superior mesenteric artery (SMA) syndrome, surgical treatment of, 359-364 complications, 364 indications/contraindications, 359, 360f, 361t postoperative management, 363-364 preoperative planning, 36D-362 results, 364 surgical approaches, 362-363 laparoscopic duodenojejunostomy, 362-363,363f positioning, 362 Strong's procedure, 363 Surveillance, Epidemiology, and End Results (SEER) database, 204

T TA90B stapler, 286 TA stapler, 157-158 TA-type stapler, 137, 137f Thylor procedure. See Laparoscopic posterior truncal vagotomy with anterior seromyotomy Tegaserod, 280 Thompson retractor, 91, 156 Total gastrectomy and esophagojejunostomy, 195-205,205f complications,203-204 contraindications, 195-196 indications for, 195 postoperative management, 203 preoperative planning, 196 CT scan, 196 endoscopic ultrasound, 196 nutritional status assessment, 196 pulmonary function tests, 196 upper gastrointestinal endoscopy, 196 results, 204 surgery incision/exposure, 197 pertinent anatomy, 196, 197f, 198f positioning, 197 technique,198-202,199f-202f Total Symptom Score, 380 Transcatheter arterial embolization (TAE) therapy, 144 Transversus abdominis plane (TAP) block, 346 Triple therapy, 113, 120 Tri-Staple technology, 158 Truncal vagotomy and gastrojejunostomy (TV 8r: GJ), 1-12 complications of, lD-11 contraindications to, 2 indications for, 1-2 postoperative management, 9-10 preoperative planning, 2 results of, 11 surgery, 3-9 antibiotics, administration of, 3 gastrojejunostomy, 6 hand-sewn, anterior or antecolic gastrojejunostomy, 6-8, 7f, Sf positioning, 3 stapled, anterior gastrojejunostomy, 8-9, 9f technique, 3 truncal vagotomy, 3-5, 4f-6f Truncal vagotomy and pyloroplasty, 13-22 pyloroplasty, 16-22 Finney pyloroplasty, 19, 20f-22f

385

HM pyloroplasty, 16-19, 17f, 18f Jaboulay pyloroplasty, 19 vagotomy, 15-16, 1St 16f Truncal vagotomy with antrectomy and Billroth I gastroduodenostomy, 23-31 complications, 3D-31 delayed gastric emptying, 30 dumping, 30 recurrent ulceration, 30 indications/contraindications, 23-24 postoperative management, 30, 30f preoperative evaluation, 24 endoscopy, 24 imaging, 24 laboratory values, 24 results, 31 surgical technique, 24-29 antrectomy, 26-27, 27f-28f Billroth I gastroduodenostomy, 28, 29f pertinent anatomy, 24, 25f positioning, 24-25 vagotomy, 25,26f Truncal vagotomy with antrectomy and Roux-en-Y reconstruction, 73-87 complications after, 86-87 delayed gastric emptying, 86-87 dumping syndrome, 86 early, 86t postvagotomy diarrhea, 86 recurrent ulcers, 87 Roux stasis syndrome, 87 indications/contraindications, 73-74 postoperative management, 86 preoperative planning, 74 surgery, 74-85 anterior vagus nerve mobilization, 76f cephalad division of gastrocolic omentum, 77f circular stapler technique, 83, 83f-85f creation of tunnel, 78f dissection of right crus of diaphragm, 75f dividing gastrocolic omentum, 76, 76f division of right gastroepiploic pedicle, 77f duodenum, division of, 78f jejunum, division of, 79f ligament of Treitz, 79f linear stapler technique, 81, 81f-82f mesenteric defect, closure of, 80f mesentery, division of, 80f mesocolic window, creation of, 81f operative techniques, 75-85 port placement, 75f positioning, 74 right gastric artery, division of, 77f stomach, division of, 78f 40 to 50 em Roux limb, creation of, 8of Tuncal vagotomy with antrectomy and Billroth II reconstruction, 45-60 antrectomy, 52-59, 53f-59f anterior anastomosis, 59f dissection oflesser curvature, 57f division of duodenum, 57f division of gastrocolic omentum, 54f division of proximal stomach, 58f division of right gastroepiploic vessels, 56f entry into lesser sac, 53f incision of gastrohepatic ligament, 54f ligation of right gastric vessels, 56f preparation of greater curvature for hemigastrectomy, 55f sutured technique, 58f indications for, 45

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386

Index

Thncal vagotomy with antrectomy and Billroth II reconstruction (continued) patient positioning, 47, 47f postoperative management, 60 preoperative planning, 45 truncal vagotomy, 47-51, 48f-52f anterior vagus trunk, isolation of, 5of division of triangular ligament, 48f exposure of anterior vagus nerve, 49f exposure of esophagogastric junction, 49f exposure of posterior vagal trunk, 51f isolation of posterior vagal trunk, 51f ligation of nerve trunk, sof mobilization of left lateral segment of liver, 47, 48f nerve division, 52f vagal anatomy and, 45-47, 4Bf

u ffitrasonic shears, 179 Uncut Roux variations, for Roux stasis syndrome prevention, 278, 279f Upper gastrointestinal (UGI) bleeding, from duodenal ulcers, 123

v Vacuum assisted closure (VAC) device, 379 Vagal nerves, 24, 25f, 45-46 Vagotomy, 13,15-16,23 anterior, 15f kinds of,13 and need of drainage procedure, 14 posterior, 16f truncal, 14f

Vagus nerve, 13, 15 Vertical banded gastroplasty, 290

w

Wedge gastrectomy, 33 Wilkie's syndrome. See Superior mesenteric artery (SMA) syndrome, surgical treatment of

X Xcel trocar, 319

z

Zollinger-Ellison syndrome, 195

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