ACS Surgery Guide to Procedures for Treating Gastric and Duodenal Disease

© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 GASTROINTESTINAL TRACT AND ABDOMEN 20 Procedures for Gastric and Duodenal Disease — 1

20 PROCEDURES FOR BENIGN AND
MALIGNANT GASTRIC AND
DUODENAL DISEASE
Thomas E. Clancy, M.D., and Stanley W Ashley, M.D., F.A.C.S.
.

Procedures for Benign Gastric and Duodenal Disease
gical management unnecessary. Definitive surgical management is
Advances in the medical management of peptic ulcer disease, indicated, however, if bleeding leads to hemodynamic instability, an
including the use of effective acid-suppressing medications (e.g., his- extensive transfusion requirement (i.e., more than 6 units), or rebleed-
tamine receptor antagonists and proton pump inhibitors [PPIs]) and ing after initial endoscopic management. Objective criteria for surgery
the treatment of Helicobacter pylori, have led to a dramatic decrease in must be determined on a patient-by-patient basis. Precise preopera-
the need for elective surgical management of uncomplicated duode- tive localization of the bleeding source is essential; a bleeding posteri-
nal and gastric ulcers. In the past, surgery was the only effective long- or duodenal ulcer, for example, cannot be managed in the same way
term option for peptic ulcer disease, but over the past two decades, it as hemorrhage from diffuse severe gastritis. Endoscopy should there-
has become an increasingly rare choice.1 Currently, operative therapy fore be performed whenever possible. Alternatively, if brisk bleeding
for peptic ulcer disease is largely reserved for the management of com- prevents clear intraluminal visualization of a bleeding site, angio-
plications such as hemorrhage, perforation, and obstruction. The graphic localization may be attempted.
recognition that medical management successfully prevents ulcer Occasionally, patients present for surgery with refractory gastric
recurrence in most patients has caused surgical management of com- ulcers. If the ulcer has not healed after 12 weeks of optimal medical
plicated ulcer disease to evolve into a more minimalist strategy that therapy, resection is indicated to rule out an occult gastric malignan-
favors damage-control surgery for complications and only infrequent- cy. In such cases, the preoperative workup should include endoscopic
ly resorts to acid-reducing operations.2 biopsies of the ulcer base and the surrounding gastric mucosa so that
In this section of the chapter, we focus primarily on procedures per- a preoperative diagnosis of malignancy can be made if possible. In
formed to treat peptic ulcer disease, though we also briefly address view of the concern about a possible gastric malignancy, it is reason-
diverticulectomy for duodenal diverticular disease. Other gastroduo- able to obtain a preoperative chest x-ray and a CT scan of the
denal procedures for nonmalignant disease are described in more abdomen so as to detect possible nodal or distant metastases.
detail elsewhere: gastric restrictive procedures and gastric bypass are
OPERATIVE PLANNING
discussed in the context of bariatric surgery [see 5:19 Bariatric
Procedures]; choledochoduodenostomy and transduodenal sphinctero- Patients undergoing gastroduodenal procedures should receive
plasty are discussed in the context of biliary tract surgery [see 5:22 general anesthesia and have a nasogastric tube and Foley catheter in
Procedures for Benign and Malignant Biliary Tract Disease]; cystogas- place. The supine position is preferred. The operation is usually done
trostomy for intractable pancreatic pseudocysts is discussed in the via an upper midline incision or, occasionally, via a bilateral subcostal
context of pancreatic surgery [see 5:24 Procedures for Benign and incision, with fixed retractors used in either case.
Malignant Pancreatic Disease]; and duodenal diverticularization is dis- The choice of procedure is primarily dictated by the indication for
cussed in the context of pancreatic and duodenal trauma [see 7:8 operation. Usually, several options are available.The first priority is to
Injuries to the Pancreas and Duodenum]. manage complications (e.g., bleeding and perforation); whether an
accompanying acid-suppressing procedure is indicated and which one
PREOPERATIVE EVALUATION
should be done depend on the clinical setting. Most commonly, duo-
The appropriate extent of preoperative evaluation for a patient denal perforation is treated with closure and omental patching, with
undergoing surgery for a benign gastroduodenal disorder is dictated or without an acid-reducing procedure. A bleeding ulcer is treated
primarily by the nature of the presenting problem. In the case of gas- with oversewing of the the bleeding vessel, with or without an acid-
tric outlet obstruction or a rare condition such as intractable peptic reducing vagotomy and pyloroplasty. Gastric outlet obstruction may
ulcer disease that is refractory to medical management, the preopera- be managed with several different approaches, including vagotomy
tive workup may be extensive and include detailed endoscopy, con- with antrectomy and vagotomy with drainage via pyloroplasty or gas-
trast studies of the upper abdomen, cross-sectional imaging with com- troenterostomy. In the rare cases of intractability, highly selective va-
puted tomography, and full laboratory panels. In most cases of com- gotomy (HSV) is the procedure of choice.
plicated peptic ulcer disease, however, the emergency nature of the sit- An important component of preoperative evaluation is determina-
uation necessarily renders an extensive preoperative workup impracti- tion of the severity and duration of disease. If symptoms are long-
cal. For instance, patients with perforated duodenal ulcers typically standing or recurrent—particularly when the patient has already
present in distress with an acute abdomen. A chest x-ray that demon- received acid-reducing or anti–H. pylori therapy—a definitive acid-
strates free intraperitoneal air is all that is needed before the patient is reducing procedure should be considered. As has been demonstrated,3
taken to the operating room; the decision to proceed to operation however, ulcer recurrence is significantly reduced even without an
should not be delayed by waiting for further images (e.g., CT scans). acid-reducing procedure when perforated ulcers are managed with
Patients who are experiencing upper GI hemorrhage secondary to anti–H. pylori agents in conjunction with a PPI.Therefore, a compliant
peptic ulcer disease should undergo endoscopy to identify the source patient who is presumed to be infected with H. pylori may not need to
of bleeding [see 5:5 Upper Gastrointestinal Bleeding]. In many cases, undergo an additional acid-reducing procedure. The evidence for this
endoscopic management of bleeding ulcers is possible, rendering sur- strategy is less clear with respect to bleeding or obstructing ulcers.


Figure 1 Omental (Graham) patch.
Three or four interrupted sutures are
placed along the ulcer edge. If possible,
the ulcer is closed primarily and rein-
forced with omentum. Primary closure
may be difficult; in a true Graham
patch, primary closure is not attempt-
ed, and omentum is used to cover the
tissue defect.

OMENTAL PATCH FOR DUODENAL PERFORATION (GRAHAM Complications
PATCH)
Persistent leakage should be uncommon after adequate closure.
Operative Technique Duodenal scarring at the area of perforation and repair may lead to
gastric outlet obstruction. Incomplete exploration and irrigation of
Perforated duodenal ulcers are typically treated by oversewing the the abdomen may result in late infection.
perforation, then placing a portion of the greater omentum over the
suture line. The duodenal ulcer wall is carefully debrided and closed
with three or four interrupted silk sutures; the tails of the sutures may
be used to hold the omentum in place. Alternatively, if the ulcer edges
are edematous and not expected to close easily, the perforation may
be closed with a true Graham patch, which involves plugging the
defect with a well-vascularized omental pedicle [see Figure 1]. Care
should be taken to avoid tying sutures too tightly; this can lead to
devascularization of the omental pedicle. Once the operation has
been completed, the abdomen is generously irrigated to remove any
contamination, and a search is made for occult collections in the sub-
phrenic space and the pelvis.

Troubleshooting
To avoid placing excessive tension on the repair, primary closure
should not be attempted if the duodenal wall is overly edematous and
thickened. For large perforations that are expected to result in gastric
outlet obstruction if closed, consideration should be given to incor-
porating the closure into a pyloroplasty.
There is some controversy regarding whether an acid-reducing
operation should be added to the omental patch procedure. If the
patient is stable and has a history of peptic ulcer disease, a definitive
ulcer operation is included; HSV may be preferable to truncal vagot-
omy and pyloroplasty, in that it is less likely to give rise to dumping
syndrome and postvagotomy diarrhea. If the patient has no history of Figure 2 Vagotomy and pyloroplasty. To control a bleeding duo-
denal ulcer, traction sutures are placed along the cephalad and
peptic ulcer disease, has a severe medical illness, is hemodynamically
caudad borders of a longitudinal incision across the pylorus.
unstable, has a long-standing perforation, or exhibits gross abdominal
Figure-eight sutures are placed at the cephalad and caudad por-
contamination, a definitive ulcer operation is omitted. In cases of tions of the ulcer to occlude the gastroduodenal artery. An addi-
gross contamination of the abdomen, it is probably inappropriate to tional U-stitch is placed to control small transverse pancreatic
divide the peritoneum over the esophagus during vagotomy and branches that may cause late bleeding. Care should be taken to
thereby expose the mediastinum to infection. avoid the underlying CBD.


Figure 3 Vagotomy and pyloroplasty. For a Heineke-
Mikulicz pyloroplasty, a full-thickness longitudinal
incision is made that extends from a point 1 cm proxi-
mal to the pylorus to a point 1 to 2 cm distal to the
pylorus. The incision is closed transversely in two lay-
ers. Superior and inferior stay sutures help align the
incision for closure.

Outcome Evaluation cautery; exposure may be facilitated by surrounding the distal esoph-
With adequate acid suppression and anti–H. pylori therapy, symp- agus with a Penrose drain for downward traction. The left (anterior)
toms of duodenal ulcer are unlikely to recur. The 1-year recurrence vagus is best identified by applying traction to the right and posteri-
rate after omental patching is substantially lower when both therapies orly, so that the nerve can be traced into the posterior mediastinum.
are employed than when only a PPI is given (5% versus 38%).3 All fibers entering the distal esophagus are divided. The main nerve
trunk is clipped proximally and distally, and a 2 cm long segment is
VAGOTOMY AND PYLOROPLASTY FOR BLEEDING DUODENAL excised.The right (posterior) vagus is exposed by applying traction to
ULCER the left and anteriorly; the nerve can then be palpated as a taut cord
Truncal vagotomy with pyloric drainage via pyloroplasty is rarely and divided in much the same manner as the anterior vagus. For a
employed as primary therapy for peptic ulcer disease, but it does play complete vagotomy, the distal esophagus must be skeletonized for
a role in emergency management of bleeding duodenal ulcers. This approximately 5 cm [see Figure 4].
approach to acid suppression fits well with the proximal duodenoto-
my used to control the hemorrhage. Exposure of the first portion of
the duodenum via a longitudinal incision in the pylorus is combined
with truncal vagotomy; the pylorus is then closed in a transverse fash-
ion to prevent the development of gastric outlet obstruction.

Operative Technique Posterior Vagus

Step 1: exposure and pyloric division A Kocher maneuver is
performed. The pylorus is identified through palpation and through
identification of the pyloric vein as it courses anteriorly. Two traction
sutures are placed in the anterior aspect of the pylorus, one superior-
ly and one inferiorly. A longitudinal incision is made that extends
approximately 2 to 3 cm on either side of the pylorus.

Step 2: ligation of bleeding vessel The bleeding ulcer bed is
directly oversewn with at least three sutures. Figure-eight sutures are
placed on the superior and inferior borders of the ulcer bed to ligate
the gastroduodenal artery proximal and distal to the ulcer, and a third
figure-eight suture is placed medially to control the transverse pan-
creatic branch [see Figure 2].

Step 3: pyloroplasty Tension is applied to the previously placed Anterior Vagus
traction sutures to convert the longitudinal incision to a transverse Divided
one. The incision is then closed transversely in two layers with full-
thickness bites of 3-0 or 2-0 nonabsorbable suture material (Heineke-
Mikulicz pyloroplasty) [see Figure 3].Tension-free closure is facilitated
by adequate duodenal mobilization (by means of the Kocher maneu-
ver) and lysis of surrounding adhesions.
Figure 4 Vagotomy and pyloroplasty. For the truncal vagotomy,
Step 4: vagotomy To perform the vagotomy, further exposure
the peritoneum over the esophagogastric junction is opened
may be needed, including mobilization of the left lateral section of the widely to afford exposure. Gentle downward traction is applied
liver and division of the triangular ligament. Downward traction on to the stomach to facilitate identification of the two vagus
the greater curvature of the stomach is essential to apply gentle ten- nerves. Surgical clips are applied to each nerve in turn, and a 2
sion to the esophagogastric junction and the proximal vagi. The peri- to 3 cm nerve segment is removed between the clips. These seg-
toneum over the esophagus is divided transversely with the electro- ments should be inspected to confirm removal of neural tissue.


Troubleshooting (CBD), particularly when the vascular inﬂow to a deeply penetrating
As this procedure becomes less frequent and surgeons’ experience duodenal ulcer is being sutured.
with it dwindles, location of the vagus nerves may prove an increas-
ingly troublesome task. In most cases, complete skeletonization of the Complications
distal esophagus in conjunction with appropriate traction should allow Leakage from a pyloroplasty is rare. Gastric outlet obstruction may
palpation of the main vagal trunks. occur secondary to either scarring or edema at the operative site;
If substantial duodenal scarring is present, a tension-free Heineke- often, it is relieved by nasogastric decompression and conservative
Mikulicz pyloroplasty may not be possible, and a Finney pyloroplasty management. The incidence of ulcer recurrence and rebleeding is
may be preferable. The Finney procedure is essentially a side-to-side quite low with adequate anti–H. pylori treatment.
anastomosis that is created in two layers between the distal stomach
ANTRECTOMY
and the proximal duodenum [see Figure 5]. Complete mobilization of
the duodenum, including adhesiolysis and a generous Kocher maneu- The primary indication for gastric resection in the setting of peptic
ver, is required. ulcer disease is chronic obstruction caused by scarring, typically from
Care should be taken to keep from injuring the common bile duct a pyloric channel ulcer. Antrectomy removes the gastrin-secreting por-

Figure 5 Vagotomy and pyloroplasty. If
a Pylorus a tension-free Heineke-Mikulicz pyloro-
plasty is not feasible, a Finney pyloroplasty
may be performed instead. (a) The distal
stomach and the proximal duodenum are
Gallbladder
aligned with stay sutures; meticulous lysis
of surrounding adhesions is essential. An
inverted U-shaped incision is made. (b)
The pyloroplasty is created in two layers.
The posterior portion of the outer layer,
consisting of seromuscular Lembert
sutures, is placed ﬁrst, followed by an
inner layer constructed with a continuous
full-thickness absorbable suture. (c) The
anterior portion of the inner layer is
closed with a continuous full-thickness
suture. Some surgeons prefer a Connell
suture at this site. (d) The anterior porti
on of outer layer, consisting of silk
b Lembert sutures, is placed.

Inverted
Incision

Duodenum

d

c
Duodenum


are divided just distal to the pylorus. The duodenum is then divided
a distal to the pylorus with a tranverse anastomosis (TA) stapler.

Step 3: reconstruction When feasible, a Billroth I reconstruc-
Billroth I tion (primary gastroduodenostomy) is preferred for maintenance of
physiologic antegrade flow (though there are no data establishing that
this maintenance of flow is beneficial). In addition, this reconstruction
avoids the complications associated with a Billroth II reconstruction
b (e.g., afferent and efferent loop syndromes and duodenal stump
leaks). A generous Kocher maneuver, if not already performed, is nec-
essary to minimize tension on the anastomosis. The lower portion of
the staple line is removed for the width of the duodenal stump, and
the anastomosis is performed in two layers or fashioned with a GIA
stapler through a gastrotomy [see Figure 6].
If a primary gastroduodenostomy is not possible, a Billroth II
reconstruction (gastrojejunostomy) is indicated. This procedure
involves a number of technical considerations: management of the
duodenal stump, the length of and placement of the afferent limb, and
the placement and method of the anastomosis. If the duodenum is not
scarred or inflamed, simple staple closure will suffice; if closure proves
Figure 6 Antrectomy: Billroth I reconstruction (gastroduo- difficult, a lateral duodenostomy tube may help decompress the
denostomy). (a) The anastomosis is done in two layers. The inner stump. The duodenal stump should be covered with an omental
layer is constructed by placing a continuous full-thickness suture. patch.
(b) The outer layer is constructed with silk Lembert sutures. The The segment used for the anastomosis should be as short as possi-
junction of the anastomosis and the gastric staple line has been ble while still being able to reach the stomach without tension;
referred to as the angle of sorrow, a term that reflects the com-
approximately 20 cm of proximal jejunum should be sufficient to
mon complication of leakage at the intersection of suture or sta-
ple lines. This junction may be reinforced with additional
serve as the afferent limb. Passing the jejunum through a retrocolic
Lembert sutures. window places less tension on the mesentery than an antecolic
approach does, though gastric emptying will occur with either
method. If a retrocolic approach is used, a window is created for the
tion of the stomach. In addition, antrectomy may be required for jejunum; this must be closed and fixed to the small bowel.
recurrent bleeding after an adequate vagotomy and pyloroplasty for a The gastrojejunostomy may be constructed either to the posterior
bleeding duodenal ulcer. Alternatively, antrectomy may be the elective wall of the stomach or to the inferior portion of the excised staple line.
operation of choice for intractable type I, II, and III gastric ulcers, as If the anastomosis is placed at the gastric staple line, the inferior por-
well as a primary emergency surgical option for perforated or bleed- tion of the staple line is excised, often together with a wedge of stom-
ing gastric ulcers. Historically, a primary Billroth I gastroduodenosto- ach behind the staple line. A two-layer anastomosis is created with an
my has been the preferred procedure, but surrounding scar tissue may outer layer of Lembert sutures and an inner layer of absorbable full-
limit the mobility of the duodenum, in which case a Billroth II gas- thickness sutures; the gastric staple line may be oversewn [see Figure
trojejunostomy may be required for a tension-free anastomosis. 7]. Alternatively, the gastrojejunostomy may be created by means of
Antrectomy is typically combined with truncal vagotomy. stapling. A GIA stapler is introduced via a gastrotomy and a small
enterotomy, and the defect is subsequently closed with a TA stapler.
Operative Technique Additional reinforcement is not necessary for this staple line.
Step 1: exposure The lesser sac is entered via the avascular Some authors recommend the use of a Braun enteroenterostomy
plane in the greater omentum, the plane between the stomach and the between the efferent and afferent limbs to reduce bile reflux and
pancreas is developed, and the lesser omentum is divided. The proxi- decompress the duodenal stump [see Figure 8a]. Staple closure of the
mal border of the antrum must be identified before the stomach is afferent limb above the enteroenterostomy may also be performed to
divided [see Step 2, below]. On the greater curvature, the antrum limit bile reflux into the stomach; this measure creates a configuration
extends to a point between the pylorus and the fundus; on the lesser referred to as an uncut Roux-en-Y [see Figure 8b]. Enteroenterostomy
curvature, it extends to a point just above the incisura. Distally, the at this site may also be performed on an emergency basis to treat affer-
dissection is carried past the pylorus. Along the lesser curvature, dis- ent limb syndrome. Staple closure of the afferent limb may discourage
section necessitates division of the descending branch of the left gas- bile reflux, but it may also lead to long-term bile reflux gastritis and
tric artery, as well as the right gastric artery. Dissection along the esophagitis.4
pylorus must be meticulous to ensure that the pancreas is not dam-
aged. If a Billroth I anastomosis is planned, dissection should contin- Troubleshooting
ue 1 cm beyond the pylorus to expose a sufficient length of duodenum In most instances, a noninflamed duodenum can readily be closed
for the anastomosis. If a Billroth II reconstruction is planned, dissec- with a TA stapler. However, the thickened and inflamed tissue present
tion need extend only far enough to allow division of the duodenum in the setting of inflammation with duodenal perforation is not
past the pylorus. amenable to easy closure. Furthermore, poor afferent limb drainage
can lead to increased pressure in the afferent limb, thus contributing
Step 2: division of stomach A gastrointestinal anastomosis to leakage. Lateral duodenostomy tubes may be used for decompres-
(GIA) stapler is used to divide the stomach at the estimated borders sion. The duodenum should be sutured to the abdominal wall in a
of the antrum [see Step 1, above].The antrum is gently retracted ante- Stamm fashion at the exit site of the tube. Alternatively, if the duode-
riorly and to the patient’s left.The right gastroepiploic artery and vein num cannot be closed without significant tension, closure may be


a b c

Figure 7 Antrectomy: Billroth II reconstruction (gastrojejunostomy). (a) The inferior portion of the
gastric resection line is excised, along with a small wedge of the stomach. (b, c) A two-layer anastomosis
is created, with an outer layer of Lembert sutures and an inner layer of full-thickness absorbable
sutures. The upper gastric staple line may be oversewn with interrupted Lembert sutures.

accomplished around a red rubber or mushroom catheter. For espe- forming a technetium-99m (99mTc)-labeled hepato-iminodiacetic
cially thick tissue, primary suture closure is preferable to staple clo- acid (HIDA) scan.
sure. Inversion of the duodenal suture line with Lembert sutures is not Duodenal leaks can rarely be closed primarily. Duodenostomy may
necessary. In addition, omental patch reinforcement of the duodenal be indicated to further decompress the afferent limb and prevent con-
stump may be desirable. tinuous leakage.The goals are to create a controlled fistula to the skin
and to prevent the accumulation of biliary fluid in the abdomen.
Complications Delayed gastric emptying after gastrojejunostomy may occur and
Leakage from the duodenal stump is a potentially devastating com- is generally managed conservatively. On rare occasions, reoperation is
plication that necessitates prompt reoperation, washout, and drainage. required for delayed anastomotic function. In the case of a Billroth I
The diagnosis of duodenal stump leakage is confirmed by aspirating reconstruction, takedown of the anastomosis is associated with devas-
bilious fluid from a right upper quadrant fluid collection or by per- cularization and duodenal stump leakage. It is therefore preferable to

Figure 8 Antrectomy: Billroth II recon-
struction (gastrojejunostomy). (a) A
Braun enteroenterostomy facilitates
decompression of the afferent limb in a
Billroth II gastrojejunostomy. It may be
done as either a sutured or a stapled
anastomosis. (b) An option is to close the
afferent limb above the enteroenterosto-
my with a TA stapler (so that the jejunal
lumen is occluded but not divided). This
configuration, often referred to as an
uncut Roux-en-Y, temporarily discour-
ages, but does not prevent, reflux of bile
into the stomach.


leave the anastomosis in place and perform a gastrojejunostomy
along the greater curvature of the stomach. In the case of a Billroth
II reconstruction, revision may be required for better positioning of
the anastomosis.
Afferent limb obstruction may occur as a consequence of adhe-
sions, internal herniation, volvulus, or a kink at the angle formed with
the gastric remnant. Obstruction to outflow of the afferent limb cre-
ates a closed-loop obstruction, with persistent secretion of bile and
pancreatic fluids into the loop. Such obstruction often presents as
recurrent pancreatitis. The diagnosis is facilitated by CT scanning; if
it is confirmed, prompt exploration is mandated. Correction of the
obstruction may necessitate conversion to a Roux-en-Y reconstruc-
tion, shortening of the afferent limb, or a side-to-side enteroenteros-
tomy with the efferent limb (see above).
Bleeding, generally in the form of intraluminal blood loss, is a fre-
quent occurrence after gastrectomy. A bloody aspirate from the naso-
gastric tube is a common presentation. If bleeding persists for more
than 5 days after the initial operation, endoscopy with endoscopic
coagulation or epinephrine injection may be considered. Endoscopic
approaches should be undertaken with care to minimize the risk of 7 cm
distending the new anastomosis.
Alkaline reflux gastritis is one of the most common long-term
complications of gastrectomy, developing in 5% and 15% of patients
after gastric surgery.5 This complication is most frequently associated
with Billroth II reconstructions. Although reflux is common, symp-
toms (e.g., epigastric pain, nausea, and bilious emesis) are relatively
Figure 9 Highly selective vagotomy. Anterior and posterior
rare. Medical management is generally ineffective. If surgery is branches of the nerve of Latarjet to the lesser curvature are
required, conversion of the Billroth II reconstruction to a Roux-en-Y ligated and divided. The distal branches, comprising the so-
reconstruction is indicated. In those patients who have a Roux-en-Y called crow’s foot, are left intact. The posterior branches may
rather than a Billroth II reconstruction, the preferred treatment is to be approached via the lesser omentum.
divert alkaline contents to a location 45 to 60 cm beyond the gastric
remnant.
typically located near the incisura angularis, approximately 6 to 7 cm
HIGHLY SELECTIVE VAGOTOMY
proximal to the pylorus. Gentle downward traction is applied to the
Although both vagotomy with antrectomy and vagotomy with stomach, the left gastric vascular arcade is identified, and all tissue
pyloroplasty drainage provide relief from duodenal ulcers, they are between this arcade and the lesser curvature is divided and ligated.
also associated with significant complications, including dumping syn- The dissection therefore includes individual branches of the vagus
drome, diarrhea, bile reflux, and poor gastric emptying. Highly selec- nerve to the stomach. It should proceed upward as far as the esopha-
tive vagotomy, also referred to as parietal cell vagotomy, was devel- gogastric junction. The posterior branches are approached either by
oped with these complications in mind; the idea was to avoid vagal rotating the stomach or by proceeding directly through the lesser
denervation of viscera other than the parietal cell mass while keeping omentum [see Figure 9].
the pylorus mechanically and functionally intact.6,7 HSV was found to
reduce postvagotomy diarrhea and dumping dramatically; however, it Step 3: dissection of esophagogastric junction The distal
was also found to be associated with a much higher rate of recurrent esophagus is cleared of all nerve fibers for a distance of approximate-
ulceration (greater than 10% at 5 years). Today, in an era character- ly 5 cm above the esophagogastric junction. The dissection must stay
ized by greatly improved medical management of peptic ulcer disease, close to the lesser curvature and the esophagus, avoiding the tissues to
most GI surgeons perform HSV very rarely, if at all. One possible use the right of the esophagus, where the main vagal trunks lie. The pos-
for this procedure in the current context might be to treat intractable terior esophagogastric junction is exposed by means of gentle traction
ulcer disease in young patients. and slight rotation of the distal esophagus. Exposure is facilitated by
downward traction provided by a Penrose drain placed around the
Operative Technique esophagogastric junction.
Step 1: exposure and gastric mobilization Wide exposure is
obtained with the help of upward retraction on the costal margin.The Troubleshooting
gastrocolic omentum is entered outside the gastroepiploic vessels to Incomplete denervation of the parietal cell mass is prevented by
preserve the blood supply to the greater curvature. Adhesions to the paying meticulous attention to dissection, particularly at the esopha-
peritoneum over the pancreas are divided sharply, and the stomach is gogastric junction.The left side of the distal esophagus must be man-
rotated upward to allow visualization of the posterior leaf of the lesser ually stripped so that the so-called criminal nerve of Grassi can be
omentum and the posterior nerve of Latarjet, which runs adjacent to identified and ligated. About 4 to 5 cm of the distal esophagus should
the descending branch of the left gastric artery. be stripped of vagal input.

Step 2: dissection of anterior and posterior nerve branches Complications
to lesser curvature The distal branches of the nerve of Latarjet are The primary complication of HSV is recurrent ulceration. The
defined, with care taken to preserve the so-called crow’s foot, which is reported rates vary, but the general view is that the 5-year ulceration


recurrence rate may be higher than 10%.8 Most recurrent ulcers Step 1: exposure and duodenotomy A generous Kocher
occur in the setting of incomplete vagal denervation. Given the small maneuver is performed to elevate the head of the duodenum. The
number of patients for whom HSV is indicated, few GI surgeons are duodenum is then opened by making a 4 cm longitudinal incision
likely to have accumulated sufficient experience with this technique to along the antimesenteric border, and the ampulla is either visualized
be proficient at it. Fortunately, most recurrent ulcers can now be man- or palpated. To identify the ampulla, it may be necessary to place a
aged medically, and few call for surgical management. catheter into the CBD via a separate choledochotomy.

LAPAROSCOPIC TREATMENT OF PEPTIC ULCER DISEASE
Step 2: diverticulectomy The orifice of the diverticulum is
Numerous reports of laparoscopic approaches to truncal vagotomy identified, and the mucosa is inverted into the lumen of the duode-
and HSV have been published over the past two decades.The laparo- num.The neck of the diverticulum is transected 2 mm from the junc-
scopic versions of these procedures proceed in much the same way as tion with the duodenal wall. The diverticular opening is then closed
the traditional open versions. In a laparoscopic HSV, the ultrasonic with interrupted seromuscular Lembert sutures of 3-0 silk and inter-
shears are frequently used to divide the anterior and posterior vagal rupted mucosal sutures of 4-0 polyglactin.The duodenum is closed in
branches to the lesser curvature from the crow’s foot to the esopha- two layers, also with an inner layer of 4-0 polyglactin and an outer
gogastric junction. Mixed procedures that combine posterior truncal layer of seromuscular Lembert sutures of 3-0 silk. Closed suction
vagotomy with more selective anterior gastric denervation are com- drainage adjacent to the duodenum is indicated.
mon. In the Taylor procedure, an anterior seromyotomy is performed
from the angle of His to the crow’s foot, and the seromuscular layers Special case: perforated duodenal diverticulum. In the setting of acute
are subsequently closed primarily.9 A variant of the laparoscopic inflammation, duodenotomy is avoided. Instead, the abscess is evacu-
Taylor procedure includes a anterior linear gastrectomy, in which a ated, and the diverticulum is excised along with just enough of the
linear strip of the stomach wall is removed parallel to the lesser cur- adjacent duodenal wall to ensure that only healthy tissue is left. If the
vature with an endoscopic GIA stapler. This procedure seems to be resulting duodenal defect is large, either sleeve resection of the duo-
functionally equivalent to HSV.The majority of the studies of laparo- denum or drainage of the open duodenal defect into a Roux-en-Y
scopic vagotomy, however, have been individual case series that do not jejunal limb may be required.
compare the laparoscopic approach with a traditional open approach.
Undoubtedly, the scarce comparative data reflect the declining indi- Troubleshooting
cations for vagotomy for intractable peptic ulcer disease.Thus, where- Inadvertent closure of the CBD may be prevented by inserting a
as laparoscopic HSV has been well described, it is by no means clear catheter into the duct. If the duodenum is markedly inflamed, suture
that it should be recommended over open HSV for those rare patients line breakdown is likely, eventually leading to a duodenal fistula. The
in whom this procedure is indicated. area can be isolated by means of pyloric exclusion or antrectomy with
More data are available on laparoscopic treatment of perforated Billroth II reconstruction. In addition, bile flow can be diverted by
duodenal ulcers. A meta-analysis of 13 studies comparing laparo- performing a choledochojejunostomy to a Roux-en-Y intestinal limb
scopic and open approaches to perforated peptic ulcers found that to prevent combined leakage of pancreatic fluid and bile.
laparoscopic repair yielded excellent results, albeit with a small but Diverticula arising from the third or the fourth portion of the duo-
insignificant increase in the reoperation rate.10 The laparoscopic denum may be approached via the transverse mesocolon and may be
approach is therefore considered as safe and effective as open Graham excised either primarily or via a transduodenal approach. Inverting the
patch repair.The procedures generally involve either suture closure of diverticulum without excising it is not recommended, because it may
the perforation followed by omentopexy or omentopexy alone, and lead to duodenal obstruction.
they should be attempted only by surgeons with advanced laparo-
scopic skills. The threshold for conversion to an open procedure
should be low if the ulcers are particularly large ulcers or prove diffi- Procedures for Gastric Cancer
cult to localize. Surgical resection remains the primary therapeutic modality for
gastric cancer [see 5:8 Tumors of the Stomach, Duodenum, and Small
DUODENAL DIVERTICULECTOMY
Bowel].The diagnosis of gastric cancer is primarily made by means of
Incidental duodenal diverticula are common. Such diverticula con- endoscopy with biopsy.There are numerous considerations that must
sist of a sac that includes only mucosa and submucosa, and most be addressed before operation, including the stage of the cancer on
occur within 2 cm of the ampulla of Vater. Complications include diagnostic imaging, the use of staging laparoscopy, the extent of the
ulceration and bleeding, compression of the CBD with cholangitis or planned gastrectomy, the extent of the planned lymphadenectomy, the
pancreatitis, and, in cases of perforation, abscess formation with peri- placement of feeding enterostomies, and the patient’s overall medical
tonitis. CT scanning is useful for differentiating this condition from fitness for surgery.
cholecystitis or pancreatitis. Surgery is rarely required; it is indicated
PREOPERATIVE EVALUATION
primarily for complications such as bleeding, perforation, and biliary
or duodenal obstruction. Endoscopy, with or without endoscopic ultrasonography (EUS), is
essential for diagnosis. Preoperative biopsy is helpful for confirming the
Operative Technique suspected pathologic process, particularly because the extent of resec-
The main surgical options are simple diverticulectomy with tion will be different if a less common lesion, such as a gastrointestinal
drainage and transduodenal diverticulectomy (as described by Iida11). stromal tumor (GIST), is identified. Endoscopic localization is critical
If the duodenum is free of inflammation, the transduodenal approach because the extent of the gastrectomy will depend on the precise loca-
is preferred because it minimizes the need for dissection of the diver- tion of the tumor. It should be noted, however, that the true location of
ticulum from the surrounding pancreas. However, if the diverticulum the tumor, as determined at laparotomy, may differ significantly from
does not involve the pancreas, simple excision flush with the duode- the preoperative estimate made on the basis of endoscopy. Abdominal
nal wall, followed by closure in two layers, may be sufficient.The ensu- CT scanning and chest radiography are indicated to rule out obvious
ing technical description focuses on transduodenal diverticulectomy. metastatic disease, which would be an indication for a more conserva-


tive surgical approach or even for nonoperative therapy.The preopera- It is generally agreed that total esophagectomy is required for type
tive physical examination should also focus on the detection of occult I esophagogastric junction tumors [see 4:4 Open Esophageal
metastatic disease, concentrating on such sites as the supraclavicular Procedures]. The necessary extent of resection for type II and III
lymph nodes and the pouch of Douglas. A bone scan is indicated if esophagogastric junction tumors has been more controversial. A
metastasis to bone is suspected. Laparoscopic staging (see below) may microscopically negative (R0) surgical margin is closely associated
be performed to identify occult metastatic disease (and, possibly, to with survival after resection of esophagogastric junction adenocarci-
prevent an unnecessary laparotomy in an otherwise ill patient).12 If the nomas, though R0 resection can be quite difficult to achieve, given
tumor is not bleeding or causing an obstruction, palliative resection the propensity of these tumors for intramural spreading. In our expe-
might be avoided. Generally, curative surgery should be attempted only rience, positive margins have not been found in patients with T1 or
when the tumor is believed to be limited to the stomach and the peri- T2 tumors, even when the margins are smaller than 4 cm. In patients
gastric lymph nodes. On occasion, however, curative-intent surgery with T3 or T4 tumors, however, proximal margins of at least 6 cm
may be considered for tumors that involve nearby resectable structures have proved necessary. For T1 and T2 tumors, total gastrectomy
(e.g., the transverse colon), provided that these structures can be without thoracotomy may yield adequate margins. For T3 and T4
removed en bloc with the primary lesion. tumors, however, extended gastrectomy with thoracotomy or
In Japan, where screening endoscopy is widespread, early gastric esophagectomy may be required.14 It is well documented that the
cancer is identified with some frequency. In Western countries, how- margin lengths measured on prefixed esophageal specimens are only
ever, the situation is different, and patients tend to present with more about 50% of the corresponding lengths measured in situ before
advanced cancers. Accordingly, although procedures such as wedge completion of resection.15 Accordingly, intraoperative decisions
resection for early gastric cancer have been described, most gastric about the extent of resection should be based on margin length
cancer patients in the United States require formal gastrectomy and requirements that may be considerably greater than those derived
lymphadenectomy. from resection specimens.

OPERATIVE PLANNING Extent of Lymphadenectomy
Considerable controversy has surrounded the question of how
Extent of Resection extensive lymphadenectomy should be for curative resection of gastric
The extent of the resection required for treatment of a gastric adenocarcinoma. One aspect of the controversy has to do with the
malignancy is determined primarily by the preoperative pathologic minimum number of lymph nodes required for analysis. It has been
diagnosis and the site of the tumor. Considerably smaller surgical suggested that a minimum of 15 lymph nodes must be removed dur-
margins are required for rare mesenchymal tumors (e.g., GISTs) than ing gastrectomy. In a study published in 2000, 5-year survival rates
are necessary for gastric adenocarcinomas, which tend to spread were significantly lower in patients with fewer than 15 lymph nodes
microscopically well beyond the gross extent of the tumor. Most mes- sampled than in those with 15 or more lymph nodes examined.16 This
enchymal tumors can be adequately treated with a wedge resection or decreased survival has been attributed primarily to understaging as
partial gastrectomy that achieves a 1 cm gross margin. Laparoscopic the result of inadequate lymphadenectomy (though, admittedly, there
approaches to such tumors have been described that employ either the is some disagreement on this point).
endoscopic GIA stapler or excision with suture closure [see The particular lymph node basins that should be sampled during
Laparoscopic Resection of Malignant Gastric Tumors, below]. Such gastrectomy has also been the subject of debate. Western surgeons
approaches may be facilitated by endoscopic tattooing of an appro- have usually limited lymphadenectomy to the perigastric (D1) lymph
priate margin or by intraoperative endoscopic guidance. For adeno- nodes. Surgeons in other countries, particularly Japan, have tended to
carcinomas, a margin of at least 5 cm is recommended. prefer a much more radical lymph node dissection that includes the
A 5 cm margin may be particularly difficult to achieve when the second-order (D2) nodes [see Figure 10]. Whereas Japanese surgeons
tumor is located along the lesser curvature. In many such cases, have reported better overall long-term stage-for-stage survival with
although the tumor appears to be distal and possibly amenable to a D2 lymph node dissections, Western surgeons have not found this
subtotal gastrectomy, a 5 cm negative margin along the lesser curva- approach to be quite so beneficial. Consequently, it has not been clear
ture would place the proximal resection margin far above the incisura whether more extensive lymph node dissection actually provides a
angularis and near the esophagogastric junction, thus necessitating survival benefit or simply improves surgical staging.To date, four ran-
total or near-total gastrectomy. For lesser-curvature tumors whose domized, controlled trials have failed to show any significant benefit
location allows adequate margins to be obtained, distal gastrectomy from extended lymph node dissection. In the largest such study, per-
with Billroth II gastrojejunostomy is preferred; for more proximal formed by the Dutch Gastric Cancer Group, more than 700 patients
tumors, total gastrectomy with esophagojejunostomy may be were randomly assigned to undergo either D1 or D2 lymphadenecto-
required. my.17 The 5-year survival rate was essentially the same in the two
Special consideration must be given to tumors of the esophagogas- groups; perioperative morbidity and mortality were significantly high-
tric junction. In the classification scheme described by Siewert and er after D2 lymphadenectomy.
colleagues,13 such tumors are defined as lying within 5 cm of the A subsequent study from the same group found that at 10 years
anatomic esophagogastric junction in either direction along the cran- after operation, D2 lymphadenectomy provided a benefit (in terms of
iocaudal axis of the esophagus and the stomach. They are classified lower local recurrence) only in the subgroup with positive second-
into three types as follows: order nodes; however, these patients could not be identified preoper-
atively.18 For the cohort as a whole, extended lymph node dissection
1. Type I: the center of the tumor lies 1 to 5 cm proximal to the generated no long-term survival benefit. Therefore, although some
esophagogastric junction. surgeons extend the lymphadenectomy to include lymph nodes along
2. Type II: the center of the tumor lies within 1 cm of the esopha- the left gastric, celiac, and common hepatic arteries (a so-called D1+
gogastric junction proximally or within 2 cm distally. dissection), the standard of care for surgeons in the United States con-
3. Type III: the center of the tumor lies 2 to 5 cm distal to the esoph- tinues to be a D1 lymphadenectomy that includes all perigastric
agogastric junction. lymph nodes and the greater omentum.


TOTAL GASTRECTOMY the relatively avascular plane. Gentle upward traction is placed on the
omentum to facilitate entry into the correct surgical plane [see Figure
Operative Technique 11]. If the procedure involves a formal D2 lymph node dissection, this
Step 1: incision and exposure The abdomen is entered via a is also a convenient time to enter the anterior leaf of the transverse
midline or bilateral subcostal incision. If a subcostal incision is utilized, mesocolon, which is resected with the anterior covering of the pan-
it may have to be extended past the xiphoid process in the midline for creas. (As noted, most U.S. surgeons perform a D1 resection or some
optimal exposure.Thorough exposure of the peritoneal cavity (includ- modification thereof and thus do not dissect the anterior peritoneal
ing the liver, all peritoneal surfaces, and, in women, the ovaries) is surface of the mesocolon and pancreas.)
undertaken to search for signs of metastatic disease. If the patient has With the dissection starting on the right side, the right gastroepi-
a proximal lesion near the gastric cardia, there may be a need for a tho- ploic artery is identified and ligated where it originates from the gas-
racotomy if the distal thoracic esophagus is to be included in the resec- troduodenal artery.The short gastric vessels are divided as the dissec-
tion specimen. If an incision into the thoracic cavity is being consid- tion proceeds along the greater curvature.The lesser omentum is also
ered, the left chest should be surgically prepared at the time of initial divided near the liver and is included with the specimen; care should
draping to allow extension of the incision across the lower left costal be taken to identify an aberrant left hepatic artery in the lesser omen-
margin if desired. In this setting, if thoracotomy is possible, preopera- tum (if present). The dissection is continued onto the peritoneal sur-
tive placement of a double-lumen endotracheal tube should be con- face of the distal esophagus.
sidered.The abdominal portion of a thoracoabdominal incision should
be performed first to allow assessment of resectability. Step 3: division of duodenum The duodenum is divided just
distal to the pyloric ring either with a GIA stapler or with a TA stapler
Step 2: dissection of omentum from colon The omentum is applied twice [see Figure 12]. The right gastric artery is identified and
separated from the colon with an electrocautery or scissors through ligated near its base. Division of the duodenum allows elevation and

a

4s
2

1

5

3
4s

6

4d

7

b 10
12
8 11
Figure 10 Illustrated are the differences between a 9
11
D1 lymphadenectomy and a D2 lymphadenectomy
for gastric cancer. (a) A D1 lymphadenectomy is
accomplished by removing the perigastric lymph
nodes with the resection specimen; these nodes
include those along the right and left cardia (1, 2), 14
those along the lesser curvature (3), those along the
greater curvature (4), the suprapyloric nodes (5),
and the infrapyloric nodes (6). (b) A D2 lym- 14
13
phadenectomy involves a more radical resection
specimen, which includes nodes along the left gas-
tric artery (7), the common hepatic artery (8), the
celiac artery (9), the splenic hilum (10), the splenic 16
artery (11), the hepatoduodenal ligament (12), the 15
posterior pancreas (13), the root of the mesentery
(14), the transverse mesocolon (15), and the aorta
(16).


Figure 11 Total gastrectomy. The omentum is dissect-
ed from the transverse colon with scissors or the elec-
trocautery. In the course of this dissection, the right
gastroepiploic artery is encountered near the pylorus
and divided near its base at the gastroduodenal artery.
The dissection continues along the greater curvature,
including ligation of the short gastric vessels. In a for-
mal D2 lymphadenectomy, the anterior leaf of the
transverse mesocolon and the anterior capsule of the
pancreas are dissected. In a D1 lymphadenectomy,
these structures are left alone.

rotation of the stomach, thereby facilitating access to the left gastric ischemic, the staple line may be inverted with Lembert sutures of
artery and the surrounding node-bearing tissue. 3-0 silk.
With the stomach gently retracted upward and anteriorly, dissection
identiﬁes the celiac axis and the left gastric artery [see Figure 13a].The Step 4: inclusion of necessary lymph nodes The degree of dis-
origin of the left gastric artery is ligated and divided, and a suture lig- section to be performed in the porta hepatis depends on the extent of
ature is placed on the proximal end. the planned lymphadenectomy. A D1 lymphadenectomy does not
A standard D1 lymphadenectomy does not include splenectomy require any of the lymph nodes in this area, but a D1+ lymphadenec-
and distal pancreatectomy.The spleen and pancreas are left in situ and tomy includes lymph nodes along the common hepatic artery. Gentle
are separated from the resection specimen by dividing and ligating the left lateral traction is placed on the stomach before division of the left
short gastric vessels (see above). gastric artery to apply some tension to the hepatic artery. The dissec-
tion proceeds along the celiac and hepatic arteries to the porta hepatis.
Troubleshooting. Leakage from the duodenal stump is a potential- The tissue surrounding the common hepatic artery and the left gastric
ly disastrous complication. If the stapled duodenum appears artery is swept medially with the specimen.

Figure 12 Total gastrectomy. The duodenum is divided
just beyond the pylorus with a GIA or TA stapler. The
duodenal staple line may be reinforced with interrupt-
ed Lembert sutures.

Right Gastroepiploic
Artery Divided


a b c

Spleen
Pancreas
Left Gastric Artery

Figure 13 Total gastrectomy. (a) The stomach is retracted cephalad to expose the left gastric vessels, which may be divided
and suture-ligated on the proximal side. Division of the distal esophagus should be preceded by placement of several stay
sutures on the proximal esophagus to prevent it from retracting into the posterior mediastinum. Reconstruction is then
carried out; options include stapled end-to-side esophagojejunostomy, hand-sewn end-to-side esophagojejunostomy, side-
to-side esophagojejunostomy, and anastomosis to a jejunal pouch. (b) In a stapled esophagojejunostomy, the anvil is secured
in the esophagus with a purse-string suture, an EEA stapler is inserted through the distal end of the Roux limb, and the
anastomosis is created to the antimesenteric side of the bowel. Once the anastomosis is complete, the end of the Roux limb
is amputated with a single firing of a GIA stapler. (c) A hand-sewn esophagojejunostomy may be fashioned with interrupted
full-thickness sutures (as shown), with a continuous full-thickness suture, or as a two-layer anastomosis. After completion
of the posterior row, a sump tube may be placed across the anastomosis into the proximal jejunum. After completion of the
anterior row, several reinforcing seromuscular sutures may be placed to reduce tension on the anastomosis.

Step 5: division of esophagus The peritoneum is divided over the suture of 3-0 or 2-0 polypropylene is placed in the esophagus and used
anterior esophagus, and the esophagus is completely dissected free of to secure the anvil of an end-to-end anastomosis (EEA) stapler. The
surrounding tissue.The esophagus is then divided either with a TA sta- body of the stapler is placed into the Roux limb, with the tip protrud-
pler or with a scalpel after the placement of a noncrushing bowel clamp. ing through the end, and the esophagojejunostomy is created on the
To keep the stump from retracting too far proximally, stay sutures of 2- antimesenteric border of the jejunum [see Figure 13b]. The open end
0 silk should be placed in the proximal esophagus before division. of the Roux limb is then closed with a TA stapler. To reduce tension
Alternatively, the specimen may be left attached and used as a handle on the anastomosis, the staple line may be reinforced with interrupted
to retract the proximal esophagus inferiorly. The esophagus may then Lembert sutures of 3-0 silk.
be divided after placement of the posterior suture line. Evaluation of the A hand-sewn end-to-side esophagojejunostomy is created in a sim-
proximal resection margin with frozen-section analysis is advisable. ilar fashion at a point near the end of the Roux limb on the antimes-
enteric border. The posterior row is placed first, with interrupted 3-0
Troubleshooting. The proximal margin may be found to harbor silk sutures as the outer layer and interrupted full-thickness 3-0
malignancy; if so, re-resection of the proximal margin should be per- absorbable sutures as the inner layer [see Figure 13c].The knots are tied
formed. Placement of stay sutures in the proximal esophagus is impor- on the inside of the bowel. The anterior row is then placed, with an
tant; if this is not done, the retracting esophagus may migrate into the inner layer of interrupted full-thickness 3-0 absorbable sutures and an
posterior mediastinum. outer layer of interrupted 3-0 silk sutures. Some surgeons prefer a sin-
gle-layer anastomosis, either with a continuous suture or with inter-
Step 6: reconstruction via esophagojejunostomy The options rupted full-thickness sutures. The available data do not favor either
for reconstruction after gastrectomy include stapled end-to-side single-layer or two-layer anastomosis in this setting.
esophagojejunostomy, hand-sewn end-to-side esophagojejunostomy, Side-to-side esophagojejunostomy requires a substantial length of
side-to-side esophagojejunostomy, and anastomosis to a jejunal pouch. intra-abdominal esophagus and necessitates extensive mobilization of
A Roux-en-Y jejunal limb is fashioned; to prevent biliary reflux, it the distal esophagus.The jejunum may be sutured to the underside of
should be at least 40 to 50 cm long.The Roux limb is then brought up the diaphragm to relieve tension on the anastomosis.
behind the colon to the esophagus. Some authors recommend Some authors report improved postoperative quality of life with a
antecolic placement of the Roux limb to prevent obstruction in the set- jejunal pouch reconstruction. For most patients with gastric cancer,
ting of recurrent disease; however, retrocolic placement may facilitate however, pouch reconstruction offers no distinct advantage.
a more tension-free anastomosis. Drains are not routinely placed; drain placement may increase the
For a stapled end-to-side esophagojejunostomy, a purse-string rate of leakage from the esophagojejunostomy.


Troubleshooting. Without a sufficient length of intra-abdominal but without division of the short gastric vessels.The omentum is sep-
esophagus, primary reconstruction can be difficult. Full mobilization arated from the transverse colon with the electrocautery, and the
of the intra-abdominal esophagus is essential. Because the esophagus entire omentum is taken with the specimen. A 5 cm proximal margin
lacks a serosa, transversely oriented Cushing-type sutures may be is ideal. Commonly, the stomach is divided at a point inferior to the
preferable to Lembert sutures on the anterior and posterior outer short gastric vessels and proximal to the incisura angularis.
layer of a hand-sewn anastomosis. Additional operative details and comments on postgastrectomy
complications are available elsewhere [see Procedures for Benign
Step 7 (optional): feeding enterostomy Many patients with Gastric and Duodenal Disease, Antrectomy, above].
gastric adenocarcinoma become significantly malnourished after gas-
LAPAROSCOPIC STAGING FOR GASTRIC CANCER
trectomy.The loss of the gastric pouch may adversely affect their abil-
ity to fulfill their caloric requirements in the early postoperative peri- The goal of laparoscopic staging before attempted curative resec-
od.To prevent further malnutrition, some authors recommend creat- tion of gastric carcinoma is to detect occult metastatic disease, the
ing a feeding jejunostomy at the time of total gastrectomy with presence of which may affect management. For example, if lapa-
esophagojejunostomy.The jejunostomy should be placed downstream roscopy reveals peritoneal studding in a patient who does not have
from the jejunojejunostomy (i.e., more than 50 cm distal to the anas- symptoms such as bleeding or obstruction, a decision may be made
tomosis).When a feeding enteroenterostomy is indicated, we prefer a to forgo attempts at resection. In the setting of T2 or T4 tumors,
Witzel jejunostomy. laparoscopic staging has been shown to detect occult metastases in
20% to 30% of patients.12
Complications The abdomen is explored with a 30º laparoscope inserted via an
D2 lymphadenectomy has been associated with numerous compli- umbilical port. To facilitate exposure, additional 5 mm ports may be
cations, including increased blood loss, longer operating time, colonic placed in the right upper and left upper quadrants. If laparoscopic
devascularization, pancreatitis, and pancreatic leakage. Although ultrasonography is available, one of the port sites should be 10 mm to
complication rates appear to be acceptably low when the procedure is allow passage of the ultrasound probe. Any suspicious lesion encoun-
done by an experienced surgeon, there is still the potential for the ben- tered is sampled and sent for frozen-section analysis.
efits of extensive lymphadenectomy to be outweighed by the addi-
LAPAROSCOPIC RESECTION OF MALIGNANT GASTRIC TUMORS
tional complications.
Anastomotic leakage at an esophagojejunostomy may lead to post- Laparoscopic gastrectomy is being performed with increasing fre-
operative infection. Intra-abdominal leaks may be managed by drain- quency. The principles of laparoscopic gastric resection are similar to
age via percutaneous drains or laparotomy, as well as by proximal naso- those of the corresponding open procedure, though extensive lymph
gastric drainage. High anastomotic leaks may result in contamination node dissections may be considerably more difficult with the mini-
of the posterior mediastinum or the pleural space, and thoracotomy or mally invasive approach. Currently, there are only a few centers where
tube thoracostomy may be necessary to achieve external drainage. laparoscopic resection of advanced gastric carcinoma is being per-
Occasionally, bleeding may be substantial enough to necessitate reop- formed with any frequency. Accordingly, it seems appropriate, for the
eration. In this situation, the gastric remnant may be entered via a trans- time being, to reserve laparoscopic gastrectomy for patients who have
verse incision just proximal to the anastomosis. As a rule, the bleeding very early cancers and those who are candidates only for palliative
can be successfully controlled by placing simple figure-eight sutures. resection.
Laparoscopic wedge resection may be appropriate for small lesions
DISTAL OR SUBTOTAL GASTRECTOMY
that are potentially benign or for malignant lesions for which exten-
Cancers of the distal stomach or antrum may be addressed by sive surgical margins are not required (e.g., GISTs [see Figure 14]).
means of a distal gastrectomy. Particular attention should be paid to The lesion is visualized intraoperatively by means of endoscopy or
tumors on the lesser curvature, where obtaining an adequate proximal marked preoperatively with India ink. Laparoscopic sutures are
margin may be a problem [see Operative Planning, Extent of placed in the tissue surrounding the lesion, then retracted upward so
Resection, above]. The dissection proceeds as in a total gastrectomy, that the portion of the gastric wall containing the lesion is elevated. A

Figure 14 Laparoscopic resection of
GIST. The tumor is visualized preopera-
tively and marked with India ink; alterna-
tively, the tumor may be identified intraop-
eratively by means of endoscopy and its
location marked with a suture. Traction
sutures may be employed to “tent up” the
lesion, thereby isolating it from the
remainder of the stomach. The tumor is
then resected with several firings of an
endoscopic linear stapler. For lesions high-
er along the greater curvature near the car-
dia, wedge resection should be performed
with an esophageal bougie in place to pre-
vent inadvertent narrowing of the esopha-
gogastric junction.


a b

Superior Mesenteric
Artery and Vein

Duodenum
Incision
in Paracolic
Peritoneum Area of Mesentery
to be Elevated Pancreas

Figure 15 Local resection of duodenal tumors. Mobilization of the right colon and upward retraction of the small
bowel mesentery allows direct access to the third and fourth portions of the duodenum. Sleeve resection of the duo-
denum with subsequent duodenojejunostomy can then be performed. (a) Avascular peritoneal attachments of the
right colon are divided, as well as avascular attachments underneath the small bowel mesentery. Dotted lines
enclose the area of mesentery to be elevated from posterior attachments. (b) Cephalad retraction of the right colon,
the small bowel, and the mesenteric vessels allows exposure of the third and fourth portions of the duodenum.

wedge resection is then performed with an endoscopic stapler. denectomy may be required. Exposure may be achieved through an
Intraoperative assessment of the surgical margin by a pathologist is upper midline or right upper quadrant incision.
useful to ensure that the margin is negative.
Operative Technique
The duodenum is mobilized with an extensive Kocher maneuver.
Procedures for Duodenal Cancer The tumor is palpated and approached via a longitudinal duodenoto-
my.The tumor is grasped and everted, and a full-thickness portion of
LOCAL RESECTION OF DUODENAL TUMORS
the duodenal wall is resected with the mass. Stay sutures are placed at
Small duodenal tumors (e.g., polyps, villous adenomas, small the ends of the duodenotomy, and the duodenotomy is closed trans-
GISTs, and neuroendocrine tumors) are occasionally amenable to versely, either with a TA stapler or with sutures. If a transverse closure
local surgical resection. The diagnosis must be conﬁrmed by endo- would place too much tension on the suture line, a longitudinal clo-
scopic biopsy before resection. Endoscopy is also useful for localiza- sure is undertaken. If possible, omentum is placed over the duodenal
tion of the lesion with respect to the ampulla and pancreatic head. closure.
Lateral lesions are removed by local resection far more easily than
lesions on the medial wall are. Troubleshooting
Intraoperative endoscopy may be required to locate small duodenal
Operative Planning lesions that cannot be palpated. During dissection, the location of the
Endoscopic conﬁrmation of the diagnosis and localization of the ampulla can be determined by passing a Fogarty catheter into the cys-
lesion are crucial for operative planning. In addition, appropriate tic duct, down the CBD, and through the ampulla. This measure
patient selection is essential. Local resection may be inappropriate for requires that a cholecystectomy be done.
lesions close to the ampulla of Vater, for large duodenal lesions, for
RESECTION OF DISTAL DUODENAL TUMORS
carcinomas, or for lesions on the medial aspect of the duodenum
abutting the pancreas. For lesions in the second or third portion of the Lesions of the distal duodenum (e.g., GISTs, carcinoids, and, rarely,
duodenum that are not amenable to local excision, pancreaticoduo- adenocarcinomas) are occasionally amenable to sleeve resection. Preop-


erative CT and endoscopy are essential to the workup of such lesions. Step 2: resection and anastomosis The duodenum is divided
Endoscopic biopsy should be performed if it is technically feasible. with the stapler approximately 1 cm proximal to the tumor. If pancre-
atic invasion is identified, pancreaticoduodenectomy should be con-
Operative Technique sidered.The distal bowel is brought through the transverse mesocolon,
Step 1: exposure of duodenum Operative access to the distal and a side-to-side duodenojejunostomy is created with an outer layer
duodenum is limited by the presence of the superior mesenteric ves- of 3-0 silk and inner layer of 3-0 polyglactin. Alternatively, the anasto-
sels and the transverse mesocolon. The third and fourth portions of mosis may be performed to the second portion of the duodenum.
the duodenum may be approached either by moving the duodenum
under the mesenteric vessels or by temporarily mobilizing the mesen- Troubleshooting
teric vessels. In the first approach, the distal duodenum and the prox- The blood supply to the third portion of the duodenum arises from
imal jejunum are mobilized upward by dissecting the ligament of numerous branches of the inferior pancreaticoduodenal arcade, each
Treitz away from its mesenteric attachments. The proximal jejunum of which must be meticulously dissected, divided, and ligated to pre-
is divided with a stapler. After extensive mobilization, the duodenum vent pancreatic trauma. The distal duodenum receives its blood sup-
is passed under the superior mesenteric vein and artery and moved to ply from branches of the superior mesenteric artery.
the right side of the abdomen. The duodenum should not be simply closed distally and drained
In the second approach, the superior mesenteric vessels are mobi- via a gastrojejunostomy; if this is done, the proximal duodenum will
lized upward to expose the third portion of the duodenum. The right not be properly decompressed.
colon is mobilized cephalad by incising the peritoneum along the white
line of Toldt from the hepatic flexure to the cecum [see Figure 15a]. Di- Complications
vision of the peritoneum is then continued along the cecum and medi- Delayed gastric emptying is common with duodenojejunosto-
ally to liberate the terminal ileum.The avascular attachments between my; it generally responds to prolonged conservative therapy. A
the small bowel mesentery and the retroperitoneum are divided by delay in the return of bowel function should generally be treated
means of cauterization and gentle blunt dissection [see Figure 15b]. with nasogastric suction; on occasion, a percutaneous gastrostomy

a b
c

c
Figure 16 Ampullectomy. (a) After a longitudinal duodenotomy
is made, the CBD is cannulated. Circumferential stay sutures of
4-0 polydioxanone are placed in the duodenal mucosa. A 2 cm
periampullary tumor is visualized. (b) The ampullary tumor is
removed from the underlying duodenum with the electrocautery.
The CBD and the pancreatic duct are entered and separately
cannulated. The CBD duct is typically seen at the 11 o’clock
position, and the pancreatic duct is typically encountered at the
3 o’clock position. (c) The duodenal mucosa is sutured directly to
the CBD and the pancreatic duct with 4-0 polydioxanone. In
addition, the CBD and pancreatic duct are carefully connected
with 4-0 polydioxanone sutures.


is required for proximal decompression. Postoperative pancreatitis the distal pancreatic duct [see Figure 16]. A Kocher maneuver is per-
may occur secondary to operative trauma; conservative manage- formed, and a longitudinal duodenotomy is made to expose the
ment is usually sufficient. ampulla. Identification of the ampulla may be facilitated by placing a
Fogarty catheter in the CBD via the cystic duct after a cholecystecto-
AMPULLECTOMY
my. If the ampulla is identified during exploration, it may simply be
Local periampullary resection is indicated primarily for rare benign cannulated. Circumferential stay sutures are placed in the mucosa.
lesions, small neuroendocrine tumors of the pancreas, and small ade- The CBD is entered at approximately the 11 o’clock position, and
nomatous or villous polyps.The likelihood of occult malignancy in an duodenal mucosa is reattached to the duct with 4-0 polydioxanone
adenomatous periampullary tumor is significantly higher when the sutures. The pancreatic duct is encountered at approximately the 3
lesion is larger than 2 cm; caution is therefore indicated in attempting o’clock position; it may be cannulated separately to facilitate identifi-
local resection of lesions of this size. The recurrence rate is high after cation.The pancreatic duct is approximated to the CBD, and the infe-
local resection of any periampullary adenocarcinoma. The preopera- rior pancreatic duct is sewn to the duodenal wall. The duodenum is
tive workup should include endoscopy with biopsy, EUS or transab- closed transversely in two layers.
dominal ultrasonography, CT scanning, and endoscopic retrograde
cholangiopancreatography (ERCP). Troubleshooting
Frozen-section analysis may identify invasive adenocarcinoma,
Operative Technique which is an indication for pancreaticoduodenectomy. This possibility
The ampulla of Vater is resected together with the distal CBD and should be carefully considered before the operation.

References

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