gastrectomia en tumor gastrico Sosa R2.pptx

Las técnicas de gastrectomia, total y parcial

1. Técnica quirúrgica de estómago y sangrado digestivo alto

2. PERSTECTIVA HISTORICA En 1602 Florian Mathies – primera gastrectomía victoriosa por un cuchillo tragado E n 1793 Mathew Baille – primera descripción acertada para ulcera y cáncer gástrico Siglo 19no , Benjamin Travers reporte de perforación duodenal E n 1810 Karl Theodor Merrem , - primera pilorectomia victoriosa en un perro

3. PERSPECTIVA HISTORICA Prof. Theodore Billroth Primera gastrectomía parcial (Billroth I) e n 1882 Woeffler – Primera Gastroyeyunostomia Primera anastomosis-en-y para convertirse en la corta venida de la Gastro-jejunostomia Cesar Roux of Lausanne popularizo la anastomosis-en-y Prof. Theodore Billroth desarrolló el (Billroth II) Gastrectomía parcial para un tumor pilórico inresecable

4. CIRUGIA GASTRICA EN EL TRATAMIENTO CANCER GASTRICO EXTENCION DE LINFADENECTOMIA D0 – Disección incompleta D1 – Grupo 1 (Peri-gastric o) ganglios linfáticos – ( Estación 1 to 6) D2 – Grupo 1 & II ( Estación 7 a 11 ) D3 – Grupo I, II & III ( Estación 12 a 14) D4 – Gr upo I, II, III y nódulos paraaortic os y paracolic os ( estación 15 y 16)

5. CIRUGIA GASTRICA EN EL TRATAMIENTO DEL CANCER MARGENES DE RESECCION R0 – Resección macro y micro completa R1 – Resección macro completa pero márgenes microscópicos positivos R2 – Resección macro y micro incompleta Márgenes de al menos 3 cm para T2 o profundos con patrón de crecimiento expansivo ( tipo 1 y 2) Márgenes de al menos 5 cm para aquellos con patrón de crecimiento infiltrativo ( tipos 3 y 4). Cuando no se puede alcanzar esta meta entonces examinar los márgenes proximales por congelación

6. CIRUGIA GASTRICA EN TRATAMIENTO DEL CANCER GASTRICO Cirugía curativa Gastrectomía estándar Principal procedimiento quirúrgico realizado con intento curativo Envuelve resección de al menos 2/3 de estomago con disección de linfáticos D2 . Gastrectomía no estándar La extensión de la resección gástrica y la linfadenectomia es alterada de acuerdo al estadio tumoral.

7. CIRUGIA GASTRICA EN EL TRATAMIENTO DEL CANCER Cirugia curativa Cirugía modificada La extensión de la resección gástrica y la linfadenectomia es reducida (D1, D1+, etc.) comparada a la cirugía estándar Cirugía extendida Gastrectom ia con resección combinada de órganos envueltos adyacentes y Gastrectomía con linfadenectomia extensa excediendo D2

8. CIRUGIA GASTRICA EN EL TRATAMIENTO DEL CANCER Cirugia no curativa Cirugía paliativa Cirugía para aliviar síntomas e.g., obstruc c ion, sangrado Gastrectomía paliativa or gastroyeyunostomia Las opciones dependen de la resecabilidad del tumor primario y el riesgo quirurgico Cirugía de reducción Ayuda a prolongar supervivencia o a dilatar el establecimiento de síntomas a través de la reducción del volumen del tumor

9. TYPES AND DEFINITIONS OF GASTRIC SURGERY Types of Gastrectomies based on volume of stomach resected Total - All the stomach is removed including the cardia and pylorus Near Total - >90% of stomach is resected Subtotal – 80 to 90% Partial – 65 to 75% Hemigastrectomy – 50% Distal Gastrectomy – 35 to 50%

10. TYPES AND DEFINITIONS OF GASTRIC SURGERY Total gastrectomy -- Total resection of the stomach. Distal gastrectomy – resection of distal 2/3 of the stomach including the pylorus Pylorus-preserving gastrectomy (PPG) Preserving the upper 1/3 of the stomach and the pylorus along with a portion of the antrum. Proximal gastrectomy - resection includes the cardi whiles preserving the pylorus

11. TYPES AND DEFINITIONS OF GASTRIC SURGERY Anatomical Extent of Gastric Resection Segmental gastrectomy – Circumferential resection of the stomach preserving the cardia and pylorus. Local resection . Non- resectional surgery -- (bypass surgery, gastrostomy, jejunostomy).

12. Types of Reconstruction after Gastrectomy Total Gastrectomy Roux-en-Y esophagojejunostomy. Jejunal interposition. Colonic interposition Distal gastrectomy Billroth I gastroduodenostomy. Billroth II gastrojejunostomy. Roux-en-Y gastrojejunostomy. Jejunal interposition. Pylorus-preserving gastrectomy Gastro-gastrostomy. Proximal gastrectomy Esophagogastrostomy. Jejunal interposition. Double tract method.

13. GENERAL INDICATIONS OF GASTRECTOMIES Complication of Peptic Ulcer Disease Intractable/Non-healing PUD Recurrent bleeding Large duodenal ulcer perforations -- > 1cm Neoplastic lesions (benign or malignant) – for curative or palliative measures Adenocarcinoma of the stomach Primary gastric melanoma Gastrointestinal stromal tumors (GISTs)

14. INDICATIONS OF GASTRECTOMIES Nutritional therapy Obesity – Sleeve gastrectomy Corrosive stricture of the stomach Trauma

15. INDICATIONS FOR TOTAL GASTRECTOMY Total Gastrectomy Extent or location of tumor does not permit adequate resection of the tumor Tumors located in body, cardia or fundus of the stomach Diffuse type of tumor -- linitis plastica Subtotal Gastrectomy Tumors limited to the antropyloric region Benign ulcers Nutritional therapy

16. PRE-OPERATIVE PREPARATION History taking Physical examination Diagnostic Investigations Upper GI Endoscopy with Biopsy -- to confirm or rule out neoplasm Abdominal CT Scan -- Involvement of adjacent structures Laparoscopy -- Tumor spread, fixity of tumour Supportive Investigations FBC, GXM, BUE and Cr, LFT, Chest Xray, ECG, ECHO

17. PRE-OPERATIVE PREPARATION Optimize the patient Correction of anaemia Correction fluid and electrolyte imbalances Correction of hypoalbuminaemia Bowel preparation Gastric lavage starting at least 5 days before surgery Repeat 1 to 2 hrs. before surgery Effluent must be clear before surgery Prophylactic antibiotic at the time of induction

18. PRE-OPERATIVE PREPARATION Anaesthesia General anaesthesia with cuffed ET tube Adequate muscle relaxation Position Supine on a flat table with mild reverse Trendelenburg position.

19. SURGICAL TECHNIQUE Incision Midline or paramedian abdominal incision OR Chevron or rooftop incision (Self-retaining subcostal retractors)

20. SURGICAL TECHNIQUE Exploration Note any ascites and peritoneal deposits Explore from the pelvis to toward the stomach Examine the greater omentum, para-aortic and the lymph nodes of the mesentery Examine the full length of the small and large bowel Draw the omentum caudally to examine the supracolic compartment

21. SURGICAL TECHNIQUE Exploration Examine the liver, adjacent diaphragm, gall bladder, free edge of lesser omentum. Examine the spleen, kidneys and adrenals Starting from the oesophageal hiatus and working distally, look and feel for the tumour involvement, fixity, glands Avoid handling or squeezing the tumor if possible Examine the duodenum, pancreas and the coeliac axis

22. SURGICAL TECHNIQUE Mobilization and Resection The greater omentum is freed from the transverse colon Dissect out the gastro-epiploic nodes Doubly ligate and divide the right gastro-epiploic vessels

23. SURGICAL TECHNIQUE Mobilization and Resection Incise the anterior leaf above the pylorus and towards the cardia The right gastric vessel and the Suprapyloric nodes will be revealed Identify the right gastric and right gastro-epiploic arteries

24. SURGICAL TECHNIQUE Duodenal Division Mobilize the 5 -6 cm of duodenum for division ( Kochers manoeuvre) Transect the duodenum with a linear stapler 1cm distal to the pylorus For total gastrectomy – proximal limit is the gastro-oesophageal junction.

25. SURGICAL TECHNIQUE Gastric Transection Divide the gastrosplenic ligament. Landmarks for Subtotal Gastrectomy 2 nd short gastric artery along the greater curvature 1 cm inferior to the esophagogastric junction along the lesser curvature

26. BILLROTH I RECONSTRUCTION A posterior row of interrupted seromuscular silk sutures between the duodenum and the stomach The superior portion of the duodenal staple line is removed The gastric staple line is opened corresponding to duodenal opening. A Posterior Mucosal layer continuous suturing with 3-0 Vicryl An Anterior Mucosal Layer continuous suturing with 3-0 Vicryl Anterior Seromuscular layer interrupted suturing with silk

27. BILLROTH II RECONSTRUCTION Choose a loop of the proximal jejunum The omega loop is pulled through the transverse colon mesentery Open the closure of the distal gastric remnant The posterior layers are sutured using use single stitches or a running suture For the anterior anastomosis, a running inverting suture is adequate An associated Braun's entero-enterostomy can be done to prevent bile reflux Side-to-side jejunostomy is done either with single stitches, a running suture, or a stapler device

28. BILLROTH II RECONSTRUCTION

29. BILLROTH II RECONSTRUCTION

30. BILLROTH II RECONSTRUCTION

31. BILLROTH II RECONSTRUCTION

32. ROUX-EN-Y RECONSTRUCTION The ligament of Treitz is identified Jejunum is dissected about 40–50cm distal to Treitz’ ligament A retro-colic passage is made for the jejunum loop The distal loop is placed side-to-side to the posterior wall of the gastric remnant. A side-to-side enteroenterostomy is then constructed

33. RECONSTRUCTION AFTER TOTAL GASTRECTOMY Loop esophagojejunostomy with entero-enterostomy Roux-en-Y reocnstruction Esophagojejunostomy Roux-en-Y configuration (end-to-side or end-to-.end) Esophagojejunostomy Roux-en-Y double tract configuration. Esophagojejunostomy with jejunal segment interposition by Longmire Colonic interposition

34. RECONSTRUCTION OPTIONS AFTER TOTAL GASTRECTOMY Choose a loop of the proximal jejunum The omega loop is pulled through the transverse colon mesentery Open the closure of the distal gastric remnant The posterior layers are sutured using use single stitches or a running suture For the anterior anastomosis, a running inverting suture is adequate An associated Braun's entero-enterostomy is done between the loops pf jejunum

35. Roux-en-Y configuration RECONSTRUCTION AFTER TOTAL GASTRECTOMY

36. Roux-en-Y configuration RECONSTRUCTION AFTER TOTAL GASTRECTOMY

37. MODIFIED VERSIONS OF R-Y RECONSTRUCTION RY configuration was modified by Hunt and Lawrence by creating a jejunal pouch Ω-pouch, S-pouch, and an aboral pouch

38. MODIFIED VERSIONS OF R-Y RECONSTRUCTION Esophagojejunostomy Roux-en-Y double tract configuration

39. Esophagojejunostomy with jejunal interposition

40. JEJUNAL INTERPOSITION

41. POSTOPERATIVE CARE Nurse patient in a propped-up position when conscious Maintain NG tube and Keep NPO IV Fluid Maintenance Strict monitoring of fluid and electrolytes IV antibiotics IV analgesics and PPI DVT Prophylaxis and Early Ambulation Chest physiotherapy Light diet can resume on POD 3

42. COMPLICATIONS Early Complications Intra-gastric haemorrhage Extragastric haemorrhage Duodenal Blowout Stomal Obstruction Afferent loop obstruction Jejunal loop obstruction Gastric remnant necrosis Postoperative pancreatitis Common bile duct injury Omental infarction

43. COMPLICATIONS Late Complications Dumping syndrome Recurrent ulcers Small gastric remnant syndrome Gastric remnant carcinoma Roux stasis syndrome Gastrojejunocolic fistula Chronic afferent loop obstruction Chronic efferent loop obstruction Internal hernia Jejunogastric intussusception

44. EARLY COMPLICATIONS Dumping Syndrome Early Dumping (15 -30min after meals) Abrupt delivery of hyperosmolar load into the small bowel Diaphoretic, weak, light-headed, and tachycardic Crampy abdominal pain, Diarrhoea Treatment – Recumbency and Infusion of NS Late Dumping (2- 3hrs after meals) Reactive (post-prandial) hypoglycaemia Relieved with sugar (dextrose)

45. POSTGASTRECTOMY PROBLEMS Treatment of Dumping Syndrome Dietary management Avoids liquids during meals Avoid Hyperosmolar liquids (e.g., milk shakes) Encourage High fibre diets Medical therapy Indicated if dietary measures are still inadequate SC Octreotide 100ug BD (can be increased to 500ug BD) α- glucosidase inhibitor (acarbose) – useful in late dumping Operative management Roux-en-Y is the preferred choice

46. POSTGASTRECTOMY PROBLEMS Gastric Stasis Mechanical cause anastomotic stricture, efferent limb kink from adhesions or constricting mesocolon, or a proximal small-bowel obstruction). Functional cause Retrograde peristalsis in the Roux-limb Clinical features – vomiting of undigested food, bloating, epigastric pain, and weight loss. Investigation EGD, upper GI and small bowel series, gastric emptying scan, and gastric motor testing Treatment Dietary modification with promotility agents Intermittent oral antibiotics

47. POSTGASTRECTOMY PROBLEMS Diarrhoea Dietary management +/- Some patient respond to codeine or loperamide Octreotide can also be started if symptoms are persistent

48. POSTGASTRECTOMY PROBLEMS Bile Reflux Gastritis and Oesophagitis Gastritis component - ablation or resection of the pylorus Oesophageal component - Dysfunction of the cardia Nausea, bilious vomiting, and epigastric pain,

49. POSTGASTRECTOMY PROBLEMS Roux syndrome Disruption of the antegrade contractions in the Roux limb Vomiting, epigastric pain, and weight loss Investigations Endoscopy – Retained food or bezoars Dilation of the gastric remnant, Dilation of the Roux limb Upper GI Series – delayed gastric motility (Confirmatory test) GI motility testing – regrade propulsive activity

50. POSTGASTRECTOMY SYNDROMES Roux syndrome Medical Treatment Promotility agents Surgical Treatment Options Paring down the gastric remnant (Gastric trimming) Near total or Total Gastrectomy Resection of Roux-limb (if dilated and flaccid) with Another Roux reconstruction Billroth II with Braun gastroenterostomy Henley loop

51. POSTGASTRECTOMY SYNDROMES Afferent loop Syndrome Intrinsic or extrinsic obstructive process along the afferent limb or at the distal anastomosis Aetiology Post-operative adhesion Internal hernia Volvulus of the intestinal segment Kinking of the afferent limb at the gastrojejunostomy Scarring due to marginal (stomal) ulceration Treatment Conversion to a Roux-en-Y Billroth I reconstruction

52. Afferent loop Sydrome

53. POSTGASTRECTOMY SYNDROMES Efferent Loop Syndrome Cause Herniation of limb behind the anastomosis Investigation Barium meal – failure of contrast to enter efferent loop Treatment Reducing the retro-anastomotic hernia and closing the retro-anastomotic space

54. POSTGASTRECTOMY PROBLEMS Gallstones Vagal denervation causing gall bladder dysmotility and stasis. Treatment – Cholecystectomy during gastrectomy Weight loss

55. POSTGASTRECTOMY PROBLEMS Anaemia Reduced production of gastric acid and intrinsic factor Poor absorption of iron, B12 and folic acid Periodic assessment for iron and B12 deficiency Supplemental iron and B12 Bone Disease Malabsorption of Ca2+ and fat (including at soluble Vitamin D) Presents as pain and/or fractures years after the index operation Supplement Calcium and Vitamin D Periodic skeletal survey