upper GI anastomosis principles - master of surgery

Learn about the Upper GI anastomosis principle the right way.

1. Principles of anastomosis in UPPER GI Asst. Prof. Dr. Azrin waheedy ahmad DEPartment of Surgery Kuliyyah of Medicine IIUM KUANTAN ADVANCE ANASTOMOSIS, BOWEL STAPLING AND TISSUE MANAGEMENT WORKSHOP 2024

2. Content Introduction Oesophagus Stomach Miscellaneous

3. introduction General surgeon and upper GI surgery Emergency – perforation/ bleeding/ obstruction Elective – benign diseases Reconstruction and anastomosis Hand sewn vs Stapler or hybrid Oesophagus , Gastric, Jejunum/ileum

4. oesophagectomy Indication – benign and malignant Total Oesophagectomy Cervical – oesophagogastric anastomosis Distal Oesophagectomy Thoracic – oesophagogastrectomy Location differs but principles remain similar Reconstruction with gastric conduit VS colonic / jejunal transposition

5. Reconstruction options

6. Oesophagogastrostomy Single layer vs double layer Handsewn vs stapler (open or laparoscopic) Oesophagus – no serosal layer (adventitia) 2 layers of muscle Stomach – thick 3 muscular layer with serosa present

7. Oesophagogastrostomy handsewn Pre-requisite – CONDUIT NOT TWISTED AND VIABLE #1 Transection of oesophagus – mucosa transected 1-2cm distal to muscular transection to avoid mucosal retraction #2 oesophageal important layer mucosa and submucosa #3 stomach full thickness suturing #4 Interrupted Absorbable 3/0 suture – start with posterior wall. #5 don’t forget to pass NG tube before completing the anterior wall.

8. Oesophagogastrostomy handsewn #6 Insert drain - cervical or chest drain “optional sump drain for stomach decompression”

9. Oesophagogastrostomy stapler Open method or laparoscopic CDH 25mm stapler Anvil is secured in the oesophagus using pursestring suturing Gastrotomy performed over area near stapler line or more distal stomach

10. Oesophagogastrostomy stapler Orvil Circular stapler Suitable for open or laparoscopic Comparable outcome to open technique

11. stomach Total gastrectomy with Roux-en-Y reconstruction Oesophagojejunostomy Jejunojejunostomy Distal Gastrectomy / Subtotal gastrectomy/ Gastric bypass or pyloric exclusion Billroth 1 reconstruction - Gastroduodenostomy Billroth 2 reconstruction - Gastrojejunostomy

12. Total Gastrectomy with Roux-en-y reconstruction #1 transect jejunum 15-20cm from Ligament of Treitz to reduce afferent loop syndrome. #2 distal jejunum brought up to oesophagus as Roux limb #3 Proximal jejunum is anastomosed to roux limb 40 cm from eosophagojejunostomy to prevent bile reflux #4 Antecolic or retrocolic approach depends on indication.

13. oesophagojejunostomy Handsewn anastomosis - similar principle to oesophagogastrostomy 3/0 absorbable interrupted or continuous Double layer technique is possible with minimal risk of luminal narrowing – surgeon’s preference Staple anastomosis using CDH 25 If possible pass NG tube through the anastomosis.

14. Oesophagojejunostomy pouch creation options

15. jejunojejunostomy 40cm from oesophagojejunal anastomosis End to side or side to side Handsewn or Stapler Absorbable 3/0 suture Full thickness suturing with outer Lembert suturing. Connell suturing technique

16. Distal gastrectomy Gastroduodenostomy – BILlroth 1 Duodenum transected 2 cm beyond the pylorus Kocher manouvre is needed for tension free anastomosis Closure in 2 layers 3/0 absorbable continuous manner Connell suturing for the corners Beware ANGLE OF SORROW – Junction between handsewn segment with the stapler edge.

17. Distal gastrectomy Gastroduodenostomy – BILlroth 1 Stapler techniques is also feasible Rarely done

18. Distal gastrectomy Gastrojejunostomy - Billroth 2 Advantage over BILLROTH 1 Less dissection larger anastomosis – Polya gastrectomy Ideal anastomosis placement – posterior distal stomach – promote emptying

19. Distal gastrectomy Gastrojejunostomy - Billroth 2 Handsewn – full thickness anastomosis with Lembert 2 nd layer 3/0 absorbable continuous suturing Jejunum 20-30cm from Ligament of Treitz brought up for anastomosis Most commonly done side to side anastomosis Iso peristaltic configuration Antecolic VS Retrocolic approach Stapler option available

20. Gastric bypass/ pyloric exclusion – billroth 2 Useful technique when dealing with severe duodenal injury beyond D1 Bypass procedure for duodenal stricture/ obstruction (palliative). Antecolic vs retrocolic If malignant disease – better to be placed higher but posteriorly Retrocolic approach – to suture stomach wall to the transverse mesentery to avoid internal herniation

21. Gastric bypass/ pyloric exclusion – billroth 2 Handsewn or stapled Handsewn – full thickness anastomosis with Lembert 2 nd layer 3/0 absorbable continuous suturing The pyloric exclusion suture will be absorbed later and allow some passage through the duodenum.

22. miscellaneous Wedge resection Enterotomy Meckels diverticulum Closure perpendicular to the bowel axis to avoid stricture 3/0 interrupted absorbable

23. Nissen duodenal stump closure Closure of duodenal perforation with fibrotic ulcer adherent to pancreas Dissect the stomach and duodenum around the ulcer leaving the posterior wall still attached. Suture the anterior wall onto the posterior wall ulcer base (onto itself) Cover the area with omentum Billroth 2 reconstruction T-tube duodenostomy to avoid stump blow out

24. Bancroft procedure for complicated duodenal ulcer stomach wall and muscle dissected proximal to pylorus Pursestring suture applied to submucosa Avoid transfixing the mucosa – ischaemia lead to leaking Seromuscular layer closed over the submucosa pursestring and cover with omentum Drain placement Billroth 2 reconstruction

25. Conclusion Oesophagus suturing – suture mucosa and submucosa Suture strength lies within the submucosa Single layer vs double layer Stomach – full thickness Good blood supply Small bowel Adequate blood supply Double layer closure for security Adhere to anastomotic principles proper orientation, no twisting Tension free Air tight Water tight Proper suturing placement / technique – approximating and not constricting

26. references Kirk’s General Surgical Operation, 6 th Ed, 2013 Maingot’s Abdominal Operations, 12 th Ed, 2013 Skandalakis’s Surgical Anatomy and Technique, 5 rd Ed, 2021 Farguharson’s Textbook of operative general surgery,10 th Ed, 2015