Partial gastrectomy with Roux-en-Y gastrojejunostomy

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  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Surgical anatomy of the stomach

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    In terms of function, the stomach mixes and stores food and is an expansion of the alimentary tract between the esophagus and the duodenum. This muscular hollow viscus produces acidic gastric juice (mucus and HCl) and enzymes, which predigest some elements of the ingested food, and portions the chyme into the duodenum.

    Usually, the stomach is located immediately inferior to the diaphragm in the left upper quadrant and medial epigastrium. Location, size and shape of the stomach vary from person to person and may differ substantially, depending on age, filling condition and body position. The moderately filled stomach has a mean length of 25-30 cm and can hold 1.5 liters, in extreme cases up to 2,5 liters.

    Within the abdominal cavity the stomach is held in position and stabilized by ligaments inserting at the liver and spleen Its convex aspect forms the major curvature (curvatura major gastrica) and its concave aspect the lesser curvature (curvatura minor gastrica). Its anterior wall is termed paries anterior gastrica and its posterior aspect paries posterior gastrica.

    Since the stomach is an intraperitoneal viscus, it is covered by the gastric serosa (tunica serosa gastrica), and only the posterior aspect of the cardia is free of serosa. Stomach rotation shifts the embryonic mesogastrics from their former sagittal position to a frontal location. The lesser omentum originates at the lesser curvature and extends to the hepatic portal, while the greater omentum originates at the greater curvature and courses to the transverse colon, spleen and diaphragm.

    The stomach displays the following portions:

    Entrance of stomach / Cardia / Ostium cardiacum:
    The superior opening of the stomach, where the esophagus enters the stomach, is 1-2 cm long. It is characterized by a marked transition from the mucosa of the esophagus to that of the stomach.

    Gastric fundus / fundus gastricus:
    Superior to the level of entrance of the esophagus the fundus arches cephalad, which then is called gastric fornix (fornix gastricus). Usually, the fundus is full of air which is swallowed automatically when ingesting food. In the erect position the fundus is the highest point of the stomach, and on abdominal films its trapped air is evident as the “gastric bubble”. A notch (incisura cardialis) clearly delimits the fundus from the entrance of the stomach.

    Body of the stomach / Corpus gastricum
    The main portion of the stomach is taken up by the gastric body. The deep mucosal folds (plicae gastricae) found here extend from the cardia to the pylorus and are also known as “magenstrasse”.

    Pylorus / Pars pylorica:
    This portion begins with the extended pyloric antrum, followed by the pyloric canal, and terminates at the actual pylorus. It is formed by the pyloric sphincter (m. sphincter pyloricus), a strong circular layer of muscle which closes off the inferior gastric orifice (ostium pyloricum). The pylorus closes off the gastric outlet and periodically lets some of the chyme pass into the adjacent duodenum.

  • Layers and structure of the gastric wall

    Gastric wall

    Under the microscope the gastric wall displays a characteristic layered structure with the following sequence from the inside out:

    • The internal aspect of the gastric wall is lined by mucosa (tunica mucosa). The gastric mucosa is made up of three sublayers: The lamina epithelialis mucosae produces viscous neutral mucus which protects the gastric mucosa against mechanical, thermal and enzymatic injury. This is followed by the loose connective tissue coat of the lamina propria mucosae into which the gastric glands (glandulae gastricae) descend. The outermost layer of the mucosa is the small lamina muscularis mucosae which can change the relief of the mucosa.
    • The gastric mucosa is followed by a loose layer of connective tissue (tela submucosa gastrica), which houses not only a dense network of blood and lymph vessels but also a nerve plexus (plexus submucosus or Meissner plexus) which controls gastric secretion. Although this plexus is independent of the central nervous system (CNS), the latter may affect the former via the autonomic nervous system.
    • Next is the marked tunica muscularis with its three sublayers, each comprising muscle fibers coursing in different directions: The inner layer of small oblique muscle fibers (fibrae obliquae), then a circular layer (stratum circulare) and finally the outermost longitudinal layer of muscle fibers (stratum longitudinale). These muscles effect the peristalsis of the stomach and ensure thorough mixing of the chyme with the gastric juice. Muscular function is controlled by a nerve plexus, the plexus myentericus or Auerbach plexus, in between the circular and longitudinal layers. Just like the plexus submucosus, this plexus is mostly autonomous but is also affected by the autonomic nervous system.
    • Next is another layer of loose connective tissue (tela subserosa gastrica).
    • The peritoneum (tunica serosa) covering the external aspect of the stomach is its final layer.

    Gastric glands

    The gastric glands (glandulae gastricae) located in the fundus and body of the stomach are part of the lamina propria mucosae. 1 mm2 of mucosal surface comprises up to 100 such glands. The ductal wall of the gland is lined with different types of cells:

    • Mucous cells: They produce the same neutral mucus as the epithelial cells.
    • Surface mucous cells: Foveolar cells are close to the surface of the gland and contain alkaline mucus, i.e., the pH of its hydrogen carbonate ions (HCO3–) is rather high. This property is rather important in controlling the gastric pH. The mucus lines the gastric mucosa and protects it against autodigestion by the aggressive hydrochloric acid (HCl) and enzymes as autodigesting proteins. This type of cells is mostly found in the cardia and fundus of the stomach.
    • Chief cells: These cells produce the inactive proenzyme pepsinogen which, once released, is activated by hydrochloric acid (HCl) to the active enzyme pepsin, the latter starting the digestion of the alimentary proteins. Since the initial contact of the enzyme with hydrochloric acid is at the surface of the gland, this ensures that the glands will not be autodigested by the enzyme. This type of cells is mostly found in the body of the stomach.
    • Parietal cells: Mostly found in the body of the stomach, these cells produce plenty of hydrogen ions (H+) needed in the production of hydrochloric acid (HCl). The latter has a rather low pH of 0.9-1.5. In addition, the parietal cells also produce the so-called intrinsic factor. Together with vitamin B12 from the ingested food this substance generates a complex in the small intestine which can pass through the intestinal wall. This vitamin plays a pivotal role in erythropoiesis (gastric resection may result in anemia).
    • G cells: Primarily found in the gastric antrum, these cells produce gastrin which increases HCl production in the parietal cells.
  • Function

    The stomach acts as a reservoir for ingested food. Since it may store food for hours, it ensures that we can meet our daily nutritional requirements with a few major meals. Peristalsis thoroughly mixes the chyme with the gastric juice, the food is broken up chemically, predigested and then portioned into the duodenum.

  • Arterial and venous blood supply, innervation

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    The arteries supplying the stomach all arise from the unpaired celiac trunk, comprise numerous anastomoses with each other and course as arterial arcades along the gastric curvatures:

    • Right gastric artery arising from the hepatic artery proper and supplying the inferior portion of the lesser curvature
    • Left gastric artery supplying the superior portion of the lesser curvature
    • Short gastric arteries arising from the splenic artery and supplying the fundus
    • Right gastro-omental artery arising from the gastroduodenal artery and supplying the inferior (right) portion of the greater curvature
    • Left gastro-omental artery arising from the splenic artery and supplying the left portion of the greater curvature
    • Posterior gastric artery arising from the splenic artery and supplying the posterior gastric wall.

    This way, the stomach is supplied along the lesser curvature by an arterial arcade between the left and right gastric artery and along the greater curvature by another arcade between the left and right gastro-omental artery.

    The 4 major veins parallel the arterial blood supply along both curvatures of the stomach. They unite to collecting veins (left and right gastric vein draining directly into the hepatic portal vein; left gastro-omental vein and the short gastric veins drain into the splenic vein; while the right gastro-omental vein drains into the superior mesenteric vein) which all drain into the portal vein.

    While gastric innervation is primarily controlled by the autonomic nervous system, there are also sensory fibers: The sympathetic nervous system innervates the pyloric muscles, while the parasympathetic nervous system (vagus nerve, CN X) supplies the other gastric muscles and the gastric glands. The vagus parallels the esophagus on the left and right and passes through the esophageal hiatus in the diaphragm; on the left side it then reaches the anterior gastric wall (t. vagalis anterior), while on the right side it innervates the posterior wall of the stomach (t. vagalis posterior). The afferent signals from sensory fibers of the stomach, on the other hand, pass via the greater splanchnic nerve to the thoracic spinal ganglia.

  • Lymphatic drainage

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    Lymphatic drainage of the stomach parallels its arterial and venous blood supply:

    • The lymphatics of the lesser curvature parallel the left / right gastric artery and drain into the left / right gastric lymph nodes
    • The lymphatics from the gastric fundus parallel the splenic artery and drain into the splenic lymph nodes
    • The lymphatics from the greater curvature parallel the suspension of the greater omentum and drain into the left / right gastro-omental lymph nodes
    • The lymphatics from the pyloric region drain into the pyloric lymph nodes.

    From these lymph nodes mentioned above the lymph then drains into the celiac nodes, the superior mesenteric nodes and the thoracic duct.
    Since the pancreatic lymph nodes are another pathway for lymph drainage, tumors of the stomach may very well metastasize into the pancreas. One special sign of gastric cancer is the frequent prominent supraclavicular lymph node of the left lateral region of the neck (Virchow / signal node) which signals advanced metastasis.

    For reasons of surgical technique, the lymph node stations are grouped into 3 compartments:

    • Compartment I (LN stations 1-6): All lymph node directly at the stomach; paracardiac (station 1+2), along the lesser and greater curvature (station 3+4), suprapyloric and infrapyloric (station 5+6).
    • Compartment II (LN station 7-11): Lymph nodes along the major vessels: Left gastric artery (station 7), common hepatic artery (station 8), celiac trunk (station 9), splenic hilum (station 10), splenic artery (station 11).
    • Compartment III (LN station 12-16): Lymph nodes at the hepatoduodenal ligament (station 12), posterior to the pancreatic head (station 13), at the mesenteric root and the mesentery (station 14+15) and along the abdominal aorta (station 16).

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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  • Access

    145-6

    Open the abdomen through an epigastric midline incision, with left periumbilical extension caudad After inserting the abdominal retractor system, explore the abdominal cavity and assess the location and extent of the primary tumor as well as any lymph node involvement and organ metastases.

  • Freeing the greater omentum and transecting the gastroepiploic vessels

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    Pull up the greater omentum and apply measured traction against the transverse colon. Dissect the greater omentum close to the upper aspect of the transverse colon and open the lesser sac.
    After freeing the hepatic flexure and descending duodenum and carefully dividing the greater omentum off its adhesions with the mesocolon on the right, divide the gastroepiploic vessels entering here. Divide the right gastroepiploic vein before its union with the superior mesenteric vein, and the right gastroepiploic artery where it leaves the gastroduodenal artery.

  • Lymphadenectomy I (hepatoduodenal ligament/LN stations 12 and 13)

    145-8

    Lymphadenectomy (LAD) starts at the hepatic hilum and continues along the hepatoduodenal ligament and common hepatic artery to the celiac trunk.

    After the cholecystectomy, not demonstrated here, incise the lesser omentum with bipolar scissors close to the liver. Start the incision on the left side of the hepatoduodenal ligament and continue to the level of the cardia. With forceps lift the connective tissue together with all its lymph nodes (LN) anterior to the common hepatic artery at the left aspect of the hepatoduodenal ligament and expose the artery. Gradually dissect the LN tissue bundle (station 12) off the portal vein and common bile duct. After inserting the index finger into the omental foramen, palpate the common hepatic artery, hepatic artery proper, portal vein, and any possibly suspect lymph nodes with thumb and index finger. Now take down LN station 13 between the head of the pancreas and the portal vein.

  • Lymphadenectomy II (common hepatic artery/station 8)

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    Transect and ligate the right gastric artery between Overholt dissecting forceps. After encircling the hepatic artery proper with a vessel loop, pull the LN tissue bundle (station 8) craniomediad and with bipolar scissors gradually take it down completely along the common hepatic artery toward the celiac trunk. Since the lymph nodes are immediately adjacent to the adventitia, ensure that the dissection is carried out close to the latter. Encircling the common hepatic artery with a vessel loop simplifies the dissection. The posterior margin of the lymph node dissection is defined by the anterior aspect of the inferior vena cava.

  • Lymphadenectomy III (celiac trunk/station 9)

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    Expose the common hepatic artery and splenic artery branching off the celiac trunk as described above and free them from the LN tissue bundle. Complete the LAD by taking down the left gastric artery close to its origin and delivering the LN tissue bundle. Do not fully expose the origin of the celiac trunk and the aorta.

  • Gastric resection

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    After grasping the stomach with organ holding forceps on the large curvature, judiciously pull the stomach craniad, thereby providing easy access to both the spleen and gastrolienal ligament. Take down any adhesions between the spleen and its surroundings with bipolar scissors.
    Transect the gastrocolic ligament on the left up to the proximal resection line. Here, transect the gastroepiploic arcade while sparing the short gastric vessels.
    Define the resection line on the lesser curvature 2 cm distal to the cardia.
    Transect the stomach with linear cutters (in the video the reusable cutters use 50 mm and 90 mm long magazines).

  • Transecting the duodenum

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    Encircle the proximal duodenum with a vessel loop about 2 cm distal to the pylorus and transect it with a linear cutter (50 mm).

  • Taking down adhesions with the pancreas and removing the specimen

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    In the video, the tumor at the posterior gastric wall adheres to the transverse mesocolon and the capsule of the pancreas. Gently dissect these adhesions which are left on the specimen. Ensure that the pancreas is not injured, and at the same time remove the tumor in its entirety with the appropriate margin. As final step – remove the specimen.

    Note: The video demonstrates inflammatory adhesions in the vicinity of the tumor, necessitating resection of the pancreatic capsule and parts of the transverse mesocolon as well.

  • Closing the mesocolic window, Lembert sutures of the staple lines

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    Close the window in the transverse mesocolon with a continuous suture. Now cover the staple line of the duodenal stump with a continuous Lembert suture PDS 4/0. The staple line at the gastric stump is secured in the same fashion. This suture starts at the lesser curvature but ends about 6 cm before reaching the greater curvature. This part of the greater curvature remains free for the anastomosis. After knotting the suture, arm the free end of the suture with a mosquito for later use in the gastroenterostomy (see step 10).

  • Preparing the Roux-en-Y limb

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    Under transillumination of the vascular arcades select a jejunal loop about 30 cm distad to the superior duodenal fold (ligament of Treitz). Divide avascular parts of the mesojejunum with electrocautery, divide any crossing vessels between clamps and secure their stumps with suture ligatures (PDS 4/0). Transect the intestine with the linear cutter. Secure the staple line of the distal limb with Lembert suture as described in step 8 (not demonstrated).

    Tips:

    • The resection line of the mesentery must ensure good blood supply to the intestine and provide enough length of the distal jejunal limb to be transposed into the upper abdomen for the gastrojejunostomy.
    • If there are neither strong primary branches nor continuous arterial arcades, the adjacent primary branches may be temporarily occluded with bulldog clamps. This will demonstrate whether the selected primary branch provides adequate blood flow to the jejunal limb.
    • Beware of obese patients! Transillumination may be fraught with problems in a fatty mesentery. In order not to endanger the intestinal blood supply divide the mesentery carefully and in steps.
    • If the blood supply is inadequate, extend the resection!
  • End-to-side gastrojejunostomy, antecolic: Suturing the posterior wall I

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  • End-to-side gastrojejunostomy, antecolic: Suturing the posterior wall II

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  • End-to-side gastrojejunostomy, antecolic: Suturing the anterior wall I

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  • End-to-side gastrojejunostomy, antecolic: Suturing the anterior wall II

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  • End-to-side jejunojejunostomy ("Roux-en-Y reconstruction") I

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  • End-to-side jejunojejunostomy ("Roux-en-Y reconstruction") II

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  • Closing the abdominal wall

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  • Prevention and management of intraoperative complications

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  • Prevention and management of intraoperative complications

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  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

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  • Literature summary

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