(cid:142)(cid:3) In functioning tumors, the principle of block and when required, replaceme nt therapy. The active hormone should be blocked pharmacologically, e.g. phaeochromacytoma block with alpha blockade, hyper-aldosteronism blocked with spironolactone. Consent (cid:142)(cid:3) Obtain consent for a laparoscopic or open procedure. (cid:142)(cid :3) Inform the patient of the possible need for postoperative steroid re- placement therapy. Position of patient (cid:142)(cid:3) Anterior, patient supine, foot down 30(cid:13), latera l tilt. (cid:142)(cid:3) Lateral, patient in full lateral position, table broken to 30(cid: 13) over ribs 10 and 11 (also used for laparoscopic approach). Strap the patient to the tab le for both approaches. Incision (cid:142)(cid:3) Anterior, long midline incision, extend it laterally through tran s-pyloric plane if access difficult. (cid:142)(cid:3) Laparoscopic (open approach) over rib 11 from the lateral border of sacro-spinalis to abdominal wall. Procedure (cid:142)(cid:3) Anterior approach. Left adrenal: pack the small intestine downwards, retract the costal margin upwards, place the left hand over the spleen and divide the posterior parietal peritoneum from the splenic flexure to the oesophageal hiatus. Apply several pairs of forceps to retract the peritoneu m downwards. Identify the kidney with the adrenal gland above it. Identify and divide betwe en ligatures the adrenal vein, which drains into the left renal vein, mobilize and remove t he gland by blunt dissection, cauterize bleeding vessels. ADRENALECTOMY (MAJOR)1 183 Right adrenal: retract the liver upwards and the hepatic flexure down- wards. Note the vena cava and kidney. Divide the posterior parietal peritoneum along the upper pole of the kidn ey to the vena cava. Iden- tify the gland, divide the two or three adrenal veins, which dra in into the vena cava between ligatures, remove the gland by blunt dissection. Secure haemo stasis. (cid:142)(cid:3) Laparoscopic approach. Divide the lieno renal ligament on the left side allowing the spleen to be mobilized medial ly. The adrenal gland will be seen lying close to the lower pole of the spleen between it a nd the kidney. Mobilize the gland using an ultracision harmonic scalpel and secure the adre nal vein with ligaclips. Right side: Mobilize the right lobe of the liver and retract it in a head- wards direction. The adrenal gland lies just lateral to the inferior vena cava abo ve the right kidney. Identify the adrenal vein early and ligate it with ligaclips to mobili ze the gland. Place the gland in a retrieval system and remove it through one of the port s ites. Postoperative care (cid:142)(cid:3) Blood pressure and blood sugar in patients with phaeoch romacytoma in high dependency or intensive care unit. Monitoring of fluid requirements as there may be further vasodilation once the phaeochromocytoma is removed. (cid:142)(cid:3) Use steroid replacement therapy in Cushing \200\231s syndrome as the contralateral gland is usually suppressed. Patients with Cushing \200\231s syndrome usually have associated myopathy and obesity which make postoperative recovery slow. (cid:142)(cid:3) Suspected adrenal carcinomas, remove a pad of fat around the adrenal gland to ensure adequate tumor clearance. Complications (cid:142)(cid:3) Hypotension due to volume disturbance (cid:142)(cid:3) Acute Addison \200\231s disease (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Hemorrhage (ci d:142)(cid:3) Chest infection as a result of subphrenic operation. CHAPTER 5 Breast and endocrine surgery 184 Pancreas (complex major) (Refer to Hepatobiliary Surgery) Pancreatic endocrine tumors may b e solitary or part of a multiple neoplasia syndrome (MEN1). Indications (cid:142)(cid:3) Removal of functioning endocrine tumors (e.g. insulinoma, glucagonoma, somatostatinoma, gastrinoma and tumors which are secreting pancreatic polypept ide). (cid:142)(cid:3) Non-functioning pancreatic tumors which may or may not be malignant. Chapter 6 185 Upper gastrointestinal surgery Y. K. S. Viswanath and S. Dresner Bleeding peptic ulcer disease 186 Perforated peptic ulcer disease 188 Oesophageal rupture and perforation 190 Gastro-oesophageal reflux disease 192 Para-oesophageal hiatus hernia repair 194 Open (Heller \200\231s) cardiomyotomy for achalas ia 196 Open splenectomy 198 Weight reduction surgery for morbid obesity 200 Radical surgery for gastric cancer 202 Preoperative preparation for oesophagectomy 206 Left thoracic subto tal oesophagectomy 208 Transhiatal oesophagectomy 210 Abdominal & right thoracic subtotal o esophagectomy 212 Three stage oesophagectomy 214 Gastric interposition as an oesophageal su bstitute 216 Colonic interposition for oesophageal replacement 218 Oesophageal anastomosis after subtotal oesophagectomy 220 Complications following oesophagectomy 224 CHAPTER 6 Upper gastrointestinal surgery 186 Bleeding peptic ulcer disease Patients with major upper gastrointestinal hemorrhage require urgent resuscitation and careful monitoring followed by early endoscopic as- sessment. Thi s is essential to identify the site and cause of bleeding and to initiate appropriate endos copic therapy. IV omeprazole 80mg bolus followed by 8mg/hour infusion for 72 hours is benef icial but does not stop active bleeding. Indication Failure of endoscopic control (including significant re-bleeding after initial s uccessful endoscopic therapy). Incision Upper midline. Position of patient Supine. Bleeding duodenal ulcer (cid:142)(cid:3) Kocherise the duodenum. Apply 2/0 Vicryl stay sutu res and perform a longitudinal duodenotomy with diathermy. With the advent of PPI medicatio n, definitive ulcer surgery (such as vagotomy) is not indicated and therefore the pyloric r ing is preserved. (cid:142)(cid:3) Clear the stomach and duodenum of clotted blood with suction. Achieve bleeding point haemostasis with digital pressure. (cid:142)(cid:3) Secure any bleeding or exposed vessel (either a branch or the main trunk of the gastroduodenal artery) by under-running with interrupted 2/0 Vicryl /2/0 PDS o r 2/0 Prolene on a small needle avoiding underly- ing structures such as the common bile du ct. Irrespective of the mate- rial employed, sutures inevitably slough off as the ulcer hea ls, long after the vessel has thrombosed. If the ulcer cavity has a tough fibrous base it m ay be feasible to exclude it from the lumen using interrupted 2/0 Vicryl or PDS. (cid:142)(cid:3) Close the duodenotomy transversely with interrupted 2/0 Vicryl or PDS, as longitudinal closure may cause stenosis. If transverse closure is not possible due to a long duodenotomy, carry out longitudinal closure with Roux-en-Y gastroenterostomy (see Radical surgery for gastric caner, this chapter). An alternative is a Finney pyloroplasty (side-to- side gastroduodenostomy in two layers with interrupted 2/0 Vicryl or PDS. Use thi s approach also if the pyloric ring has been transgressed although it is more common to clo se such a gastroduodenotomy transversely with interrupted 2/0 Vicryl or PDS as a Heineke \200\223Mickulicz pyloroplasty. BLEEDING PEPTIC ULCER DISEASE1 187 With giant ulcers the first part of the duodenum may completely disintegrate and once opene d prove difficult to close. Retrieve this situation with an antrectomy with Roux-en-Y recon struction (see Radical surgery for gastric cancer, this chapter). Close the duodenal stump primarily with a linear sta- pler or interrupted 2/0 Vicryl or PDS. Alternatively, suture t he margins to the fibrous ulcer cavity overlying the pancreas (Nissen technique). To preven t duodenal stump leak, drain the duodenum with a Foley catheter inserted through the closur e line or, preferably, by a T-tube in the healthy lateral wall of the second part of the du odenum. CHAPTER 6 Upper gastrointestinal surgery 188 Perforated peptic ulcer disease Although the incidence of peptic ulcer disease has declined dramatically, perforation continues to affect significant numbers of elderly and medi- cal ly unfit patients. Delay in diagnosis beyond 24 hours is associated with a 7-fold increase in mortality, 3-fold risk of morbidity and double the hospital stay. Indication (cid:142)(cid:3) Clinical diagnosis of a perforated viscus with diffuse peritoni tis, varying degrees of shock and (usually) free sub-diaphragmatic gas on erect CXR. (cid:142)(cid:3) Deterioration in the condition of patients with localized signs initially selected for conservative management. Preoperative preparation (cid:142)(cid:3) Naso-gastric decompression decreases further spil lage of gastroduo- denal contents and peritoneal contamination. (cid:142)(cid:3) Careful fluid resuscitation with placement of urinary catheter central venous access. (cid:142)(cid:3) Broad spectrum IV antibiotics and IV anti-secretory medication. Position of patient Supine. Incision Upper midline. Procedure On opening the peritoneal cavity a variable quantity of gas and bile- stained flu id will be encountered, confirming the diagnosis. Foul smelling faeculent fluid and gas ind icate a colonic perforation. Depending on the duration of the peptic perforation there may be extensive fibrinous exu- date and omental adhesions in the sub-hepatic space overlying t he duo- denum. The commonest site of perforation is the anterior wall of the first part of the duodenum. If this is clear then the anterior and posterior aspects of the stomach shoul d be inspected and if no perforation is found the remainder of the GI tract must be thoroug hly assessed. (cid:142)(cid:3) Close small perforations by oversewing interrupted full thic kness 2/0 Vicryl sutures along the margins of the ulcer, leaving the ends long, so that a well va scularised omental patch can be lightly oversewn onto the primary repair. (cid:142)(cid:3) Often the ulceration is chronic and the defect large with a friable margin. Attempts at primary closure may cause sutures to cut out or result in duodenal sten osis. In this situation place interrupted 2/0 Vicryl sutures away from the ulcer margins an d simply use them to secure the omental patch directly onto the perforation. PERFORATED PEPTIC ULCER DISEASE1 189 (cid:142)(cid:3) Repair gastric perforation in a similar fashion. Biopsy the ulcer to exclude malignancy (approximately 6% of cases). With the advent of powerful antisecretory m edication, definitive ulcer surgery (such as a vagotomy) is now no longer indicated. (cid:142)(cid:3) Thoroughly wash the peritoneal cavity with 3 litres of warm saline. Drainage is unnecessary and may increase morbidity. Closure Mass closure with 1 PDS and clips to skin. Complications (cid:142)(cid:3) 10% mortality (cid:142)(cid:3) Multi-organ dysfunction syndr ome (cid:142)(cid:3) Pelvic/sub-phrenic abscess formation (cid:142)(cid:3) Wound infection (cid:142)(cid:3) On-going leak and duodenal fistula formation. Discharge (cid:142)(cid:3) 7 \200\22310 days if uncomplicated recovery. (cid:142)(cid:3) >9 0% have Helicobacter pylori infection. Discharge with eradication therapy and an 8 week cou rse of proton pump inhibitor to prevent ulcer recurrence. (cid:142)(cid:3) Follow-up endoscopy to check healing/biopsy gastric ulcers. Laparoscopic surgery Laparoscopic omental patching has now widely been reported with compar able results to open surgery with the apparent established advan- tages of decreased pain, wound infection, incisional herniation and hospital stay. However, the procedure is technic ally demanding and time- consuming and at present should be confined to enthusiasts within the context of a clinical trial. CHAPTER 6 Upper gastrointestinal surgery 190 Oesophageal rupture and perforation Indications (cid:142)(cid:3) Boerhaave \200\231s syndro me (post-vomiting/barogenic spontaneous rupture) (cid:142)(cid:3) Iatrogenic perforation (e ndoscopic or operative) (cid:142)(cid:3) Traumatic injury (penetrating gun/stab wounds or b lunt compression injury) (cid:142)(cid:3) Ingestion of corrosive agent or foreign body. Preoperative evaluation (cid:142)(cid:3) CXR (surgical emphysema/pneumo-mediastinum/hydro-p neumothorax) (cid:142)(cid:3) Video endoscopy to assess site/size of injury and associated pathology (cid:142)(cid:3) Contrast radiography to assess extent of any leak (cid:142)(cid: 3) CT. General considerations (cid:142)(cid:3) Contained or small perforations with minimal contam ination can usually be treated conservatively as long as there is no distal obstruction. Th ese usually occur after instrumental perforation in a starved patient. Insert an NG tube en doscopically if recognized early. (cid:142)(cid:3) Treat malignant perforation in the prese nce of advanced disease with a covered endo-prosthesis. (cid:142)(cid:3) Carry out surgery on injuries with heavy contamination, free uncontained leakage or distal luminal obstruction. T-tube drainage This is the standard approach to those perforations or ruptures that are as sociated with heavy contamination, tissue necrosis and local sepsis. (cid:142)(cid:3) After initial debridement, wash-and myotomy, insert a large bore T-tube into the oesophageal defect and secure in place by longitudinal closure with interru pted 2/0 Vicryl. This creates a controlled oesophago-cutaneous fistula. Remove the T-tube a fter 3 \200\2234 weeks. (cid:142)(cid:3) Insert large bore intercostal drains and close the chest. (cid:142)(cid:3) Insert a feeding jejunostomy via a mini laparotomy for prolonged enteral nutrition. Primary repair This is suitable only for injuries recognized early prior to infection and n ecrosis of local tissues. (cid:142)(cid:3) Boerhaave \200\231s syndrome usually affects the lower left esophagus. Ex- plore chest via a left low (8th or 9th interspace) postero-later al thoracotomy. Extensive lavage of food material and debridement of devitalised tissue is required. Open the mediastinal pleura widely, per- form a long myotomy to expose the whole length of the mucosal tear which is longer than the muscular breach. (cid:142)(cid:3) Carry out repair in two layers with interrupted 3/0 PDS. Use an intercostal flap for further reinforcement to prevent on-going leakage. (cid:142)(cid:3) Insert large bore intercostal drains and close the chest. (cid:142)(cid:3) Insert a feeding jejunostomy for prolonged enteral nutrition via a mini laparotomy. This page intentionally left blank CHAPTER 6 Upper gastrointestinal surgery 192 Gastro-oesophageal reflux disease The principle of surgery is to construct and/or accentuat e the barrier function between the esophagus and stomach to prevent gastro- oesophageal ref lux. Indications for anti-reflux surgery (cid:142)(cid:3) Failed medical therapy (cid:142)(cid:3 ) Recurrent stricture formation whilst medical therapy (cid:142)(cid:3) Patient (who is fit ) preference for surgery over long term medical therapy (cid:142)(cid:3) Reflux induced malnutrition in children/mentally handicap (cid:142)(cid:3) In association with Heller \200\231s myotomy for achalasia cardia (cid:142)(cid:3) Reflux induced episodic aspiration with risk of pulmonary fibrosis. Position of patient Supine. Surgical approaches (cid:142)(cid:3) Transthoracic (cid:142)(cid:3) Transabdominal (cid:142 )(cid:3) Open method (cid:142)(cid:3) Laparoscopic method. Types of surgery Complete fundoplication with formation of 360(cid:13) wrap is the most pop u- lar and is known by the name Nissen fundoplication. Various modifica- tions have been ma de to the original surgery described by Nissen in order to reduce postoperative side effect s such as gasbloat syndrome, dysphagia etc. Short and floppy wrap is one such modification that is performed commonly with division of short gastric vessels. In Nissen \200\223 Rosse tti fundoplication the short gastric vessels are not divided and the wrap is fashioned usin g anterior fundus. Surgical outcome The anti-reflux surgery is successful in 85 \200\22390% of patients. The o verall postoperative mortality is <1 in 1000 (0.1%). Perioperative complications comprise p neumothorax, splenectomy in <1% and oesophageal perfora- tion. Late complications can occur in 10 \200\22315%, including gasbloat, tempo- rary dysphagia and increased flatulence. This page intentionally left blank CHAPTER 6 Upper gastrointestinal surgery 194 Para-oesophageal hiatus hernia repair Indication Acute presentations (cid:142)(cid:3) Oesop hageal or gastric obstruction (cid:142)(cid:3) Upper GI bleeding (cid:142)(cid:3) Acute org ano-axial or mesentero-axial gastric volvulus (cid:142)(cid:3) Gastric strangulation or per foration. Chronic symptoms (cid:142)(cid:3) Post-prandial pain (70%) (cid:142)(cid:3) Nause a and vomiting (40%) (cid:142)(cid:3) Dysphagia (40%) (cid:142)(cid:3) Gastro-oesophageal r eflux (mixed sliding/rolling hernia) 30%. Preoperative preparation (cid:142)(cid:3) CXR and contrast radiography (cid:142)(cid:3) Att empted NG decompression (cid:142)(cid:3) Upper GI endoscopy. Position of patient Supine. Open technique Upper midline with self-retaining and sternal elevating retractors. Procedure The para-oesophageal defect contains most of the herniated viscus (usu- ally stom ach). (cid:142)(cid:3) Reduce the stomach and other herniated organs such as omentum, spleen or colon with gentle downward traction and by tilting the table head-up. (cid:142)(cid:3) Dissect the peritoneal hernia sac free from its mediastinal attachments and excise it. (cid:142)(cid:3) Ligate the posterior aspect of the sac. (cid:142)(cid:3) In the acute situ ation, carefully assess organ damage and carry out resection if necessary. (cid:142)(cid:3) In the presence of an associated sliding hiatus hernia, mobilize the esophagus into the abdomen and carry out a posterior crural repair with non-absorbable sutu res as for a standard fundoplication. Then close the hernial defect with interrupted 1 Nylo n or Prolene, buttressing the sutures with PTFE patches so that they do not cut out of the diaphragm. (cid:142)(cid:3) If the defect is large a tension free suture repair my not be possible. In this situation, suture a PTFE or polypropylene mesh or special pre-shaped hiatus hernia me sh (Fig. 6.1) is sutured to the margins of the defect using interrupted 2/0 Prolene and the n covered with omen- tum to prevent inflammatory damage or migration into adjacent or- gans . At the end of the repair the hiatus should allow the passage of an index finger adjacent to the esophagus. PARA-OESOPHAGEAL HIATUS HERNIA REPAIR1 195 5 10 5 10 5 Fig. 6.1 Mesh repair of hiatus hernia Fig. 6.2 Port sites for laparoscopic repair (5 = 5mm, 10 = 10mm) (courtesy CR Bard, Inc.) Even in the absence of any sliding component or history of reflux symptoms, many surgeons p erform a fundoplication to further fix the stomach within the abdomen. This is usually a fu ll 360 posterior wrap (see section on anti-reflux surgery). An alternative approach, part icularly in elderly frail patients, is to perform a gastropexy or percutaneous gastro- tomy . A gastropexy is carried out by suturing the gastric fundus to the diaphragm and the great er curve to the left side of the anterior abdominal wall using a series of interrupted non- absorbable sutures. A gastrotomy is fashioned around a ConfloTM PEG tube and sutured to the anterior abdominal wall using 2/0 Vicryl, with subsequent removal 6 \200\2238 weeks later. Closure Mass closure with 1 PDS and clips to skin. Laparoscopic repair The main principles of the operation are as that of the open procedure. The procedure is carried out with the patient in modified lithotomy and anti-Trendelenberg position with operating surgeon standing between the legs. The port sites are shown in Fig . 6.2. CHAPTER 6 Upper gastrointestinal surgery 196 Open (Heller \200\231s) cardiomyotomy for achalasia Indication Achalasia is characterized b y a hypertensive non-relaxing lower oeso- phageal sphincter (LOS) associated with non-coord inated spastic oeso- phageal peristalsis. Pneumatic balloon dilatation of the LOS and myoto my have similar results, although concomitant fundoplication at the time of surgery can pre vent gastro-oesophageal reflux. Transabdominal cardiomyotomy Incision Upper midline. Procedure (cid:142)(cid:3) Carry out a preoperative endoscopy which will allow clearance of any retained debris in the esophagus and deflation of the stomach. If an anti-reflux procedure is planned, leave the endoscope in situ or replaced with a bougie passed over a guide-wire. Self-retaining and sternal elevating retractors provide good access to the hiatus. (cid:14 2)(cid:3) Retract the left lobe of the liver after division of the triangular ligament. Divide the phreno-oesophageal ligament and develop the peri-oesophageal plane up into the posterior mediastinum preserving the vagi. Insert 2/0 Vicryl muscular retraction s tay sutures to facilitate an antero-lateral oesophageal myotomy >8cm using McIndoe scissor dissection through the circular and longitudinal muscle fibers. (cid:142)(cid:3) Spread the muscle fibers widely apart using tissue forceps to prevent reco nstitution, causing the mucosa and submucosa to bulge outwards. Continue the myotomy 1 \200 \2232cm across onto the stomach with the scalpel to ensure complete LOS division. Controversy exists whether all patients require anti-reflux surgery, al- though it is commo n to perform a partial anterior fundoplication over the abdominal area of the myotomy. The antero-lateral aspect of the fundus is sutured in 3 longitudinal rows to each muscular edge of the myotomised segment and then to the right crus (Dor procedure) using interrupted abs orbable sutures. Closure Mass closure with 1 PDS and clips to skin. Transthoracic cardiomyotomy Thoracic surgeons favor a postero-lateral 6th interspace thorac otomy. This approach provides superior exposure of the esophagus allowing a longer myotomy up to the level of the aortic arch. Recent innovations include minimally invasive thoracosc opic myotomy although long-term results are not yet available. OPEN (HELLER \200\231S) CARDIOMYOTOMY FOR ACHALASIA1 197 Complications (cid:142)(cid:3) Perforation (cid:142)(cid:3) Recurrent dysphagia due to inad equate myotomy or an over-tight fundoplication (cid:142)(cid:3) Gastro-oesophageal reflux (cid:142)(cid:3) Diverticulum formation (cid:142 )(cid:3) Malignant change (surveillance endoscopy may be indicated). Laparoscopic cardiomyotomy Position and preoperative preparation (cid:142)(cid:3) Patients are placed in lithotomy position with the operator between the legs. (cid:142)(cid:3) Apply intermittent pneumatic compression stockings to minimize DVT risk. (cid:142)(cid:3) Undertake preoperative endoscopy as for open cardiomyotomy. Procedure (cid :142)(cid:3) Insert a 10mm midline port 5 \200\22310cm above the umbilicus using the open technique and create 12 \200\22314mmHg capno-pertioneum. (cid:142)(cid:3) Use the 30(cid:13) laparoscope. Insert a Nathanson retractor 5mm port site just below the xiphisternum to elevate the left lobe of the liver. (cid:142)(cid:3) Insert two further 5 \200\22310mm left and right subcostal ports for the h iatal dissection and subsequent suturing together with an additional 10mm left upper quadra nt port for gastric retraction using an atraumatic Babcock. (cid:142)(cid:3) Divide the proximal gastro-hepatic ligament using the harmonic scalpel, pr eserving the hepatic branch of the vagus and exposing the right crus. (cid:142)(cid:3) Divide the phreno-oesophageal ligament around its antero-lateral aspect. Mobilize the dilated esophagus by blunt mediastinal dissection preserving the vagi. Then free the esophagus from the left crus and retract at least 5 \200\2236cm into the abd omen. If an anterior fundoplication is planned then a large retro-oesophageal window in fro nt of the crura is not required. A crural repair is not carried out unless the hiatus is wi dened. (cid:142)(cid:3) Create a 6cm myotomy over the right antero-lateral aspect of the esophagus using bipolar scissors or the harmonic scalpel, preserving the anterior vagus. Co ntinue the myotomy over the 2cm of the cardia and suture a Dor partial anterior fundoplicat ion intra-corporeally as described in the open repair. It is not usual to divide the short gastric vessels to allow an adequate mobilization of the fundus. Check for haemostasis and perforation. Drains are not usually required. Closure (cid:142)(cid:3) 1 PDS on J-shaped needle to rectus sheath. (cid:142)(cid:3) Subcut aneous 3/0 Monocryl to skin. Complications As for open cardiomyotomy. CHAPTER 6 Upper gastrointestinal surgery 198 Open splenectomy Indications (cid:142)(cid:3) Trauma (cid:142)(cid:3) Hematological conditi ons. Position of patient Supine. Incision (cid:142)(cid:3) Long midline for trauma (cid:142)(cid:3) Extended left subcostal for elective procedures. Procedure (cid:142)(cid:3) Draw the splenic flexure of the colon and any associated omental attachments inferiorly and separate from the spleen. (cid:142)(cid:3) Open the lesser sac and divide the gastro-splenic ligament with ligation o f the short gastric vessels along the greater curve and fundus of the stomach with 2/0 Vicr yl. (cid:142)(cid:3) Identify the splenic artery along the superior border of the pancreas and control distally with a vascular sling. (cid:142)(cid:3) Gently retract the spleen medially and divide the posterior peritoneal attachments of the phrenico-splenic and lieno-renal ligaments. Separate the tail of the pan creas from the spleen and doubly ligate the splenic vein and artery separately in continuit y with a non-absorbable 2/0 suture. Then remove the spleen. Emergency situation (cid:142)(cid:3) Mobilize the spleen forward by dividing the posterior peritoneal attachments and clamping the pedicle early to prevent further blood loss. Then continue the procedure as above. (cid:142)(cid:3) Preservation of the spleen is desirable. Repair small tears or achieve hae mostasis with selective ligation of the splenic vessels at the hilum. Control splenic capsu lar tears by diathermy or application of collagen impregnated packs. If splenectomy is perf ormed some surgeons may re-implant splenic tissue into the omentum, particularly if there a re no splenuculi. A large bore drain is left in the splenic bed. Closure In two layers with 1 PDS. Clips to skin. Complications (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Subphrenic haematoma/abscess (ci d:142)(cid:3) Pancreatitis/pancreatic leak from ischaemia or trauma (cid:142)(cid:3) Overwh elming post-splenectomy infection (cid:142)(cid:3) A-V fistula formation between splenic ve in/artery if ligated together. Prophylaxis (cid:142)(cid:3) Pneumoccal/Hib/mennigococcal vaccines (cid:142)(cid:3) Life-lo ng penicillin. OPEN SPLENECTOMY1 199 Laparoscopic splenectomy With the advent of harmonic scalpel and ligasure, small to large s pleens can be removed through the laparoscopic method. Some surgeons em- ploy hand assisted techniques using a pneumosleeve to preserve the pneumoperitoneum. Usually at least four po rts are necessary and the procedure can be carried out in right lateral/supine or modified lithotomy position depending on the surgeons preference. CHAPTER 6 Upper gastrointestinal surgery 200 Weight reduction surgery for morbid obesity People with a Body Mass Index (BMI) equal to or exceeding 40kg/m2, or between 35kg/m2 and 40kg/m2 with significant comorbid conditions sat isfy the criteria as having morbid obesity. In England and Wales it was esti- mated in 1998 that 0.6% of men and 1.9% women were morbidly obese amounting to 2500 people/200,000 popul ation. Surgery is recommended as a management alternative for morbidly obese people providing the following criteria are accomplished: (cid:142)(cid:3) They shoul d have been receiving multidisciplinary intensive management in a specialized weight manage ment clinic. (cid:142)(cid:3) There should be no specific clinical or psychological contraindications. ( cid:142)(cid:3) They should be aged 18 years or over. (cid:142)(cid:3) They should demonstr ate all appropriate non-surgical measures have been sufficiently tried and failed. (cid:142)(cid:3) They should be fit for anesthesia and surgery. (cid:142)(cid:3) They shoul d be self-motivated and understand the need for long term follow-up. (cid:142)(cid:3) Secondary causes such as hypothyroidism, Cushing \200\231s syndrome etc. s hould be identified and treated by a specialist endocrinologist. Preoperative preparation Comprehensive, multidisciplinary assessment involving various prof es- sionals such as an endocrinologist, dietician, physiotherapist, upper GI surgeon, psych ologist, and anesthetist is necessary. All patients need sleep capnography to exclude apnoe a, as they require post surgery inten- sive therapy unit (ITU) and/or or high dependency un it (HDU) manage- ment. Position of patient Supine. Surgical principles The principal aim of surgery is to improve the quality of life through significant reduction of weight and maintaining that weight loss on a longer term. Broadly, surgical interventional procedures are classified into two categories; restrictive and mal absorptive. In the former the size of the stomach is restricted so the patient feels full w ith less food and in the later the segments of GI tract are bypassed so as to limit the abs orption of food. Vertical gastroplasty (restrictive procedure) This involves creation of a long narrow gastr ic tube along the lesser curve of the stomach. A stapling device is used to carry out the v ertical partition. WEIGHT REDUCTION SURGERY FOR MORBID OBESITY1 201 Horizontal gastroplasty (restrictive procedure) This entails creation of a small proximal g astric reservoir and establishes continuity through a small anterior gastro-gastrostomy. Th e horizontal partition is usually achieved through four rows of staples across the stomach. Gastric bypass (restrictive and malabsorptive procedure) Following creation of a small gast ric reservoir, a good length (usually 100cm) of the proximal small intestine is bypassed. T his is achieved by Roux-en-y anastomoses. The bypass induces a state of malabsorption and a id further weight loss. Gastric banding (restrictive procedure) A purpose made prosthesis such as the Swedish adjus table gastric band (SAGB) is inserted around the proximal stomach just below the cardia. Th e prosthesis is connected through the tubing to a reservoir that is deposited in subcutaneo us tissue. The balloon on the inner aspect of the prosthesis can be inflated or deflated so as to affect the gastric reservoir outlet size. CHAPTER 6 Upper gastrointestinal surgery 202 Radical surgery for gastric cancer Preparation for gastric surgery All patients require tho rough fitness assessment and exclusion of dis- tant/unresectable disease using CT, endoscop ic ultrasound and staging laparoscopy. In general palliative resection or bypass is not ind icated unless there is obstruction or significant bleeding. Position of patient Supine. Extent of gastric resection The stomach can be divided into thirds (lower \200\224L, middle \200\224M, upper \200\224U). Distal third (L) tumors require subtotal gastrectomy (approxi mately 80% of the stomach) with preservation of the fundus and short gastric arterial suppl y. Middle third (M), proximal third (U) and whole stomach tumors (LMU) require total gastre ctomy. Tumor at the cardia requires total gastrectomy with excision of 5cm of distal esopha gus. The GI continuity is established through Roux-en-Y anastomosis. Early tumors of the pr oximal stomach may be treated by proximal subtotal gastrectomy and jejunal interposition. T 4 disease into pancreas, spleen, colon or liver may require additional organ resection in y oung fit patients without distant disease. Lymphadenectomy Radical excision of the stomach and associated lymph nodes is widely practi ced in Japan and specialist Western Centers. Gastric cancer with lymph node metastases may remain a loco-regional disease and radical excision with lymphadenectomy can be justified o n the following grounds: (cid:142)(cid:3) Optimal pathological disease staging and estimate of prognosis (cid:142)(cid:3) Improved loco-regional control (cid:142)(cid:3) Prolonged su rvival and possible cure. The pattern of lymphatic spread has been carefully documented in rela- tion to the primary tumor and divided into three tiers based on the relative incidenc e of nodal disease. (cid:142)(cid:3) N1 (perigastric tier) (cid:142)(cid:3) N2 (nodes along main arterial supply to the stomach) (cid:142)(cid:3) N3 (distant nodal stations away from the stomach). The amount of nodal dissection performed is represented as D1, D2 or D3 depe nding on how many tiers are removed. There is strong support- ing evidence that a D2 gastre ctomy should be the standard surgical pro- cedure for gastric cancer, although the case for this approach remains unproven in randomized trials. The morbidity of more extensive D3 re sections, particularly if the distal pancreas or spleen needs to be re- sected, appears to outweigh the potential benefits. The N1, N2, N3 and metastatic (M) nodes for gastric cancer subsites are shown in Table 6.1. RADICAL SURGERY FOR GASTRIC CANCER1 203 Table 6.1 Nodes for gastric cancer subsites No. Location LMU/MUL MLU/UML LD/L LM/M/ML MU/UM U 1 Right paracardial 1 2 1 1 1 2 Left paracardial 1 M 3 1 1 3 Lesser curve 1 1 1 1 1 4sa Short gastric 1 M 3 1 1 4sb Left gastroepiploic 1 3 1 1 1 4d Right gastroepiploic 1 1 1 2 2 5 Suprapyloric 1 1 1 3 3 6 Infrapyloric 1 1 1 3 3 7 Left gastric artery 2 2 2 2 2 8a 2 2 2 2 2 Anterior common hepatic artery 8b 3 3 3 3 3 Posterior common hepatic artery 9 Coeliac artery 2 2 2 2 2 10 Splenic hilum 2 M 3 2 2 11p Proximal splenic artery 2 2 2 2 2 11d Distal splenic artery 2 M 3 2 2 12a 2 2 2 3 3 Left hepatoduodenal ligament 12b,p Posterior hepatoduo- denal lligament 3 3 3 3 3 13 Retropancreatic 3 3 3 M M 14v 2 2 3 M M Superior mesenteric vein 14a M M M M M Superior mesenteric artery L, lower; M, middle; U, upper, D, distal. Gastroenterostomy A Roux-en-Y gastro-enterostomy is almost always employed, as it is associ ated with lowest degree of bile reflux. Bilroth 1 reconstruction after subtotal gastrectomy produces maximal bile reflux into the gastric remnant. Bilroth II and Polya (retro-colic l oop gastro-jejunostomy) re- constructions were frequently carried out for benign peptic ulc er surgery but also produce bile reflux and in symptomatic patients require revision to a R oux-en-Y configuration. Loop gastro-jejunostomy continues to be employed for palliative byp asses, as there is only one anastomosis. It may be combined with a division of the stomach above the site of the malig- nant obstruction to prevent future in-growth into the anastomo sis as a \200\230Divine exclusion \200\231. CHAPTER 6 Upper gastrointestinal surgery 204 Indications (cid:142)(cid:3) Reconstruction after gastric resection (cid:142)(cid:3) Draina ge procedure after peptic ulcer surgery (cid:142)(cid:3) Obstructing/inoperable gastric/duo denal/pancreatic malignancy (cid:142)(cid:3) Revision of previous peptic ulcer surgery (cid :142)(cid:3) By-pass surgery for morbid obesity. Roux-en-Y reconstruction (cid:142)(cid:3) Divide the proximal jejunum just beyond the DJ fl exure. Divide the mesenteric vessels to provide a mobile well-vascularised distal segment. Create a retro -colic window in an avascular part of the transverse mesocolon. (cid:142)(cid:3) Perform a stapled oesophago-gastrostomy if reconstruction is carried out a fter total gastrectomy. Place a 2/0 Prolene purse string in the esophagus either by hand ap plication between stay sutures or by using a purse string instrument. Secure an appropriate size circular gun head (usually 28mm diameter) in place. Insert the gun into the open end of the Roux loop from the left hand side of the patient and create an end-side anastomosis taking care not to twist the mesentery or catch additional tissue in the anastomosis. (cid:142)(cid:3) Keep the blind end of the jejunum as short as possible and closed with a l inear stapler. Oversewn with 2/0 Vicryl. Occasionally, the blind end is deliberately kept l ong so as to create a side-to-side pouch reconstruction. (cid:142)(cid:3) Employ a hand sewn continuous two-layer anastomosis after subtotal gastrec tomy between the lowest part of the gastric remnant and the Roux loop using 2/0 PDS or Vicr yl. An end-side anastomosis is usually too narrow and a side-side anastomosis is preferred. (cid:142)(cid:3) Close the blind end of the Roux loop with a linear stapler and oversew it. In constructing the anastomosis this blind end is positioned on the patient \200\231s righ t hand side (in contrast to total gastrectomy) so that there is dependent drainage from the stomach. (cid:142)(cid:3) After completing the gastro-jejunostomy, secure it beneath the colon and i ncorporate closure of the window in the transverse mesocolon. (cid:142)(cid:3) Perform the distal Roux anastomosis 40 \200\22350cm distally as a side-to-end jejuno-jejunostomy using one or two layers of 2/0 PDS or Vicryl. Loop gastro-jejunostomy (cid:142)(cid:3) Identify a mobile proximal jejunal segment. The re trocolic route is the shortest and associated with the best position for drainage. (cid:142)(cid:3) Perform the anastomosis along the lower greater curve in two layers with 2 /0 Vicryl or PDS with 5 \200\22310cm of iso-peristaltic jejunum. Then secure the gastro-jej unostomy below the transverse mesocolon. This page intentionally left blank CHAPTER 6 Upper gastrointestinal surgery 206 Preoperative preparation for oesophagectomy Indications (cid:142)(cid:3) Malignancy (cid:14 2)(cid:3) End-stage benign disease (cid:142)(cid:3) Occasionally emergency resection requir ed for corrosive injury/perforation or spontaneous rupture. Staging malignant disease Endoscopy (cid:142)(cid:3) Site/size of tumor (cid:142)(cid:3) Di latation for improved nutrition (cid:142)(cid:3) Insertion of feeding naso-gastric tube (ci d:142)(cid:3) Histological diagnosis (cid:142)(cid:3) Suitability of oesophageal replacemen t (stomach/colon). Exclude distant/unresectable disease (cid:142)(cid:3) CT thorax/abdomen (cid:142)(cid:3) Endoscopic ultrasound (cid:142)(cid:3) PET scanning (cid:142)(cid:3) Bone scintigraphy (cid:142)(cid:3) Laparoscopy (cid:142)(cid:3) Bronchoscopy. Re-stage after neo -adjuvant treatment (cid:142)(cid:3) Assess fitness for surgery (cid:142)(cid:3) Full blood count/electrolytes/liver function tests (cid:142)(cid:3) Pulmonary function tests (cid:142 )(cid:3) Arterial blood gasses (cid:142)(cid:3) Exercise test (cid:142)(cid:3) ECG (cid:142 )(cid:3) Cardiological/respiratory consultation (cid:142)(cid:3) Nutritional assessment and hyperalimentation (cid:142)(cid:3) Anesthetic assessment \200\224single lung anesthesia/th oracic epidural. Preparation for surgery (cid:142)(cid:3) Stop smoking (cid:142)(cid:3) Control of dental ca ries (cid:142)(cid:3) Thrombo-embolic prophylaxis (cid:142)(cid:3) Intravenous broad-spectr um antibiotic cover (cid:142)(cid:3) Cross match four units of blood (cid:142)(cid:3) Inten sive care/high dependency bed availability (cid:142)(cid:3) Colon preparation if required f or a conduit (cid:142)(cid:3) Psychological preparation and counseling. Rationale for radical surgery and lymphadenectomy (cid:142)(cid:3) Optimal staging (cid:142 )(cid:3) Improved loco-regional control (cid:142)(cid:3) Improved cure rate. This page intentionally left blank CHAPTER 6 Upper gastrointestinal surgery 208