Gastrectomy

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As gastrectomy ( Greek γαστρεκτομή , compare ancient Greek γαστήρ Gaster and resection ) is the complete removal (in medical parlance total extirpation ) of the stomach called. It is usually required to treat gastric cancer. The term is to be distinguished from gastric resection , in which only part of the stomach is removed for the treatment of benign diseases of the stomach and duodenum .

The first complete gastrectomies were performed by PS Connor in December 1883 (with a fatal outcome) and (also with a fatal outcome) Jules Emile Péan as well as successfully Carl B. Schlatter on September 6, 1897 (as deputy senior physician of Rudolf Ulrich Krönlein ) in Zurich and CB Brigham in February 1898 in San Francisco.

indication

Macroscopic structure of the stomach. (E) esophagus (1) fundus, (2) great curvature, (3) body, (5) antrum, (6) pylorus, (7) angular incisura, (8) lesser curvature, (9) mucosal folds (through fenestration) , (D) duodenum
Positional relationship between duodenum and pancreas; Pancreatic head left, tail right in the picture

An absolute indication for gastrectomy is the curative removable gastric carcinoma , unless the general condition of the patient does not allow such a large operation. A 4/5 gastric resection can only be performed in exceptional cases , when a very small tumor ( stage up to T1 ) is close to the gastric outlet ( antrum ) .

Systematic lymph node removal is a regular part of tumor gastrectomy ; depending on the location and size of the tumor, an extended gastrectomy may have to be performed. The spleen and the tail of the pancreas are often removed at the same time ("abdominally extended left regional gastrectomy").

If the tumor is very distal , the duodenum and the head of the pancreas may have to be partially removed (partial duodenopancreatectomy ); this is called an "abdominally enlarged right-regional gastrectomy".

A gastrectomy with removal of the lower third of the esophagus is referred to as a " transmediastinal extended gastrectomy". This procedure is necessary if the tumor is very high in the cardia area .

There are seldom indications for gastrectomy in benign diseases: Mallory-Weiss syndrome is a bleeding ( hemorrhagic ) inflammation of the mucous membrane in the lower area of ​​the esophagus and / or in the area of ​​the stomach entrance (cardia) and, in extreme cases, cannot be otherwise lead to breast-feeding mass bleeding. The "Ulcus Dieux-la-foie" is a rare gastric ulcer located high on the cardia, occasionally with heavy arterial bleeding; If endoscopic hemostasis does not succeed here, an emergency gastrectomy may have to be performed.

Elimination of pain, positioning and access

The gastrectomy is performed exclusively under anesthesia . An additional epidural catheter placed before the operation (preoperatively) helps during and after the operation, among other things, to eliminate pain.

The procedure is performed in a supine position with the lower thoracic spine slightly hyperextended. The longitudinal incision of the upper abdomen (median upper abdominal laparotomy ) can be sufficient access for slim patients; a combination of longitudinal and transverse laparotomy in the sense of an upside-down T offers a better overview. This allows one of the extensions described above to be carried out without problems. The operating field is kept open by a so-called retractor system .

If transmediastinal enlargement is required, the access must occasionally be supplemented with a right-sided opening of the thoracic cage ( thoracotomy ) and the operation performed as a "two-cavity procedure" (chest cavity and abdominal cavity opened).

In addition to the open surgical technique, the gastrectomy can also be performed completely laparoscopically.

Removal of the stomach and lymphadenectomy

Overview of the gastrointestinal tract (spleen not shown, lies to the left behind the stomach)

The gastrectomy begins with the detachment of the left lobe of the liver from the diaphragm to expose the lower esophagus in order to determine in advance whether the operation can be performed abdominally or whether a thoracotomy is necessary. Then the large mesh ( greater omentum ) is detached from the large intestine and the omental bursa is opened. The spread of the tumor into the retroperitoneum can now be assessed, i.e. towards the pancreas and left kidney .

The blood supply to the greater curvature (s. First image), consisting of the artery gastroomentalis artery and the artery gastroomentalis sinistra and the accompanying vein is cut abgangsnah. This is followed by opening the small network of the lesser omentum , locating the right gastric artery near the pylorus and cutting it. The upper duodenum is now divided just below the pylorus; a stapler ( forklift ) is usually used for this. The lymphadenectomy is now started in the area of ​​the severed arterial stumps near the abdominal aorta ( abdominal aorta ). The connective tissue containing lymph nodes is removed from the hepatic artery ( arteria hepatica communis ), the splenic artery ( arteria splenica ) along the upper edge of the pancreas and the duodenal artery ( arteria gastroduodenalis ) and these arteries are thus completely exposed. At the common origin of these arteries ( Truncus celiacus ), the lymph tissue is removed up to the abdominal artery . The short arteries between the spleen and stomach ( arteriae gastricae breves ) are now severed and the great curvature exposed up to the esophagus. In the case of left regional enlargement, the short arteries are left and the spleen is attached to the vascular pedicle. Now the end section of the esophagus can also be cut with a forklift. The stomach, the large mesh and the spleen are now omitted en bloc as a preparation .

Gastric replacement

Gastrectomy with interposal of the small intestine

There are about 100 methods of gastric replacement. Therefore, only the three most important basic forms are explained here.

Esophagoduodenostomy with small bowel interposition

An isolated section of the small intestine ( jejunum ) left on its vascular supply is sewn between the esophageal and duodenal stump. The jejunum is preferred because of its good mobility. The connection between the esophagus and the interposal (“esophago-jejunostomy”) can be implemented as an end-to-side anastomosis or with an additional “jejunoplication”, a wrapping of the anastomosis with the upper part of the small intestine. The purpose of this is to prevent reflux as a substitute for the valve function of the cardia . Jejunum interposition was first used in 1935 by the Japanese T. Seo.

Small intestine loop with gastric replacement (esophagojejunostomy)

Analogous to the procedure for the Billroth II resection , a jejunal loop can be anastomosed on the esophagus. A long side-to-side anastomosis of this loop just below the esophagojejunostomy creates a kind of reservoir in the sense of a replacement stomach. Here, too, a Braun foot point anastomosis is created. The duodenal stump is closed blindly.

Simple loop of small intestine

Here the upper jejunum is cut at a suitable point. The distal, laxative loop is pulled up to the esophagus and anastomosed with it - with or without jejunoplication. The end of the feeding loop is connected end-to-side with the discharging loop ( Roux -Y anastomosis). The duodenal stump is also closed blindly.

Risks and Complications

Non-specific surgical risks are intra- and postoperative bleeding ( blood reserves must be kept ready), wound healing disorders, formation of incisional hernias , thrombosis , pulmonary embolism and postoperative pneumonia .

Specific risks are injuries to the biliary tract, liver, spleen (if not removed anyway) and the left kidney. The risk of anastomotic leakage is relatively high, especially at the esophageal anastomosis , and can only be avoided by paying close attention to the blood flow and being absolutely free of tension. In addition to peritonitis , mediastinitis may also be at least as dangerous if the anastomosis is above the diaphragm . The complication of anastomotic leakage has been shown to be bacterial and can be avoided by local antimicrobial prophylaxis (decontamination).

Late complications, also known as agastric syndrome , are on the one hand pernicious anemia due to the lack of vitamin B12 , which can only be absorbed by the intrinsic factor formed in the gastric mucosa . For prophylaxis, vitamin B12 must be injected every three months , as it can no longer be used orally due to the missing stomach. On the other hand, a dumping syndrome can develop due to the loss of the reservoir function of the stomach when eating large amounts of carbohydrate-rich food. In early dumping, the carbohydrates in the small intestine withdraw water from the vascular system, which, together with a stimulation of the parasympathetic nervous system, can lead to a drop in blood pressure and even to a volume shock. Late dumping, on the other hand, occurs about 2 hours after ingestion of excessive insulin secretion, which leads to palpitations and hypoglycemia. Most of the time, the symptoms go away with getting used to and adjusting your eating habits.

literature

  • JR Siewert, AH Hölscher, J. Lange et al .: Interventions in gastric carcinoma in Breitner. Edited by F. Gschnitzer et al. Surgical Operation Manual Volume IV: Surgery of the Abdominal 2 . 2nd Edition. Verlag Urban & Schwarzenberg, Munich / Vienna / Baltimore 1989, ISBN 3-541-14442-4
  • S. Kitano, H.-K. Yang: Laparoscopic Gastrectomy for Cancer . Springer, 2012, ISBN 978-4-431-54002-1

Individual evidence

  1. ^ PS Connor: Society proceedings: Cancer of the stomach, gastrostomy, gastroenterostomy. In: Med. News (Philadelphia). Volume 45, 1884, pp. 576-580.
  2. ↑ Barbara I. Tshisuaka: Péan, Jules Emile. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , p. 1119.
  3. ^ Carl Schlatter: On nutrition and digestion after complete removal of the stomach - oesophagoenterostomy - in humans. In: Bruns' Contributions to Clinical Surgery. Volume 19, 1897, pp. 757-776.
  4. ↑ CB Brigham: Case of removal of the entire stomach for carcinoma: Successful esophago-duodenostomy: Recovery. In: Boston med. surg. J. 138/18, 1898, pp. 415-419.
  5. ↑ Max Raab, Federico Gutiérrez: Overview of the development of gastric replacement after gastrectomy. In: Würzburg medical history reports. Volume 5, 1987, pp. 271-310, here: pp. 272 ​​f.
  6. ↑ Max Raab, Federico Gutiérrez: Overview of the development of gastric replacement after gastrectomy. In: Würzburg medical history reports. Volume 5, 1987, pp. 271-310.
  7. ↑ Max Raab, Federico Gutiérrez: Overview of the development of gastric replacement after gastrectomy. In: Würzburg medical history reports. Volume 5, 1987, pp. 271-310, here: p. 291.
  8. ↑ HM Schardey, T Kamps, HG Rau, S Gatermann, G Baretton, FW. Schildberg: Bacteria: a major pathogenic factor for anastomotic insufficiency. In: Antimicrob Agents Chemother . 1994 Nov; 38 (11), pp. 2564-2567.
  9. ↑ HM Schardey, U Joosten, U Finke, KH Staubach, R Schauer, A Heiss, A Koistra, HG Rau, R Nibler, S Lüdeling, K Unertl, G Ruckdeschel, H Exner, FW. Schildberg: The prevention of anastomotic leakage after total gastrectomy with local decontamination. A prospective, randomized, double-blind, placebo-controlled multi center trial. In: Ann Surg 1997 Feb; 225 (2), pp. 172-180.
  10. ↑ AD Olivas, BD Shogan, V Valuckaite, A Zaborin, N Belogortseva, M Musch, F Meyer, WL Trimble, G An, ​​J Gilbert, O Zaborina, JC. Alvery: Intestinal tissues induce an SNP mutation in Pseudomonas aeruginosa that enhances its virulence: possible role in anastomotic leak. In: PLOS ONE 2012; 7 (8), p. E44326, doi: 10.1371 / journal.pone.0044326