clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Complete devascularization of the esophagus and stomach viewed from behind, from the left side of the patient. The esophagus is circumferentially devascularized for 7cm above the gastroesophageal junction. The preservation of the spleen can be seen.

The right gastroepiploic vein is ligated below the pylorus while the right gastroepiploic artery is preserved.

The preparation of the stomach is similar to the spleen preserving technique and has been described in the previous chapters. Briefly, the upper two-thirds of the stomach are isolated. The gastric vessels are ligated close to the stomach wall. Unlike in the spleen preserving procedure, care must be taken to preserve the right gastric artery and vein as well as the left gastric vein. It is important to perform the gastric isolation close to the stomach wall in order to preserve vessels draining to the azygos veins.

The lower 12cm of the esophagus is isolated. The venus plexus directly on the esophagus are transsected. The vagus nerve is also divided during this maneuver. All transverse vessels to the esophagus must be separated and ligated. It is important to preserve longitudinal vessels parallel to the esophagus, which drain in the azygos system.

A transverse incision is performed in the well vascularized distal part of the stomach. An end-to-end anastomosis (EEA) stapler is introduced and advanced to the lower esophagus. A ligature is placed around the EEA stapler and the esophagus is transsected 5cm above the gastro-esophageal junction. After firing the EEA stapler an intact mucosa ring must be present in the head of the EEA.

As in the first two procedures, an extramucosal pyloroplasty according to Mikulic is performed. The muscles of the pylorus are divided longitudinally without opening the mucosa. The incision is closed with transverse single sutures (PDS 2-0).

Tricks of the Senior Surgeon

■Preserve the blood flow to the azygos system (left gastric vein).

■Perform gastric devascularization after splenectomy.

■Introduce the EEA stapler in the distal nonischemic stomach.

SECTION 6

Pancreas

Michael G. Sarr

Introduction

Michael G. Sarr

The last two decades have witnessed the escalating evolution of surgical thought/approach toward pancreatic diseases. New operations, new approaches, new techniques, and maybe even new philosophies of the operative management of pancreatic disease have been embraced based on a better understanding of etiopathogenesis of pancreatic diseases (e.g., necrotizing pancreatitis), introduction of new technology (laparoscopy, minimal access approaches, interventional radiology/endoscopy), and the vast advances in both diagnosis (computed tomography, endoscopic ultrasonography, magnetic resonance imaging, positron emission tomography) and critical care medicine. Indeed, even a new disease has been described (intraductal papillary mucinous neoplasm); though it had always been there, we just never recognized it! With these advances, experience with certain operations has increased markedly (e.g., pancreaticoduodenectomy) as operative morbidity and mortality have decreased, convincing our internal medicine/gastroenterologic colleagues that aggressive resectional approaches to the pancreas (in experienced centers) are associated with operative mortalities of <5% and are no longer complicated by the mortality rates of 20–25% of the 1960s and 1970s.

New operations have appeared:

■Chronic pancreatitis

–Duodenum-preserving head resection (Beger/Frey procedures)

–Thoracoscopic splanchnicectomy

■Necrotizing pancreatitis

–Aggressive necrosectomy with several different techniques of peripancreatic drainage

–Minimal access necrosectomy (not just drainage)

■Recurrent pancreatitis

–Sphincterotomy/septectomy

■Pancreas transplantation

–Islet cell, segmental, whole organ

■New technology

–Laparoscopic approaches to enucleation of pancreatic islet cell neoplasms, distal pancreatectomy, internal (enteric) drainage of pseudocyst, gastrojejunostomy, even necrosectomy for necrotizing pancreatitis

■New philosophies

–Laparoscopic staging of pancreatic malignancies to avoid non-therapeutic celiotomies

But, other basic techniques, approaches, and operations have not changed dramatically and require the same careful, systematic exposure, and operative skills.

This section deals with both the old and the new. Each topic is written by an expert and includes his or her tricks that facilitate, speed, or improve the exposure and conduct of the operations involved.

The next two decades will continue this relentless evolution in surgery of the pancreas. It will be interesting to watch how the current state-of-the-art changes – won’t it?

Drainage of Pancreatic Pseudocysts

Gerard V. Aranha, Lawrence W. Way, Scott G. Houghton

Introduction

The goals of surgical treatment of most pancreatic pseudocysts are to provide a pathway of internal (enteric) drainage of the “leaking” exocrine secretions to allow the pseudocyst cavity to collapse, thereby either “sealing off” the ductal leak or creating

a permanent internal fistula for drainage. Internal drainage includes cystogastrostomy, cystojejunostomy, and less commonly cystoduodenostomy. Internal drainage can also be accomplished by endoscopic cystogastrostomy or cystoduodenostomy in selected patients.

Indications and Contraindications