clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Sometimes one or two anterior sutures are mandatory to avoid an “S-shape” of the distal esophagus. The inferior edge of the newly created hiatus may produce an external compression leading to dysphagia (B).

Some groups use a prosthetic reinforcement with polytetrafluoroethylene (PTFE) of posterior cruroplasty to reduce the rate of postoperative wrap herniation into the mediastinum.

B

Postoperative Complications

■Pneumothorax

■Pleural effusion

■Vagus nerve injury (anterior and posterior bundles)

■Cardiac dysrhythmia

■Pericarditis

■Pneumonia

■Pneumothorax

■Pulmonary embolism

Tricks of the Senior Surgeon

■Use nonabsorbable mattress sutures to perform the posterior cruroplasty.

■At the end of the procedure, perform an anterior gastropexy to avoid postoperative gastric volvulus.

Management of the Duodenal Stump

Matthias Peiper, Wolfram T. Knoefel

Introduction

Preoperative Investigations/Preparation for Procedure

■Analysis of abdominal secretion in the drain tube (bilirubin, amylasis, lipase)

■Physical examination

■Abdominal ultrasound

■CT

The abdominal cavity is opened through the previous incision.

STEP 1

If the dehiscence is small or barely visible, an omental flap is performed and the area well drained. For some patients, primary suture of the duodenum might be performed. This is usually hand-sewn, though some surgeons prefer the stapler technique.

STEP 2

If technically feasible, an end-to-side duodenojejunostomy may be performed using single-layered sutures (Vicryl 3-0).

STEP 3

If the duodenum is opened widely and its walls edematous, a primary closure is usually unsuccessful since the sutures will not last. Here it is suggested to insert a Foley catheter into the leak, which may be fixated using a purse-string suture. The catheter shall be completely covered by the greater omentum and externalized using a separate incision. Most fistulas will close spontaneously after 3–4weeks. An alternative is to cover of the leak by a jejunal loop using the Roux-Y technique.

STEP 4

Late suture dehiscences will present usually 2weeks after (distal) gastrectomy. This course is less dramatic, since postsurgical adhesions lead to a compartmentation of the abdominal cavity. If the drainage is already removed, duodenal juice might drain via the former drainage incision. By using total parenteral nutrition as well as antibiotics, the fistula will close spontaneously. An alternative is the interventional placement of a drainage, such as a Sonnenberg catheter, for optimized drainage of the duodenal fluid.

284 SECTION 2 Esophagus, Stomach and Duodenum

Standard Postoperative Investigations

■ Daily check of the abdominal drainage

Postoperative Complications

■Recurrent insufficiency

■Insufficiency of the duodenojejunostomy

■Peritonitis

■Sepsis

■Pancreatitis

■Fistula formation

■Wound infection

Tricks of the Senior Surgeon

■Tissue should not be too edematous. Therefore, the indication for relaparotomy should immediately be established once duodenal stump insufficiency has been diagnosed.

■For some patients, all organ-preserving surgical interventions might not lead to improvement of the patient’s condition. As ultima ratio a partial duodenopancreatectomy (Whipple procedure) might be necessary.

Preoperative Investigations/Preparation for the Procedure

Clinical

■Physical examination (abdominal hernia, former abdominal surgery)

■Phenotype of obesity: androgenic (central obesity) vs gynecoid (peripheral obesity) (note: male/androgene phenotype and BMI >50 associated with increased preand perioperative morbidity)

■ECG, pulmonary function tests (if necessary), sleep study if symptoms suggest sleep apnea, and detailed cardiac evaluation if necessary (echocardiography, functional cardiac scintigraphy)

Laboratory

■Nutritional and metabolic parameters

■Hormonal parameters

■Baseline arterial blood gas

Upper GI Examinations

■Gastroscopy in selected patients, esophageal manometry in patients with gastroesophageal reflux disease if a restrictive procedure is to be performed (VBG, gastric banding)

■Radiology: upper GI studies for reoperative surgery and especially after failed gastric banding (reflux, esophageal dysmotility, pouch dilatation, band penetration?)

Anthropometry/Body Composition (Optional)

■Bioimpedance analysis

■Calorimetry

Psychologic Evaluation

■Exclude psychosis (rare), severe uncontrolled depression, active substance abuse, or borderline personality disorder

■Establish psychiatric care if necessary