Types of interventions and indications
Gastric surgery encompasses a wide range of surgical interventions, the choice of which directly depends on the nature of the pathology. The main indications include peptic ulcer disease, polyposis, and malignancies (cancer). In these cases, surgeons perform resection (partial removal), gastroenteroanastomosis placement (bypass creation), or gastrectomy (total removal).
In addition to radical surgeries, other types of interventions are used in clinical practice:
- Removal of ingested foreign bodies.
- Gastrotomy — incision of the organ lumen for diagnostic purposes to examine the mucosa.
- Gastrostomy — a palliative measure aimed at creating an artificial fistula to ensure enteral nutrition in patients with esophageal obstruction.
Gastrectomy and reconstruction
Gastrectomy implies complete removal of the organ and is indicated for advanced gastric cancer. This is a major oncological surgery in which the stomach is resected en bloc together with the greater and lesser omentum, ligamentous apparatus, and regional lymph nodes.
After removing the organ, it is necessary to restore the continuity of the digestive tract. For this purpose, an esophagojejunal anastomosis is formed.
Stages of reconstruction:
- A loop of the jejunum is taken 30–40 cm distal to the duodenojejunal flexure (flexura duodenojejunalis).
- The selected loop is passed through a specially created opening in the transverse mesocolon.
- An end-to-side anastomosis is formed between the esophagus and the jejunal loop using a double-layer intestinal suture.
- An enteroenterostomy is mandatory between the afferent and efferent loops of the jejunum to prevent reflux of contents.
Leakage of the esophagojejunal anastomosis is the most frequent and formidable complication of such reconstruction. This is due to the anatomical feature of the esophagus: its walls are not covered by peritoneum (serosa), which significantly impairs sealing and healing.
Stump closure and post-gastrectomy syndrome
When performing a gastric resection, the surgeon must securely close the lumen of the remaining part of the duodenum. Numerous proprietary techniques have been proposed for closing the duodenal stump, among which:
- Schmieden's marginal suture.
- Classic purse-string suture.
- Moynihan's method.
- Yudin's "snail" method.
Post-gastrectomy syndrome, manifesting with various dyspeptic disorders, may develop in patients after resection or total removal of the organ. To prevent this condition, plastic substitution of the removed stomach with a segment of the small or large intestine is used. This helps restore the physiological passage of food masses through the duodenum.
Vagotomy and drainage procedures
Vagotomy is the transection of the trunks or branches of the vagus nerves (n. vagus). The surgery is used for the surgical treatment of duodenal ulcers.
The pathogenetic rationale of vagotomy is that transecting sensory (viscerosensory) and secretory fibers completely abolishes the first, complex reflex phase of digestion. As a result, gastric juice secretion is significantly reduced.
Since vagotomy affects motility, it is increasingly combined with drainage procedures (pyloroplasty). Their main goal is to facilitate gastric emptying. The principle consists of a longitudinal incision of the scarred pylorus followed by transverse suturing of the wound edges.
Main types of pyloroplasty:
- Heineke-Mikulicz pyloroplasty: the classic option involving incision of the lumen (mucosa) of the stomach and duodenum.
- Finney pyloromyotomy: partial incision exclusively of the muscular layer of the pylorus (seromyotomy) without opening the mucosa.
Briefly: answers to topical questions
Which gastric ligaments must be transected during mobilization in surgery?
- Gastrocolic ligament (lig. gastrocolicum) — transected during mobilization along the greater curvature.
- Gastrophrenic ligament — incised to mobilize the gastric fundus.
Which arteries supply the stomach and are subject to ligation during its removal?
Blood supply to the stomach comes from the celiac trunk system via the following arteries:
- Left and right gastric arteries (aa. gastricae sinistra et dextra).
- Left and right gastroepiploic arteries (aa. gastroepiploicae sinistra et dextra).
- Short gastric arteries (aa. gastricae breves).
What are the types of gastric resection depending on the volume of resected tissue?
Depending on the volume of removed tissue, sources mention:
- Subtotal gastric resection — partial removal of the organ.
- Resection of 1/3 of the stomach — removal of part of the stomach while preserving the short arteries and the left gastroepiploic artery.
What are the classic methods for restoring GI tract continuity after gastric resection?
- Billroth I procedure — creation of a gastroduodenal anastomosis.
- Billroth II procedure — closure of the duodenal stump and creation of an end-to-side anastomosis between the gastric stump and the jejunum.
- Hofmeister-Finsterer modification — a Billroth II resection where the anastomosis is placed in the lower third of the gastric stump; the afferent loop is sutured to the closed part of the lesser curvature, forming a "spur" that prevents reflux into the stomach.
What types of vagotomy are used to treat peptic ulcer disease?
The following types of vagotomy are used to treat peptic ulcer disease:
- Bilateral truncal vagotomy.
- Selective vagotomy.
- Selective proximal vagotomy.
To remember the essence of pyloroplasty: LONG-TRANS — LONGitudinal incision, TRANSverse suturing. This widens the narrowed pylorus and facilitates food evacuation.
Class and exam questions
Why does anastomotic leakage frequently occur after gastrectomy?
This is due to the fact that sutures are applied to the wall of the esophagus, which lacks a serosal covering (peritoneum). The absence of the peritoneum significantly impairs sealing and healing processes.
What is the difference between Heineke-Mikulicz and Finney pyloroplasty?
In the Heineke-Mikulicz method, the lumen of the stomach and intestine is fully opened. Finney's method is a seromyotomy where only the muscular layer is incised without damaging the mucosa.
Why is an enteroenterostomy performed during gastrectomy?
The anastomosis between the afferent and efferent loops of the jejunum is necessary to prevent reflux of intestinal contents into the esophagus.
What is the mechanism of action of vagotomy in peptic ulcer disease?
Transection of the branches of the vagus nerve (n. vagus) eliminates the first (complex reflex) phase of digestion. This leads to a sustained decrease in the secretion of aggressive gastric juice.
What else to study on this topic
- Technique of Schmieden's marginal suture and purse-string suture
- Topographic anatomy of the vagus nerves (n. vagus)
- Stages of esophagojejunostomy formation
- Pathogenesis and clinical manifestations of post-gastrectomy syndrome
- Surgical anatomy of the ligamentous apparatus and blood supply of the stomach
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