GASTRECTOMY

From Big Medical Encyclopedia

GASTRECTOMY (Greek gaster stomach + Greek ektome excision, removal; synonym extirpation of a stomach) — operation of full removal of a stomach. One of methods of surgical treatment of malignant tumors of a stomach, is much less often applied at some other diseases (polyposes, highly located ulcer, Zollinger's syndrome — Ellisona).

Made the first successful G. in 1897 shveyts. surgeon Shlatter (S. Schlatter). Operation was finished with imposing of an esophageal and enteric anastomosis. In 1898 Brigkhy and Mac-Doneld (S. V. of Brigham, R. M of McDonald) reported about successful G. with an esophageal and duodenal anastomosis. In Russia the first extirpation of a stomach at cancer with a favorable outcome was manufactured

by V. M. Zykov in 1911. Technical complexity of operation was the cause of its very slow implementation in surgical practice. So, N. P. Trinkler (1911) gives summary statistics of 25 cases of G. from which only 13 were successful. By 1933 in the world literature data on 165 operations executed by 55 surgeons (a lethality of 63%) were published. In 40th and 50th 20 century technology of operation was in details developed, numerous options are offered. Was widely adopted and became in large surgical institutions a usual operative measure.

Rice 1. The scheme of recovery of a continuity of a digestive tract after a gastrectomy: and — ezofagoyeyunoanastomoz; — an ezofagoduodenostomiya; 1 — a gullet; 2 — a diaphragm; 3 — a jejunum; 4 — a duodenum.

The most widespread way of reconstruction at G. is the elementary — ezofagoyeyunoanastomoz with a Brownian anastomosis (fig. 1, a). Other modifications of G. are used less often, according to certain indications.

A number of the receptions providing creation of an artificial tank on site of a remote stomach by means of a side anastomosis is offered. For the purpose of the prevention of a reflux of intestinal contents on the bringing loop applied an anastomosis across Ru. Much attention was paid to development of the modifications of an operative measure allowing later G. to keep a passage of food through a duodenum (an ezofagoduodenostomiya — fig. 1,6). However because of anatomic features of a gullet and duodenum this operation can be applied only in limited number of cases.

After development of methods of intestinal plastics at stomach operations began to apply substitution of a remote Stomach by the site of a small bowel, and often combined recovery of a passage through a duodenum with simultaneous creation of voluminous tanks. A number of technical offers [A. E. Zakharov's operations, A. M. Betaneli, E. J. Poth] was caused by the aspiration to slow down a passage through the enteric segment transplanted to the place of a stomach; for same Nissen, Shperling (R. Nissen, E. Sperling), etc. suggested to leave unextracted the gatekeeper. Recovery of a passage through a duodenum in some modifications of G. is reached by transplantation of segments of a large intestine. Many of the listed operative measures differ in big technical complexity and injury») that keeps surgeons from their broad use by the oncological patient.

Indications

make G. at cancer of a body of a stomach or its upper third, and also at the tumors extending to the most part of body. At limited tumors of cardial department of a stomach in some cases the resection of proximal department — the operation having functional advantages before is reasonable. The vast majority of modern surgeons is negative to the idea to make G. according to basic indications, i.e. at any localization of a carcinoma of the stomach as it was offered in due time To. P. Sapozhkov (1946), Scott and Longmayer (H. Scott, W, Longmire, 1949), Lakhey (F. Lahey, 1950), etc.

The surgeon accepts the final decision on a possibility of a radical oncotomy of a stomach and on the volume of operation only in the course of the intervention when limits of distribution and the nature of tumoral growth (exophytic, endophytic), existence of metastasises in limf, nodes are specified. Each surgeon operating on a stomach concerning malignant tumors shall be always ready by.

Great practical value Has a question of indications to the so-called combined G. when together with a stomach the body to which passes a tumor (a cross colon, a spleen, a pancreas, a liver) is removed partially or completely. The solution of this question depends on data of the Clinicoradiological research, as well as on operational finds. Experience shows that the combined operations are proved only when germination of a tumor of a stomach in adjacent bodies has limited character or limited increase limf, nodes, napr, in a hilus lienis takes place. Similar operations become unpromising at multiple metastasises.

Contraindications consist of contraindications of oncological character (spread of a tumor on nearby bodies, innidiation out of limits regional limf, pools, the remote metastasises) and contraindications of the general plan (high degree of operational risk at elderly patients with associated diseases).

Preoperative preparation it has to be carried out taking into account the specific features revealed as a result of clinical trial and be limited to, whenever possible, short terms (7 — 10 days). The issue of rational preoperative preparation shall be resolved by the surgeon together with the anesthesiologist, the therapist and other specialists. Basic elements of preoperative preparation are directed to recovery broken biol, balance and correction of a homeostasis: the good nutrition providing energy, nitric and vitamin balance; compensation of deficit of water and electrolytes intravenous infusions of liquids; correction of disturbance of volume of the circulating blood hemotransfusion, a packed red cells, proteinaceous blood substitutes; treatment of disturbances of cardiovascular system; normalization of dysfunctions of external respiration (respiratory gymnastics, sanitation of respiratory tracts). Antibiotics in the preoperative period are appointed according to special indications (germination of a tumor in a cross colon, the accompanying inflammatory diseases of lungs).

Anesthesia at G. the general. The multicomponent endotracheal anesthesia using muscular relaxants and the managed breath allows to perform quietly operation and creates optimal conditions for the effective actions preventing disturbances of a hemodynamics and gas exchange.

Technology of operation

the Gastrectomy in strict sense of this word consider such operation when in remote drug, in addition to a stomach, find elements of an esophageal and intestinal epithelium. Operation for cancer includes, except removal of a stomach, removal of all its copular device and regional limf, nodes.

The right choice of operational access at G. plays an essential role, considerably defining radicalism of operation, and provides conditions for reliable imposing of an anastomosis. In each case access is chosen taking into account localization and the nature of growth of a tumor, and also age and the general condition of the patient.

Transabdominal. — the most frequent operation at a widespread carcinoma of the stomach. This access is less traumatic, than transpleural or combined, and, therefore, is more shown to the elderly and weakened patients. The best access to upper parts of a stomach is provided by median laparotomy (see), edges if necessary it can be added with a resection of a xiphoidal shoot of a breast and a partial sternotomy. At subcardial localization of cancer with limited distribution on abdominal department of a gullet transabdominal G. is made, resorting to a diafragmokrurotomiya on A. G. Savinykh.

Fig. 2. Diagrammatic representation of borders of a gastrectomy (black line; the dotted line designated border of crossing of a big epiploon).
Fig. 3. The scheme of mobilization of a stomach on big curvature and preparation for crossing of a gastrosplenic sheaf: 1 — a diaphragm; 2 — a gullet; 3 — the zheludochnoselezenochny sheaf (is pressed); 4 — a pancreas; 5 — a big epiploon; 6 — a stomach.
Fig. 4. Scheme of imposing of an esophageal and intestinal anastomosis two-row seam: 1 — imposing of the first row of seams; 2 — imposing of the second row of seams.

The main stages of transabdominal G. with imposing of an ezofagoyeyunoanastomoz the following. After audit of an abdominal cavity, edge includes survey of a back wall of a stomach, gastropancreatic sheaf, a hilus lienis, at a possibility of performance of radical operation start mobilization of a stomach (borders are presented in the figure 2). The big epiploon is separated from a cross colon, release a stomach on big curvature on the course of a gastrosplenic sheaf and in the field of a bottom (fig. 3). A distal part of a stomach will be mobilized bandaging of the right gastric vessels then tie up and cross the left gastric artery in its initial department. The stomach is cut from a duodenum, the stump of the last is taken in. Further, having provided good exposure of subphrenic space, cross both vagus nerves, abdominal department of a gullet, delete a stomach and start imposing of an esophageal and intestinal anastomosis (fig. 4).

Fig. 5. Scheme of imposing of an ezofagoyeyunoanastomoz device PKS-25: and and — stages of operation; in — operation is complete; 1 — a gullet; 2 — a stapler of PKS-25; 3 — a jejunum; 4 — a spleen; 5 — a cross colon; 6 — a pancreas.

There is a large number of various modifications of imposing of an anastomosis of a jejunum with a gullet — the most responsible stage of operation. Advantage remains on the party technically of the simplest and reliable methods, to the Crimea it is necessary to carry the so-called horizontal esophageal and intestinal anastomosis created by two-row seams. The method of imposing of an esophageal and intestinal anastomosis by means of a stapler of PKS-25 (fig. 5) was widely adopted.

Transpleural. it is shown at cancer of an upper part of a stomach passing to a gullet or if there are signs of germination of a tumor in a diaphragm. The section is made on VII or VIII mezhreberye) in position of the patient on the right side (see. Thoracotomy ). It is reasonable to continue a section on a front abdominal wall towards a navel with crossing of a costal arch. After audit of a pleural cavity make a diaphragmotomy and continue operation in an abdominal cavity. Transpleural access provides great opportunities for careful audit of bodies of the upper floor of belly and chest cavities and allows to impose an esophageal and intestinal anastomosis more reliably. In our country the first, transpleural access was made by B. V. Petrovsky in 1946.

Abdomino-thoracic access it is shown at cancer of an upper part of a stomach when there are doubts in operability. Position of the patient — on the right side with a body tilt on 45 ° to the operating table. Through an abdominal part of a section carry out audit of an abdominal cavity then in case of not operability the abdominal wall is taken in, and operation on it comes to an end. If radical operation is feasible, the section is continued on the VIII mezhreberye and open a pleural cavity. The combined double-stage access (a median laparotomy and the subsequent thoracotomy) demanding carrying out operation in two stages and changes of position of the patient on the operating table has no advantages.

At G. which is carried out by transpleural or abdomino-thoracic access, mobilization of a stomach is carried out in the direction from top to down, i.e. begun with mobilization of a gullet and proximal department of a stomach. The main details of the technology of operation remain the same.

The postoperative period

Treatment after operation shall be based with respect for the principles of individualization. Main actions: 1) the adequate postoperative anesthesia providing prevention of painful shock, sufficient lung ventilation and recovery of normal functions of an organism (anesthetics, long peridural anesthesia, to lay down. anesthesia); 2) treatment of respiratory insufficiency and prevention of pulmonary complications (the oxygenotherapy, respiratory gymnastics, means improving drainage of a bronchial tree, antibiotics and streptocides); 3) prevention and treatment of cardiovascular disturbances (cardiac glycosides, an Euphyllinum, according to indications — glucocorticoids); 4) prevention of tromboembolic episodes (early physical activity of the patient, to lay down. physical culture and massage, purpose of anticoagulants under control of a koagulogramma); 5) correction of water and electrolytic disturbances and good parenteral nutrition (intravenous injection fiziol, solution, polyionic solutions containing potassium, strong solutions of glucose, transfusion of the drugs containing proteins, amino acids, the emulsified fats, hemotransfusion, vitamin therapy).

Food of patients through a mouth is usually begun from the 5th day after G., and in the first day resolve water or tea, in the next days liquid food (kissel, juice, crude eggs, butter, broth, liquid porridge, etc.); food is fractional, small portions to 6 times a day, K 14 — transfer to the 15th day of patients to a table No. 1 (see. Clinical nutrition ).

Postoperative complications: insufficiency of seams esophageal and intestinal from the mouth (the most frequent complication), pneumonia, a thrombembolia of a pulmonary artery.

Full removal of a stomach often leads results of operation to considerable disturbances in an organism of operated. The patients who are almost cured of cancer in the remote postoperative period show a number of the complaints testimonial of the fact that the organism not always provides the necessary level of compensation of the lost functions. Many disturbances have the expressed clinical picture (frustration of food, agastralny anemia, a reflux esophagitis, a dumping syndrome, etc.) and can be combined by the concept «syndrome after a gastrectomy» (see. Postgastrorezektsionny syndrome ). The patients who transferred G. need constant medical observation and treatment.

The lethality after a gastrectomy averages apprx. 7% with fluctuations (from 3,3 to 26,1%, according to different authors). The long-term results of operation are various depending on a stage, the nature of a tumor (gistol, a structure, type of growth) and its localizations in a stomach (according to many authors, the 5-year perezhivayemost makes apprx. 30%).


Bibliography: Babichev S. I. Total gastrectomy, M., 1963; Berezov Yu. E., Cancer of cardial department of a stomach, M., 1960; Kvashnin Yu. K. and Pantsyrev Yu. M. Effects of a gastrectomy, M., 1967; Mait V. S., etc. Resection of a stomach and gastrectomy, M., 1975; To Petya r with about N of B, E. Rak of proximal department of a stomach, M., 1972; Petrovsky B. V. Surgical cancer therapy of a gullet and cardia, M., 1950; C and c and N go K. N. and Bogdan about to A. V. Pishchevodnogkishechnye and an esophageal and gastric anastomosis, M., 1969; Yudin S. S. Etudes of gastric surgery, M., 1955; McNeer G. Pack G. T. Neoplasms of the stomach, Philadelphia, 1967; Schlatter C. t)ber Ernahrung und Verdauung nach vollstandiger Entfernung des Magen-Osophagoenterostomie bein Menschen, Bruns’ Beitr. klin. Chir., Bd 19, S. 757, 1897

Yu. M. Pantsyrev.

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