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Postsurgical Endoscopic Anatomy 12 Postsurgical Endoscopic Anatomy Sreeni Jonnalagadda and Alisa Likhitsup CHAPTER OUTLINE Introduction, 124 Operations Without Alteration of the Operations With Alteration of the Antireflux Procedures, 124 Pancreaticobiliary Anatomy, 126 Pancreaticobiliary Anatomy, 137 Nissen Fundoplication, 124 Billroth I, 126 Pancreaticoduodenectomy (Whipple Partial Fundoplications (Dor and Billroth II, 126 Procedure), 137 Toupet), 126 Roux-en-Y Gastrectomy, 130 Roux-en-Y Belsey Mark IV, 126 Gastrojejunostomy Without Gastric Hepaticojejunostomy, 138 Collis Gastroplasty, 126 Resection, 130 Choledochoduodenostomy, 139 Bariatric Surgery, 131 INTRODUCTION To perform Nissen surgery, the distal esophagus, the cardio- esophageal junction, the gastric fundus, and the right and left Patients who have undergone surgical procedures that altered crura are dissected. Careful dissection is required to avoid the upper gastrointestinal (GI) anatomy are often referred for transection of the nerve of Latarjet, a branch of anterior vagal endoscopic evaluation.1 It is essential for gastroenterologists to trunk supplying the pylorus. Damage to this branch can result understand the postoperative anatomical alterations to select in delayed gastric emptying.13,14 After hernia reduction, the right the appropriate endoscope and accessories and obtain meaningful and left crura are approximated with sutures (see Fig. 12.1A). and accurate diagnostic information.2–5 Division of the short gastric vessels may be required to mobilize This chapter discusses the most common surgical procedures the fundus.15,16 The gastric fundus is mobilized posterior to the involving the upper GI tract. Technical details and common cardioesophageal junction, creating a 360-degree wrap by the variations are described for each surgical procedure. The endo- placement of two or three sutures involving stomach-esophagus- scopic correlates to anatomical alterations are described. Available stomach in the anterior portion of the wrap (see Fig. 12.1B1). surgical reports should always be reviewed before the endoscopic The anterior and posterior vagus nerves are usually contained examination. in the wrap and attached to the esophagus. At the end of the procedure, the wrap must lie below the diaphragm without ANTIREFLUX PROCEDURES tension.17,18 During endoscopy, an intact Nissen fundoplication is easily Nissen Fundoplication identifiable. During antegrade endoscope passage, the gastro- Fundoplication is an effective antireflux operation, performed esophageal junction appears tight on visualization, but offers by creating a gastric plication over the distal esophagus just mild resistance to passage of the endoscope. The retroflexed proximal to the cardioesophageal junction to restore the com- view reveals an encircling redundant mucosa with several parallel petency of lower esophageal sphincter. This is a standard operative rugal folds overlying the gastric cardia, as well as less capacious treatment in select patients with gastroesophageal reflux disease stomach fundus (see Figs. 12.1B2). Although this is a 360-degreee (GERD) (Fig. 12.1).6 wrap, the redundant fold appears as a 270-degree free cuff margin Fundoplication was first described by Dr. Rudolph Nissen in because the border continuous with the lesser curvature is not 1955.7 This procedure is frequently performed along with hiatal evident.19 The crural closure should maintain the cardia below hernia surgery.8,9 A modified technique called a floppy Nissen the diaphragm with the stomach completely insufflated with air. fundoplication can be accomplished by shortening the wrap from Occasionally, sutures in the distal esophagus may be observed, 5 cm to 2 cm. Despite being more lax than a conventional Nissen indicating migration through the wall or inappropriate penetra- fundoplication, it is equally effective for GERD management, tion depth of the stitches during the procedure; this may or may with the additional benefit of a lower incidence of postoperative not be associated with symptoms.20 gas-bloat syndrome or dysphagia. A laparoscopic approach to Findings associated with failure of the fundoplication include this procedure has proved to be safe and reliable. Laparoscopic esophagitis, lack of the encircling fold on a retroflexed view, floppy Nissen fundoplication has become the surgical gold patulous gastroesophageal junction, migration of the wrap standard treatment for GERD.10–12 through an enlarged esophageal hiatus, or hourglass appearance 124 CHAPTER 12 Postsurgical Endoscopic Anatomy 124.e1 Abstract Keywords Patients who have undergone surgical procedures that altered postsurgical endoscopic anatomy the upper gastrointestinal (GI) anatomy are often referred for postsurgical anatomy endoscopic evaluation. It is essential for gastroenterologists to endoscopy understand the postoperative anatomical alterations to select bariatric surgery the appropriate endoscope and accessories and obtain meaningful and accurate diagnostic information. This chapter discusses the most common surgical procedures involving the upper GI tract. Technical details and common variations are described for each surgical procedure. The endoscopic correlates to anatomical alterations are described. Available surgical reports should always be reviewed before the endoscopic examination. CHAPTER 12 Postsurgical Endoscopic Anatomy 125 A B1 FIG 12.1 Antireflux procedures.A, Esophageal hiatus is narrowed by sutures that approximate the crura of the diaphragm. B1, Nissen fundoplica- tion: a short and loose 360-degree wrap is created around the distal esophagus; B2, Parallel rugal folds encircle the cardia and the insertion tube of the endoscope. The cardia is below the diaphragm, and there is no hiatal enlargement. C, Toupet fundoplication: a posterior partial wrap is created by suturing the edges of the stomach to the anterior esophagus, leaving a space in between. D, Dor procedure: a partial anterior fundoplica- tion usually performed following a Heller myotomy. E, Belsey-Mark IV procedure: a partial wrap is created through a B2 thoracotomy by progressive invagination of the esophagus into the stomach. C E D 126 SECTION I Equipment and General Principles of Endoscopy of the proximal stomach (indicating slippage and irregularity the duodenum (Fig. 12.2A).31 The gastric resection is usually in the dome shape of the fundus, which in turn indicates limited to the antrum, and a truncal vagotomy is often performed parahiatal hernia). A squamocolumnar junction located more in conjunction with the resection. The gastroduodenostomy than 1 cm proximal to the margin of the wrap has been reported anastomosis is found toward the greater curvature. A promi- to be a major endoscopic clue in diagnosis of postfundoplication nent gastric fold representing the closed part of the stomach problems.21 An upper GI contrast study can delineate the precise is often observed along the lesser curvature ending at the relationship between the wrap and diaphragmatic hiatus when gastroduodenostomy. A mucosal pattern change from gastric endoscopic examination is unable to clarify if the wrap is intact. folds to flat duodenal surface indicates the anastomosis site. The Gastric food retention secondary to gastroparesis may be related duodenal bulb is partially resected, and the circular folds of to damage to the vagus nerves during the procedure.21 Some the second portion are visualized endoscopically immediately patients with persistent dysphagia have a tight wrap that causes distal to the anastomosis. Major and minor papillae appear to resistance to the advancement of the endoscope and these patients be more proximal in the duodenum than in a patient with intact may benefit from endoscopic dilation.22 anatomy. Following the loss of the pylorus, bile reflux is very commonly seen. Partial Fundoplications (Dor and Toupet) A partial fundoplication is created with the fundus partially Billroth II enveloping the distal esophagus, enabling a reduction in post- In a Billroth II reconstruction after a partial gastrectomy, the operative dysphagia and gas-related side effects.23 A Dor fundo- duodenal stump is closed and a gastrojejunostomy is created plication is performed anteriorly, and is usually performed in (see Fig. 12.2B). This type of reconstruction is commonly used patients who also require a Heller myotomy (see Fig. 12.1C). for complicated peptic ulcer disease or localized gastric antral Toupet fundoplication is performed posteriorly and is best carcinoma wherein extensive resection is required. The remaining indicated in patients with impaired esophageal body motility stomach is variable in length and may allow retroflexion maneuver (see Fig. 12.1D).24–26 Partial fundoplications also have a prominent if an adequate residual stomach remains. The gastric remnant fold overlying the cardia, which is less evident than 360-degree usually contains frothy bile and mucosal erythema from the wraps when observed endoscopically.27 alkaline reflux.32 The gastrojejunostomy is located at the distal end of the stomach where two stomal openings corresponding Belsey Mark IV to an end-to-side anastomosis can be identified (see Fig. 12.2C). The Belsey Mark IV fundoplication requires a thoracotomy. A There are several variations in surgical technique to perform partial 240-degree anterior wrap is created by the placement of the gastrojejunostomy, each with a distinct endoscopic appearance. three sutures involving stomach fundus and distal esophagus, The technique selected depends on surgeon preference, and there resulting
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