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10 Bile Diverting Operations for Management of Esophageal Disease Bile Diverting Operations for 10 Management of Esophageal Disease INDICATIONS OPERATIVE STRATEGY Disabling bile reflux symptoms after esophageal Bile Diversion after Failed surgery Antireflux Procedures Bile diversion is considered only after multiple failed PREOPERATIVE PREPARATION antireflux procedures. Generally vagotomy and antrectomy with bile diversion via a Roux-en-Y recon- Confirm bile reflux by visual inspection at endos- struction (Figs. 10–1, 10–2) is the procedure of copy, radionuclide scan, or 24-hour pH monitoring. choice. If transabdominal vagotomy does not appear Insert a nasogastric tube. feasible because of excessive scar tissue around the abdominal esophagus,transthoracic or thoracoscopic PITFALLS AND DANGER POINTS vagotomy is an alternative. Injury to liver, pancreas, or stomach Damaging blood supply to residual gastric pouch Fig. 10–1 Fig. 10–2 127 128 Bile Diverting Operations for Management of Esophageal Disease Bile Diversion after Bile Diversion Following Esophagogastrectomy Esophagogastrectomy Bile diversion after esophagogastrectomy is used Incision and Exposure when bile reflux complicates otherwise successful Make a midline incision from the xiphoid to a point esophageal resection with esophagogastrectomy. somewhat below the umbilicus. Divide the various Perform the dissection with extreme care to avoid adhesions subsequent to prior surgery and expose traumatizing the blood supply to the residual stomach. the pyloroduodenal region. Because of the previous Generally,the gastric remnant is supplied only by the surgery (esophagogastrectomy) (Fig. 10–3) this area right gastric and right gastroepiploic vessels.A varia- is now located 5–8cm from the diaphragmatic tion of this procedure, the duodenal switch proce- hiatus. dure, is also illustrated. Dividing the Duodenum, OPERATIVE TECHNIQUE Duodenojejunostomy, Roux-en-Y Reconstruction Vagotomy and Antrectomy Divide the duodenum at a point 2–3cm beyond the with Bile Diversion pylorus. Be careful not to injure the right gastric or right gastroepiploic vessels, as they constitute the Incision and Exposure entire blood supply of the residual gastric pouch.To Ordinarily a long midline incision from the xiphoid divide the duodenum, first free the posterior wall of to a point about 5cm below the umbilicus is the duodenum from the pancreas for a short distance. adequate for this operation. Divide the many adhe- If possible,pass one jaw of a 55/3.5mm linear stapler sions and expose the stomach. Evaluate the difficulty behind the duodenum, close the device, and fire the of performing a hemigastrectomy, rather than stapler. Then divide the duodenum flush with the other available operations. Insert an Upper Hand or stapling device. Lightly cauterize the everted mucosa Thompson retractor and determine if a transabdomi- nal vagotomy is feasible. Vagotomy If dissecting the area of the esophagogastric junction appears too formidable a task,thoracoscopic or trans- thoracic vagotomy is an option. Hemigastrectomy Close the duodenal stump by stapling or suturing. Roux-en-Y Gastrojejunostomy Create a Roux-en-Y limb of jejunum and then perform an end-to-side gastrojejunostomy using sutures or staples.Position this anastomosis so it sits about 1cm proximal to the stapled closed end of the jejunum. Complete construction of the Roux-en-Y segment by anastomosing the proximal cut end of the jejunum near the ligament ofTreitz to the side of the descend- ing segment of jejunum at a point 60cm distal to the gastrojejunostomy. Close the defect in the jejunal mesentery with interrupted sutures. Closure Close the abdominal wall without drainage in the usual fashion. Fig. 10–3 Operative Technique 129 and remove the stapler, which leaves the proximal Establish an end-to-end duodenojejunostomy (Fig. duodenum open. Leave 1cm of the posterior wall of 10–5, point A to point D) utilizing one layer of inter- the duodenum free (Fig. 10–4, point A) to construct rupted 4-0 silk for the seromuscular layer and con- an anastomosis with the jejunum. tinuous or interrupted sutures of atraumatic 5-0 PG Develop a Roux-en-Y limb of jejunum then bring for the mucosal layers. the open distal end of the divided jejunum (Fig. 10– Complete the construction of the Roux-en-Y 4, point D) to the level of the duodenum. Generally segment by creating an end-to-side jejunojejunos- it most comfortably assumes an antecolic position, tomy at a point 60cm distal to the duodenojejunos- but occasionally it is feasible to bring it through an tomy. Close the defect in the jejunal mesentery with incision in the mesocolon (retrocolic). interrupted sutures. Fig. 10–4 130 Bile Diverting Operations for Management of Esophageal Disease Fig. 10–5 Operative Technique 131 Bile Diversion by Divide and carefully ligate the numerous small vessels Duodenojejunostomy Roux-en-Y emerging from the area of the pancreas and entering Switch Operation the duodenum on both anterior and posterior sur- faces until a 2cm area of the posterior wall of duode- Incision and Exposure num has been cleared. Do not dissect the proximal 2–3cm of duodenum from its attachment to the pan- Make a midline incision from the xiphoid to a point creas. Dissecting the next 2cm of duodenum free of about 3–4cm below the umbilicus. the pancreas provides enough length to allow stapled Duodenojejunostomy closure of the duodenal stump and a duodenojejunal end-to-end anastomosis. Be careful not to injure the Perform a thorough Kocher maneuver, freeing the pancreatic segment of the distal common bile duct or head of the pancreas and duodenum anteriorly and the duct of Santorini, which enters the duodenum posteriorly. Place a marking suture on the anterior at a point about 2cm proximal to the papilla of wall of the duodenum precisely 3cm distal to the Vater. pylorus.This represents the probable point at which After this step has been completed, make a 2cm the duodenum will be transected. Now approach the transverse incision across the anterior wall of the point at which the duodenum and pancreas meet. duodenum near the marking suture (Fig. 10–6). Fig. 10–6 132 Bile Diverting Operations for Management of Esophageal Disease Insert an index finger and palpate the ampulla. Confirm its location by compressing the gallbladder and liver, observing the influx of bile into the distal duodenum. Now use a 55/3.5mm linear stapler to occlude the duodenal stump just distal to the mark- ing suture. Complete the transection of the duo- denum after the stapler has been fired by cutting along the stapling device with a scalpel,cauterize the mucosa and check the staple line in the usual fashion. At a point 20cm distal to the ligament of Treitz, transect the jejunum and incise its mesentery down to,but not across,the arcade vessel (Fig. 10–7,C and D). Limiting the incision in the mesentery to 3cm helps preserve the innervation of the intestinal pace- maker in the upper jejunal mesentery.Bring the distal transected end of the jejunum through a small incision in the mesocolon and make an end-to-end anasto- mosis between the proximal transected duodenum to the jejunum using 4-0 interrupted silk sutures for the seromuscular layer and 5-0 Vicryl sutures for the mucosa (Fig. 10–8, A and C). Then perform an end-to-side jejunojejunostomy to the descending limb of jejunum (Fig. 10–8) at a point 60cm distal to the duodenojejunostomy. Eliminate any defect in the mesocolon or the jejunal mesentery by suturing. Irrigate the abdominal cavity and abdominal wound and close the abdomen in the usual fashion without drainage. Fig. 10–8 COMPLICATIONS Intestinal obstruction Anastomotic leak REFERENCES Appleton BN, Beynon J, Harikrishnan AB, Manson JM. Inves- tigation of oesophageal reflux symptoms after gastric surgery with combined pH and bilirubin monitoring. Br J Surg 1999;86:1099. Critchlow JF,Shapiro ME, Silen W.Duodenojejunostomy for the pancreaticobiliary complications of duodenal diver- ticulum.Ann Surg 1985;202:56. DeLangen ZL, Slooff MJ, Jansen W. The surgical treatment of postgastrectomy reflux gastritis. Surg Gynecol Obstet 1984;158:322. DeMeester TR, Fuchs KH, Ball CS, et al. Experimental and clinical results with proximal end-to-end duodenojeju- nostomy for pathological duodenogastric reflux. Ann Fig. 10–7 Surg 1987;206:414. References 133 Mason RJ, DeMeester TR. Importance of duodenogastric Smith J, Payne WS. Surgical technique for management of reflux in the surgical outpatient practice. Hepatogastro- reflux esophagitis after esophagogastrectomy for malig- enterology 1999;46:48. nancy: further application of Roux-en-Y principle. Mayo Oberg S, Peters JH, DeMeester TR, et al. Determinants of Clin Proc 1975;50:588. intestinal metaplasia within the columnar-lined esopha- Stein HJ, Barlow AP, DeMeester TR, et al. Complications gus.Arch Surg 2000;135:651. of gastroesophageal reflux disease: role of the lower Oberg S, Ritter MP, Crookes PF, et al. Gastroesophageal esophageal sphincter, esophageal acid and acid/alkaline reflux disease and mucosal injury with emphasis on exposure, and duodenogastric reflux. Ann Surg 1992; short-segment Barrett’s esophagus and duodenogastro- 216:35. esophageal reflux. J Gastrointest Surg 1998;2:547..
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