Prof. G. de Manzoni “Recenti acquisizioni fisiopatologiche post chirurgia digestiva maggiore”...
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Transcript of Prof. G. de Manzoni “Recenti acquisizioni fisiopatologiche post chirurgia digestiva maggiore”...
![Page 1: Prof. G. de Manzoni “Recenti acquisizioni fisiopatologiche post chirurgia digestiva maggiore” STOMACO Bari, November 8th University of Verona Department.](https://reader036.fdocuments.in/reader036/viewer/2022062300/56649e2a5503460f94b18833/html5/thumbnails/1.jpg)
Prof. G. de Manzoni
“Recenti acquisizioni fisiopatologiche post chirurgia
digestiva maggiore”STOMACO
Bari, November 8th
University of VeronaDepartment of SurgeryDivision of Upper G.I.
SurgeryProf. G. de Manzoni
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Gastric Physiology
LESHis Angle
Pacemaker region
Pyloric sphincter
Allow: o bolous transito Mix of the bolous
Avoid:o acid refluxo biliary refluxo quick passage in
the duodenum
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Gastric PhysiologyParietal
cells
Mucus cells
HCl production
Protection
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Gastric Physiology
Vagus nerve
Celiac plexus
o Motility
o Secretions
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Gastric Pathology
Peptic Ulcer
Cancer
Obesity
Main
VCancer of
gastric stump
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Surgical goals
Resection Reconstruction
o Resection margins
(T0)
o Nodal dissection
(N0)
o Acid-Biliary reflux
o Good emptying
o Number of meals
o Body weight
o QOL
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Surgical goalsThe
importance of QOL…
Cunningham D, et al. (2006) N Engl J Med
CT group: 36%
Surgery alone: 23%
5 y OS for advanced gastric
cancer
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“cutting less does not always lead to better
results…”
Surgical goals
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Gastric resections
Total Gastrectomy
JGCA (2011) Gastric Cancer
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Distal Gastrectomy
JGCA (2011) Gastric Cancer
o Distal gastric tumors
o ≥ 3 or 5 cm proximal
margin (according to growth
pattern)
Gastric resections
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Pylorus Preserving
JGCA (2011) Gastric Cancer
o Middle gastric tumors
o ≥ 4 cm from pylorus
Gastric resections
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Proximal Gastrectomy
JGCA (2011) Gastric Cancer
o Proximal tumors
o ≥ ½ distal stomach preserved
Gastric resections
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Gastric reconstructions
Total Gastrectomy
Roux-en-YLongmire
interposition
o Less biliary reflux o Preservation of
physiological route
o Improved absorption
o Reduced weight loss
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Gastric reconstructions
Total Gastrectomy
o Review of 9 RCT (1985-2009)
o Roux-en-Y VS Longmire
interposition
Body weight
No Differences QOL
Esophagitis
Mariette, et al.(2010) J Visc Surg
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Gastric reconstructions
Total Gastrectomy
o Multicenter RCT (105 pz)
o Roux-en-Y VS Longmire
interposition
QOLNo Differences
Ishigami, et al.(2011) Am J Surg
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Gastric reconstructionsPouch or
not?
Principles:
o Increase food intake at each
meal
o Prevent dumping syndrome
o Prevent reflux esophagitis (?)
Better QOL?
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Gastric reconstructionsPouch or
not?
Dumping syndrome
o 9 RCT Roux-en-Y (474 pz)
Eating capability
Body weight
Long term better QOL…
Gertler, et al.(2009) Am J Gastroenterol
Pouch is better in…
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Total Gastrectomy… In Japan
Kumagai, et al.(2012) Surg Today
o 145 Japanese institutions
o 138 use Roux-en-Y reconstruction
o 26 institutions performs Pouch
95% Roux-en-Y reconstruction
Gastric reconstructions
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Mariette, et al. (2010) J Visc Surg
Distal Gastrectomy
Roux-en-YBillroth IBillroth II (+
Braun)
o Restore
physiologic path
o Always possible
without tension
o Less biliary reflux
Gastric reconstructions
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Csendes, et al. (2009) Ann Surg
Distal Gastrectomy Roux-en-YBillroth II V
So 75 pz (mean fu 182-193 months)
o Surgery for peptic ulcer
Less reflux for Roux in long term follow-
up
Gastric reconstructions
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Lee, et al. (2012) Surg Endosc
Distal Gastrectomy Roux-en-YBillroth II
+ BraunVS
o 159 pz (12 months fu)
o Prospective randomized trial
Endoscopic findings
Biliary reflux3.7% Roux vs
75% BII
Hepatobiliary scan
Gastric reconstructions
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Distal Gastrectomy
Roux-en-YBillroth IBillroth II (+
Braun)
o High biliary
reflux
Gastric reconstructions
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Inokuchi, et al. (2012) Gastric CancerSano, et al. (2007) Int J Clin Oncol
Distal Gastrectomy Roux-en-Y Billroth IV
S
Endoscopic findings
Gastric reconstructions
o Esophagitis
o Gastritis
o Food residue
o Bile reflux
P<0.05Better for Roux
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Lee, et al. (2012) Surg Endosc
Distal Gastrectomy
Roux3.7%
Biliary Reflux
Roux-en-Y Billroth IVS
o 159 pz (12 months fu)
o Prospective randomized trial
Hepatobiliary scan
Billroth I56.3%
Gastric reconstructions
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Takiguchi, et al. (2012) Gastric Cancer
Distal Gastrectomy Roux-en-Y Billroth IV
S
o 268 pz (21 months median fu)
o Multicenter randomized phase II
EORTC QLQ-C30
NO differencesin QOL
Gastric reconstructions
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Distal Gastrectomy
Roux-en-YBillroth I
o High biliary
reflux
o High gastritit
o High
esophagitis
o High food
residue
NO differencesin QOL…
but
Gastric reconstructions
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Roux-en-Y
o Less biliary
reflux
o Less gastritis
o Less esophagitis
o Less food
residue
o Roux stasis
syndrome
o Difficult
endoscopic
management of
bile ducts
Gastric reconstructions
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Distal Gastrectomy… In Japan
Kumagai, et al.(2012) Surg Today
o 145 Japanese institutions
o 112 (77%) use B1 reconstruction as first
choice
o 30 (21%) use Roux reconstruction as first
choice
77% B1
21% Roux
Gastric reconstructions
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Gastric reconstructions
Pylorus Preserving
Billroth I
Evolution
o Less dumping syndrome
o Less gastritis
o Less reflux esophagitis
o Less gallbladder stones
o More delayed gastric
emptying
o (Limited oncological
dissection)
Pros
Cons
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Morita, et al.(2008) Br J Surg
Preservation of hepatich and pyloric branchs
Preservation of coeliach branch
Preservation of infrapyloric vessels
o 611 pz (50 months median fu)
Gastric reconstructions
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Pylorus Preserving
o 39 pz (40 months mean fu)
o Pylorus preserving VS Billroth I
Park, et al.(2008) World J Surg
But…
Better Symptom score
Delayed Gastric
emptying for solids
Scintigraphic system
Gastric reconstructions
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Proximal Gastrectomy
Pros Cons
Reflux esophagitis
Improved nutrition
Anastomotic stricture
Theoretically better for early stages proximal cancer and Siewert III
because of better QOL…
Gastric reconstructions
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Proximal Gastrectomy
Kim, et al.(2012) Gastric Cancer
Laparoscopy assisted proximal gastrectomy VS total gastrectomy
o 131 pz
o Endoscopic evaluation for stenosis
o Modified Visick score for GERD
High Stenosis
High GERD
Gastric reconstructions
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Proximal Gastrectomy
Kim, et al.(2012) Gastric Cancer
Same nutritional status
No advantages for PG instead of TG…
Gastric reconstructions
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Our experience (2000-2010)
50 pz
Siewert II24 pz
Siewert III26 pz
o Short gastric conduit
reconstruction
o T-T mediastinal anastomosis
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4 months30 pz
10 months15 pz
Reflux 9 (30%) 5 (33.3%)
Stenosis 6 (20%) 1 (6,7%)
Non pathologic 15 (50%) 9 (60%)
Our experience (2000-2010)
Endoscopic diagnosis
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Cardias adenocarcinoma
Ivor Lewis
Siewert III
Total gastrecto
my
Proximal gastrecto
my
Siewert II Siewert I
Total gastrecto
my
Ivor Lewis
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Ivor Lewis – Personal Tecnique
o Narrow gastric conduit
o Intramediastinical conduit
position
o GERD reduction
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Termino-Terminal Anastomosis
o Better vascularization
o Avoids the “could de sac”
o Without weaknesses
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Prefer intrathoracic anastomosis
o Eases the venous outflow
o Less tension on the anastomosis
o Over-azygos for GERD reduction
o Shorter conduit with better
vascularization
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4 months106 pz
10 months80 pz
Esophagitis 24 (22,6%) 20 (25%)
Stenosis 21 (19,8%) 3 (3,7%)
Non pathology
61 (57,6%) 57 (71,3%)
Our experience until 2010
o Ivor Lewis
o EAC + SCC
o PPI for 12 months post-op
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Velanovich, et al.(2007) Dis Esophagus
QOL questionnaire
o Good reliability
o Good responsiveness
o Good praticality (2 minutes)
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6 months 12 months
Esophagitis 5 (25%) 7 (35%)
Stenosis 3 (15%) 0 (0%)
Score > 10 6 (30%)
...2011 results
o Ivor Lewis
o EAC + SCC
o PPI for 12 months post-op
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Prophylactic Cholecistectomy?
Rationale
o Higher risk of gallstones formation Vagal denervation Postoperative fasting Extent of lymphadenectomy Extent of gastric resection Digestive reconstruction
o Difficult endoscopic management (Roux-en-Y)
o Higher morbi-mortality for subsequent
cholecistectomy
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hepatich branch of vagus nerve
Alteration in hormons production: cholecystokinin
and secretin
Altered motilityAltered motility
Altered secretions
Physiophatology
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Cholelythiasis
In general
population 10%Symptomatic in 30%
15-25% develop cholelythiasis
…5 y after gastric surgery
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Gillen, et al.(2010) World J Surg
o 16 studies (retrospective and
prospective)
o 3735 pz
CCE: cholecistectomy
High morbidity in delayed CCE
Low additional morbidity for the
whole cohort
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Gillen, et al.(2010) World J Surg
o 16 studies (retrospective and
prospective)
o 3735 pz
Simultaneous cholecystectomyseems not to be necessary
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Bernini, et al.(2012) Gastric Cancer
o RCT – end of recruitment analysis
o Propylactic cholecystectomy (PC) VS standard surgery (SS)
o Roux-en-Y and Billroth II
Perioperative complications
Biliary:PC 1.5% vs SS 0%
N.S.
Overall:PC 25% vs SS 17%
N.S.
1 pz: Bile from drainage: Conservative management (desappear in a few
days)
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Giacopuzzi S, de Manzoni G…Cordiano C, et al.(2008) Biliary Lithiasis
Prophylactic cholecystectomy
Extended lymphadenecto
my (D2-D3)Total
Gastrectomy
Early stage (long survivor)
PC
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Nothing is perfect… but everything can be
improved…