Chapter 51 - Gastric procedures (including laparoscopic antireflux, gastric bypass, and gastric banding)

Summary

In the current era, elective gastric procedures performed under general anesthesia are primarily performed for benign lesions (wedge resection and proximal or distal gastrectomy), malignant neoplasm (subtotal or total gastrectomy with lymph node dissection), antireflux wrap procedures (Nissen and Toupet fundoplications), and antiobesity procedures (gastric bypass, sleeve gastrectomy, and banding). The medical treatment of peptic ulcer disease (proton pump inhibitors and Helicobacter pylori treatment) has resulted in a significant reduction in the amount of surgery done for complications of peptic ulcer disease. Nevertheless, these procedures are still performed in patients whose disease is undiagnosed at the time of operation or remains refractory to medical treatment. These procedures include parietal cell vagotomy (PCV), vagotomy and pyloroplasty (VP), vagotomy and antrectomy (VA), and hemigastrectomy alone. All of these procedures can be achieved through open or laparoscopic means.

Denervation of the fundus and body of the stomach or PCV is still occasionally necessary for patients with life-threatening complications of duodenal ulcers (hemorrhage, perforation, or obstruction). Such patients usually have untreated Helicobacter pylori infections or a virulent ulcer diathesis of unknown cause. Vagotomy and pyloroplasty and VA involve cutting the vagal nerve trunks at the esophageal hiatus and resecting the pylorus or performing a pyloroplasty, where the pylorus is opened longitudinally and closed transversely. With antrectomy, all the gastrin-secreting cells are removed as well and reanastomosis of the remaining stomach to the duodenum (Billroth I) or jejunum (Billroth II) is performed.