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Laparoscopic Gastric Resections. Dmitry Oleynikov M.D, F.A.C.S Associate Professor of Surgery Joseph and Richard Still Faculty Fellow in Medicine Director of Minimally Invasive And Robotic Surgery University Of Nebraska School Of Medicine. Major Contributors to Adoption Laparoscopic Approach.

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laparoscopic gastric resections

Laparoscopic Gastric Resections

Dmitry Oleynikov M.D, F.A.C.S

Associate Professor of SurgeryJoseph and Richard Still Faculty Fellow in MedicineDirector of Minimally Invasive AndRobotic Surgery

University Of Nebraska School Of Medicine

major contributors to adoption laparoscopic approach
Major Contributors to Adoption Laparoscopic Approach
  • Experience With Laparoscopic Gastric Surgery

Antireflux

Bariatric

  • Evidence of Appropriate Oncological Outcomes
  • Innovations In Instrumentation
innovations in instrumentation
Innovations In Instrumentation
  • Flexible Therapeutic Endoscopes
  • Reticulating Instruments/Staplers
  • Angled Laparoscopes
  • Laparoscopic Vessel Sealers
  • Suturing Devices and Laparoscopic Needle Drives
  • Laparoscopic/Endoscopic Ultrasound
indications
Indications
  • Benign Disease:
    • Pancreatic Rests
    • PUD
    • GIST
  • Malignancies:
    • Carcinoids
    • (GIST)
    • Gastric Cancer

Zia M, Morris-Stiff G, Luhmann A et all. Ann R Coll Surg Engl.2010 Aug 31[in print]

pancreatic rests
Pancreatic Rests
  • Rare: 1-2% in Autopsy Studies
  • May Cause Epigastric Pain, Bleeding, Nausea/Vomiting
  • Rare Potential for Neoplastic Change
  • Sometimes Only Diagnosed on Final Pathology
peptic ulcer disease
Peptic Ulcer Disease
  • Indications:
    • Intractable Disease
    • Obstruction
    • Perforation
    • Generally NOT for Acute Hemorrhage
gist gastrointestinal stromal tumors
GIST:Gastrointestinal Stromal Tumors
  • 80% Occur in Gastric Fundus or Body
  • Size > 5cm or >5mitosis/HPF=Increased Malignant Potential
    • Also Hemorrhage, DNA content, Necrosis
    • Lymphatic Spread Unusual
    • Nonetheless, all GISTs Should be Excised
  • Only Require 1 cm Margin
  • Therefore…Often Amendable to Wedge

Karakousis GC, Singer S, Zheng J et all, Ann Surg Oncol.2011 Jan 5 [in print]

carcinoids
Carcinoids
  • 9% Carcinoids are Gastric, but only 0.3% Gastric Tumors are Carcinoids
  • Most Asymptomatic
    • Found Incidentally
  • Usually Submucosal
    • Pink to Yellow
    • May Bulge into Lumen

2

three categories
Three Categories

Type 1

  • 70 to 80% of Gastric Carcinoids
  • Associated with Chronic Atrophic Gastritis /Pernicious Anemia/ZE
    • Chronic Stimulus Gastrin
  • Derived from Enterochromaffin-like (ECL) Cells
type 1
Type 1
  • 6th and 7th decade, F>M
  • Carcinoid Syndrome Rare
  • Usually Indolent/ Benign
  • Metastases <10% of Tumors <2cm
  • ~20% present in larger tumors
type 2
Type 2
  • Associated with Gastrinomas (Zollinger-Ellison Syndrome) or MEN type 1
  • <5% of Gastric Carcinoids
  • ECL cells
  • Associated With MEN1 gene locus (11q13)
  • Behave Similar to Type 1 (Both Serotonin Producing)
type 3
Type 3
  • “Sporadic Carcinoids”
  • 20% of Gastric Carcinoids
  • Poorly Differentiated
  • Most Aggressive – Local or Hepatic Metastases up to 65%
  • May Have Carcinoid Syndrome
    • Often Produce 5-Hydroxytryptophan
treatment carcinoids
Treatment Carcinoids
  • Type I and II
    • < 2 cm Simple Excision: Check Margins!
    • Mucosal may be amendable to endoscopic resection
    • EUS may help
    • Incomplete resection…Tattoo, then Lap excision
  • Type III and Type I/II > 2cm
    • More extensive resection

Ozao-Choy J,Buch K, Strauchen JA et all. J Surg Res.2010 Jul;162(1):22-5

Hoshino M, Omura N, Yano F et all. Hepatogastroenter, 2010;57(98):379-8

gastric cancer
Gastric Cancer
  • Surgical Excision is Only Curative Treatment
  • Laparoscopy/EUS Aid in Staging
  • Wedge for Smaller/Submucosal Lesions
  • 3 Techniques Later Stages
    • Total Laparoscopic Technique
    • Lap Assisted Technique
    • Hand Assisted Technique
  • Lap Resection Associated Low Mortality/Morbidity

Zia, et al. Ann R Coll Surg Engl. 2010 Aug 31 Epub

Avital S, Brasesco O, Szomstein S, et all. Surg Endosc.2003 May;17(5):763-5

surgical techniques
Surgical Techniques

Anterior Gastric Lesions

  • Simple Staple Wedge
  • Suture Elevation/Wedge
  • Excision and Closure Defect
conclusion
Conclusion
  • Laparoscopic Gastric Resection is Safe and Feasible
  • Adequate Oncologic Resection is Possible Laparoscopically
  • Further Advances in Technique and Instrumentation Will Expand the Role of Laparoscopy for Gastric Disease