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Laparoscopic Gastric Resections

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

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  1. 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

  2. Major Contributors to Adoption Laparoscopic Approach • Experience With Laparoscopic Gastric Surgery Antireflux Bariatric • Evidence of Appropriate Oncological Outcomes • Innovations In Instrumentation

  3. Innovations In Instrumentation • Flexible Therapeutic Endoscopes • Reticulating Instruments/Staplers • Angled Laparoscopes • Laparoscopic Vessel Sealers • Suturing Devices and Laparoscopic Needle Drives • Laparoscopic/Endoscopic Ultrasound

  4. 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]

  5. 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

  6. Peptic Ulcer Disease • Indications: • Intractable Disease • Obstruction • Perforation • Generally NOT for Acute Hemorrhage

  7. 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]

  8. 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

  9. 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

  10. Type 1 • 6th and 7th decade, F>M • Carcinoid Syndrome Rare • Usually Indolent/ Benign • Metastases <10% of Tumors <2cm • ~20% present in larger tumors

  11. 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)

  12. 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

  13. 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

  14. 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

  15. Lymph Nodes D1 vs D2

  16. Surgical Techniques Anterior Gastric Lesions • Simple Staple Wedge • Suture Elevation/Wedge • Excision and Closure Defect

  17. Simple Staple Wedge

  18. Simple Staple Wedge

  19. Excision and Closure Defect

  20. Posterior Gastric Wall

  21. Intragastric Resection

  22. 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

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