Nova técnica de anastomose gastrojejunal no tratamento paliativo do câncer da cabeça do pâncreas

New technique of palliative gastrojejunostomy for carcinoma of the head of the pancreas

ARTIGOS ORIGINAIS

Nova técnica de anastomose gastrojejunal no tratamento paliativo do câncer da cabeça do pâncreas

New technique of palliative gastrojejunostomy for carcinoma of the head of the pancreas

Marcel Cerqueira Cesar Machado, TCBC-SP^I; José Eduardo Monteiro da Cunha, TCBC-SP^I; Sonia Penteado^II; José Jukemura^II; Paulo Herman^II; Marcel Autran Cesar Machado, ACBC-SP^III

^IProfessor Associado do Departamento de Gastroenterologia da FMUSP

^IIMédica Assistente do Hospital das Clínicas da FMUSP

^IIIPós-Graduando do Departamento de Gastroenterologia da FMUSP

^{Endereço para correspondência}

RESUMO

A maioria dos pacientes com câncer de pâncreas apresenta estdios avançados e é tratada paliativamente. Dos que são submetidos exclusivamente a derivação biliar, cerca de 30%-50% vão apresentar na evolução necessidade de tratamento de obstrução duodenal. As técnicas atualmente empregadas para derivação gástrica podem acarretar vômitos pós-operatórios, principalmente quando feitas profilaticamente. Uma nova técnica foi planejada para evitar alterações no mecanismo de esvaziamento gátrico e a recirculação do conteúdo alimentar. Esta técnica consta de anastomose gastrojejunal entre o corpo gátrico e a primeira alça jejunal tipo Braun em que a alça aferente é bloqueada evitando o ciclo vicioso alimentar. A reconstituição do trânsito alimentar é feita a jusante desta anastomose, impedindo o refluxo biliar para o estômago. Dezenove pacientes foram tratados consecutivamente sem complicações. A sonda nasogástrica foi retirada em torno do terceiro dia de pós-operatório e iniciada realimentação no dia seguinte. Não se observaram vômitos no pós-operatório imediato ou tardio em decorrência de retardo do esvaziamento gátrico.

Unitermos: Câncer do pâncreas; Tratamento paliativo; Anastomose gastrojejunal.

ABSTRACT

Pancreatic cancer is most often diagnosed too late for curative resection. Therefore most of patients with pancreatic cancer are only submitted to palliative procedures. From those submitted to biliary bypass alone about 30 % need treatment for gastric obstruction at some point of the follow up. Surgical techniques for gastroenterostomy currently in use carry themselves delaying in the gastric emptying mechanisms and circulus vitiosus through the non obstructed duodenum. The objetive of this paper is to describe a new technique devised to avoid those problems and to improve the functional results of prophylatic gastroenterostomy. This was accomplished by a gastrojejunostomy in the upper body of the stomach and constructing the jejunal loop in a Braun fashion, whose afferent loop is blocked. The main features of this technique are the position of the gastroenterostomy with a low distubance of gastric motility and the construction of the jejunal loop in order to avoid the circulus vomiting. Nineteen patients were consecutively submitted to this procedure and no post operative complications were observed. Nasogastric tube was taken off in about three days and oral feeding resumed the next day. Vomits were not observed neither in the early post operative period nor in the long term follow up. This newly designed type of reconstruction is a effective gastric beypass and avoids the problem of food reentry.

Key words: Pancreatic Cancer; Palliative treatment; Gastrojejunostomy.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Recebido em 15/1/99

Aceito para publicação em 14/6/99

Trabalho realizado no Departamento de Gastroenterologia da Faculdade de Medicina da Universidade de São Paulo - FMUSP.

• 1. Warshaw AL, Femandez-del Castilho C. Pancreatic carcinoma. N Engl J Med 1992;326:455-65.
• 2. Song SM, Reber, HA. Surgical palliation for pancreatic cancer. Surg Clin of North Am 1989; 69:599-611.
• 3. Sarr MG, Carneron JL. Surgical management of unresectable carcinoma of the pancreas. Surgery 1982; 91: 123-33.
• 4. Huguiér M, Baumel H, Manderscheid JL. La chirurgie palliative. In Le cancer du pâncreas exocrine. Baumel H, Huguier M, eds. Springer- Verlag. France. Paris. 1991;109-118.
• 5. Watanapa P, Williarnson RCN. Surgical palliation for pancreatic cancer: developments during the past two decades. Br J Surg 1992;79:8-20.
• 6. Dobemeck RC, Bemdt GA. Delayed gastric emptying after palliative gastrojejunostomy for carcinoma of the pâncreas. Arch Surg 1987; 122:827-9
• 7. Cunha JEM, Machado MCC, Bacchella T, et al - Palliative gastroenterostomy for pancreatic cancer. European IHPBA Congress 1995;531-534.
• 8. Slim K, Pezet D, Riff Y, et al. L'exclusion antrale: un complement à l'anastomose gastrojejunal palliative dans le cancer du pancreas. Presse Med 1996;25:674-676.
• 9. Gough JR, Mumme G. Biliary and duodenal bypass for carcinoma of the head of the pancreas. J Surg Oncoil984; 26:282-84.
• 10. Richards AB, Sosin H. Cancer of the pâncreas: the value of radical and palliative surgery. Ann Surg 1973;177:325-331.
• 11. Proppsito D, Santoro R, Mancini B, et al. Palliative procedures in the treatment of non ressectable pancreatic tumors: retrospective study of 294 cases and review of the literature. Ann Ital Chir 1998;69: 185-193.
• 12. Lillemoe Kd, Pitt HA.Palliation: Surgical and otherwise. Cancer 1996; 78:605-14.
• 13. Van Wagensveld BA, Coene PP, VanGulik TM, et al. Outcome of palliative biliary and gastric bypass surgery for pancreatic head carcinoma in 126 patients. Br J Surg 1997; 84:1.402-6.
• 14. Van der Schelling GP, van der Bosch RP, linkenbijl JH, et al. Is there a place for gastroenterostomy in patients with advanced cancer of the head of the pâncreas? World J Surg 1993;17:128-32.
• 15. Konishi M, Ryu M, Kinoshita T, et al. Stomach-preserving gastric by pass for unresectabe pancreatic cancer. Surg Today 1997; 27:429-33.
• 16. Kasuaya H, Nakao A, Nomoto S, et al. Postoperative delayed emptying in pylorus-preserving pancreatoduodenectomy using pancreatogastrostomy: Comparison of the reconstruction positions. Hepato- gastroenterology 1997; 44:856-860.
• 17. Shyr YM, Su CH, King KL, et al. Randornized trial of three types of  gastrojejunostomy in unresectable periampullary cancer. Surgery 1997;120:506-12.
• 18. Lucas CE, Ledgerwood AM, Sasce JM, et al. Antrectomy: a safe and effective bypass for unresectable pancreatic cancer. Arch Surg 1994; 129:795-799.

Endereço para correspondência:

Dr. Marcel C. C. Machado Hospital das Clínicas

Av. Dr. Enéas de Carvalho Aguiar, 255 – 9ºandar s/9074

05403-900 - São Paulo - SP

Datas de Publicação

• Publicação nesta coleção
  27 Jan 2010
• Data do Fascículo
  Ago 1999

Histórico

• Recebido
  15 Jan 1999
• Aceito
  14 Jun 1999