Plate 28

The Polya procedure, or a modification of it, is one of the safest and most widely used repairs after extensive gastric resections have been performed, whether for ulcer or cancer.

The schematic drawing (Figure 1) shows the position of the viscera after this operation is completed, which in principle consists of uniting the jejunum to the open end of the stomach. The jejunum may be anastomosed either behind or in front of the colon. In the retrocolic anastomosis, a loop of jejunum is brought through a rent in the mesentery of the colon to the left of the middle colic vessels and near the ligament of Treitz (Figure 2). In the antecolic anastomosis, a longer loop must be used in order to pass in front of the colon freed of fatty omentum. If the resection has been done for ulcer to control the acid factor, it is important that the afferent jejunal loop be made reasonably short, since long loops are more prone to subsequent marginal ulceration. The jejunum is grasped with Babcock forceps and brought up through the opening made in the mesocolon, with the proximal portion in juxtaposition to the lesser curvature of the stomach (Figure 2). The abdomen is then completely walled off with warm, moist sponges. The jejunal loop is grasped in an enterostomy clamp and approximated to the posterior surface of the stomach adjacent to the noncrushing clamp by a layer of closely placed, interrupted 00 silk mattress sutures (Figure 3). This posterior row should include both the greater curvature and the lesser curvature of the stomach. Otherwise, subsequent closure of the angles may be insecure. The ends of the sutures are cut, except those at the lesser and greater curvatures, B and A, which are retained for purposes of traction (Figure 4). When the end of the stomach has been closed with staples, a noncrushing enterostomy clamp is applied several centimeters from the line of staples. This provides fixation of the gastric wall during suturing and in addition controls oozing and gross soiling. The border of the stomach is cut away with scissors. An opening is made lengthwise in the jejunum, approximating in size the opening in the stomach. The fingers hold the jejunum down flat, and the incision is made close to the suture line (Figure 5). Small submucosal bleeding vessels are ligated with fine 000 or 0000 silk.

The mucous membranes of the stomach and jejunum are approximated by a continuous mucosal absorbable synthetic suture as the opposing surfaces are approximated by Allis clamps applied to either angle (Figure 6). A continuous suture on a straight or curved needle is started in the middle and is carried toward either angle as a running suture or as an interlocking continuous suture, if preferred. The corners are inverted with a Connell-type suture that is continued anteriorly, and the final knot is tied on the inside of the midline (Figure 7). Some prefer to approximate the mucosa with multiple interrupted 000 silk sutures. The anterior layer is closed with the knots on the inside by using an interrupted Connell-type suture. The enterostomy clamps are released to inspect the anastomosis for any leakage or bleeding. Additional sutures may be required. The anterior serosal layers are then approximated with interrupted 00 silk mattress sutures (Figure 8). Finally, at the upper and lower angles of the new stoma, additional mattress sutures are placed so that any strain exerted on the stoma is met by these additional reinforcing serosal sutures and not by the sutures of the anastomosis (Figure 9). In the retrocolic anastomosis the new stoma is anchored to the mesocolon with interrupted mattress sutures, care being taken to avoid blood vessels in the mesocolon (Figure 10).

The closure is performed in a routine manner without drainage.

The patient is placed in a semi-Fowler's position when conscious. Any significant deficiencies resulting from the measured blood loss during surgery should be corrected transfusions. Antibiotics may be used as prophylaxis against peritoneal sepsis, especially in the presence of achlorhydria.

The fluid intake is maintained daily at approximately 2,000 mL by the intravenous administration of Ringer's lactate solution. Serum electrolyte determinations are made daily as long as intravenous fluids are given. The patient's weight should be recorded daily. Accurate records of the intake and output from all sources are mandatory. Parenteral vitamins may be given.

Pulmonary complications are common; therefore the patient is encouraged to cough and sit upright. If the patient's condition warrants, he or she may be out of bed on the first day after operation. Water in sips is allowed 24 hours after operation. Constant gastric suction is maintained during the procedure and for a few days after operation. It may be discontinued when the tube can be clamped for at least 12 hours without symptoms of gastric distention appearing. After the nasal tube is removed, the patient may be placed on a postgastrectomy diet regimen that progresses gradually from bland liquids to six small feedings per day. Fruit juices may be diluted in half and milk added cautiously as tolerated. Beverages containing caffeine, excessive sugar, or carbonation should be avoided. A diet consistent with an ulcer regimen should gradually be replaced by an unlimited diet. An additional daily intake of fats should be encouraged for those patients well below their ideal body weight. All carbohydrates may not be tolerated well, especially in the morning, for several weeks after operation. Smoking should be prohibited until the patient's weight has returned to a satisfactory level. Frequent evaluation of the patient's dietary intake and weight trends is strongly advised during the first year after surgery and at longer intervals thereafter for at least 5 years.