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Surgery_Schwartz. with a curative intent. Am J Gastroenterol. 2008;103:2589-2597.Brunicardi_Ch25_p1009-p1098.indd 109601/03/19 6:06 PM 1097ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25McCort JJ. Esophageal carcinosarcoma and pseudosarcoma. Radiology. 1972;102:519-524.Medical Research Council Oesophageal Working Party. Surgi-cal resection with or without preoperative chemotherapy in oesophageal cancer: a randomized controlled trial. Lancet. 2002;359:1727-1733.Naunheim KS, Petruska PJ, et al. Preoperative chemotherapy and radiotherapy for esophageal carcinoma. J Thorac Cardiovasc Surg. 1992;103:887-893.Nicks R. Colonic replacement of the esophagus. Br J Surg. 1967; 54:124-128.Nigro JJ, Hagen JA, DeMeester TR, et al. Occult esophageal ade-nocarcinoma: extent of disease and implications for effective therapy. Ann Surg. 1999;230:433-438.Omloo JM, Lagarde SM, Hulscher JB, et al. Extended transtho-racic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus:


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Surgery_Schwartz. Ann Surg. 1999;230:433-438.Omloo JM, Lagarde SM, Hulscher JB, et al. Extended transtho-racic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: Five year survival of a randomized clinical trial. Ann Surg. 2007;246(6):992-1000.Orringer MB, Marshall B, Iannettoni MD. Transhiatal esopha-gectomy: clinical experience and refinements. Ann Surg. 1999;230:392.Orringer MB, Marshall B, Chang AC, et al. Two thousand tran-shiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246(3):363-372; discussion 372-374.Ott K, Herrmann K, Lordick F, et al. Early metabolic response evaluation by fluorine-18 fluorodeoxyglucose positron emis-sion tomography allows in vivo testing of chemosensitivity in gastric cancer: long-term results of a prospective study. Clin Cancer Res. 2008;14:2012-2018.Pacifico RJ, Wang KK, Wongkeesong LM, et al. Combined endo-scopic mucosal resection and photodynamic therapy versus esophagectomy for management of


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Surgery_Schwartz. study. Clin Cancer Res. 2008;14:2012-2018.Pacifico RJ, Wang KK, Wongkeesong LM, et al. Combined endo-scopic mucosal resection and photodynamic therapy versus esophagectomy for management of early adenocarcinoma of the esophagus. Clin Gastroenterol Hepatol. 2003;1:252-257.Pera M, Cameron AJ, Trastek VF, Carpenter HA, Zinsmeister AR. Increasing incidence of adenocarcinoma of the esoph-agus and esophagogastric junction. Gastroenterology. 1993;104(2):510-513.Pera M, Trastek VF, Carpenter HA, Allen MS, Deschamps C, Pairolero PC. Barrett’s esophagus with high-grade dysplasia: an indication for esophagectomy? Ann Thorac Surg. 1992;54:199-204.Pera M, Trastek VF, Carpenter HA, et al. Influence of pancreatic and biliary reflux on the development of esophageal carcinoma. Ann Thorac Surg. 1993;55:1386-1392.Peters JH, Clark GWB, Ireland AP, Chandrasoma P, Smyrk TC, DeMeester TR. Outcome of adenocarcinoma arising in Barrett’s esophagus in endoscopically surveyed and non-surveyed patients. J


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Surgery_Schwartz. JH, Clark GWB, Ireland AP, Chandrasoma P, Smyrk TC, DeMeester TR. Outcome of adenocarcinoma arising in Barrett’s esophagus in endoscopically surveyed and non-surveyed patients. J Thorac Cardiovasc Surg. 1994;108(5):813-821.Peters JH, Hoeft SF, Heimbucher J, et al. Selection of patients for cura-tive or palliative resection of esophageal cancer based on preopera-tive endoscopic ultrasound. Arch Surg. 1994;129:534-539.Peters JH. Surgical treatment of esophageal adenocarcinoma: con-cepts in evolution. J Gastrointest Surg. 2002;6:518.Rasanen JV, Sihvo EIT, Knuuti J, et al. Prospective analysis of accuracy of proton emission tomography, computed tomogra-phy and endoscopic ultrasonography in staging of adenocarci-noma of the esophagus and esophagogastric junction. Ann Surg Oncol. 2003;10:954-960.Ravitch M. A Century of Surgery. Philadelphia: Lippincott; 1981:56.Reed CE. Comparison of different treatments for unresectable esophageal cancer. World J Surg. 1995;19:828.Reid BJ, Weinstein WM,


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Surgery_Schwartz. M. A Century of Surgery. Philadelphia: Lippincott; 1981:56.Reed CE. Comparison of different treatments for unresectable esophageal cancer. World J Surg. 1995;19:828.Reid BJ, Weinstein WM, Kewin KJ, et al. Endoscopic biopsy can detect high-grade dysplasia or early adenocarcinoma in Barrett’s esophagus without grossly recognizable neoplastic lesions. Gastroenterology. 1988;94(1):81-90.Ribeiro U, Jr, Posner MC, Safatle-Ribeiro AV, Reynolds JC. Risk factors for squamous cell carcinoma of the oesophagus. Br J Surg. 1996;83:1174-1185.Rice TW, Boyce GA, Sivall MV. Esophageal ultrasound and the preoperative staging of carcinoma of the esophagus. J Thorac Cardiovasc Surg. 1991;101:536-543.Rice TW, Rusch VW, Ishwaran H, et al. Cancer of the esopha-gus and esophagogastric junction: data-driven staging for the seventh edition of the American Joint Committee on Cancer/International Union Against Cancer Cancer Staging Manuals. Cancer. 2010;15:3763-3773.Robertson CS, Mayberry JF, Nicholson JA.


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Surgery_Schwartz. staging for the seventh edition of the American Joint Committee on Cancer/International Union Against Cancer Cancer Staging Manuals. Cancer. 2010;15:3763-3773.Robertson CS, Mayberry JF, Nicholson JA. Value of endoscopic surveillance in the detection of neoplastic changes in Barrett’s esophagus. Br J Surg. 1988;75:760-763.Rösch T, Lorenz R, et al. Endosonographic diagnosis of submuco-sal upper gastrointestinal tract tumors. Scand J Gastroenterol. 1992;27:1-8.Rosenberg JC, Budev H, Edwards RC. Analysis of adenocarci-noma in Barrett’s esophagus utilizing a staging system. Cancer. 1985;55:1353-1360.Ruol A, Portale G, Castoro C, et al. Effects of neoadjuvant ther-apy on perioperative morbidity in elderly patients undergo-ing esophagectomy for esophageal cancer. Ann Surg Oncol. 2007;14:3243-3250.Skinner DB, Dowlatshahi KD, DeMeester TR. Potentially curable carcinoma of the esophagus. Cancer. 1982;50:2571-2575.Skinner DB, Little AG, Ferguson MK, Soriano A, Staszak VM. Selection of operation


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Surgery_Schwartz. DB, Dowlatshahi KD, DeMeester TR. Potentially curable carcinoma of the esophagus. Cancer. 1982;50:2571-2575.Skinner DB, Little AG, Ferguson MK, Soriano A, Staszak VM. Selection of operation for esophageal cancer based on staging. Ann Surg. 1986;204:391-401.Smithers BM, Cullinan M, Thomas JM, et al. Outcomes from salvage esophagectomy post definitive chemoradiotherapy compared with resection following preoperative neoadjuvant chemoradiotherapy. Dis Esophagus. 2007;20:471-477.Sonnenberg A, Fennerty MB. Medical decision analysis of chemo-prevention against esophageal adenocarcinoma. Gastroenterol-ogy. 2003;124:1758-1766.Streitz JM, Jr, Ellis FH, Jr, Gibb SP, et al. Adenocarcinoma in Barrett’s esophagus. Ann Surg. 1991;213:122-125.Turnbull AD, Rosen P, Goodner JT, et al. Primary malignant tumors of the esophagus other than typical epidermoid carcinoma. Ann Thorac Surg. 1973;15:463-473.Urschel JD, Ashiku S, Thurer R, et al. Salvage or planned esophagectomy after chemoradiation for


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Surgery_Schwartz. tumors of the esophagus other than typical epidermoid carcinoma. Ann Thorac Surg. 1973;15:463-473.Urschel JD, Ashiku S, Thurer R, et al. Salvage or planned esophagectomy after chemoradiation for locally advanced esophageal cancer: a review. Dis Esophagus. 2003;16:60-65.Vigneswaran WT, Trastek VK, Pairolero PC, et al. Extended esoph-agectomy in the management of carcinoma of the upper tho-racic esophagus. J Thorac Cardiovasc Surg. 1994;107:901-907.Walsh TN, Noonan N, Hollywood D, Kelly A, Keeling N, Hennessy TP. A comparison of multimodal therapy and surgery for esophageal adenocarcinoma. N Engl J Med. 1996;335:462-467.Watson WP, Pool L. Cancer of the cervical esophagus. Surgery. 1948;23:893.Benign Tumors and CystsBardini R, Segalin A, Ruol A, et al. Videothoracoscopic enucleation of esophageal leiomyoma. Am Thorac Surg. 1992;54:576-577.Bonavina L, Segalin A, Rosati R, Pavanello M, Peracchia A. Surgical therapy of esophageal leiomyoma. J Am Coll Surg. 1995;181:257-262.Esophageal


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Surgery_Schwartz. esophageal leiomyoma. Am Thorac Surg. 1992;54:576-577.Bonavina L, Segalin A, Rosati R, Pavanello M, Peracchia A. Surgical therapy of esophageal leiomyoma. J Am Coll Surg. 1995;181:257-262.Esophageal PerforationBrewer LA III, Carter R, Mulder GA, Stiles QR. Options in the management of perforations of the esophagus. Am J Surg. 1986;152:62-69.Bufkin BL, Miller JI, Jr, Mansour KA. Esophageal perfora-tion. Emphasis on management. Ann Thorac Surg. 1996;61: 1447-1451.Chang C-H, Lin PJ, Chang JP, et al. One-stage operation for treat-ment after delayed diagnosis of thoracic esophageal perforation. Ann Thorac Surg. 1992;53:617-620.Brunicardi_Ch25_p1009-p1098.indd 109701/03/19 6:06 PM 1098SPECIFIC CONSIDERATIONSPART IIEngum SA, Grosfeld JL, West KW, et al. Improved survival in chil-dren with esophageal perforation. Arch Surg. 1996;131:604-611.Gouge TH, Depan HJ, Spencer FC. Experience with the Grillo pleural wrap procedure in 18 patients with perforation of the thoracic esophagus. Ann Surg.


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Surgery_Schwartz. perforation. Arch Surg. 1996;131:604-611.Gouge TH, Depan HJ, Spencer FC. Experience with the Grillo pleural wrap procedure in 18 patients with perforation of the thoracic esophagus. Ann Surg. 1989;209:612-617.Jones WG II, Ginsberg RJ. Esophageal perforation: a continuing challenge. Ann Thorac Surg. 1992;53:534-543.Pate JW, Walker WA, Cole FH, Jr, Owen EW, Johnson WH. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg. 1989;47:689-692.Reeder LB, DeFilippi VJ, Ferguson MK. Current results of therapy for esophageal perforation. Am J Surg. 1995;169:615-617.Salo JA, Isolauri JO, Heikkilä LJ, et al. Management of delayed esophageal perforation with mediastinal sepsis. Esopha-gectomy or primary repair? J Thorac Cardiovasc Surg. 1993;106:1088-1091.Sawyer R, Phillips C, Vakil N. Shortand long-term outcome of esophageal perforation. Gastrointest Endosc. 1995;41:130-134.Segalin A, Bonavina L, Lazzerini M, De Ruberto F, Faranda C, Peracchia A. Endoscopic management of


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Surgery_Schwartz. Vakil N. Shortand long-term outcome of esophageal perforation. Gastrointest Endosc. 1995;41:130-134.Segalin A, Bonavina L, Lazzerini M, De Ruberto F, Faranda C, Peracchia A. Endoscopic management of inveterate esophageal perforations and leaks. Surg Endosc. 1996;10:928-932.Weiman DS, Walker WA, Brosnan KM, Pate JW, Fabian TC. Noniat-rogenic esophageal trauma. Ann Thorac Surg. 1995;59:845-849.Whyte RI, Iannettoni MD, Orringer MB. Intrathoracic esophageal perforation. The merit of primary repair. J Thorac Cardiovasc Surg. 1995;109:140-144.Caustic InjuryAnderson KD, Rouse TM, Randolph JG. A controlled trial of cor-ticosteroids in children with corrosive injury of the esophagus. N Engl J Med. 1990;323:637-640.Ferguson MK, Migliore M, Staszak VM, Little AG. Early evaluation and therapy for caustic esophageal injury. Am J Surg. 1989;157:116-120.Lahoti D, Broor SL, Basu PP, Gupta A, Sharma R, Pant CS. Corro-sive esophageal strictures. Predictors of response to endoscopic dilation.


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Surgery_Schwartz. for caustic esophageal injury. Am J Surg. 1989;157:116-120.Lahoti D, Broor SL, Basu PP, Gupta A, Sharma R, Pant CS. Corro-sive esophageal strictures. Predictors of response to endoscopic dilation. Gastrointest Endosc. 1995;41:196-200.Popovici Z. About reconstruction of the pharynx with colon in extensive corrosive strictures. Kurume Med J. 1989;36:41-47.Sugawa C, Lucas CE. Caustic injury of the upper gastrointesti-nal tract in adults: a clinical and endoscopic study. Surgery. 1989;106:802-806.Wu M-H, Lai W-W. Surgical management of extensive corro-sive injuries of the alimentary tract. Surg Gynecol Obstet. 1993;177:12-16.Zargar SA, Kochhar R, Mehta S, Mehta SK. The role of fiberoptic endoscopy in the management of corrosive ingestion and modi-fied endoscopic classification of burns. Gastrointest Endosc. 1991;37:165-169.Techniques of Esophageal ReconstructionAkiyama H. Esophageal reconstruction. Entire stomach as esopha-geal substitute. Dis Esophagus. 1995;8:7-9.Banki F, Mason RJ,


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Surgery_Schwartz. Endosc. 1991;37:165-169.Techniques of Esophageal ReconstructionAkiyama H. Esophageal reconstruction. Entire stomach as esopha-geal substitute. Dis Esophagus. 1995;8:7-9.Banki F, Mason RJ, DeMeester SR, et al. Vagal sparing esopha-gectomy: a more physiologic alternative. Ann Surg. 2002; 236:324-336.Burt M, Scott A, Williard WC, et al. Erythromycin stimu-lates gastric emptying after esophagectomy with gastric replacement. A randomized clinical trial. J Thorac Cardiovasc Surg. 1996;111:649-654.Cheng W, Heitmiller RF, Jones BJ. Subacute ischemia of the colon esophageal interposition. Ann Thorac Surg. 1994;57:899-903.DeMeester TR, Johansson KE, Franze I, Eypasch E, Lu CT, McGill JE, Zaninotto G. Indications, surgical technique, and long-term functional results of colon interposition or bypass. Ann Surg. 1988(4);208:460-474.DeMeester TR, Kauer WK. Esophageal reconstruction. The colon as an esophageal substitute. Dis Esophagus. 1995;8:20-29.Dexter SPL, Martin IG, McMahon MJ. Radical


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Surgery_Schwartz. bypass. Ann Surg. 1988(4);208:460-474.DeMeester TR, Kauer WK. Esophageal reconstruction. The colon as an esophageal substitute. Dis Esophagus. 1995;8:20-29.Dexter SPL, Martin IG, McMahon MJ. Radical thoracoscopic esophagectomy for cancer. Surg Endosc. 1996;10:147-151.Ellis FH, Jr, Gibb SP. Esophageal reconstruction for complex benign esophageal disease. J Thorac Cardiovasc Surg. 1990; 99:192-199.Finley RJ, Lamy A, Clifton J, et al. Gastrointestinal function fol-lowing esophagectomy for malignancy. Am J Surg. 1995; 169:471-475.Fok M, Cheng SW, Wong J. Pyloroplasty versus no drainage in gas-tric replacement of the esophagus. Am J Surg. 1991;162:447-452.Gossot D, Cattan P, Fritsch S. Can the morbidity of esophagec-tomy be reduced by the thoracoscopic approach? Surg Endosc. 1995;9:1113-1115.Honkoop P, Siersema PD, Tilanus HW, Stassen LP, Hop WC, van Blankenstein M. Benign anastomotic strictures after tran-shiatal esophagectomy and cervical esophagogastrostomy. Risk factors and


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Surgery_Schwartz. P, Siersema PD, Tilanus HW, Stassen LP, Hop WC, van Blankenstein M. Benign anastomotic strictures after tran-shiatal esophagectomy and cervical esophagogastrostomy. Risk factors and management. J Thorac Cardiovasc Surg. 1996;111(6):1141-1148.Liebermann-Meffert DMI, Meier R, Siewert JR. Vascular anatomy of the gastric tube used for esophageal reconstruction. Ann Thorac Surg. 1992;54:1110-1115.Maier G, Jehle EC, Becker HD. Functional outcome following oesophagectomy for oesophageal cancer. A prospective mano-metric study. Dis Esophagus. 1995;8:64-69.Naunheim KS, Hanosh J, Zwischenberger J, et al. Esophagectomy in the septuagenarian. Ann Thorac Surg. 1993;56(4):880-884.Nishihra T, Oe H, Sugawara K, et al. Esophageal reconstruction. Reconstruction of the thoracic esophagus with jejunal pedicled segments for cancer of the thoracic esophagus. Dis Esophagus. 1995;8:30-39.Peters JH, Kronson J, Bremner CG, et al. Arterial anatomic con-siderations in colon interposition for esophageal


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Surgery_Schwartz. pedicled segments for cancer of the thoracic esophagus. Dis Esophagus. 1995;8:30-39.Peters JH, Kronson J, Bremner CG, et al. Arterial anatomic con-siderations in colon interposition for esophageal replacement. Arch Surg. 1995;130:858-863.Stark SP, Romberg MS, Pierce GE, et al. Transhiatal versus trans-thoracic esophagectomy for adenocarcinoma of the distal esophagus and cardia. Am J Surg. 1996;172:478-482.Valverde A, Hay JM, Fingerhut A, et al. Manual versus mechani-cal esophagogastric anastomosis after resection for carcinoma. A controlled trial. French Associations for Surgical Research. Surgery. 1996;120:476-483.Watson T, DeMeester TR, Kauer WK, Peters JH, Hagen JA. Esoph-agectomy for end stage benign esophageal disease. J Thorac Cardiovasc Surg. 1998;115(6):1241-1247.Wu M-H, Lai W-W. Esophageal reconstruction for esophageal strictures or resection after corrosive injury. Ann Thorac Surg. 1992;53:798-802.Brunicardi_Ch25_p1009-p1098.indd 109801/03/19 6:06 PM


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Surgery_Schwartz. StomachRobert E. Roses and Daniel T. Dempsey 26chapterThe stomach stores and facilitates the digestion and absorption of ingested food and helps regulate appetite. Treatable dis-eases of the stomach are common, and it is accessible and rela-tively forgiving of surgical manipulation. To provide accurate diagnosis and rational treatment, the physician must under-stand gastric anatomy, physiology, and pathophysiology; this includes a sound understanding of the mechanical, secretory, and endocrine processes by which the stomach accomplishes its important functions and a familiarity with the common benign and malignant gastric disorders. Important historical milestones1-6 that influenced the contemporary understand-ing of gastric disease and surgical therapy are summarized in Table 26-1.ANATOMYAnatomic Relationships and Gross MorphologyThe stomach is the most proximal abdominal organ of the diges-tive tract (Fig. 26-1).7 The part of the stomach attached to the esophagus is called the


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Surgery_Schwartz. Relationships and Gross MorphologyThe stomach is the most proximal abdominal organ of the diges-tive tract (Fig. 26-1).7 The part of the stomach attached to the esophagus is called the cardia. Just proximal to the cardia at the gastroesophageal (GE) junction is the anatomically indistinct but physiologically demonstrable lower esophageal sphincter. At the distal end, the readily apparent pyloric sphincter con-nects the stomach to the proximal duodenum. The stomach is relatively fixed at these points, but the majority of the stomach is quite mobile with the shorter lesser curvature on the right and the longer greater curvature on the left.The superior-most part of the stomach is the distensible fundus, bounded superiorly by the diaphragm and laterally by the spleen. The angle of His is where the fundus meets the left side of the GE junction. Generally, the inferior extent of the fun-dus is considered to be the horizontal plane of the GE junction, where the body (corpus) of the stomach


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Surgery_Schwartz. the fundus meets the left side of the GE junction. Generally, the inferior extent of the fun-dus is considered to be the horizontal plane of the GE junction, where the body (corpus) of the stomach begins. The body of the stomach contains most of the parietal (oxyntic) cells, some of which are also present in the cardia and fundus. At the angularis incisura, the lesser curvature turns rather abruptly to the right, marking the anatomic beginning of the antrum, which comprises the distal 25% to 30% of the stomach.Anatomy 1099Anatomic Relationships and Gross Morphology / 1099Arterial and Venous Blood Supply / 1100Lymphatic Drainage / 1100Innervation / 1101Histology / 1102Physiology 1105Acid Secretion / 1105Pepsinogen Secretion / 1108Intrinsic Factor / 1108Gastric Mucosal Barrier / 1109Gastric Hormones / 1109Gastric Motility and Emptying / 1110Diagnosis of Gastric Disease 1115Signs and Symptoms / 1115Diagnostic Tests / 1115Helicobacter Pylori Infection 1117Peptic Ulcer


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Surgery_Schwartz. / 1109Gastric Hormones / 1109Gastric Motility and Emptying / 1110Diagnosis of Gastric Disease 1115Signs and Symptoms / 1115Diagnostic Tests / 1115Helicobacter Pylori Infection 1117Peptic Ulcer Disease 1120Pathophysiology and Etiology / 1121Clinical Manifestations / 1123Diagnosis / 1123Complications / 1124Medical Treatment of Peptic Ulcer Disease / 1125Surgical Treatment of Peptic Ulcer Disease / 1127Bleeding Peptic Ulcer / 1131Operation for Bleeding Peptic Ulcer / 1133Perforated Peptic Ulcer / 1134Obstructing Peptic Ulcer / 1136Intractable or Nonhealing Peptic Ulcer / 1136Zollinger-Ellison Syndrome / 1136Stress Gastritis and Stress Ulcer 1137Atrophic Gastritis 1138Malignant Neoplasms of the Stomach 1139Adenocarcinoma / 1139Pathology / 1143Gastric Lymphoma / 1149Gastrointestinal Stromal Tumor / 1149Gastric Neuroendocrine Tumors / 1151Benign Gastric Neoplasms 1152Leiomyoma / 1152Lipoma / 1152Gastroparesis / 1152Massive Upper Gastrointestinal Bleeding / 1152Isolated Gastric


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Surgery_Schwartz. Stromal Tumor / 1149Gastric Neuroendocrine Tumors / 1151Benign Gastric Neoplasms 1152Leiomyoma / 1152Lipoma / 1152Gastroparesis / 1152Massive Upper Gastrointestinal Bleeding / 1152Isolated Gastric Varices / 1153Hypertrophic Gastropathy (Ménétrier’s Disease) / 1153Watermelon Stomach (Gastric Antral Vascular Ectasia) / 1154Dieulafoy’s Lesion / 1154Bezoars/Diverticula / 1154Foreign Bodies / 1154Mallory-Weiss Syndrome / 1155Volvulus / 1155Gastrostomy 1155Postgastrectomy Problems 1156Dumping Syndrome / 1156Diarrhea / 1157Gastric Stasis / 1157Bile Reflux Gastritis and Esophagitis / 1158Roux Syndrome / 1158Gallstones / 1159Weight Loss / 1159Anemia / 1159Bone Disease / 1159Laparoscopic Gastric Operations 1159Brunicardi_Ch26_p1099-p1166.indd 109901/03/19 7:11 PM 1100The liver, colon, spleen, pancreas, and occasionally the kidney, abut the stomach (Fig. 26-2). The left lateral segment of the liver usually obscures part of the anterior stomach. Infe-riorly, the stomach is attached to


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Surgery_Schwartz. pancreas, and occasionally the kidney, abut the stomach (Fig. 26-2). The left lateral segment of the liver usually obscures part of the anterior stomach. Infe-riorly, the stomach is attached to the transverse colon by the gastrocolic omentum. The lesser curvature is tethered to the liver by the hepatogastric ligament, also referred to as the lesser omentum or pars flaccida. Posterior to the stomach is the lesser omental bursa and the pancreas.Arterial and Venous Blood SupplyThe stomach is the most richly vascularized portion of the ali-mentary tube with ample blood flow and a dense intramural vascular anastomotic network. The large majority of the gastric blood supply is from the celiac axis via four named arteries (Fig. 26-3). The left and right gastric arteries form an anasto-motic arcade along the lesser gastric curvature, and the right and left gastroepiploic arteries form an arcade along the greater gastric curvature. The left gastric artery is consistently the larg-est artery to


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Surgery_Schwartz. along the lesser gastric curvature, and the right and left gastroepiploic arteries form an arcade along the greater gastric curvature. The left gastric artery is consistently the larg-est artery to the stomach and usually arises directly from the celiac trunk and divides into an ascending and descending branch along the lesser gastric curvature. Approximately 20% of the time, the left gastric artery supplies an aberrant vessel that travels in the gastrohepatic ligament (lesser omentum) to the left side of the liver. Rarely, this is the only arterial blood supply to this part of the liver (replaced left hepatic artery), and inadvertent ligation may lead to clinically significant hepatic ischemia. The more common smaller accessory left hepatic artery may be ligated without significant consequences.The second largest artery to the stomach is the right gas-troepiploic artery, which consistently arises from the gastro-duodenal artery behind the first portion of the duodenum. The left


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Surgery_Schwartz. consequences.The second largest artery to the stomach is the right gas-troepiploic artery, which consistently arises from the gastro-duodenal artery behind the first portion of the duodenum. The left gastroepiploic artery arises from the splenic artery, and, together with the right gastroepiploic artery, forms the rich gastroepiploic arcade along the greater curvature. The right gastric artery usually arises from the hepatic artery near the pylorus and hepatoduodenal ligament and runs proximally along the distal stomach. In the fundus along the proximal greater curvature, the short gastric arteries and veins arise from the splenic circulation. There also may be additional vascular branches to the proximal stomach from the phrenic and splenic circulation.The veins draining the stomach generally parallel the arteries. The left gastric (coronary vein) and right gastric veins usually drain into the portal vein, though occasionally the coro-nary vein drains into the splenic vein. The right


Surgery_Schwartz

Surgery_Schwartz. parallel the arteries. The left gastric (coronary vein) and right gastric veins usually drain into the portal vein, though occasionally the coro-nary vein drains into the splenic vein. The right gastroepiploic vein drains into the superior mesenteric vein near the inferior border of the pancreatic neck, and the left gastroepiploic vein drains into the splenic vein.The richness of the gastric blood supply and its many anastomotic connections have important clinical implications. At least two of the four named gastric arteries may be occluded or ligated without inducing gastric ischemia. This is done rou-tinely when the stomach is mobilized and pedicled on the right gastric and right gastroepiploic vessels to reach into the neck as an esophageal replacement (see Chapter 25) or during sleeve gastrectomy for weight loss when the gastroepiploic arcade is interrupted proximally and distally prior to gastric resection (see Chapter 27). Following radical subtotal gastrectomy dur-ing which the


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Surgery_Schwartz. gastrectomy for weight loss when the gastroepiploic arcade is interrupted proximally and distally prior to gastric resection (see Chapter 27). Following radical subtotal gastrectomy dur-ing which the right and left gastric arteries and both gastroepi-ploic arteries are all ligated, the gastric remnant is adequately supplied by short gastric arteries as long as the splenic artery is patent and intact. Angiographic control of gastric bleeding from a deep ulcer or tumor often requires embolization of more than one feeding artery. Because of the rich venous interconnections in the stomach, a transjugular intrahepatic portosystemic shunt (TIPSS) can effectively decompress esophagogastric varices in patients with portal hypertension.8,9Lymphatic DrainageGenerally speaking, the gastric lymphatics parallel the blood vessels (Fig. 26-4).10 The cardia and medial half of the corpus commonly drain to nodes along the left gastric and celiac axis. The lesser curvature side of the antrum usually


Surgery_Schwartz

Surgery_Schwartz. parallel the blood vessels (Fig. 26-4).10 The cardia and medial half of the corpus commonly drain to nodes along the left gastric and celiac axis. The lesser curvature side of the antrum usually drains to the right gastric and pyloric nodes, while the greater curvature half of the distal stomach drains to the nodes along the right gas-troepiploic chain. The proximal greater curvature side of the stomach usually drains into nodes along the left gastroepiploic or splenic hilum. The nodes along both the greater and lesser Key Points1 Whenever testing suggests Helicobacter pylori infec-tion, treatment should be initiated and eradication confirmed.2 Lifelong acid suppression should be considered in any patient admitted to a hospital because of peptic ulcer dis-ease. Acid suppressive medication may be equivalent to sur-gical vagotomy in preventing recurrent peptic ulcer or ulcer complications.3 If possible, gastric resection for peptic ulcer is avoided in the asthenic or high-risk


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Surgery_Schwartz. may be equivalent to sur-gical vagotomy in preventing recurrent peptic ulcer or ulcer complications.3 If possible, gastric resection for peptic ulcer is avoided in the asthenic or high-risk patient.4 Though less common in the United States, gastric cancer is a major cause of cancer-related morbidity and mortality worldwide.5 Diagnostic laparoscopy with peritoneal lavage should be considered in the evaluation of clinical stage 2 and 3 patients with gastric cancer.6 Multimodality therapy for gastric cancer, including resec-tion in combination with perioperative chemotherapy or adjuvant chemoradiotherapy is associated with a survival advantage compared to surgery alone.7 Most patients with primary gastric lymphoma can be treated without gastric resection.8 Localized gastrointestinal stromal tumors of the stomach are treated with full thickness excision. Adjuvant (or neo-adjuvant) imatinib is indicated for higher-risk lesions.9 Gastric neuroendocrine tumors may arise in the presence


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Surgery_Schwartz. tumors of the stomach are treated with full thickness excision. Adjuvant (or neo-adjuvant) imatinib is indicated for higher-risk lesions.9 Gastric neuroendocrine tumors may arise in the presence (types 1 and 2) or absence (type 3) of hypergastrinemia. Type 3 gastric neuroendocrine tumors should usually be treated with subtotal gastrectomy and regional lymphadenectomy.10 Roux-en-Y gastrojejunostomy with a large (>50%) proxi-mal gastric remnant should be avoided because marginal ulceration and/or gastric stasis (Roux syndrome) may become problematic.Brunicardi_Ch26_p1099-p1166.indd 110001/03/19 7:11 PM 1101STOMACHCHAPTER 26curvature commonly drain into the celiac nodal basin. There is a rich anastomotic network of lymphatics that drain the stomach, often in a somewhat unpredictable fashion. Thus, a tumor aris-ing in the distal stomach may give rise to positive lymph nodes in the splenic hilum. The rich intramural plexus of lymphatics and veins accounts for the fact that there can be


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Surgery_Schwartz. Thus, a tumor aris-ing in the distal stomach may give rise to positive lymph nodes in the splenic hilum. The rich intramural plexus of lymphatics and veins accounts for the fact that there can be microscopic evi-dence of malignant cells in the gastric wall at a resection margin that is several centimeters away from palpable malignant tumor. It also helps explain the not infrequent finding of positive lymph nodes, which may be many centimeters away from the primary tumor, with closer nodes that are uninvolved.Not surprisingly, extensive and meticulous lymphadenec-tomy is considered by many surgeons to be an important part of an operation for gastric cancer. Surgeons and pathologists have numbered the primary and secondary lymph node groups to which the stomach drains (see Fig. 26-4).11,12Innervation13The vagus nerves provide the extrinsic parasympathetic innerva-tion to the stomach, and acetylcholine is the most important neu-rotransmitter. From the vagal nucleus in the floor of the


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Surgery_Schwartz. vagus nerves provide the extrinsic parasympathetic innerva-tion to the stomach, and acetylcholine is the most important neu-rotransmitter. From the vagal nucleus in the floor of the fourth cerebral ventricle, the vagus traverses the neck in the carotid sheath and enters the mediastinum, where it gives off the recur-rent laryngeal nerve and divides into several branches around the esophagus. These branches come together again above the esophageal hiatus and form the left (anterior) and right Table 26-1Historic milestones in gastric surgeryDATEEVENTDATEEVENT350 b.c.– 201 a.d. 1363 1586 1600–1700 16881737 1833 1869 1875 1879 1880 1880 1881 1884 1885Existence of gastric ulceration was acknowledged by Diocles of Carystos (350 b.c.), Celsus, and Galen (131–201 a.d.).Guy de Chauliac describes closure of gastric wound.Marcellus Donatus of Mantua describes gastric ulcer at autopsy.Reports of surgeons cutting stomach to remove foreign bodies.Muralto describes duodenal ulcer at


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Surgery_Schwartz. describes closure of gastric wound.Marcellus Donatus of Mantua describes gastric ulcer at autopsy.Reports of surgeons cutting stomach to remove foreign bodies.Muralto describes duodenal ulcer at autopsy.Morgagni describes both gastric and duodenal ulcer at autopsy.William Beaumont reports data recorded during his care of Alexis St. Martin who developed a gastric fistula from a left upper quadrant musket wound.Maury reportedly performs feeding gastrostomy to palliate esophageal stricture following consultation with Samuel D. Gross.Sidney Jones in London publishes the first successful gastrostomy for feeding.Paen performed distal gastrectomy and gastroduodenostomy. The patient died 5 d later.Rydygier resected a distal gastric cancer, and the patient died 12 h later.Billroth resects distal gastric cancer and performs gastroduodenostomy (Billroth I). Patient Therese Heller recovers and survives 4 mo.Anton Wolfler performs loop gastrojejunostomy to palliate an obstructing distal gastric


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Surgery_Schwartz. gastric cancer and performs gastroduodenostomy (Billroth I). Patient Therese Heller recovers and survives 4 mo.Anton Wolfler performs loop gastrojejunostomy to palliate an obstructing distal gastric cancer.Rydygier reports an unsuccessful gastrojejunostomy for benign gastric outlet obstruction.Billroth performs a successful distal gastrectomy and gastrojejunostomy (Billroth II) for gastric cancer.1886188818921902 1891–1913 1920–1950 1943 1952 1953 1955 1957 1980–2000 1990–current 1995–current2000–currentHeineke performs pyloroplasty.Mikulicz performs similar operation.Jaboulay describes bypassing the intact pylorus with gastroduodenostomy.Finney from Baltimore describes pyloroplasty technique.Different techniques of gastrostomy are described by Witzel (1891), Stamm (1894), and Janeway (1913).Subtotal gastrectomy grows popular as an operation for peptic ulcer. Von Haberer and Finsterer proponents.Dragstedt and Owen describe transthoracic truncal vagotomy to treat peptic


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Surgery_Schwartz. and Janeway (1913).Subtotal gastrectomy grows popular as an operation for peptic ulcer. Von Haberer and Finsterer proponents.Dragstedt and Owen describe transthoracic truncal vagotomy to treat peptic ulcer disease. By the early 1950s, it is well recognized that some patients developed gastric stasis after this procedure, and transabdominal truncal vagotomy and drainage (pyloroplasty or gastrojejunostomy) become a standard ulcer operation.Farmer and Smithwick describe good results with truncal vagotomy and hemigastrectomy for peptic ulcer.Edwards and Herrington (Nashville) describe truncal vagotomy and antrectomy for peptic ulcer.Zollinger and Ellison describe the eponymous syndrome.Griffith and Harkins (Seattle) describe parietal cell vagotomy (highly selective vagotomy) for the elective treatment of peptic ulcer disease.Japanese surgeons and other surgical groups from East Asia demonstrate that more aggressive lymphadenectomy may improve survival in patients with gastric


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Surgery_Schwartz. elective treatment of peptic ulcer disease.Japanese surgeons and other surgical groups from East Asia demonstrate that more aggressive lymphadenectomy may improve survival in patients with gastric cancer.Evolving role of laparoscopic techniques in the treatment of surgical gastric disease.Dramatic increase in bariatric operations.Development of natural orifice translumenal endoscopic surgery, such as transgastric appendectomy and peroral pyloromyotomy.Development of robotic gastrectomy.Brunicardi_Ch26_p1099-p1166.indd 110101/03/19 7:11 PM 1102SPECIFIC CONSIDERATIONS PART II(posterior) vagal trunks (mnemonic LARP). Near the GE junc-tion the anterior vagus sends a branch (or branches) to the liver in the gastrohepatic ligament, and continues along the lesser curvature as the anterior nerve of Latarjet (Fig. 26-5). Simi-larly, the posterior vagus sends branches to the celiac plexus and continues along the posterior lesser curvature. The nerves of Latarjet send segmental branches


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Surgery_Schwartz. nerve of Latarjet (Fig. 26-5). Simi-larly, the posterior vagus sends branches to the celiac plexus and continues along the posterior lesser curvature. The nerves of Latarjet send segmental branches to the body of the stomach before they terminate near the angularis incisura as the “crow’s foot,” sending branches to the antropyloric region. There may be additional branches to the distal stomach and pylorus that travel near the right gastric and/or gastroepiploic arteries. In 50% of patients, there are more than two vagal nerves at the esophageal hiatus. The branch that the posterior vagus sends to the posterior fundus is termed the criminal nerve of Grassi. This branch typically arises above the esophageal hiatus and is easily missed during truncal or highly selective vagotomy (HSV). Vagal fibers originating in the brain synapse with neu-rons in Auerbach’s myenteric plexus and Meissner’s submu-cosal plexus. In the stomach, the vagus nerves affect secretion (including acid), motor


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Surgery_Schwartz. Vagal fibers originating in the brain synapse with neu-rons in Auerbach’s myenteric plexus and Meissner’s submu-cosal plexus. In the stomach, the vagus nerves affect secretion (including acid), motor function, and mucosal bloodflow and cytoprotection. They also play a role in appetite control and per-haps even mucosal immunity and inflammation.14,15 Most of the axons contained in the vagal trunks are afferent (i.e., carrying stimuli from the viscera to the brain).The extrinsic sympathetic nerve supply to the stomach originates at spinal levels T5 through T10 and travels in the splanchnic nerves to the celiac ganglion. Postganglionic sympa-thetic nerves then travel from the celiac ganglion to the stomach along the blood vessels.Neurons in the myenteric and submucosal plexuses consti-tute the intrinsic nervous system of the stomach. There may be more intrinsic gastric neurons than extrinsic neurons, but their function is poorly understood.The characterization of the vagus as the


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Surgery_Schwartz. the intrinsic nervous system of the stomach. There may be more intrinsic gastric neurons than extrinsic neurons, but their function is poorly understood.The characterization of the vagus as the cholinergic system and the sympathetic system as the adrenergic system of innerva-tion is a misleading oversimplification. Although acetylcholine is an important neurotransmitter mediating vagal function, and epinephrine is important in the sympathetic nerves, both sys-tems (as well as the intrinsic neurons) have various and diverse neurotransmitters, including cholinergic, adrenergic, and pepti-dergic (e.g., substance P and somatostatin).HistologyThere are four distinct layers of the gastric wall: mucosa, sub-mucosa, muscularis propria, and serosa (Fig. 26-6).7 The inner layer of the stomach is the mucosa, which is lined with colum-nar epithelial cells of various types. Beneath the basement mem-brane of the epithelial cells is the lamina propria, which contains connective tissue, blood


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Surgery_Schwartz. is the mucosa, which is lined with colum-nar epithelial cells of various types. Beneath the basement mem-brane of the epithelial cells is the lamina propria, which contains connective tissue, blood vessels, nerve fibers, and inflammatory cells. Beneath the lamina propria is a thin muscle layer called the muscularis mucosa, the deep boundary of the mucosal layer of the gut. The epithelium, lamina propria, and muscularis mucosa constitute the mucosa (Fig. 26-7).16 The epithelium of the gastric mucosa is columnar glandular. Scanning electron micrographs show a smooth mucosal carpet punctuated by the openings of the gastric glands or units. The gastric glands are lined with different types of epithelial cells, depending upon their loca-tion in the stomach (Fig. 26-8 and Table 26-2).17,18 There are also endocrine cells present in the gastric glands. Progenitor or stem cells in the isthmus and base of the glands differentiate and BodyFundusEsophagusCardiaPylorusDuodenumPyloric antrum


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Surgery_Schwartz. There are also endocrine cells present in the gastric glands. Progenitor or stem cells in the isthmus and base of the glands differentiate and BodyFundusEsophagusCardiaPylorusDuodenumPyloric antrum Lessercurvature GreatercurvatureFigure 26-1. Anatomic regions of the stomach. (Reproduced with permission from Zuidema GD, Yeo CJ: Shackelford’s Surgery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)Figure 26-2. Anatomic relationships of the stomach. (Reproduced with permission from Zuidema GD, Yeo CJ: Shackelford’s Surgery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)Liver (left lobe) Celiac trunk(splenic, gastric, hepatic)Gastrohepatic omentum Stomach(posterior wall)SpleenPancreasTransverse colonLesser omental spaceGastrocolic ligamentRight kidneyHepatoduodenal ligamentGallbladderT lictBrunicardi_Ch26_p1099-p1166.indd 110201/03/19 7:11 PM 1103STOMACHCHAPTER 26replenish


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Surgery_Schwartz. colonLesser omental spaceGastrocolic ligamentRight kidneyHepatoduodenal ligamentGallbladderT lictBrunicardi_Ch26_p1099-p1166.indd 110201/03/19 7:11 PM 1103STOMACHCHAPTER 26replenish sloughed cells on a regular basis. Genetic studies show that there are several different subpopulations of stem cells in the gastric glands and that during conditions of stress even chief cells exhibit the plasticity required to regenerate other types of gastric epithelial cells.19 Throughout the stomach, the luminal carpet consists primarily of mucus-secreting surface epithelial cells (SECs) that extend down into the gland pits for variable distances. These cells also secrete bicarbonate and play an important role in protecting the stomach from injury due to acid, pepsin, and/or ingested irritants. In fact, all epithelial cells of the stomach (except the endocrine cells) contain carbonic anhydrase and are capable of producing bicarbonate.In the cardia, the gastric glands are branched and


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Surgery_Schwartz. In fact, all epithelial cells of the stomach (except the endocrine cells) contain carbonic anhydrase and are capable of producing bicarbonate.In the cardia, the gastric glands are branched and secrete primarily mucus and bicarbonate, and little acid. In the fundus and body, the glands are more tubular, and the pits are deep. Parietal and chief cells are common in these glands (Fig. 26-9). Histamine-secreting enterochromaffin-like (ECL) cells and somatostatin-secreting D cells are also found. Parietal cells Figure 26-3. Arterial blood supply to the stomach. a. = artery; v. = vein. (Reproduced with permission from Zuidema GD, Yeo CJ: Shackelford’s Surgery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)StomachCeliac a.Short gastric arteries(vasa brevia)SpleenDescending colonPancreasDuodenumTransverse colonPylorusSup. pancreatic duodenal a.Abdominal AortaInferior pancreatic duodenal a.Hepatic a.Left gastric a.Branchesto


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Surgery_Schwartz. arteries(vasa brevia)SpleenDescending colonPancreasDuodenumTransverse colonPylorusSup. pancreatic duodenal a.Abdominal AortaInferior pancreatic duodenal a.Hepatic a.Left gastric a.Branchesto greateromentumSplenic a. & v.L. gastroepiploic a. Sup. mesenteric a. & v. Inferior mesenteric a.Ileocolic a.Jejunum21534a4b6128971011Figure 26-4. Lymph node stations draining the stomach according to the Japanese Research Society for Gastric Cancer. Stations 3 to 6 are commonly removed with D1 gastrectomy. Stations 1, 2, and 7 to 12 are commonly removed with D2 gastrectomy. (Reproduced with permis-sion from Hermanek P, Hutter RVP, Sobin LH, et al: TNM Atlas: Illustrated Guide to the TNM/pTNM Classification of Malignant Tumours, 4th ed. Berlin: Springer-Verlag; 1997.)Brunicardi_Ch26_p1099-p1166.indd 110301/03/19 7:11 PM 1104SPECIFIC CONSIDERATIONS PART IIRight vagus n.Hepatic br. left vagusCeliac br. rt. vagusNerve of LaterjetPyloric br.Left vagus n.Figure 26-5. Vagal


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Surgery_Schwartz. 110301/03/19 7:11 PM 1104SPECIFIC CONSIDERATIONS PART IIRight vagus n.Hepatic br. left vagusCeliac br. rt. vagusNerve of LaterjetPyloric br.Left vagus n.Figure 26-5. Vagal innervation of the stomach. br. = branch; n. = nerve; rt. = right. (Reproduced with permission from Menguy R: Surgery of Peptic Ulcer. Philadelphia, PA: Elsevier/Saunders; 1976.)Surface epitheliumGastric pitsLymphoid noduleLamina propria mucosaSubmucosaSmooth muscle layersSerosaMuscularis mucosaeFigure 26-6. Layers of the gastric wall. (Reproduced with permis-sion from Fawcett DW: Bloom and Fawcett’s Textbook of Histology, 11th ed. Philadelphia, PA: Elsevier/Saunders; 1986.)Figure 26-7. Gastric mucosa. (Used with permission from Emma Furth, MD.)Brunicardi_Ch26_p1099-p1166.indd 110401/03/19 7:11 PM 1105STOMACHCHAPTER 26secrete acid and intrinsic factor into the gastric lumen, and bicarbonate into the intercellular space. They have a character-istic ultrastructural appearance with secretory canaliculi


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Surgery_Schwartz. 26secrete acid and intrinsic factor into the gastric lumen, and bicarbonate into the intercellular space. They have a character-istic ultrastructural appearance with secretory canaliculi (deep invaginations of the surface membrane) and cytoplasmic tubulo-vesicles containing the acid-producing apparatus H+/K+-ATPase (proton pump) (see Fig. 26-9). There are numerous mitochon-dria; in fact, the parietal cell is the most mitochondria-rich cell in the body. When the parietal cell is stimulated, the cytoplasmic tubulovesicles fuse with the membrane of the secretory cana-liculus; when acid production ceases, the process is reversed. Arguably, parietal cells produce the only truly essential sub-stance made by the stomach (i.e., intrinsic factor). Parietal cells tend to occupy the midportion of the gastric glands found in the corpus of the stomach.Chief cells (also called zymogenic cells) secrete pep-sinogen I, which is maximally activated at a pH of 2.5. They tend to be clustered toward the


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Surgery_Schwartz. gastric glands found in the corpus of the stomach.Chief cells (also called zymogenic cells) secrete pep-sinogen I, which is maximally activated at a pH of 2.5. They tend to be clustered toward the base of the gastric glands and have a low columnar shape. Ultrastructurally, chief cells have the characteristics of protein-synthesizing cells: basal granular endoplasmic reticulum, supranuclear Golgi apparatus, and api-cal zymogen granules (Fig. 26-10). When stimulated, the chief cells produce two immunologically distinct proenzyme forms of pepsinogen: predominantly pepsinogen I and some pepsinogen II, most of which is produced by SECs. These proenzymes are activated in an acidic luminal environment.In the antrum, the gastric glands are again more branched and shallow, parietal cells are rare, and gastrin-secreting G cells and somatostatin-secreting D cells are present. A variety of hormone-secreting cells are present in various proportions throughout the gastric mucosa (Fig. 26-11).20


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Surgery_Schwartz. and gastrin-secreting G cells and somatostatin-secreting D cells are present. A variety of hormone-secreting cells are present in various proportions throughout the gastric mucosa (Fig. 26-11).20 Histologic analy-sis suggests that in the normal stomach, 13% of the epithelial cells are oxyntic (parietal) cells, 44% are chief (zymogenic) cells, 40% are mucous cells, and 3% are endocrine cells. In gen-eral, the antrum produces gastrin but not acid, and the proximal stomach produces acid but not gastrin. The border between the corpus and antrum migrates proximally with age (especially on the lesser curvature side of the stomach).Deep to the muscularis mucosa is the submucosa, which is rich in branching blood vessels, lymphatics, collagen, vari-ous inflammatory cells, and nerve fibers and ganglion cells of Meissner’s autonomic submucosal plexus. The collagen-rich submucosa gives strength to GI anastomoses. The mucosa and submucosa are folded into the grossly visible gastric rugae, which


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Surgery_Schwartz. cells of Meissner’s autonomic submucosal plexus. The collagen-rich submucosa gives strength to GI anastomoses. The mucosa and submucosa are folded into the grossly visible gastric rugae, which tend to flatten out as the stomach becomes distended.Below the submucosa is the thick muscularis propria (also referred to as the muscularis externa), which consists of an incomplete inner oblique layer, a complete middle circular layer (continuous with the esophageal circular muscle and the circular muscle of the pylorus), and a complete outer longitudinal layer (continuous with the longitudinal layer of the esophagus and duodenum). Within the muscularis propria is the rich network of autonomic ganglia and nerves that make up Auerbach’s myen-teric plexus. Specialized pacemaker cells, the interstitial cells of Cajal (ICC), also are present.The outer layer of the stomach is the serosa, also known as the visceral peritoneum. This layer provides significant tensile strength to gastric anastomoses.