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216]

Mini Symposium: The feasibility and advantages of billroth-I

Gastrointestinal
reconstruction in distal gastric cancers
following resection
Ganesh MS, Reddy KG1, Venkata Subbareddy DS1
Department of Surgical Oncology,Vydehi Institute of oncology, Bangalore, 1Viswabharathi Cancer
Hospital, Kurnool, India

Correspondence to: Dr. Ganesh M. S. E-mail: msganesh1965@gmail.com

Abstract
BACKGROUND: Gastric carcinomas are common malignancies in southern India and distal stomach remains the commonest
site in low socio economic groups. Surgery still remains an important modality of treatment to achieve local control and also
relieve obstructive symptoms. In this study we investigated the feasibility of performing a gastrectomy and billroth-1 type of
anastomosis in a rural cancer center setting, with parameters like adequacy of margins, ease of anastomosis and its functional
results were analysed MATERIALS AND METHODS: Eight patients presenting to a rurally based cancer center underwent a
distal gastrectomy and billroth-1 type of anastomosis for continuity restoration RESULTS: All the patients had adequate proximal
and distal marg. The surgical time varied between-hrs. The anastomosis was constructed without any tension on bowel ends
in all patients. The average time to start oral feeds varied between- None of the patients showed symptoms of bile reflux nor
dumping. The average hospital stay varied between- CONCLUSIONS: Billroth-1 anastomosis is a physiologically more natural
way of restoring continuity following a gastrectomy and it is a procedure which would be technically more simpler and decrease
per and post operative complications and allow speedier post operative recovery following surgery on distal gastric cancers.

Key words: Distal gastric cancer, billroth-1 anastomosis, gastrectomy

Introduction of treatment apart from chemotherapy and radiation

Gastric cancers are common in south Indian population
and remain a significant cause for cancer induced
mortality. The type of diet; smoking and alcohol and
low socio economic status are the main reasons for
this preponderance. Distal stomach represented by
pyloric antrum and part of body of the stomach remain
common site for most of the gastric malignancies in
this group. Due to late presentation most patients
present with some form of gastric outlet obstruction/
symptoms related to the tumor like bleeding from the
ulcerated lesions. Surgery remains an important modality
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DOI:
10.4103/0019-509X.102922
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therapy which have adjuvant role.
Distal gastrectomy with clearance of lymph nodes to
various extent remains the standard surgical approach
and restoration of continuity can be achieved by two or
three methods. In India the billroth- type-II anastomosis
is commonly carried out in many centers wherein there
is closure of duodenal stump and a gastrojejunostomy
fashioned.
This study is carried out in a cancer center which
caters mainly to patients hailing from rural Andhra
pradesh. The aim of our study was to look for the
benefits and feasibility of carrying out restoration by
billroth-1 anastomosis for distal gastric cancers keeping
in view the need to hasten post operative recovery and
commence early oral feeding. Another long term goal is
to standardize the procedure and extend it for suitable
patients, as an alternative to billroth-II anastomosis

Indian Journal of Cancer | April-June 2012 | Volume 49 | Issue 2 251

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Mandakulutur, et al.: Billroth-1 reconstruction in distal gastric cancers
Materials and Methods
Between November 2010 and February 2011 seven
patients diagnosed with gastrc cancers underwent distal
gastrectomy for adeno carcinoma of distal stomach and
had continuity restored by billroth-I anastomosis. We
evaluated the per operative findings, procedural details
and post operative recovery and pathological adequacy
following the procedures.
The age of the patients ranged from 19 years to
62 years. Median age of presentation was 53 years.
All of the patients had epigastric pain and loss of
appetite at presentation. Three patients gave history of
episodic vomiting though not typical of Gastric outlet
obstruction. Two patients presented with typical features
of gastric outlet obstruction. Four patients were anaemic
with Hb% levels less than 8 gm/dl and needed pre
surgery transfusion. The OGD scopy revealed ulcero
proliferative lesions in the pyloric antrum in four
and antrum and body in three patients. One patient
had lesion extending along lesser curve to involve
incisura. Four out of seven patients had significant food
residue and needed gastric lavage prior to scopy. The
ultrasonography revealed thickening of antral region
in one patient and normal in others. CT scan revealed
thickening of antral region in all patients and perigastric
nodes were identified in two patients pre operatively. No
distant metastasis was identified in any of the patients.
After adequate preparation, all patients were taken up
for exploratory laparotomy and possible resection. Per
opereative findings included mobile nodular growth in
antral region in all patients. In all patients the tumor
was involving the serosal surface. The tumor was
extending to proximal body in one patient and along
lesser curvature till incisura in another. Perigastric nodes
were found in four out of seven patients. The stomach
was distended in two patients and showed features of
chronic obstruction. In two patients the tumor was
adherent to the surface of pancreas superficially and
could be dissected free. In one patient the mesocolon
was densely adherent but could be removed without
resorting to doing a colectomy since the middle colic
vessels were free.
Results
A distal radical gastrectomy was possible in six out
of seven patients and in one patient the tumor was
relatively densely adherent to pancreatic surface and
this type of resection we consider as palliative. Though
we had the know-how to do a D2 resection keeping
in view various factors associated with patients and
252
available evidence, we confined ourselves to carrying out
a D-1 resection in all patients. We could achieve good
grossly free margins proximally and a 1-1.5 cm margin
at duodenal end. To facilitate this and have an adequate
duodenal stump for anastomosis we had to mobilize the
entire first part of duodenum and also kocherise it in all
patients. A gastro duodenal anastomosis was carried out
in two layers using interrupted sutures and a nasogastric
tube was passed thro in to duodenum. The anastomosis
was comfortably done in all except in one patient where
in we felt that it was under little stretch. This was the
patient in whom we excised significant part of body
and lesser curvature as well. The average blood loss was
around 400 ml and mean operative time was 2.5 hours.
All patients had uneventful recovery from surgery
The post operative period recovery was something we
analysed in more detail. The stay till discharge from
the day of surgery ranged from 7-11 days. None of
the patients had features suggesting gastric atony /bile
reflux symptoms. The mean aspirate from Ryles tube
was around 150 ml per day and was bilious. By 5 th
postoperative day all patients could get their naso gastric
tubes removed and had commencement of oral feeds
by 7th postoperative day. None of the patients had any
serious postoperative complications, which warranted
repeat exploration. None of the patient despite poor
nutritional status had postoperative wound infection.
The postoperative pathological results were as follows.
All were adeno carcinomas with varied differentiations.
Two patients had a diffuse type of gastric cancer.
The tumor was involving the serosa in four-patients
and involving beyond muscularis till serosa in others.
Lymphatic emboli were present in six out of seven
patients and vascular and perineural invasion was
not evident in any. The resected margins were
microscopically free in all the patients. The gross
unstretched distal macroscopic margin ranged from
0.5 cm in three patients to 1 cm in four patients. The
proximal resected margin varied between 3-6 cms. On
average 10-19 lymph nodes were isolated and studied by
the pathologist for evidence of metastasis. Three patients
were node positive with number of nodes involved
ranging from 1-8.
Discussion
Distal gastric cancers are still common in rural south
Indian population. The crude incidence rates of gastric
cancer are highest reported in Chennai and it ranks as
the second commonest digestive tract cancer in India. [1]
Most of the cancers are either T3 or T4 and present
with symptoms like epigastric pain, early satiety and
vomiting when gastric outlet obstruction sets in.
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Mandakulutur, et al.: Billroth-1 reconstruction in distal gastric cancers

Surgery remains an important modality in achieving
reasonable local control. It is accepted that a D1
type of gastrectomy with a minimum of 12 nodes
constitutes adequate resection in most circumstances.
Most distal gastric cancers due to their location are
amenable for a surgical resection. Restoration of
continuity following gastrectomy can be achieved
by couple of procedures, but in India a billroth-
II type of gastrojejunal anastomosis after closure
of duodenal stump is the most common procedure
performed. Billroth-I anastomosis is an alternative
type of reconstruction most commonly performed by
Japanese surgeons. The obvious advantages include-
a simplified anastomosis, shorter surgical time and
more physiological restoration of continuity. In most
of the reviews the post operative recovery is faster
and smoother.[2] The incidence of bile reflux and gall
stone formation is also less though in some studies
a rou-en-y billroth-II anastomosis is supposed to be
more advantageous and less complicated.[3] Incidence
of dumping also is low in comparison to billroth-
II type reconstruction. This type of reconstruction
is preferred in laparoscopic gastrectomies as well
which are shown to have many potential benefits
over open gastrectomies. [4] Other modifications to
billroth-1 anastomosis include pylorus preserving
gastrectomy which results in even lesser dumping
syndrome.[5] In our study, this reconstruction did not
in any way hamper with the oncological soundness
of gastrectomies performed. We plan to offer this
procedure to most of the patients presenting with
distal gastric cancers who can be potential candidates
for surgical resection.
References
1. Pavithran K, Doval DC, Pandey KK. Gastric cancer in India. Gastric
Cancer 2002;5:240-3.
2. Sah BK, Chen M-M, Yan M, Zhu Z-G. Gastric cancer surgery: Billroth
I or Billroth II for distal gastrectomy? BMC Cancer 2009;9:428.
3. Nunobe S, Okaro A, Sasako M, Saka M, Fukagawa T, Katai H, et al.
Billroth 1 versus Roux-en-Y reconstructions: A quality-of-life survey
at 5 years. Int J Clin Oncol 2007;12:433-9.
4. Huscher CG, Mingoli A, Sgarzini G, Sansonetti A, Di Paola M,
Recher A, et al. Laparoscopic versus open subtotal gastrectomy for
distal gastric cancer: Five-year results of a randomized prospective
trial. Ann Surg 2005;241:232-7.
5. Park do J, Lee HJ, Jung HC, Kim WH, Lee KU, Yang HK. Clinical
outcome of pylorus preserving gastrectomy in gastric cancer in
comparison with conventional distal gastrectomy with billroth-I
anastomosis. World J Surg 2008;32:1020-36.
How to cite this article: Ganesh MS, Reddy KG, Venkata Subbareddy DS.
The feasibility and advantages of billroth-I reconstruction in distal gastric
cancers following resection. Indian J Cancer 2012;49:251-3.
Source of Support: Nil, Conflict of Interest: Nil.

News

7th SFO (SAARC Federation of Oncology) Conference

Dates: 14 and 15 December 2012

Venue: Hotel Radisson, Dhaka, Bangladesh

Abstract Submission Deadline: 31 August 2012

Notification of Acceptance: 30 September 2012

Conference Secretariat: Secretariat, 7th SFO Conference, Oncology Club, Room # 602, Renaissance Hospital,
House # 60/A, Road # 4A, Dhanmandi R/A, Dhaka – 1205, Bangladesh
Email: asifmahmud60@gmail.com; CC: sfo.secretatiat2012@gmail.com

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