Distal gastrectomy with B1, B2 anastomsis or Roux-En-Y

Jeffrey A. Neale MD 1/31/08

Partial gastrectomies
1.) Consist of the removal of the distal portion of the stomach.

Resection based a.) Type of disease, (ulcer or carcinoma) b.) Location of the basic disease (duodenal ulcer, gastric ulcer, high-gastric ulcer),
Types of Resection 1.) Antral, 2.) Two-thirds, 3.) Four-fifths, 4.) High subtotal gastrectomy.

The Billroth I operation = gastroduodenostomy a.) end-to-end b.) end-to-side.

In the Billroth II = Gastrojejunostomy a.) End-to-side. b.) As an alternative, Roux-Y reconstructions can be done.
A decisive difference between the Billroth I and II procedure 1.) B1 duodenal passge remains intact. 2.) B2 preformed as an antrectomy. 3.) Gastroduodenostomy is difficult after more extended gastrectomies. (increase complications) 4.) More extended partial gastrectomy, a Billroth II or Roux-Y reconstruction should be favored.

Arguments for B1
Preservation of the duodenal passage. Is this anatomic area important a.) Acids are neutralized in the duodenum by pancreatic and duodenal bicarbonate. Via hormones or signals b.) After distal stomach resection, this regulation is disturbed regardless of the type of anastomosis. c.) Proportioned, regulated stomach emptying is no longer possible because the antrum and pylorus are gone.

d.)Experimental and clinical investigations = undisturbed pancreatic function, after gastrectomy,

e.) Altered pancreatic function is apparent after gastrojejunostomy (Billroth II).

Arguments for B1 cont

f.) Fat loss in the feces is considerably greater after Billroth II resection than after gastroduodenostomy. g.) This loss may indicate insufficient digestion of food by pancreatic enzymes. h.) Chronic atrophic gastritis seem to be present to a lesser degree after a Billroth I

i.) The same is true for the frequency of carcinoma of the stomach remnant.
j.) After Billroth II resection, the tonicity of the lower esophageal sphincter disappears, but this functional disturbance of the cardia is rarely of clinical relevance.

Arguments for B2 or Roux-En- Y

1.) Larger portion of the stomach can be resected.

2.) Pick B2 if there will be tension on anastomosis.

3.) Billroth II reconstruction results in early dumping symptoms a.) Those patients should undergo, if conservative treatment fails, relaparotomy + reconstruction according to Roux-Y. b.) The Roux-Y offers a better control to avoid enterogastric reflux into the gastric remnant and is the method of choice when early dumping or reflux problems occur

Indication for Partial Gastrectomy

Gastric Ulcer Pre-Pyloric Ulcer Comlicated Ulcers Early Carconoma and Carcinoma of the Antrum

Gastric ulcer
The main indication is gastric ulcer, a.) usually recurrent ulcer after failed treatment

1.) Removed in toto during distal resection and can be examined histologically. 2.) The point of least resistance on the antrum-corpus border of the lesser curvature is eliminated. 3.) The number of chief cells is reduced by removal of a part of the fundus. 4.) The antrum as the point for the formation of gastrin is eliminated. 5.) The remainder of the stomach is partly vagotomized by dissection of the lesser curvature above the resection border.
6.) The standard reconstruction for partial gastrectomy in gastric ulcer patients is Billroth I.

Prepyloric
Secretory in nature hx of Vagotomy for tx historically After five years of using this procedure showed relatively high recurrence rates; Now seen as and treated like a gasric ulcer Partial gastric resections for prepyloric ulcers should be combined with selective gastric vagotomy.

Complicated Ulcers

Elective ulcer surgery has decreased in the decade of potent antisecretory drugs, The frequency of operations for complicated ulcers is stable. Intractable ulcers represent a good indication for partial gastrectomy. Large perforated ulcers, especially if there is the suspicion of malignancy, sometimes require resection rather than suturing.

Standard = total gastrectomy with adequate lymphadenectomy is the method of choice.

Early Carcinoma and Carcinoma of the Antrum

As an exception, = well differentiated and early (T1/T2 N0) gastric adenoca Procedure: Four-fifths of the stomach is resected lymphadenectomy, and a Billroth II or Roux-Y reconstruction is done. In the Far East, mucosal cancers of the antrum = common Procedure: Partial gastrectomy and Billroth I reconstruction.
THE FUTURE 1.) Limited gastric resections for carcinoma of the antrum may be promoted by detection and examination of the sentinel lymph node. a.) NEGATIVE = A partial gastrectomy; b.) POSITIVE = Total gastrectomy with D2 lymphadenectomy may be indicated. This concept is under evaluation.

Gastroduodenostomy with Anastomosis to the Side of the Greater Curvature of the Stomach

1.) Best Approach the midline epigastric incision 2.) Alternate Approach = a.) Transverse epigastric rectus muscle-cutting incision b.) Upper vertical muscle- splitting incision to the right can be made.

Important Concepts
a.) Goal to avoid any traction injury to the middle colic vessels during dissection b.) Dissection toward the duodenum, the small fragile vessels = ligated c.) Meticulous dissection in this region will avoid any unnecessary bleeding or injury to the pancreas.

The dissection(STOMACH)
The middle of the greater curvature by incision of the gastrocolic ligament = omental bursa is opened. Gastric ulcers 1.) Can be done between the gastroepiploic vessels and the gastric wall. In carcinoma 1.) Length of greater omentum=to the extent of the resection of the greater curvature must be removed at the same time.

Dissection of the Sotmach

When the omental bursa has been opened:

a.) Soft rubber Penrose drain can be placed around the stomach. b.) The dissection is then continued along the greater curvature toward the duodenum. c.) Near the pylorus, the omentum becomes thick and divides into a front and back layer. d.) The dissection should be continued bluntly e.) The layers of tissue carrying the vessels then should be ligated individually.

Duodenum

Begins above or just below the second portion of the duodenum from a lateral direction, = Kocher maneuver. The peritoneal reflection is sharply cut along the lateral duodenal wall between the second portion of the duodenum and the beginning of the hepatoduodenal ligament. By putting traction on the second portion of the duodenum medially, (part bluntly, part sharply) until the duodenum is mobilized. In this way, a good general exposure can be achieved;

Duodenum
Expose the back wall of Duodenum 3-5 cm By stretching the stomach, dissect the greater curvature toward the left medial duodenal wall, Then toward the back wall, Toward the lateral duodenal up to the hepatoduodenal ligament Allows, 3 to 5 cm of the back wall of the duodenum can be exposed.

Differentiatie 1st part (free) duodenum to the part fixed dorsally on the pancreas , use Schnidt Recognized by course of the gastroduodenal artery. At this point, the serosa reaches from the duodenum to the head of the pancreas Dont ligate supply important to duodenum and Panceas Separate from Pancreas and divide first part with GIA 60 stapler

After mobilization of the duodenum,

1.) The right gastric artery is divided between clamps and ligated above the pylorus 2.) The dissection is continued along the lesser curvature of the stomach, through gastrohepatic ligament 3.) At Inscisura Angularis Isolate branches of Left gastric and divide with 2.0 silk 4.) Withdraw ng tube prior to dividing stomach Proximally

9.) Resect by cutting of the duodenum between holding sutures. 10.) The duodenum is temporarily closed with a sponge; the resection borders of the stomach are then determined. 11.) A sewing instrument (e.g., stapler, TA-90) facilitates the final step of stomach removal. 12.) The incision follows at an angle of 45 degrees to the lesser curvature 13.) Option can oversew staple line

14.) After removal of the distal portion of the stomach, a clamp is fitted at right angles to the greater curvature.
15.) The clamp is thus pushed far enough orally for the removal level to correspond in size to the duodenal lumen. 16.) The anastomosis should be performed without clamps.

1.) Duodenum to the end of the greater curvature. 2.) The two cut surfaces are placed adjacent to each other and two corner stitches are placed, 3.) Start at the stomach through the seromuscular layers. 4.) At the duodenum, this stitch is done from inside to outside. 5.) The corner suture at the lesser curvature is tied, whereas the suture on the opposite side is left open

Anastamosis

(3-0 polyglycolic acid). Through all layers of the back wall at the cut edge of the lesser curvature, inside to outside All layers of the posterior wall of the duodenum from outside to inside. The suture is led back grasping only mucosa, first of the duodenum and then of the stomach. Knotting these sutures leads to an exact coaptation, especially at the level of the mucosa.

The back Wall

Front Wall

One row of interrupted sutures through all layers with tangential stitches of the mucosa with the same technique as the corner stitches

Beware of the called Jammerecke (angle of sorrow) on the lesser curve

Use the triple seromuscular structure, (duodenal walls as well as the front and back wall of the stomach.

The front wall is closed by interrupted sutures with seromuscular stitches that grasp the mucosa tangentially.

The so-called angle of Sorrow ,Jammerecke is traditionally covered by a triple seromuscular suture, The front wall of the stomach, The duodenum, and the back wall of the stomach.

Check For Patency

1.) Checked for patency with the thumb and index finger.
2.) The position of the stomach tube is also checked to ensure it crosses the anastomosis

End to side gastroduodenostomy

In difficult duodenal ulcers, 1.) Impossible to preserve enough duodenal wall for a tension-free anastomosis. 2.) Is safer to close the duodenum with a row of TA-55 staples. 3.) Intestinal passage can then proceed by end-to-side anastomosis a.) Dissected stomach lumen is anastomosed onto the front wall of the duodenum. b.) An oblique incision should be made on the duodenal front wall so it goes medial -lateral. c.) The suturing technique is the same as for the end-toside anastomosis. In technically difficult duodenal stump closures, additional coverage of the stump with the back wall of the stomach can be obtained.

End to Side gastroduodenostomy

After removal of the distal stomach, the gastric lumen is anastomosed onto the front wall of the duodenum

Anastomosis Using stapler

Usually not necessary.

High cost of the device compared with sutures.

No differences of anastomotic leak rates between handsewn and stapled Billroth

After the duodenum is cut, a circular purse-string suture is performed at the edge of the opening.
The anvil of the EEA stapler (size 28 of 31) is placed in the duodenum, The purse-string suture is tied around the center rod of the anvil. The EEA stapler is then introduced into the stomach and, at the posterior wall of the stomach, The sharp tip of the center rod of the EEA stapler is pushed through the gastric wall.

Procedure

After removal of the tip. Fire of the instrument, Excised circular tissue doughnuts of duodenum and stomach are inspected for completeness.

Laparoscopic B1
Several working groups have shown it is feasible. Claims 1.) Reduces perioperative pain and hospital stay. BUT 1.) OR time is longer, 2.) The procedure is technically demanding, and it requires expensive instruments.

Four to five working trocars and a 30-degree fiberoptic laparoscope.

Procedure

The greater and lesser curvatures are dissected by a harmonic scalpel. The distal margin is performed with monopolar coagulation,
Proximal resection margin is formed by multiple endolinear staples. The anastomosis is made with single, extracorporeally knotted stitches, identical to open surgery

Billroth 2
1.) A loop of jejunum 12 to 15 cm from the ligament of Treitz 2.) Selected and brought through an opening in the transverse mesocolon 3.) Brought to the left of the middle colic vessels. 4.) The stoma should be placed in the prepyloric region or at the most dependent portion of stomach 5.) The loop of jejunum is aligned along the lower half of the gastric staple line with 3-0 silk stay sutures

Surgical Technique: Billroth II Gastrectomy

The right epiploic artery + vein and right gastric artery are divided between clamps and ligated

THE B2
Duodenum is divided by help of a linear stapler (TA55) 2 cm aborally to the pylorus

Oversewing of the staple line of the duodenal stump (seromuscular interrupted sutures, resorbable, 3-0)
Distal antrum is temporarily closed with a clamp. Dissection of the greater and lesser curvature occurs with greater extension In the standard Billroth II, left gastric + left epiploic artery = preserved,

The B2

The resection is completed by transverse application of a linear stapler (TA-90.

The first or second loop of the jejunum placed tension-free Retrocolonic opposite greater curvature

B2

The loop should be long + have a jejunojejunostomy (Braun) b/w acsending and descending loop. Stay sutures are placed at both sides of the anastomosis. Noncrushing Doyen clamps are placed on both sides of the proposed anastomosis to occlude the jejunum.

With electrocautery a longitudinal enterotomy is made in the loop of jejunum, and the appropriate length of adjacent gastric staple line is sharply excised

The gastrojejunostomy is performed by single interrupted sutures 3.0 a.) The Back wall is sutured by interrupted mattress sutures b.) The front wall by extramucosal interrupted sutures.

For additional security at this location, the adjacent jejunal wall can be used to cover the angle of sorrow

Stapled Billroth II Anastomosis,

A.) Stay sutures are placed to hold the loop of jejunum adjacent to the gastric remnant. B.) A small stab incision is made in the jejunum and at the adjacent posterior wall along the greater curvature of the stomach.
C.) The limbs of the GIA stapler are inserted and fired. D.) It is important to have at least 2 cm of posterior gastric wall between the gastric staple line and the gastrojejunostomy to avoid necrosis.

Before finalization of the front wall, a g tube is placed distally to the anastomosis. The tube can be removed at the 2nd or 3rd day.
In order to prevent enterogastric (bile) reflux, Braun anastomosis, side-to-side and 30 cm aborally of the gastrojejunostomy is mandatory. This anastomosis =handsewn (interrupted or continous technique, resorbable) or stapled (GIA 55).

B2

Roux- En- Y Gastrojejunosotmy

Indications 1.) Divert bile away from gastic oulet secondary to alteration from a pyloroplasty

2.) EGD = Post op Reflux gastritis 3.) Early dumping

1.) Isolate B1 anastomosis ant and Post 2.) Try not to sacrifice Duodenum ie Risk increase injury to pancreas 3.) Divide and close duodenum and reinforce 4.) Reflect Transverse colon 5.) Follow Jejunum distal 40-50cm from Ligament of treitz, free from adehsions 6.) Exam arcades of Jejunum, 7.) Divide 2 arcades, resect a short seg of bowel

Roux- En- Y

Roux-En-Y

Distal segment of jejunum is passed via mesoclon L of Middle colic vessels The Proximal end clsoed in two layers, or if stapled, already closed Approximate moblized jejunum with Antrum Apply Non crushing clamps to prevent soiling anastomosis constructed and hole in mesocolon closed Jejunojejunal anastomosis is done 40 cm distal to Gastro-Jejunosotmy

Surgical Technique:

Roux-Y Gastrojejunostomy

Postoperative Care Drains after partial gastric resections are usually not required, Except for partial gastric resections for perforation. A gastric tube is useful but can be removed after 1 to 2 days. Liquid intake usually is begun at the 3rd postoperative day. All patients receive one shot of antibiotic perioperatively.

Post Operative Complications

Anastamotic leak (1% to 4%),

Bleeding (2%), Passage disorders (2% to 5%), Postoperative pancreatitis (0.9%).

Suture Insufficiency
Infrequent, conservative therapy as long as no dehiscence does first 3 or 4 days . It is imperative that the leak be well drained. Treatment: Good drainage by a gastric tube, adequate external drains High doses of proton pump inhibitors Parenteral nutrition It is usually possible for the anastomotic leak to heal.

Gastric emptying

Gastric stasis is a problem = anastomotic edema or a hematoma and resolves after 10 to 14 days with good drainage of the stomach.

Intragastric or Intraperitoneal bleeding

Infrequent Management ( depends on the extent of bleeding) Endoscopicand injection therapy Reoperation if >4units four units of blood per 24 hours lost volume possible. The stomach must be reopened with a horizontal incision approximately 3 to 5 cm above the anastomosis.

Mortality
Results and Postoperative Disease A mortality of 1% to 2%

Chronic gastritis and Stump Cancer

IN 80% to 90% chronic gastritis of varying degree occurs Presents approx 15 to 25 years after resection. That atrophic changes less Billroth I< Billroth II not been sufficiently proven. Gastric stump cancer is higher after Billroth II. Gastrectomy = 8x risk of Cancer increase in nl population

Chronic Gastritis
Only 10% of patients complain of symptomsand need tx The cause = enterogastric reflux. The clinical signs and symptoms A.) Epigastric pain, B.) Feeling of fullness, nausea, and bile vomiting. C.) Disappearence of symptoms post bile vomiting is characteristic, as is its intensification by stimulation of bile or pancreatic secretion. Treatment Metoclopramide, Spasmolytics Antiperistaltic jejunal interposition is rarely necessary

Pathogenesis of Stump Cancer

Enterogastric reflux, Achlorhydria, Bacteria overgrowth,

H. pylori

Treatment consists of Resection of the gastric remnant, Esophagojejunostomy, and regional lymphadenectomy.