distal gastrectomy with b1, b2 anastomsis or
TRANSCRIPT
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Distal gastrectomy with B1, B2
anastomsis or Roux-En-Y
Jeffrey A. Neale MD 1/31/08
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Partial gastrectomies
1.) Consist of the removal of the distal portion of the stomach.
Resection baseda.) Type of disease, (ulcer or carcinoma)b.) Location of the basic disease (duodenal ulcer, gastric ulcer,
high-gastric ulcer),
Types of Resection1.) Antral,
2.) Two-thirds,3.) Four-fifths,4.) High subtotal gastrectomy.
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The Billroth I operation = gastroduodenostomya.) end-to-endb.) end-to-side.
In the Billroth II = Gastrojejunostomya.) End-to-side.b.) As an alternative, Roux-Y reconstructions can be done.
A decisive difference between the Billroth I and II procedure1.) 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-Yreconstruction should be favored.
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Arguments for B1
Preservation of the duodenal passage.Is this anatomic area important
a.) Acids are neutralized in the duodenum by pancreaticand duodenal bicarbonate. Via hormones or signals
b.) After distal stomach resection, this regulation isdisturbed regardless of the type of anastomosis.
c.) Proportioned, regulated stomach emptying is no longerpossible because the antrum and pylorus are gone.
d.)Experimental and clinical investigations = undisturbedpancreatic function, after gastrectomy,
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Arguments for B1 cont
e.) Altered pancreatic function is apparent aftergastrojejunostomy (Billroth II).
f.) Fat loss in the feces is considerably greater after BillrothII resection than after gastroduodenostomy.
g.) This loss may indicate insufficient digestion of food bypancreatic enzymes.
h.) Chronic atrophic gastritis seem to be present to a lesserdegree after a Billroth I
i.) The same is true for the frequency of carcinoma of thestomach remnant.
j.) After Billroth II resection, the tonicity of the lower
esophageal sphincter disappears, but this functionaldisturbance of the cardia is rarely of clinical relevance.
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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 earlydumping symptoms
a.) Those patients should undergo, if conservativetreatment fails, relaparotomy + reconstruction
according to Roux-Y.b.) The Roux-Y offers a better control to avoid
enterogastric reflux into the gastric remnant andis the method of choice when early dumping or
reflux problems occur
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Indication for Partial Gastrectomy
Gastric Ulcer
Pre-Pyloric Ulcer
Comlicated Ulcers Early Carconoma and Carcinoma of theAntrum
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Gastric ulcerThe main indication is gastric ulcer,a.) usually recurrent ulcer after failed treatment
1.) Removed in toto during distal resection and can be examinedhistologically.
2.) The point of least resistance on the antrum-corpus border ofthe lesser curvature is eliminated.
3.) The number ofchief cells is reduced by removal of a part ofthe fundus.
4.) The antrum as the point for the formation ofgastrin iseliminated.
5.) The remainder of the stomach is partly vagotomized bydissection of the lesser curvature above the resection border.
6.) The standard reconstruction for partial gastrectomy in gastriculcer patients is Billroth I.
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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 prepyloriculcers should be combined with selectivegastric vagotomy.
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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 thesuspicion of malignancy, sometimes require
resection rather than suturing.
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Early Carcinoma and Carcinoma ofthe Antrum
Standard = total gastrectomy with adequate lymphadenectomy is themethod of choice.
As an exception, = well differentiated and early (T1/T2 N0) gastricadenoca
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 = commonProcedure: Partial gastrectomy and Billroth I reconstruction.
THE FUTURE
1.) Limited gastric resections for carcinoma of the antrum may bepromoted 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.
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Gastroduodenostomy with Anastomosis tothe Side of the Greater Curvature of the
Stomach1.) Best Approach the midline epigastric incision
2.) Alternate Approach =
a.) Transverse epigastric rectus muscle-cuttingincision
b.) Upper vertical muscle- splitting incision to the
right can be made.
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Important Concepts
a.) Goal to avoid any traction injury to themiddle colic vessels during dissection
b.) Dissection toward the duodenum, thesmall fragile vessels = ligated
c.) Meticulous dissection in this region willavoid any unnecessary bleeding or injuryto the pancreas.
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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 gastroepiploicvessels and the gastric wall.
In carcinoma
1.) Length of greater omentum=to theextent of the resection of the greatercurvature must be removed at the same
time.
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Dissection of the Sotmach When the omental bursa has been opened:
a.) Soft rubber Penrose drain can be placed aroundthe stomach.
b.) The dissection is then continued along thegreater curvature toward the duodenum.
c.) Near the pylorus, the omentum becomes thickand divides into a front and back layer.
d.) The dissection should be continued bluntly
e.) The layers of tissue carrying the vessels thenshould be ligated individually.
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Duodenum
Begins above or just below the second portionof the duodenum from a lateral direction, =Kocher maneuver.
The peritoneal reflection is sharply cut alongthe lateral duodenal wall between the secondportion of the duodenum and the beginning ofthe hepatoduodenal ligament.
By putting traction on the second portion ofthe duodenum medially, (part bluntly, partsharply) until the duodenum is mobilized.
In this way, a good general exposure can beachieved;
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DuodenumExpose the back wall of Duodenum 3-5 cm
By stretching the stomach, dissect thegreater curvature toward the left medial
duodenal wall, Then toward the back wall,
Toward the lateral duodenal up to the
hepatoduodenal ligamentAllows, 3 to 5 cm of the back wall of the
duodenum can be exposed.
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Differentiatie 1st part(free) duodenum to thepart fixed dorsally on the
pancreas , use Schnidt Recognized by course of
the gastroduodenalartery.
At this point, the serosareaches from theduodenum to the head ofthe pancreas
Dont ligate supplyimportant to duodenumand Panceas
Separate from Pancreasand divide first part with
GIA 60 stapler
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After mobilization of the duodenum,
1.) The right gastric artery is
divided between clamps andligated above the pylorus
2.) The dissection is continuedalong the lesser curvature of
the stomach, throughgastrohepatic ligament
3.) At Inscisura Angularis
Isolate branches of Leftgastric and divide with 2.0silk
4.) Withdraw ng tube prior to
dividing stomach Proximally
9 ) R t b tti f th
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9.) Resect by cutting of theduodenum betweenholding sutures.
10.) The duodenum istemporarily closed with asponge; the resectionborders of the stomachare then determined.
11.) A sewing instrument(e.g., stapler, TA-90)facilitates the final step ofstomach removal.
12.) The incision follows atan angle of 45 degrees tothe lesser curvature
13.) Option can oversew
staple line
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14.) After removal of the distal portion ofthe 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 correspondin size to the duodenal lumen.
16.) The anastomosis should beperformed without clamps.
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Anastamosis1.) Duodenum to the end
of the greater curvature.
2.) The two cut surfacesare placed adjacent toeach other and twocorner stitches areplaced,
3.) Start at the stomachthrough the seromuscularlayers.
4.) At the duodenum, this
stitch is done from inside tooutside.
5.) The corner suture at thelesser curvature is tied,whereas the suture on the
opposite side is left open
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The back Wall (3-0 polyglycolic acid).
Through all layers of the
back wall at the cut edgeof the lesser curvature,inside to outside
All layers of theposterior wall of theduodenum from outsideto inside.
The suture is led backgrasping only mucosa,
first of the duodenumand then of the stomach.
Knotting these suturesleads to an exactcoaptation, especially at
the level of the mucosa.
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Front Wall One row of interrupted sutures through all
layers with tangential stitches of themucosa with the same technique as thecorner stitches
Beware of the called Jammerecke (angleof sorrow) on the lesser curve
Use the triple seromuscular structure,(duodenal walls as well as the front and
back wall of the stomach.
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The front wall is closed byinterrupted sutures withseromuscular stitches that graspthe mucosa tangentially.
The so-called angle of Sorrow,Jammerecke is traditionallycovered by a triple seromuscular
suture,The front wall of the stomach,The duodenum, and the backwall of the stomach.
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Check For Patency
1.) Checked for patency with the thumb andindex finger.
2.) The position of the stomach tube is alsochecked to ensure it crosses the
anastomosis
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End to side gastroduodenostomyIn difficult duodenal ulcers,
1.) Impossible to preserve enough duodenal wall for atension-free anastomosis.
2.) Is safer to close the duodenum with a row of TA-55staples.
3.) Intestinal passage can then proceed by end-to-sideanastomosis
a.) Dissected stomach lumen is anastomosed onto the frontwall of the duodenum.
b.) An oblique incision should be made on the duodenalfront wall so it goes medial -lateral.
c.) The suturing technique is the same as for the end-to-side anastomosis. In technically difficult duodenal stump
closures, additional coverage of the stump with the backwall of the stomach can be obtained.
E d t Sid
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End to Sidegastroduodenostomy
After removal of thedistal stomach, the
gastric lumen isanastomosed onto thefront wall of theduodenum
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Anastomosis Using stapler
Usually not necessary.
High cost of the device compared withsutures.
No differences of anastomotic leak ratesbetween handsewn and stapled Billroth
P d
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Procedure 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 thegastric wall.
After removal of the tip.
Fire of the instrument,
Excised circular tissue doughnuts of duodenum and stomach areinspected for completeness.
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Laparoscopic B1
Several working groups have shown it isfeasible.
Claims
1.) Reduces perioperative pain and hospitalstay.
BUT
1.) OR time is longer,
2.) The procedure is technically demanding,
and it requires expensive instruments.
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Procedure Four to five working trocars and a 30-degree fiberoptic
laparoscope.
The greater and lesser curvatures are dissected by aharmonic scalpel.
The distal margin is performed with monopolarcoagulation,
Proximal resection margin is formed by multipleendolinear staples.
The anastomosis is made with single, extracorporeally
knotted stitches, identical to open surgery
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Billroth 21.) A loop of jejunum 12 to 15 cm from the
ligament of Treitz2.) 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 theprepyloric region or at the most dependent
portion of stomach5.) 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
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Surgical Technique: Billroth IIGastrectomy
The right epiploicartery + vein and rightgastric artery aredivided betweenclamps and ligated
THE B2
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THE B2
Duodenum is divided byhelp of a linear stapler (TA-55) 2 cm aborally to thepylorus
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B2
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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 singleinterrupted sutures 3.0
a.) The Back wall is sutured by interrupted mattress sutures
b.) The front wall by extramucosal interrupted sutures.
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For additional securityat this location, theadjacent jejunal wall
can be used to coverthe angle of sorrow
Stapled Billroth II Anastomosis
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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 jejunumand at the adjacent posterior wall along the
greater curvature of the stomach.
C.) The limbs of the GIA stapler are inserted andfired.
D.) It is important to have at least 2 cm ofposterior gastric wall between the gastric stapleline and the gastrojejunostomy to avoid
necrosis.
B2
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B2 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 orcontinous technique, resorbable) or stapled (GIA
55).
Roux En Y Gastrojejunosotmy
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Roux- En- Y Gastrojejunosotmy
Indications
1.) Divert bile away from gastic ouletsecondary to alteration from apyloroplasty
2.) EGD = Post op Reflux gastritis
3.) Early dumping
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Roux- En- Y1.) Isolate B1 anastomosis ant and Post
2.) Try not to sacrifice Duodenum ie Riskincrease injury to pancreas
3.) Divide and close duodenum and
reinforce4.) 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 ofbowel
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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 withAntrum
Apply Non crushing clamps to prevent
soiling anastomosis constructed and holein mesocolon closed
Jejunojejunal anastomosis is done 40 cm
distal to Gastro-Jejunosotmy
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Post Operative Complications
Anastamotic leak (1% to 4%),
Bleeding (2%),
Passage disorders (2% to 5%),
Postoperative pancreatitis (0.9%).
S ff
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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.
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Gastric emptying
Gastric stasis is a problem = anastomoticedema or a hematoma and resolves after
10 to 14 days with good drainage of thestomach.
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Intragastric or Intraperitoneal
bleeding Infrequent
Management
( depends on the extent of bleeding)
Endoscopicand injection therapy
Reoperation if >4units four units of bloodper 24 hours lost volume possible.
The stomach must be reopened with ahorizontal incision approximately 3 to 5 cm
above the anastomosis.
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Mortality
Results and Postoperative Disease
A mortality of 1% to 2%
Chronic gastritis and Stump
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Chronic gastritis and StumpCancer
IN 80% to 90% chronic gastritis ofvarying degree occurs
Presents approx 15 to 25 years after
resection. That atrophic changes less Billroth I