distal gastrectomy with b1, b2 anastomsis or

7/30/2019 Distal Gastrectomy With B1, B2 Anastomsis Or

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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

distal gastrectomy with b1, b2 anastomsis or

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