Gastric Resection & Reconstruction

Dr SD Sanyal

GASTRIC RESECTION

History

• The earliest recorded operations on the stomach were performed for penetrating injuries

• Late 1800s: Experimental studies by Billroth confirmed the feasibility of removing the pylorus

• Rydygier 1881: First successful pylorectomy• Rydygier 1884 : First gastroenterostomy

History

• Billroth 1881: Performed the first successful pylorectomy – Duodenum anastomosed to the lesser curvature of the stomach and the greater curvature oversewn.

• Billroth 1885: Resection of a large pyloric carcinoma, using an anterior gastro-jejunostomy

Indications

1. Malignancy2. Peptic Ulcer Disease:

- Bleeding- Perforation- Obstruction- Failed medical therapy- Risk of malignancy

3. GIST

Gastric Resection• Special considerations:

1. Physiology of vagal innervation and gastric emptying2. Surface and vascular anatomy of the stomach3. Principles of reconstruction following resection ie.

Billroth I, Billroth II and Roux-en-Y configuration4. Principles of surgical stapling techniques and hand-

sewn suturing techniques5. Specific early and late postoperative complications

Gastric Resections

• Types:1. Wedge resections2. Gastrectomy:

- Antrectomy/Hemigastrectomy 35-50%- Partial 65%- Subtotal 80%- Near total 90%- Total/ Radical(D2)

Gastric Resection

• Pre operative evaluation and preparation:1. Endoscopy2. Imaging

- EUS- Computed Tomography

3. Comorbidities4. Nutritional status5. Pre-operative antibiotics6. DVT prophylaxis

Wedge Resection• Upper midline incision• Greater curvature lesions:

- Wedge resection with 2 cms free margin- Lesion within 2cms of Pylorus or GE jn

Consider conversion to formal resection

- Closure in 2 layers• Lesser curvature lesions:

- Mucosal approach- Possible sacrifice of one/ both nerves of Latarjet

Consider Pyloroplasty

- Possible sacrifice of Rt/Lt gastric arteries- Consider formal resection withBI/BII reconstruction

Resection

Repair: 2 layer

Antrectomy

• Removes Distal 35% of the stomach• Upper midline incision• Truncal vagotomy to be performed• Billroth I/II reconstruction• Distal margin: Flush beyond Pylorus• Proximal margins:

Lesser curvature : Incisura angularisGreater curvature: Termination of RGEA

Division of Greater Omentum

Lesser omentum Greater omentum

Distal Resection

Proximal Gastrectomy

Indications:- Ca involving the Cardia- GE jn lesions : Siewarts type I&II

• Disadvantages:- Alkaline reflux

Extent of Resection

Reconstruction

Sub-total & Near totalGastrectomy

Sub Total• Ca Pylorus• Ca Antrum• Primary Gastric Lymphoma• Extended Hemigastrectiomy

in princple• Removes upto 80% of

stomach

Near Total• Roux stasis syndrome• Gastroparesis • Ca body of stomach• Lymphoma• Removes upto 90% of

stomach

Sub-total & Near totalGastrectomy

• Special considerations:1. Chevron incision2. Left gastric artery is always ligated3. Division of branches of LGEA & Short gastrics after

defining the limit of resection4. Cuff of gastric wall(1-2cms) to be left back in Near

total gastrectomy5. 1to 2 upper branches of Short gastrics to be left

back in Near total gastrectomy6. Extended lymphadenectomy: D2 resection

Total gastrectomy• Indication: Carcinoma stomach• Aims:

- Clear esophageal and duodenal margins- Clearance of local and regional lymph nodes- Clearance of lymph nodal basins along Left gastric, RGEA and Short gastrics- En bloc removal of stomach and omentum- Removal of lymphoid tissue over pancreatic capsule- D2 lymphadenectomy

• Reconstruction:- Roux en Y with direct Esophagoenterostomy- Jejunal pouch

Total gastresctomy: Extent of resection

Division of Gastrocolic ligament

Division of Duodenum

Exposure of Lesser Sac

Division of Left Gastric

Esophageal transection

Lymph node zones

Lymph Node Stations

Gastric Reconstruction

Reconstruction Techniques

1. Billroth I2. Billroth II3. Roux en Y technique

Billroth I

• Gastric remnant anastomosed to Duodenum• Advantages:

1. Restoring the normal GI continuity2. Leaving specialised duodenal mucosa next to the gastric mucosa3. Avoiding problems with the afferent and efferent loops4. Easier performance of Endoscopy and ERCP5. Decreased incidence of carcinoma in the stomach remnant

Laparotomy

Billroth I

Stomach Remnant

Gastroduodenostomy

Variations of Billroth I

A. Billroth (1881) B. Billroth (1881) C. Kocher (1890) D. Kutscha-Lissberg (1925)

E. v. Haberer (1920) F. v. Haberer (1920), Finney (1923) G. Winkelbauer (1927) H. Schoemaker (1911) I. Harkins, Nyhus (1960

Posterior Serosal layer

Mucosal layer

Anterior Mucosal & Seromuscular layers

Stapled technique

Billroth II

• Indication:- Prevention of undue tension on the anastomosis secondary to scarring

• Points to consider:- Stapled vs Hand sewn closure of duodenum- Antecolic vs Retrocolic position of the Jejunal loop- Length of the Afferent limb

Variations A. Billroth II

B. Kronelin C. von Eiselberg D. BraunE. Roux F. Roux-en-Y G. Ploy and Reichel H. Finsterer-Hofmeister I. Balfour J. Moynihan K. Tanner

Gastric resection

Retrocolic window

Two layer anastomosis

Closure of Retrocolic window

Stapled technique

Roux-en-Y reconstruction

Division of Jejunum

Anastomosis

Anastomosis

Anastomosis

Completed Roux-en-Y

Post Gastrectomy Syndromes

Types

3 main types:

1.Gastric reservoir dysfunction 2. Vagal denervation 3. Aberrations in surgical

reconstruction

Gastric Reservoir Dysfunction

• Dumping Syndrome• Metabolic abnormalities

Dumping Syndrome

• Early Dumping• Late Dumping

Early Dumping 15 minutes to 1 hour after a meal.

Due to rapid release of hyperosmolar food into small bowel > rapid shift in extracellular fluid > systemic hypotension.

Loss of receptive stomach relaxation

Nausea, vomiting, epigastric fullness, abdominal cramping and diarrhea, palpitation, diaphoresis.

Relieved by lying down.

Late Dumping1 to 3 hours after a meal.

Carbohydrates absorbed quickly > blood sugar level rises > hyper-insulinemia and consequent hypoglycemia.

Fainting, tremor, prostration, decreased consciousness.

Relieved by food.

Management• CONSERVATIVE:

Low carbohydrate diet (prefer complex carbohydrate)

Small meal with solid and liquid food

Somatostatin analogues; Octreotide100 mcg IV 15-60 minutes before meal to slow transit time.

Alpha glucosidase inhibitor medication in late dumping

Anti Dumping Diet

Management

SURGICAL:Iso/anti peristaltic segment of jejunum

interposed between stomach and small bowel (10-20 cm)

Conversion to Roux-en-Y gastro-jejunostomy.

Conversion of Billroth II to Billroth I

Inter-positioned Isoperistaltic Jejunal loop(Henley)

Interpostioning of Anti-peristaltic jejunal loop

BII to BI

Metabolic abnormalitiesAnaemia: *Iron Deficiency( reduced absorption) *Pernicious anemia( reduced intrinsic factor) *Folate deficiency (malabsorption).

Metabolic Bone disease( decreased Vit.D & Ca absorption)

* Unexplained aches and pains in back or long bones *Rx : Ca and Vit D supplements

Vagal Denervation

Diarrhea

Gastroparesis

Gallstone

Diarrhoea

Uncontrolled bowel movements > increased stool frequency .

Conservative Rx : CholestyramineCodeineLoperamide

Surgical : 10 cm segment of reversed jejunal anastomosis placed 70-100 cm from ligament of Treitz .

Gastroparesis

• 50% of Pt have this syndrome• Most pts diagnosed if not taking adequate oral intake 7-14 days

post-op after gastric procedure• Symptoms: nausea, bloating, fullness, early satiety, vomiting• Gastric emptying studies( thin barium/ gastrograffin) – normal:

60% solid, 80% liquid clearance at 60 min.• Nuclear Medicine solid phase gastric emptying test-Gold

standard -> 50% solid-2Hrs >10% solid-4 Hrs

Acute Gastroparesis

Causes: • Metabolic/Neuronal

• Electrolytes – hypomagnesemia, hypokalemia• Endocrine – hypothyroidism, DM• Medications – opiates, anticholinergics, antidepressants

• Functional– Preoperative gastric outlet obstruction-affects contraction– Effects of truncal vagotomy – Stomal edema, adhesions, kinking, hematoma,

intussusception

Treatment

Conservative • NGT decompression• Prokinetic agents• Correction of

Electrolytes• patience

After failed treatment • Minimum of 3-4 wks

– No improvement – re-explore

– Look for mechanical causes

– Place feeding tube – jejunostomy

Chronic Gastroparesis

• Diagnosis of exclusion – rule out stricture, internal hernia, stomal edema, intussusception

• ~2% of patients after gastric surgery • Symptoms start later in the post-op period

Chronic Gastroparesis

Diagnosis• Symptoms – early satiety, nausea, vomiting,

postprandial bloating, hiccups, belching– Increase throughout the day

• Emesis of food ingested days earlier – pathognomonic

• Need UGI to rule out other syndromes

Treatment

Conservative treatment• Same as acute

gastroparesis• More emphasis

prokinetic agents

Surgical treatment• Resection of atonic

portion• Using a different type of

reconstruction• Only total gastrectomy

may be curative• Gastric pacing

?-Low/High Frequency

Gall Stones

Division of hepatic branches of anterior Vagal trunk.

Gallbladder dysmotilitySurgery indicated only if

pathological.No indication for prophylactic

cholecystectomy.

Aberrations in Surgical Reconstruction

Alkaline reflux gastritisAfferent and efferent loop obstructionRoux syndrome

Alkaline Reflux GastritisReflux of alkaline secretions into gastric

remnant.Billroth II>IManifests after 1yrReflux symptoms: epigastric pain, bilious

vomitingDiagnosis:

- Clinical + evidence of bile reflux on endoscopy- Bernstein Test- 24 hr pH monitoring

Alkaline Reflux Gastritis

Medical management:- PPI- Cholestyramine- UDCA

Braun’s procedureRoux en Y Gastro- jejunostomy with

afferent limb measuring at least 40cm.

Alkaline Reflux Gastritis

Alkaline Reflux Gastritis

Afferent & Efferent loops

Afferent loop syndrome

More commonAcute<ChronicExclusively with B IIRetrocolic > Antecolic Afferent loop > 40cmsGJ anastomosis above the retrocolic windowSymptoms:- Severe postprandial epigastric pain(30-60 mins)- projectile vomiting

Avoid excess length of afferent loopRelease trapped loop.Mgt is always surgical

Efferent loop syndrome Less commonD/D: Gastroparesis, Alkaline reflux gastritis, Roux limb

syndromeSymptoms:

- Epigastric pain- Nausea/vomiting- Relief on vomiting

Internal herniation of efferent limb behind the anastomosis

Surgical management

Roux SyndromeDisruption of normal myoelectric patternSymptom complex characterized by:

- chronic postprandial epigastric pain- fullness- vomiting after Roux-en-Y reconstruction

Post Vagotomy gastric atony. Medical treatment is successful in only about

half of cases: Prokinetic drugsSurgical :remove most or all of the gastric

remnant is usually successful.

Uncut Roux Loop

Thank You