Distal gastrectomy with Distal gastrectomy with B1, B2 anastomsis or B1, B2 anastomsis or

Roux-En-Y Roux-En-Y

Jeffrey A. Neale MD 1/31/08 Jeffrey A. Neale MD 1/31/08

Partial gastrectomiesPartial gastrectomies

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

Resection basedResection baseda.) Type of disease, (ulcer or carcinoma) a.) Type of disease, (ulcer or carcinoma) b.) Location of the basic disease (duodenal ulcer, gastric b.) Location of the basic disease (duodenal ulcer, gastric

ulcer, high-gastric ulcer), ulcer, high-gastric ulcer),

Types of ResectionTypes of Resection1.) Antral, 1.) Antral, 2.) Two-thirds, 2.) Two-thirds, 3.) Four-fifths, 3.) Four-fifths, 4.) High subtotal gastrectomy. 4.) High subtotal gastrectomy.

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

In the Billroth II = GastrojejunostomyIn the Billroth II = Gastrojejunostomya.) End-to-side. a.) End-to-side. b.) As an alternative, Roux-Y reconstructions can be b.) As an alternative, Roux-Y reconstructions can be

done.done.

A decisive difference between the Billroth I and II procedure A decisive difference between the Billroth I and II procedure 1.) B1 duodenal passge remains intact.1.) B1 duodenal passge remains intact.2.) B2 preformed as an antrectomy.2.) B2 preformed as an antrectomy.3.) Gastroduodenostomy is difficult after more extended 3.) Gastroduodenostomy is difficult after more extended

gastrectomies. gastrectomies. (increase complications)(increase complications)4.) More extended partial gastrectomy, a Billroth II or Roux-Y 4.) More extended partial gastrectomy, a Billroth II or Roux-Y

reconstruction should be favored.reconstruction should be favored.

Arguments for B1Arguments for B1Preservation of the duodenal passage. Preservation of the duodenal passage. Is this anatomic area importantIs this anatomic area important

a.) Acids are neutralized in the duodenum by a.) Acids are neutralized in the duodenum by pancreatic and duodenal bicarbonate. Via pancreatic and duodenal bicarbonate. Via hormones or signalshormones or signals

b.) After distal stomach resection, this regulation is b.) After distal stomach resection, this regulation is disturbed regardless of the type of anastomosis. disturbed regardless of the type of anastomosis.

c.) Proportioned, regulated stomach emptying is no c.) Proportioned, regulated stomach emptying is no longer possible because the antrum and pylorus longer possible because the antrum and pylorus are gone. are gone.

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

Arguments for B1 contArguments for B1 cont……e.) Altered pancreatic function is apparent after e.) Altered pancreatic function is apparent after

gastrojejunostomy (Billroth II). gastrojejunostomy (Billroth II).

f.) Fat loss in the feces is considerably greater after f.) Fat loss in the feces is considerably greater after Billroth II resection than after gastroduodenostomy. Billroth II resection than after gastroduodenostomy.

g.) This loss may indicate insufficient digestion of food g.) This loss may indicate insufficient digestion of food by pancreatic enzymes.by pancreatic enzymes.

h.) Chronic atrophic gastritis seem to be present to a h.) Chronic atrophic gastritis seem to be present to a lesser degree after a Billroth I lesser degree after a Billroth I

i.) The same is true for the frequency of carcinoma of i.) The same is true for the frequency of carcinoma of the stomach remnant.the stomach remnant.

j.) After Billroth II resection, the tonicity of the lower j.) After Billroth II resection, the tonicity of the lower esophageal sphincter disappears, but this functional esophageal sphincter disappears, but this functional disturbance of the cardia is rarely of clinical disturbance of the cardia is rarely of clinical relevance.relevance.

Arguments for B2 or Roux-En- YArguments for B2 or Roux-En- Y1.) Larger portion of the stomach can be 1.) Larger portion of the stomach can be

resected.resected.

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

3.) Billroth II reconstruction results in early 3.) Billroth II reconstruction results in early dumping symptoms dumping symptoms

a.) Those patients should undergo, if a.) Those patients should undergo, if conservative treatment fails, relaparotomy + conservative treatment fails, relaparotomy + reconstruction according to Roux-Y. reconstruction according to Roux-Y.

b.) The Roux-Y offers a better control to avoid b.) The Roux-Y offers a better control to avoid enterogastric reflux into the gastric remnant enterogastric reflux into the gastric remnant and is the method of choice when early and is the method of choice when early dumping or reflux problems occur dumping or reflux problems occur

Indication for Partial Indication for Partial GastrectomyGastrectomy

Gastric UlcerGastric Ulcer Pre-Pyloric UlcerPre-Pyloric Ulcer Comlicated UlcersComlicated Ulcers Early Carconoma and Carcinoma of Early Carconoma and Carcinoma of

the Antrumthe Antrum

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

1.) Removed in toto during distal resection and can be 1.) Removed in toto during distal resection and can be examined histologically.examined histologically.

2.) The point of least resistance on the antrum-corpus 2.) The point of least resistance on the antrum-corpus border of the lesser curvature is eliminated.border of the lesser curvature is eliminated.

3.) The number of 3.) The number of chief cells chief cells is reduced by removal of a is reduced by removal of a part of the fundus.part of the fundus.

4.) The antrum as the point for the formation of 4.) The antrum as the point for the formation of gastringastrin is eliminated.is eliminated.

5.) The remainder of the stomach is partly vagotomized 5.) The remainder of the stomach is partly vagotomized by dissection of the lesser curvature above the by dissection of the lesser curvature above the resection border. resection border.

6.) The standard reconstruction for partial gastrectomy in 6.) The standard reconstruction for partial gastrectomy in gastric ulcer patients is Billrothgastric ulcer patients is Billroth I. I.

Prepyloric Prepyloric Secretory in nature hx of Vagotomy for Secretory in nature hx of Vagotomy for

tx tx

historicallyhistorically After five years of using this procedure After five years of using this procedure

showed relatively high recurrence showed relatively high recurrence rates; rates;

Now seen as and treated like a gasric Now seen as and treated like a gasric ulcerulcer

Partial gastric resections for prepyloric Partial gastric resections for prepyloric ulcers should be combined with ulcers should be combined with selective gastric vagotomy.selective gastric vagotomy.

Complicated UlcersComplicated Ulcers Elective ulcer surgery has decreased in the Elective ulcer surgery has decreased in the

decade of potent antisecretory drugs, decade of potent antisecretory drugs,

The frequency of operations for The frequency of operations for complicated ulcers is stable. complicated ulcers is stable.

Intractable ulcers represent a good Intractable ulcers represent a good indication for partial gastrectomy. indication for partial gastrectomy.

Large perforated ulcers, especially if there Large perforated ulcers, especially if there is the suspicion of malignancy, sometimes is the suspicion of malignancy, sometimes require resection rather than suturing. require resection rather than suturing.

Early Carcinoma and Early Carcinoma and Carcinoma of the AntrumCarcinoma of the Antrum

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

As an exception,As an exception, = well differentiated and early (T1/T2 N0) = well differentiated and early (T1/T2 N0) gastric adenocagastric adenoca

ProcedureProcedure: Four-fifths of the stomach is resected : Four-fifths of the stomach is resected lymphadenectomy, and a Billroth II or Roux-Y lymphadenectomy, and a Billroth II or Roux-Y reconstruction is done.reconstruction is done.

In the Far East, mucosal cancers of the antrum = common In the Far East, mucosal cancers of the antrum = common Procedure:Procedure: Partial gastrectomy and Billroth I reconstruction. Partial gastrectomy and Billroth I reconstruction.

THE FUTURETHE FUTURE1.) Limited gastric resections for carcinoma of the antrum may 1.) Limited gastric resections for carcinoma of the antrum may

be promoted by detection and examination of the sentinel be promoted by detection and examination of the sentinel lymph node.lymph node.

a.) NEGATIVE = A partial gastrectomy; a.) NEGATIVE = A partial gastrectomy; b.) POSITIVE = Total gastrectomy with D2 lymphadenectomy b.) POSITIVE = Total gastrectomy with D2 lymphadenectomy

may be indicated. may be indicated. This concept is under evaluation. This concept is under evaluation.

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

the Stomachthe Stomach1.) Best Approach the midline epigastric 1.) Best Approach the midline epigastric

incisionincision

2.) Alternate Approach =2.) Alternate Approach =

a.) Transverse epigastric rectus muscle-a.) Transverse epigastric rectus muscle-cutting incision cutting incision

b.) Upper vertical muscle- splitting incision b.) Upper vertical muscle- splitting incision to the right can be made.to the right can be made.

Important ConceptsImportant Concepts

a.) Goal to avoid any traction injury to a.) Goal to avoid any traction injury to the middle colic vessels during the middle colic vessels during dissectiondissection

b.) Dissection toward the duodenum, b.) Dissection toward the duodenum, the small fragile vessels = ligatedthe small fragile vessels = ligated

c.) Meticulous dissection in this region c.) Meticulous dissection in this region will avoid any unnecessary bleeding will avoid any unnecessary bleeding or injury to the pancreas.or injury to the pancreas.

The dissection(STOMACH)The dissection(STOMACH) The middle of the greater curvature by The middle of the greater curvature by

incision of the gastrocolic ligament = incision of the gastrocolic ligament = omental bursa is opened. omental bursa is opened.

Gastric ulcers Gastric ulcers

1.) Can be done between the gastroepiploic 1.) Can be done between the gastroepiploic vessels and the gastric wall. vessels and the gastric wall.

In carcinoma In carcinoma

1.) Length of greater omentum=to the 1.) Length of greater omentum=to the extent of the resection of the greater extent of the resection of the greater curvature must be removed at the same curvature must be removed at the same time. time.

Dissection of the SotmachDissection of the Sotmach When the omental bursa has been opened:When the omental bursa has been opened:

a.) Soft rubber Penrose drain can be placed a.) Soft rubber Penrose drain can be placed around the stomach. around the stomach.

b.) The dissection is then continued along the b.) The dissection is then continued along the greater curvature toward the duodenum.greater curvature toward the duodenum.

c.) Near the pylorus, the omentum becomes c.) Near the pylorus, the omentum becomes thick and divides into a front and back thick and divides into a front and back layer. layer.

d.) The dissection should be continued bluntly d.) The dissection should be continued bluntly

e.) The layers of tissue carrying the vessels e.) The layers of tissue carrying the vessels then should be ligated individually.then should be ligated individually.

DuodenumDuodenum

Begins above or just below the second portion Begins above or just below the second portion of the duodenum from a lateral direction, = of the duodenum from a lateral direction, = Kocher maneuverKocher maneuver.. The peritoneal reflection is sharply cut The peritoneal reflection is sharply cut

along the lateral duodenal wall between the along the lateral duodenal wall between the second portion of the duodenum and the second portion of the duodenum and the beginning of the hepatoduodenal ligament. beginning of the hepatoduodenal ligament.

By putting traction on the second portion of By putting traction on the second portion of the duodenum medially, (part bluntly, part the duodenum medially, (part bluntly, part sharply) until the duodenum is mobilized.sharply) until the duodenum is mobilized.

In this way, a good general exposure can In this way, a good general exposure can be achieved;be achieved;

DuodenumDuodenumExpose the back wall of Duodenum 3-5 cmExpose the back wall of Duodenum 3-5 cm

By stretching the stomach, dissect the By stretching the stomach, dissect the greater curvature toward the left greater curvature toward the left medial duodenal wall, medial duodenal wall,

Then toward the back wall, Then toward the back wall, Toward the lateral duodenal up to the Toward the lateral duodenal up to the

hepatoduodenal ligamenthepatoduodenal ligament Allows, 3 to 5 cm of the back wall of Allows, 3 to 5 cm of the back wall of

the duodenum can be exposed. the duodenum can be exposed.

Differentiatie 1st part Differentiatie 1st part (free) duodenum to the (free) duodenum to the part fixed dorsally on the part fixed dorsally on the pancreas , use Schnidtpancreas , use Schnidt

Recognized by course of Recognized by course of the gastroduodenal the gastroduodenal artery. artery.

At this point, the serosa At this point, the serosa reaches from the reaches from the duodenum to the head of duodenum to the head of the pancreasthe pancreas

Don’t ligate supply Don’t ligate supply important to duodenum important to duodenum and Panceasand Panceas

Separate from Pancreas Separate from Pancreas and divide first part with and divide first part with GIA 60 staplerGIA 60 stapler

After mobilization of the duodenum,After mobilization of the duodenum,

1.) The right gastric artery is 1.) The right gastric artery is divided between clamps and divided between clamps and ligated above the pylorusligated above the pylorus

2.) The dissection is continued 2.) The dissection is continued along the lesser curvature of along the lesser curvature of the stomach, through the stomach, through gastrohepatic ligamentgastrohepatic ligament

3.) At Inscisura Angularis 3.) At Inscisura Angularis Isolate branches of Left Isolate branches of Left gastric and divide with 2.0 gastric and divide with 2.0 silk silk

4.) Withdraw ng tube prior to 4.) Withdraw ng tube prior to dividing stomach Proximallydividing stomach Proximally

9.) Resect by cutting of the 9.) Resect by cutting of the duodenum between duodenum between holding sutures. holding sutures.

10.) The duodenum is 10.) The duodenum is temporarily closed with temporarily closed with a sponge; the resection a sponge; the resection borders of the stomach borders of the stomach are then determined.are then determined.

11.) A sewing instrument 11.) A sewing instrument (e.g., stapler, TA-90) (e.g., stapler, TA-90) facilitates the final step facilitates the final step of stomach removal.of stomach removal.

12.) The incision follows at 12.) The incision follows at an angle of 45 degrees an angle of 45 degrees to the lesser curvatureto the lesser curvature

13.) Option can oversew 13.) Option can oversew staple linestaple line

14.) After removal of the distal portion 14.) After removal of the distal portion of the stomach, a clamp is fitted at of the stomach, a clamp is fitted at right angles to the greater curvature.right angles to the greater curvature.

15.) The clamp is thus pushed far 15.) The clamp is thus pushed far enough orally for the removal level to enough orally for the removal level to correspond in size to the duodenal correspond in size to the duodenal lumen.lumen.

16.) The anastomosis should be 16.) The anastomosis should be performed without clamps.performed without clamps.

AnastamosisAnastamosis1.) Duodenum to the end 1.) Duodenum to the end

of the greater curvature.of the greater curvature.

2.) The two cut surfaces 2.) The two cut surfaces are placed adjacent to are placed adjacent to each other and two each other and two corner stitches are corner stitches are placed,placed,

3.) Start at the stomach 3.) Start at the stomach through the seromuscular through the seromuscular layers. layers.

4.) At the duodenum, this 4.) At the duodenum, this stitch is done from inside to stitch is done from inside to outside.outside.

5.) The corner suture at the 5.) The corner suture at the lesser curvature is tied, lesser curvature is tied, whereas the suture on the whereas the suture on the opposite side is left openopposite side is left open

The back Wall The back Wall (3-0 polyglycolic acid). (3-0 polyglycolic acid).

Through all layers of the Through all layers of the back wall at the cut edge back wall at the cut edge of the lesser curvature, of the lesser curvature, inside to outsideinside to outside

All layers of the All layers of the posterior wall of the posterior wall of the duodenum from outside duodenum from outside to inside. to inside.

The suture is led back The suture is led back grasping only mucosa, grasping only mucosa, first of the duodenum first of the duodenum and then of the stomach.and then of the stomach.

Knotting these sutures Knotting these sutures leads to an exact leads to an exact coaptation, especially at coaptation, especially at

the level of the mucosathe level of the mucosa. .

Front Wall Front Wall One row of interrupted sutures through One row of interrupted sutures through

all layers with tangential stitches of the all layers with tangential stitches of the mucosa with the same technique as the mucosa with the same technique as the corner stitchescorner stitches

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

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

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

The so-called “angle of The so-called “angle of Sorrow” ,Jammerecke is Sorrow” ,Jammerecke is traditionally covered by a traditionally covered by a triple seromuscular suture,triple seromuscular suture,

The front wall of the stomach, The front wall of the stomach, The duodenum, and the back The duodenum, and the back wall of the stomach. wall of the stomach.

Check For PatencyCheck For Patency

1.) Checked for patency with the 1.) Checked for patency with the thumb and index finger. thumb and index finger.

2.) The position of the stomach tube is 2.) The position of the stomach tube is also checked to ensure it crosses the also checked to ensure it crosses the anastomosisanastomosis

End to side gastroduodenostomyEnd to side gastroduodenostomyIn difficult duodenal ulcers,In difficult duodenal ulcers,

1.) Impossible to preserve enough duodenal wall for a 1.) Impossible to preserve enough duodenal wall for a tension-free anastomosis. tension-free anastomosis.

2.) Is safer to close the duodenum with a row of TA-55 2.) Is safer to close the duodenum with a row of TA-55 staples. staples.

3.) Intestinal passage can then proceed by end-to-side 3.) Intestinal passage can then proceed by end-to-side anastomosisanastomosis

a.) Dissected stomach lumen is anastomosed onto the a.) Dissected stomach lumen is anastomosed onto the front wall of the duodenum.front wall of the duodenum.

b.) An oblique incision should be made on the duodenal b.) An oblique incision should be made on the duodenal front wall so it goes medial -lateral.front wall so it goes medial -lateral.

c.) The suturing technique is the same as for the end-to-c.) The suturing technique is the same as for the end-to-side anastomosis. In technically difficult duodenal stump side anastomosis. In technically difficult duodenal stump closures, additional coverage of the stump with the back closures, additional coverage of the stump with the back wall of the stomach can be obtained.wall of the stomach can be obtained.

End to Side End to Side gastroduodenostomygastroduodenostomy

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

Anastomosis Using stapler Anastomosis Using stapler

Usually not necessary. Usually not necessary.

High cost of the device compared with High cost of the device compared with sutures. sutures.

No differences of anastomotic leak No differences of anastomotic leak rates between handsewn and stapled rates between handsewn and stapled Billroth Billroth

ProcedureProcedure After the duodenum is cut, a circular purse-string suture is After the duodenum is cut, a circular purse-string suture is

performed at the edge of the opening. performed at the edge of the opening.

The anvil of the EEA stapler (size 28 of 31) is placed in the The anvil of the EEA stapler (size 28 of 31) is placed in the duodenum, duodenum,

The purse-string suture is tied around the center rod of the The purse-string suture is tied around the center rod of the anvil. anvil.

The EEA stapler is then introduced into the stomach and, at the The EEA stapler is then introduced into the stomach and, at the posterior wall of the stomach, posterior wall of the stomach,

The sharp tip of the center rod of the EEA stapler is pushed The sharp tip of the center rod of the EEA stapler is pushed through the gastric wall. through the gastric wall.

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

are inspected for completeness. are inspected for completeness.

Laparoscopic B1Laparoscopic B1Several working groups have shown it is Several working groups have shown it is

feasible. feasible.

ClaimsClaims

1.) Reduces perioperative pain and hospital 1.) Reduces perioperative pain and hospital stay. stay.

BUTBUT

1.) OR time is longer,1.) OR time is longer,

2.) The procedure is technically demanding, 2.) The procedure is technically demanding, and it requires expensive instruments.and it requires expensive instruments.

ProcedureProcedure Four to five working trocars and a 30-degree fiberoptic Four to five working trocars and a 30-degree fiberoptic

laparoscope.laparoscope.

The greater and lesser curvatures are dissected by a The greater and lesser curvatures are dissected by a harmonic scalpel. harmonic scalpel.

The distal margin is performed with monopolar The distal margin is performed with monopolar coagulation, coagulation,

Proximal resection margin is formed by multiple Proximal resection margin is formed by multiple endolinear staples. endolinear staples.

The anastomosis is made with single, extracorporeally The anastomosis is made with single, extracorporeally knotted stitches, identical to open surgeryknotted stitches, identical to open surgery

Billroth 2Billroth 21.) A loop of jejunum 12 to 15 cm from the 1.) A loop of jejunum 12 to 15 cm from the

ligament of Treitzligament of Treitz

2.) Selected and brought through an 2.) Selected and brought through an opening in the transverse mesocolonopening in the transverse mesocolon

3.) Brought to the left of the middle colic 3.) Brought to the left of the middle colic vessels. vessels.

4.) The stoma should be placed in the 4.) The stoma should be placed in the prepyloric region or at the most prepyloric region or at the most dependent portion of stomachdependent portion of stomach

5.) The loop of jejunum is aligned along the 5.) The loop of jejunum is aligned along the lower half of the gastric staple line with lower half of the gastric staple line with

3-0 silk stay sutures3-0 silk stay sutures

Surgical Technique: Billroth II Surgical Technique: Billroth II GastrectomyGastrectomy

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

THE B2THE B2

Duodenum is divided by help of a linear stapler (TA-55) 2 cm aborally to the pylorus

The B2The B2 Oversewing of the staple line of the duodenal stump Oversewing of the staple line of the duodenal stump

(seromuscular interrupted sutures, resorbable, 3-0) (seromuscular interrupted sutures, resorbable, 3-0)

Distal antrum is temporarily closed with a clamp. Distal antrum is temporarily closed with a clamp.

Dissection of the greater and lesser curvature occurs with greater Dissection of the greater and lesser curvature occurs with greater extensionextension

In the standard Billroth II, left gastric + left epiploic artery = In the standard Billroth II, left gastric + left epiploic artery = preserved,preserved,

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

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

B2B2 The loop should be long + have a jejunojejunostomy (Braun) The loop should be long + have a jejunojejunostomy (Braun)

b/w acsending and descending loop.b/w acsending and descending loop.

Stay sutures are placed at both sides of the anastomosis.Stay sutures are placed at both sides of the anastomosis.

Noncrushing Doyen clamps are placed on both sides of the proposed Noncrushing Doyen clamps are placed on both sides of the proposed anastomosis to occlude the jejunum.anastomosis to occlude the jejunum.

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

The gastrojejunostomy is performed by single The gastrojejunostomy is performed by single interrupted sutures 3.0 interrupted sutures 3.0

a.) The Back wall is sutured by interrupted mattress sutures a.) The Back wall is sutured by interrupted mattress sutures

b.) The front wall by extramucosal interrupted 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 Stapled Billroth II Anastomosis,Anastomosis,A.) Stay sutures are placed to hold the loop of A.) Stay sutures are placed to hold the loop of

jejunum adjacent to the gastric remnant. jejunum adjacent to the gastric remnant.

B.) A small stab incision is made in the jejunum B.) A small stab incision is made in the jejunum and at the adjacent posterior wall along the and at the adjacent posterior wall along the greater curvature of the stomach.greater curvature of the stomach.

C.) The limbs of the GIA stapler are inserted and C.) The limbs of the GIA stapler are inserted and fired. fired.

D.) It is important to have at least 2 cm of D.) It is important to have at least 2 cm of posterior gastric wall between the gastric staple posterior gastric wall between the gastric staple line and the gastrojejunostomy to avoid line and the gastrojejunostomy to avoid necrosisnecrosis..

B2B2 Before finalization of the front wall, a g tube is Before finalization of the front wall, a g tube is

placed distally to the anastomosis. placed distally to the anastomosis.

The tube can be removed at the 2nd or 3rd day.The tube can be removed at the 2nd or 3rd day.

In order to prevent enterogastric (bile) reflux, In order to prevent enterogastric (bile) reflux,

Braun anastomosis,” side-to-side and 30 cm Braun anastomosis,” side-to-side and 30 cm aborally of the gastrojejunostomy is mandatory. aborally of the gastrojejunostomy is mandatory.

This anastomosis =handsewn (interrupted or This anastomosis =handsewn (interrupted or continous technique, resorbable) or stapled (GIA continous technique, resorbable) or stapled (GIA 55). 55).

Roux- En- Y Roux- En- Y GastrojejunosotmyGastrojejunosotmy

IndicationsIndications

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

2.) EGD = Post op Reflux gastritis2.) EGD = Post op Reflux gastritis

3.) Early dumping 3.) Early dumping

Roux- En- YRoux- En- Y1.) Isolate B1 anastomosis ant and Post1.) Isolate B1 anastomosis ant and Post

2.) Try not to sacrifice Duodenum ie Risk 2.) Try not to sacrifice Duodenum ie Risk increase injury to pancreasincrease injury to pancreas

3.) Divide and close duodenum and 3.) Divide and close duodenum and reinforcereinforce

4.) Reflect Transverse colon4.) Reflect Transverse colon

5.) Follow Jejunum distal 40-50cm from 5.) Follow Jejunum distal 40-50cm from Ligament of treitz, free from adehsionsLigament of treitz, free from adehsions

6.) Exam arcades of Jejunum, 6.) Exam arcades of Jejunum,

7.) Divide 2 arcades, resect a short seg of 7.) Divide 2 arcades, resect a short seg of bowelbowel

Roux-En-YRoux-En-Y Distal segment of jejunum is passed via Distal segment of jejunum is passed via

mesoclon L of Middle colic vesselsmesoclon L of Middle colic vessels The Proximal end clsoed in two layers, or The Proximal end clsoed in two layers, or

if stapled, already closed if stapled, already closed Approximate moblized jejunum with Approximate moblized jejunum with

AntrumAntrum Apply Non crushing clamps to prevent Apply Non crushing clamps to prevent

soiling anastomosis constructed and soiling anastomosis constructed and hole in mesocolon closedhole in mesocolon closed

Jejunojejunal anastomosis is done 40 cm Jejunojejunal anastomosis is done 40 cm distal to Gastro-Jejunosotmydistal to Gastro-Jejunosotmy

Surgical Surgical Technique: Roux-Y Technique: Roux-Y GastrojejunostomyGastrojejunostomy

Postoperative CarePostoperative Care Drains after partial gastric Drains after partial gastric

resections are usually not required,resections are usually not required, Except for partial gastric resections Except for partial gastric resections

for perforation. for perforation. A gastric tube is useful but can be A gastric tube is useful but can be

removed after 1 to 2 days. removed after 1 to 2 days. Liquid intake usually is begun at the Liquid intake usually is begun at the

3rd postoperative day. 3rd postoperative day. All patients receive one shot of All patients receive one shot of

antibiotic perioperatively.antibiotic perioperatively.

Post Operative Post Operative ComplicationsComplications

Anastamotic leak (1% to 4%), Anastamotic leak (1% to 4%),

Bleeding (2%), Bleeding (2%),

Passage disorders (2% to 5%), Passage disorders (2% to 5%),

Postoperative pancreatitis (0.9%).Postoperative pancreatitis (0.9%).

Suture InsufficiencySuture Insufficiency Infrequent, conservative therapy as long as Infrequent, conservative therapy as long as

no dehiscence does first 3 or 4 days . no dehiscence does first 3 or 4 days . It is imperative that the leak be well It is imperative that the leak be well

drained. drained.

Treatment:Treatment: Good drainage by a gastric tube, adequate Good drainage by a gastric tube, adequate

external drainsexternal drains High doses of proton pump inhibitorsHigh doses of proton pump inhibitors Parenteral nutrition Parenteral nutrition It is usually possible for the anastomotic It is usually possible for the anastomotic

leak to heal.leak to heal.

Gastric emptyingGastric emptying

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

Intragastric or Intragastric or Intraperitoneal bleedingIntraperitoneal bleeding

Infrequent Infrequent

Management Management

( depends on the extent of bleeding)( depends on the extent of bleeding) Endoscopicand injection therapy Endoscopicand injection therapy Reoperation if >4units four units of blood Reoperation if >4units four units of blood

per 24 hours lost volume possible. per 24 hours lost volume possible. The stomach must be reopened with a The stomach must be reopened with a

horizontal incision approximately 3 to 5 cm horizontal incision approximately 3 to 5 cm above the anastomosis. above the anastomosis.

Mortality Mortality

Results and Postoperative DiseaseResults and Postoperative Disease

A mortality of 1% to 2% A mortality of 1% to 2%

Chronic gastritis and Stump Chronic gastritis and Stump CancerCancer

IN 80% to 90% chronic gastritis of IN 80% to 90% chronic gastritis of varying degree occursvarying degree occurs

Presents approx 15 to 25 years after Presents approx 15 to 25 years after resection. resection.

That atrophic changes less Billroth I< That atrophic changes less Billroth I< Billroth IIBillroth II not not been sufficiently proven. been sufficiently proven.

Gastric stump cancer is higher after Gastric stump cancer is higher after Billroth II. Billroth II.

Gastrectomy = 8x risk of Cancer increase Gastrectomy = 8x risk of Cancer increase in nl population in nl population

Chronic GastritisChronic Gastritis Only 10% of patients complain of symptomsand need Only 10% of patients complain of symptomsand need

tx tx The cause = enterogastric reflux. The cause = enterogastric reflux.

The clinical signs and symptoms The clinical signs and symptoms A.) Epigastric pain,A.) Epigastric pain, B.) Feeling of fullness, nausea, and bile vomiting. B.) Feeling of fullness, nausea, and bile vomiting. C.) Disappearence of symptoms post bile vomiting is C.) Disappearence of symptoms post bile vomiting is

characteristic, as is its intensification by stimulation of characteristic, as is its intensification by stimulation of bile or pancreatic secretion.bile or pancreatic secretion.

TreatmentTreatment Metoclopramide, Metoclopramide, SpasmolyticsSpasmolytics Antiperistaltic jejunal interposition is rarely necessaryAntiperistaltic jejunal interposition is rarely necessary

Pathogenesis of Stump Pathogenesis of Stump CancerCancer Enterogastric reflux, Enterogastric reflux,

Achlorhydria, Achlorhydria, Bacteria overgrowth,Bacteria overgrowth, H. pyloriH. pylori

Treatment consists ofTreatment consists of Resection of the gastric remnant, Resection of the gastric remnant, Esophagojejunostomy, and regional Esophagojejunostomy, and regional

lymphadenectomy.lymphadenectomy.