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Chapter • Subtotal Gastrectomy, Antrectomy, BillrothII, and Roux-en-Y Reconstruction
Step 3
Braun’s anastomosis
Braun’s anastomosis is performed as distal as possible (> 40 cm) to avoid biliary reflux into the
gastric remnant. Side-to-side jejunostomy is done either with interrupted stitches, a running
suture, or a stapler device (. Fig. 20.12).
. Fig.20.12
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Step 1
Section II • Esophagus, Stomach, and Duodenum
Roux-en-Y Reconstruction
Procedure
Dissection of the jejunum
e ligament of Treitz is identified, and the jejunum is transected about 40–50 cm distal to Treitz’
ligament (.
part is closed using a running suture or interrupted stitches. e distal loop is placed side-to-side
to the posterior wall of the gastric remnant without exerting any tension on the mesentery. A
retrocolic route is preferable. Before performing the anastomosis, the serosa of the jejunal loop is
fixed to the serosa of the gastric remnant over a distance of 5–6 cm, thus building the outer layer
of the backward suture (
Fig. 20.13a
). For convenience, a stapler device may be used. e blind end of the distal
. Fig. 20.13b).
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. Fig.20.13
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Chapter • Subtotal Gastrectomy, Antrectomy, BillrothII, and Roux-en-Y Reconstruction
Step 2
Gastrojejunostomy
e jejunal loop and the gastric wall are opened along the antimesenteric border using electrocautery, and the posterior part of the anastomosis is done with a running suture representing the inner
l
ayer, completed by a running inverting suture on the anterior part of the gastrojejunostomy. However, interrupted stitches in monolayer technique as well as the appliance of a stapler device are also
adequate. e technique is similar to the gastrojejunostomy in the BillrothII reconstruction (Step2).
e transected limb of proximal jejunum is anastomosed end-to-side to the Roux-en-Y limb
40 to 60cm distal to the gastrojejunostomy.
Postoperative Investigations
We prefer to use a nasogastric tube to keep the stomach remnant decompressed for two
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days to facilitate healing of the gastrojejunostomy and until oral feeding can be started.
Postoperative Complications
z Short term
Anastomotic leakage of the gastrojejunostomy
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Leakage from the duodenal stump
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Acute pancreatitis, pancreatic fistula
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Early dumping syndrome
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Biliary stricture
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z Long term
Biliary reflux
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Stricture of the gastrojejunostomy
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Stump carcinoma
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Late dumping syndrome
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Indications
Local Excision in the Stomach
Ulcers that do not respond to medical treatment, perforation, or bleeding require surgical intervention. Gastric ulcers in bleeding, an endoscopic treatment is the first-line approach. If bleeding
cannot be controlled by endoscopic means, surgical excision is the therapy of choice.
Local excision in the stomach is indicated when the extension of the ulcer allows for re-approximation of the edges of the excision without exerting any tension on the anastomosis. e test for
Helicobacter pylori and the maintenance of antacid medications are mandatory. Work-up includes
gastrin testing and testing for elevated serum calcium levels, both risk factors in complicated ulcers.
Endoscopically uncontrollable bleeding and perforation are indications. for an emergency
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procedure.
Standard Preoperative Investigations
In Case of Bleeding
Endoscopy with the identification of the bleeding site: active bleeding is identified by endos-
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copy or systemic hemoglobin values. Blood pressure and heart rate are recorded.
In Case of Suspected Perforation
Standard x-ray of the abdomen in upright and le semiprone positions.
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Gas insufflation via a gastric tube may facilitate the diagnosis in conventional x-ray examination;
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in case of peritonitis without direct evidence of free abdominal gas, a CT scan should be obtained.
Especially in retroperitoneal perforation of the duodenum, free gas may not be seen in
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standard x-ray films.
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Step 1
Step 2
Section II • Esophagus, Stomach, and Duodenum
Procedure in Perforated Gastric Ulcers
Exposure of the ulcerative lesion
e ulcerative lesion is completely exposed. In case of perforation of the posterior gastric wall,
the omentum of the stomach and of the colon is separated, and the omental bursa is exposed (see
. Fig. 20.2).
Excision of the ulcer
In case of chronic granulation, the wall of the ulcer is excised longitudinally (. Fig. 20.14).
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Step 3
. Fig.20.14
Closure
e ulcer is closed in a crosswise technique by single layer stitches with an absorbable suture
(. Fig. 20.15).
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. Fig.20.15
Chapter • Subtotal Gastrectomy, Antrectomy, BillrothII, and Roux-en-Y Reconstruction
Procedure in Bleeding Gastric Ulcers Refractory to Endoscopic
Treatment
Step 1
Step 2
Step 3
Gastrotomy and exposure of the bleeding site
In bleeding without perforation, gastrotomy is the exposure of choice. Use a longitudinal incision
of the anterior gastric wall.
Isolation of the bleeding
In bleeding of the posterior gastric wall, verify if the source of bleeding arises from an ulceration of
the splenic artery. In this case, obtain proximal and distal control of the artery, ligate these regions
and then address excision of the ulcer. Additional stitches placed around the ulcer wall on all four
sides may help to control bleeding. e use of a nonabsorbable suture is preferable. Collaterals
maintain blood supply to the spleen, and splenectomy is not required.
Closure
Closure of the incision with the single-layer technique.
Local Excision in the Duodenum
In complicated duodenal ulcers, local excision is the therapy of choice. Depending on the size
of the ulcer and its surrounding tissue, a duodenojejunostomy with a Roux-en-Y reconstruction
may be indicated. Further, the gastroduodenal artery should be ligated in case of bleeding ulcers.
Indications and Preoperative Investigations
Step 1
ese correspond to those in gastric ulcers and bleeding (see “Local Excision in the Stomach”, earlier).
Ventral Duodenal Wall
Exposure of the duodenum
e duodenum is completely exposed and opened longitudinally on the lateral wall aer a full
Kocher maneuver.
In case of perforation, the ulcerative lesion is excised (
. Fig. 20.16).
. Fig.20.16
Section II • Esophagus, Stomach, and Duodenum
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Step 2
Closure of the incision
e incision is closed crosswise using single stitches. Kocher’s maneuver may lower the tension to
the suture. Mind that the duodenal passage is not compromised. Depending on the extent of the
excision, primary closure might not be advisable. In this case, a duodenojejunostomy is required
using a Roux-en-Y reconstruction (
. Fig. 20.17).
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. Fig.20.17
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Chapter • Subtotal Gastrectomy, Antrectomy, BillrothII, and Roux-en-Y Reconstruction
Posterior Duodenal Wall
Step 1
Step 2
Exposure of the duodenum
Aer exposing the duodenum, Kocher’s maneuver is performed, and the posterior wall of the
duodenum is completely exposed in case of perforation. In case of bleeding, the anterior wall is
opened, and interrupted stitches are placed on all four sides of the ulcerative lesion (
. Fig.20.18
Excision of the ulcerative lesion
e ulceration is excised (see “Local Excision in the Stomach”, Step2). As a rule, primary closure of
the lesion may not be advisable, as mobilization of the posterior duodenal wall is limited. Hence, a
duodenojejunostomy is put in place. e gastroduodenal artery is exposed and ligated at its origin.
In case of bleeding ulcers, this step might be taken first, when the bleeding source has previously
been identified in gastroduodenoscopy.
. Fig. 20.18).
Standard Postoperative Investigations
e clinical course of the patient and the careful daily observation of the drains if placed are the
key points in postoperative care.
Postoperative Complications
Anastomotic leaks and abscess formation
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Peritonitis
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Anastomotic strictures
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Delayed gastric emptying
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Recurrence of bleeding and ulcerations
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Pancreatitis
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Lesion to the pancreatic duct/papilla Vateri with biliary congestion
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Section II • Esophagus, Stomach, and Duodenum
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Tricks of the Senior Surgeon
When mobilizing the minor curvature of the stomach, bear in mind that a replaced left he-
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patic artery may be present.
Take care that the duodenal stump is closed without any tension on the wall.
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Mobilize the duodenum if required.
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The gastroduodenal artery should be carefully preserved to maintain adequate blood supply
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to the duodenum in case of BillrothII reconstruction.
To avoid any biliary reflux, choose an adequate length of the jejunal limb > 40 to 50 cm distal
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to the gastrojejunostomy.
Transillumination of the mesentery of the proximal jejunum will nicely outline the vascular
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arcade when constructing a Roux-en-Y limb.
To avoid any stricture of the anastomosis, choose a length of the gastrotomy for the anasto-
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mosis of 5–6 cm in gastroenterostomy.
In case of Roux-en-Y reconstruction, the blind end of the jejunal loop should be kept short to
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avoid the building of a reservoir within the blind end.
In case of BillrothII procedure and an inadvertent injury to the spleen requiring a splenec-
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tomy, take care that the remnant part of the stomach is adequately supplied with blood as
the short gastric arteries arise from the splenic artery. In case of hypoperfusion, resection of
the gastric remnant is necessary, and an esophagojejunostomy should be done.
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Total Gastrectomy with Conventional Lymphadenectomy
Jürg Metzger
In 1884 Connor attempted the first total gastrectomy in humans, reestablishing continuity with
an esophagoduodenostomy. His patient did not survive the operation. In 1897 Schlatter carried
out the first successful total gastrectomy. In 1892, Roux described a new procedure where the
jejunal loop was divided and the distal limb was joined to the esophagus. e proximal limb of
the loop was anastomosed to the jejunum some 45 cm distal to the esophagus. A large number
of gastric substitutes have been tried over the past century, grouped into large and small bowel
procedures. Some operations preserve the continuity through the duodenum. Others bypass
the duodenal passage. Some procedures include a pouch construction and/or an antireflux
modification. Currently, Roux-en-Y reconstruction is still the most widely used procedure aer
a total gastrectomy.
Indications and Contraindications
Indications
Contraindications
Adenocarcinomas arising in corpus or fundus of the stomach
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Malignant tumors arising in the antrum of the stomach and showing less well dierentiated
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histology (high grade tumors)
Zollinger-Ellison syndrome
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Mesenchymal tumors (e. g., gastrointestinal stromal tumors [GISTs])
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Palliative gastrectomy for severe bleeding
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Familial gastric carcinoma
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Peritoneal carcinomatosis
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Malignant inltration into neighboring organs
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Child-Pugh B–C cirrhosis with severe portal hypertension
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Preoperative Investigation and Preparation for the Procedure
History: Cardiac disease, pulmonary disease, gastric outlet function,
melena, alcohol, smoking, Helicobacter pylori infection, diet,
geographic risk, genetic factors
Clinical evaluation: Nutritional status (NRS: nutritional risk score)
Laboratory tests:
Gastroscopy: To prove the diagnosis (biopsies), endoscopic ultrasound CT
Diagnostic laparoscopy:
Hb, coagulation parameters, tumor markers, albumin, prealbumin
scan: assessment of resectability, distant metastases
If peritoneal carcinosis is suspected
Procedure
z Access
Midline incision or bilateral subcostal incision, division of round and falciform ligament (. Fig. 21.1)
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_21, © Springer-Verlag Berlin Heidelberg 2016
Section II • Esophagus, Stomach, and Duodenum
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Step 1
Exposure and exploration of the abdomen with focus on
Liver metastases
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Peritoneal carcinosis
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Tumor localization and size
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Lymph node enlargement
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Penetration into pancreas, spleen, and transverse colon
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Mesentery of the proximal small bowel
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. Fig.21.1
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