clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer
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Subtotal Gastrectomy, Antrectomy,
Billroth II and Roux-en-Y Reconstruction
and Local Excision in Complicated Gastric Ulcers
Joachim Ruh, Enrique Moreno Gonzalez, Christoph Busch
Subtotal Gastrectomy
Introduction
In subtotal gastrectomy, 75% of the stomach is resected. The passage is reconstructed using the proximal jejunum either as an omega loop or as a Roux-en-Y reconstruction.
Indications and Contraindications
Indications |
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Gastric carcinoma of the intestinal type in the distal part of the stomach |
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Complicated ulcers of the distal part of the stomach and the duodenum |
Preoperative Investigations/Preparation for the Procedure
■In gastric carcinoma, the carcinoma should be clearly identified as an intestinal type in histopathological work-up.
■The location of the carcinoma/ulcerative lesion should be clearly identified by means of endoscopy.
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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Procedure |
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STEP 1 |
Abdominal incision and mobilization of the stomach |
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For laparotomy, a transverse epigastric incision should be chosen. In case of inadequate |
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exposure, this incision should be extended with a midline incision. This approach |
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provides adequate exposure up to the gastroesophageal junction. Alternatively, a midline |
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laparotomy is adequate. |
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Following the exploration of the whole abdomen for metastatic disease in case of |
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gastric cancer, the gastric lesion should be located.
The greater omentum of the stomach is dissected from the transverse colon, exposing the posterior wall of the stomach and opening the lesser sac (A).
A
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STEP 1 (continued) |
Abdominal incision and mobilization of the stomach |
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The pylorus is freed from adjacent connective tissue (B), and the omentum minus is opened along the minor curvature. Care has to be taken not to overlook a left hepatic artery. The left gastric artery is exposed as well as the coronary vein. Both structures are ligated and transected (C). Thus, the lymphatic tissue along the lesser and greater curvature is included in the specimen. The right gastric artery and vein are ligated and transected as well as the right gastroepiploic artery and vein at the greater curve, preserving the arcade vessels of the proximal part of the stomach.
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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STEP 2 |
Resection |
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The resection margins are set at the pyloric region about 1cm distal to the pylorus and the proximal third of the stomach (A). The duodenum is divided with the stapler device. It is recommended to make a single layer closure of the gastric incision with a running suture or single stitches. In case a stapler device is used, the serosa should be adapted with seromuscular stitches (B). The duodenal stump should be treated with special care, avoiding any tension on the suture line. For its closure, single stitches are used (C).
For the gastrojejunostomy, an omega loop, i.e., the Billroth II reconstruction (STEP 1–3), or a Roux-en-Y reconstruction (STEP 1) is used.
Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers |
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Antrectomy
Introduction
In antrectomy, 25% of the distal part of the stomach is resected.
Indications and Contraindications
Indications |
■ Complicated duodenal ulcers and ulcers of the prepyloric region. Antrectomy is |
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performed in combination with bilateral truncal vagotomy. This procedure reduces |
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acid secretion by reduction of acetylcholine stimulus of the vagus nerve and gastrin |
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production of the antrum. |
Preoperative Investigations
■Endoscopic verification of the lesion
■Exclusion of gastrinoma and hypercalcemia as risk factors
■Exclusion of carcinoma (multiple biopsies)
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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Procedure |
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STEP 1 |
Mobilization of the stomach and vagotomy |
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As in subtotal gastrectomy, the stomach is mobilized and freed from the omentum, and the pylorus is isolated. The vagal trunks are identified on the distal part of the
esophagus, with the anterior branch of the nerve lying on the left part of the esophagus, and the posterior branch lying on the back or to the right side of the esophagus (A). About 2cm of each branch is resected, and the nerve ends are ligated (B).
A
B
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STEP 2
STEP 3
STEP 4
Exposure of the antrum
The pylorus (see “Subtotal Gastrectomy” STEP 1, Fig. B) and the distal part of the stomach are dissected, ligating the vasculature on the greater and lower curvature. Using a stapling device is the most convenient way to perform the resection.
Resection margins
The resection margins are set similar to the subtotal gastrectomy concerning the duodenum (see “Subtotal Gastrectomy” STEP 1). The proximal resection line is placed below the gastroesophageal junction on the lower curvature and in the middle between the fundus and the pylorus at the greater curvature.
Reconstruction of the passage
For reconstruction of the passage, the Billroth II (STEP 1–3) or the Roux-en-Y procedure is used (STEP 1).
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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Billroth II Reconstruction |
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Procedure |
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The gastrojejunostomy is done with an omega loop. |
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STEP 1 |
Placement of the omega loop |
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Choose a loop of the proximal jejunum that can easily be mobilized to the distal part of |
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the posterior wall of the remnant stomach. The distance of the loop is kept short when |
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a retrocolic route is chosen. |
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Prepare a small passage in the mesentery of the transverse colon and pull the omega |
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loop through the mesentery. Mind that no tension is exerted on the mesentery when the |
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loop is in place. |
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Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers |
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STEP 2 |
Gastrojejunostomy |
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Open the closure of the distal gastric remnant and the antimesenteric side of the omega loop. For the backward layer, use single stitches or a running suture (A, B).
A
B
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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STEP 2 (continued) |
Gastrojejunostomy |
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For the anterior anastomosis, a running inverting suture is adequate. However, a monolayer with single stitches is also possible as well as the appliance of a stapling device (C). To avoid anastomotic stricture, the gastrojejunostomy should be performed over a distance of 5–6cm.
C