Stomach: Gastrectomy

Antrectomy (Distal Gastrectomy)

Antrectomy (Distal Gastrectomy)

  • Goals:
    • Goal for CA: R0 Resection
    • Goal for PUD: To Remove All G Cells Requires
      • Requires ≥ 35% of Distal Stomach Removed
      • About 45% of Lesser Curvature or 7 cm from Pylorus
      • About 15% of Greater Curvature
  • Procedure:
    • Preform a Kocher Maneuver to Minimize Tension
    • Mobilize the Greater Curvature
      • Ligate the Right Gastroepiploic Artery at the Pylorus
      • Continue Dissection Around the Greater Curvature to the Extent Required for Reconstruction
    • Mobilize the Lesser Curvature
      • Divide the Lesser Omentum from the Incisura to the Pylorus
      • Ligate the Right Gastric Artery at the Pylorus
    • Resect Antrum & Pylorus as Appropriate
    • Preform Selected Reconstruction

Antrectomy Reconstructions

  • Billroth I
    • Gastroduodenal Anastomosis
    • Procedure: Stomach Remnant is Connected Directly to the Remaining Duodenum in a Continuous Fashion
    • Comparison:
      • More Anatomic than Billroth II
      • Risk for Increased Tension
  • Billroth II
    • Gastrojejunal Anastomosis
    • Procedure: Stomach Remnant is Connected Distally to the Jejunum Creating an Afferent Limb
    • Limbs:
      • Afferent Limb: Proximal Duodenojejunal Limb
      • Efferent Limb: Common Distal Jejunal Limb
    • Comparison:
      • Overall More Complications Than Billroth I
      • Highest Risk of Blind Loop Syndrome
  • Roux-en-Y
    • Procedure:
      • Jejunum is Divided 40 cm Distal to the Ligament of Treitz
      • Jejunojejunostomy is Made
        • The Proximal End is Set 50-70 cm Down the Distal End
        • A Side-to-Side Anastomosis is Made
      • Gastrojejunostomy is Made
        • The New Roux Limb is Anastomosed to the Stomach
      • All Mesentery Defects are Closed
    • Limbs:
      • Roux Limb: Continuous Limb in Continuity with Stomach
      • Biliopancreatic Limb
    • Comparison:
      • Less Dumping Syndrome
      • Less Alkaline Reflux Gastritis
      • Higher Risk of Marginal Ulcers

Billroth I 1

Billroth II 1

Roux-en-Y 1

Total Gastrectomy & D2 Lymphadenectomy

Total Gastrectomy & D2 Lymphadenectomy

  • First Divide Hepatoduodenal Ligament to Visualize the Right Crus
  • Divide Gastrocolic Ligament & Short Gastric Vessels
    • Include Greater Curvature Lymph Nodes (Station 4) in Specimen
  • Retract Stomach Up & Divide the Left Gastric Artery
  • Preform a D2 Lymphadenectomy
    • Start from the Proximal Common Hepatic (Station 8) & Continue to the Left Gastric Pedicle (Station 7)
    • Continue Posteriorly to Celiac Node (Station 9) & Along the Splenic Artery (Station 11)
      • Consider Inclusion of Splenic Hilum (Station 10) with Splenectomy
    • Return Stomach to Natural Position
    • Continue Dissection from Common Hepatic to the Anterior Hepatoduodenal Ligament to Include Hepatic Artery Nodes (Station 12a)
  • Divide the Lesser Omentum Along the Lesser Curvature
    • Include Lesser Curvature Lymph Nodes (Station 3) in Specimen
  • Extend Hiatal Dissection from Right Crus to the Left Crus both Anteriorly & Posteriorly
    • Include Pericardial Lymph Nodes (Stations 1-2) in Specimen
  • Dissect the Proximal Duodenum to Include Pyloric Lymph Nodes (Stations 5-6)
  • Resection
    • Transect Duodenum 1-2 cm Distal to Pylorus
    • Transect the Distal Esophagus
    • Send Both Margins for Frozen Section
  • Proceed with Greater Omentectomy
  • Reconstruction of Choice Once Frozen Section Found Negative

Total Gastrectomy Reconstructions

  • Roux-en-Y Esophagojejunostomy
    • Classic Roux-en-Y with a Straight Jejunal Roux Limb
  • Roux-en-Y with Jejunal J-Pouch (Hunt-Lawrence)
    • Procedure:
      • Jejunum is Divided 20-40 cm Distal to the Ligament of Treitz
      • Distal End is Folded onto Itself and Formed into a Jejunal J-Pouch of 10 cm
      • Jejunojejunostomy is Made with Proximal End Set 40-50 cm Down the Distal End
      • Esophagojejunostomy is Made Anvil Circular Stapler from Esophagus to the J-Pouch
    • Pouch Allows Prolonged Retention of Food
    • Outcomes
      • Best Outcomes
      • Best Nutrition & Weight Gain
      • Better Quality of Life
      • Lower Risk of Esophagitis, Heartburn & Dumping Syndromes
  • Roux-en-Y with Looped Esophagojejunostomy
    • End Esophagus to Side of Jejunum with a Small Blind End
  • Jejunal Interposition
    • Segment of Jejunum Resected and Interposed Between Esophagus & Proximal Duodenum
  • Colon Interposition
    • Segment of Colon Resected and Interposed Between Esophagus & Proximal Duodenum
  • Double Tract
    • Jejunum Transected & Distal Limb is Anastomosed to the Esophagus Similar to Roux-en-Y
    • The Distal End of the Proximal Limb is Anastomosed About 40-50 cm Down the Roux Limb
    • The Proximal End of the Proximal Limb is Anastomosed About 15-30 cm Down the Roux Limb Creating a Second Tract

Complications & Postgastrectomy Syndromes

Malnutrition

  • Weight Loss is Common and Can Be Significant
  • Anemia – Iron, Folate & B12
    • Iron is the Most Common Vitamin Deficiency (Absorbed in Duodenum)
  • Osteoporosis – Calcium

Gastric Emptying

Billroth II Obstructions

  • Afferent Loop Obstruction
    • Pathogenesis:
      • Afferent Loop is Obstructed Causing Accumulation of Pancreatic/Hepatobiliary Secretions with Severe Epigastric Pain
      • High Intraluminal Pressure Eventually Overcomes Positional Obstruction & Forces Fluid into the Stomach
      • Causes High-Volume Bilious Vomiting & Relief of Symptoms
    • Most Common Cause: Redundant Antecolic Afferent Limb (> 30-40 cm)
      • More at Risk for Kinking, Volvulus and Adhesions
    • Blind-Loop Syndrome (Also Known as Afferent Loop Syndrome)
    • Tx: Surgery (Conversion to Roux-en-Y)
  • Efferent Loop Obstruction
    • Sx: Abdominal Pain, Distention & Bilious Vomiting
    • Dx: Upper GI Contrast Study
    • Tx: Balloon Dilation
      • Surgery if Needed

Afferent Loop Obstruction; Dilated Proximal Bowel (Black Arrow), Normal Distal Bowel (White Arrow) 2

Alkaline (Bile) Reflux Gastritis

  • Bile Reflux into Stomach When Pylorus Unable to Prevent
  • Histologic Bile Gastritis is Common but Clinical Bile Gastritis with Symptoms are Uncommon
  • Most Common After Billroth II
  • Sx: Abdominal Pain & Bilious Vomiting
    • Pain Does NOT Resolve After Emesis (Compared to Afferent Loop Syndrome)
  • Dx: HIDA
  • Tx: Conservative (PPI, Reglan/Metoclopramide & Cholestyramine)
    • If Fails: Conversion to Roux-en-Y Gastrojejunostomy
      • Keep Roux Limb > 40 cm, Around 60 cm

Marginal Ulcers

  • Ulcers that Develop at the Gastrojejunal Anastomosis
    • Can Be on Either Side of the Anastomosis
  • More Common After Roux-en-Y (Lacks the Buffering Afferent Limb Contents to Counteract Acid in Jejunal Mucosa)
  • Retained Antrum Syndrome
    • Recurrent Ulcer After Billroth II from Inadequate Removal of the Distal Antrum/Pylorus
    • Retained Antral G Cells are Not Exposed to Luminal Acid Causing Increased Gastrin Secretion & Intense Acid Secretion in the Proximal Remnant & Marginal Ulcers
  • Risk Factors:
    • Ischemia
    • H. pylori
    • Gastrogastric Fistula
    • Smoking
    • NSAIDs
  • Advise All Patient to Avoid Smoking & NSAIDs
  • Tx: PPI & H. pylori Tx
    • If Fails: Surgery

Marginal Ulcer of GJ Anastomosis 3

Duodenal Stump Blowout (Postgastrectomy Duodenal Leak)

  • Causes:
    • Poor Surgical Technique
    • Inadequate Closure
    • Devascularization
    • Pancreatitis
    • Afferent Obstruction
  • Tx: Decompressive Duodenostomy Tubes & Drains

References

  1. Terrone DG, Lepanto L, Billiard JS, Olivié D, Murphy-Lavallée J, Vandenbroucke F, Tang A. A primer to common major gastrointestinal post-surgical anatomy on CT-a pictorial review. Insights Imaging. 2011 Dec;2(6):631-638. (License: CC BY-2.0)
  2. Chhabra P, Singh Rana S, Sharma V, Sharma R, Gupta R, Kumar Bhasin D. An unusual cause of simultaneous common bile and pancreatic duct dilation. Gastroenterol Rep (Oxf). 2015 Aug;3(3):258-61. (License: CC BY-3.0)
  3. Adduci AJ, Phillips CH, Harvin H. Prospective diagnosis of marginal ulceration following Roux-en-Y gastric bypass with computed tomography. Radiol Case Rep. 2016 Feb 17;10(2):1063. (License: CC BY-NC-ND-4.0)