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 ■ Gastric carcinoma of the intestinal type in the distal part of the stomach ■ 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. 144 SECTION 2 Esophagus, Stomach and Duodenum Procedure STEP 1 Abdominal incision and mobilization of the stomach For laparotomy, a transverse epigastric incision should be chosen. In case of inadequate exposure, this incision should be extended with a midline incision. This approach provides adequate exposure up to the gastroesophageal junction. Alternatively, a midline laparotomy is adequate. Following the exploration of the whole abdomen for metastatic disease in case of 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 Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers 145 STEP 1 (continued) Abdominal incision and mobilization of the stomach 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. 146 SECTION 2 Esophagus, Stomach and Duodenum STEP 2 Resection 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 147 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 performed in combination with bilateral truncal vagotomy. This procedure reduces acid secretion by reduction of acetylcholine stimulus of the vagus nerve and gastrin production of the antrum. Preoperative Investigations ■ Endoscopic verification of the lesion ■ Exclusion of gastrinoma and hypercalcemia as risk factors ■ Exclusion of carcinoma (multiple biopsies) 148 SECTION 2 Esophagus, Stomach and Duodenum Procedure STEP 1 Mobilization of the stomach and vagotomy 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 Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers 149 STEP 2 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. STEP 3 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. STEP 4 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). 150 SECTION 2 Esophagus, Stomach and Duodenum Billroth II Reconstruction Procedure The gastrojejunostomy is done with an omega loop. STEP 1 Placement of the omega loop Choose a loop of the proximal jejunum that can easily be mobilized to the distal part of the posterior wall of the remnant stomach. The distance of the loop is kept short when a retrocolic route is chosen. Prepare a small passage in the mesentery of the transverse colon and pull the omega loop through the mesentery. Mind that no tension is exerted on the mesentery when the loop is in place. Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers 151 STEP 2 Gastrojejunostomy 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 152 SECTION 2 Esophagus, Stomach and Duodenum STEP 2 (continued) Gastrojejunostomy For the anterior anastomosis, a running inverting suture is adequate. However, a mono- layer 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 Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers 153 STEP 3 Braun’s anastomosis Braun’s anatomosis is performed as distal as possible (>40cm) to avoid biliary reflux into the gastric remnant. Side-to-side jejunostomy is done either with single stitches, a running suture, or a stapler device (A, B, C). A B C 154 SECTION 2 Esophagus, Stomach and Duodenum Roux-en-Y Reconstruction Procedure STEP 1 Dissection of the jejunum The ligament of Treitz is identified, and the jejunum is dissected about 40–50cm distal to Treitz’ ligament (A). For convenience, a stapler device may be used. The blind end of the distal part is closed using a running suture or single stitches. The 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 5–6cm, thus building the outer layer of the backward suture (B). A B Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers 155 STEP 2 Gastrojejunostomy The 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 layer, completed by a running inverting suture on the anterior part of the gastrojejunostomy. However, single stitches in monolayer technique as well as the appliance of a stapler device are also adequate. The technique is similar to the gastrojejunostomy in the Billroth II reconstruction (STEP 2). The dissected jejunal loop is anastomosed end-to-side to the distal part of the jejunum 40–50cm distal to the ligament of Treitz. Postoperative Investigations ■ The gastric tube should be kept until there are no further signs of gastric reflux or gastrointestinal atonia are present. Indwelling drains should be kept until enteral nutrition has been started. Postoperative Complications ■ Short term: – Insufficiency of the gastrojejunostomy – Insufficiency of the duodenal stump – Acute pancreatitis, pancreatic fistula – Early dumping syndrome – Biliary stricture ■ Long term: – Biliary reflux – Stricture of the gastrojejunostomy – Stump carcinoma – Late dumping syndrome 156 SECTION 2 Esophagus, Stomach and Duodenum Local Excision in the Stomach Introduction Ulcers that do not respond to medical treatment, perforation, or bleeding require surgical intervention. In bleeding, an endoscopic treatment is the firstline 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 readaption without exerting any tension on the anastomosis. The test for Helicobacter pylori and the maintenance of antacid medication are mandatory. Work-up includes gastrin testing and testing for elevated serum calcium levels, both risk factors in complicated ulcers. Indications and Contraindications Indications