Keywords

Introduction

Partial gastrectomy is performed for a number of reasons including carcinoma, ulcer disease, and gastric outlet obstruction. Removal of a portion of the stomach is followed by a reconstruction to restore intestinal continuity. Several options exist, including Bilroth I (BI), Bilroth II (BII), and Roux-en-Y (REY). The BII gastrojejunostomy is the focus of this chapter. While the BI maintains the normal anatomic configuration, the resulting tension created by a gastroduodenostomy can be troublesome as it increases risk of leak or may lead surgeons to perform an inadequate resection in order to preserve proximal gastric length [1]. As a result of these concerns, the BII reconstruction was developed as a tension-free anastomosis between the stomach and jejunum brought up as a loop. This option was not without its own challenges, and a third option was conceived to ameliorate these issues. The REY, which seems less fraught with the complications seen in BII reconstruction, has become favored in recent literature. Despite concerns regarding the BII and the sequelae of this procedure, it still has a role in the armamentarium of the foregut surgeon. Individual patient factors must be taken into account when selecting a method for reconstruction, and the situations in which a BII may be the better option are outlined below.

Advantages of the Billroth II Reconstruction

When choosing between procedures for restoring the continuity of the GI tract, the surgeon must weigh the pros and cons of each technique (Table 59.1). There are several patient-centered considerations that would favor the BI reconstruction. Performing intestinal reconstructions on the multiply operated abdomen can be problematic. Incidence of adhesions increases with number of abdominal operations, and the risk of inadvertent enterotomy is 6% when adhesiolysis must be performed [2]. The Billroth II is a technically straightforward procedure to perform in the setting of extensive abdominal adhesions limiting small bowel mobility. The jejunal loop selected must be able to reach the stomach, while other adhesions can be left in place. For a REY reconstruction, adhesiolysis must be performed to accurately measure the afferent and efferent limbs and also to achieve the necessary length for a tension-free anastomosis. In the event that adhesions are particularly dense and unintentional bowel injury is a concern, a BII is a reasonable alternative to avoid much of the obligatory adhesiolysis. Additionally, the prognosis and vitality of the patient may be a factor to consider. If a patient has limited physiologic reserve and expeditious completion of the case is necessary, the speed of a BII reconstruction may be the preferred approach.

Table 59.1 Advantages and disadvantages of Billroth II reconstruction
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In addition to patient-oriented decision, technical concerns may favor the application of a BII reconstruction. The BII classically entails a single anastomosis. Unlike a REY which requires both a gastrojejunostomy (GJ) and a jejunojejunostomy (JJ), the GJ can be performed alone. With that said, in order to avoid alkaline reflux from the afferent limb, a Braun enteroenterostomy between the afferent and efferent limbs is recommended when performing a BII [3]. Thus the appeal of the single anastomosis may only be advantageous in situations where the benefit of limiting new bowel connections outweighs the risk of reflux. The anatomy of a BII may be preferable when endoscopic access to the biliary tree is anticipated. Following partial gastrectomy, the classic transgastric approach to the proximal duodenum can be prohibitively difficult outside of a BI reconstruction. When the extent of gastric resection prohibits use of this method, BII or REY are the remaining options. Though laparoscopic access to a remnant stomach has allowed endoscopic retrograde cholangiopancreatography (ERCP) to be performed in patients with gastric bypass, the REY reconstruction in the setting of partial gastric resection lacks even this option. ERCP in this population becomes difficult if not impossible as the endoscope must be directed down the Roux limb, through the jejunojejunostomy and retrograde through the biliopancreatic limb. With BII reconstruction, endoscopic intubation of the afferent limb provides a direct path to the biliopancreatic tree. Though the approach in either case is still from the distal duodenum and opposite of conventional ERCP, it is a more direct route with BII anatomy compared with REY.

When choosing between surgical options, it is also necessary to consider complications of the alternate reconstruction options. The morbidities of a BII will be discussed later in this chapter. With that said, it is important to note that the REY does have complications not seen in BII. Roux stasis is isolated to the REY anatomy. Symptoms include abdominal pain, nausea, vomiting, and postprandial bloating. It is estimated to occur in up to 30% of patients and is thought to result from disruption of electrical signaling involved in bowel motility [4]. Though evidence for this is debated, it prompts careful consideration of the reconstructive options in the setting of a patient with known bowel motility issues. When the REY is not an option, deciding between Billroth I and II is usually based on the extent of the resection. While BI maintains the normal physiologic path for food to travel, the more stomach taken for adequate resection translates to increased likelihood of tension on a BI anastomosis and thus higher chance of leak [1]. Certainly there is no option that is free of potential morbidity. Given this, it is important to consider the specific issues with each alternative prior to committing to an operation.

Technique

A Billroth II gastrojejunostomy can be approached both laparoscopically and open. Gastric surgery is increasingly being performed with minimally invasive techniques and has been proven safe even in the setting of gastric cancers.

Laparoscopy

Patients undergoing partial gastrectomy with Billroth II reconstruction laparoscopically are placed supine. The legs can be kept straight or in split-leg position depending on the surgeon’s preference to stand on the patient’s right or between the legs. The decision to tuck arms is also at the discretion of the surgeon. Preoperative endoscopy may be performed to localize pathology and orient port sites. A 12 mm port for a 30 ° laparoscope is utilized through a site just cephalad and to the left of the umbilicus. Working ports are selected based on the operative plan and moved further to the left and superiorly if more proximal dissection of the stomach is needed. After placement of the camera port, additional working ports are oriented to allow for unhindered access to the pathology in the left upper quadrant (Fig. 59.1). Once the ports are in place, the patient is placed in steep reverse Trendelenburg, and a liver retractor is positioned to optimize visualization of the foregut [5].

Fig. 59.1
figure 1

Port placement for laparoscopic Billroth II anastomosis. 12 mm camera port near umbilicus. Lateral 12 mm port on right for stapling and suturing devices. 5 mm right-sided port for operating surgeon. 5 mm assist port on left. Optional 5 mm liver retractor port in the epigastrium

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Given the variety of indications for a distal gastrectomy and the associated extent of lymph node harvest, a complete discussion on the technique of a partial gastrectomy is beyond the scope of this chapter. In short, the greater curve of the stomach is mobilized from the gastrocolic ligament distally toward the pylorus and proximally beyond the lesion to be resected. The gastrohepatic ligament is opened to enter the lesser sac, and the lesser curve is similarly dissected toward the pylorus and GE junction. Posterior attachments to the stomach are divided to free the stomach. Endoscopic staplers are used to divide the stomach distal to the pylorus. The location for division of the proximal stomach is determined by pathology and is also performed with linear staplers. Several loads may be needed and depend on the level at which the transection is performed. Once the stomach is resected, reconstruction is performed [5].

For an intracorporeal Billroth II, a jejunal loop can be brought up in a retrocolic or antecolic fashion. Antecolic is the preferred technique as it eliminates creation of an additional site for internal hernia through the transverse mesocolon and avoids risk of injury to colonic blood supply. The antecolic technique does pose a risk for additional tension as the loop must travel over the bulk of the colon. To decrease this possibility, the omentum is divided and a path for the jejunal loop is created. This division of the omentum is continued cephalad toward the transverse colon and then laterally, splitting it into two tongues to create adequate space anterior to the colon for the jejunal loop to reach the proximal stomach staple line.

Having divided the omentum, the ligament of Treitz is again identified, and a site for the gastrojejunostomy is selected approximately 35 cm distal to this landmark. The jejunal limb is brought over the colon between the divided omentum. The jejunal limb is oriented so that it is isoperistaltic. A stay suture is placed between the jejunum and gastric staple line. A posterior suture line is created from left to right with an absorbable suture. Next, a gastrotomy and an enterotomy are made on the medial aspect of the suture line. The interior row of the anastomosis is created with a linear stapler fired through these defects. The common gastroenterostomy is closed with a running absorbable suture. An imbricating anterior row is performed in a running fashion with absorbable suture. Once complete, a leak test is performed by insufflating via an orogastric tube or endoscope while submerging the anastomosis under saline.

Open

In the open technique, the stomach is approached through a midline incision with the patient supine. Dissection and mobilization of the stomach mirrors that which is performed using a laparoscopic technique. The distal margin of the partial gastrectomy is typically two centimeters past the pylorus, and the proximal extent of the resection is dictated by the pathology. With a BII gastrojejunostomy, there is much less tension than a BI, and the proximal extent of resection is decided based on pathology and is free from the conflicting goals of an adequate margin and tension-free reconstruction. Division of the stomach is performed using a linear stapler. Currently, there is no consensus as to the utility of oversewing the duodenal stump and the stomach staple lines. At the time of resection, concurrent truncal vagotomy can be considered in the case of ulcer disease secondary to acid hypersecretion.

The BII reconstruction is performed by bringing a jejunal loop to the greater curve of the remaining stomach. The jejunum is measured from the ligament of Treitz and a site 35 cm distal to this structure is selected. This loop can be brought either retrocolic or antecolic and the gastrojejunostomy is performed. There are several described techniques including anastomoses that are handsewn or fashioned with stapling devices. Prior to closure of the GJ, a nasogastric tube can be advanced past the anastomosis if needed [1].

Braun Enterostomy

Once the BII GJ anastomosis is completed, a Braun enteroenterostomy between the ascending and descending loops can be considered. The enteroenterostomy is created 30 cm distal to the gastrojejunostomy. This second anastomosis connects the afferent to the efferent limb and is utilized to prevent bile reflux and direct alkaline contents away from the stomach. This can be performed in a side-to-side fashion by either open or laparoscopic technique [1].

Postoperative Management

Immediately following a BII reconstruction, the patient is initially kept NPO. Nasogastric decompression is most beneficial in the setting of gastric outlet obstruction as a degree of transient gastroparesis is often seen in this population. With that said, a nasogastric tube may be placed at the discretion of the surgeon based upon patient risk factors. Perioperative antibiotics should be administered according to Surgical Care Improvement Program (SCIP) Guidelines. Redosing of antibiotics should be completed based on operative time. Typically no drains are required. The gastric tube can be removed in 1–2 days if placed, and PO liquids can generally be started around postoperative day 2. In the situation where a patient is unable to take oral intake, an NGT advanced beyond the anastomosis can be used as early feeding access [1].

Postoperative Complications

The mortality of a partial gastrectomy is approximately 1–2% and is independent of the reconstruction type. Mortality increases if the procedure is done emergently. Gastric resections performed for ulcer disease may be complicated by ulcer recurrence 1–4% of the time. Bleeding occurs in 2% of cases and anastomotic leak ranges from 1 to 4% [1]. Postgastrectomy morbidities may occur when a Billroth II reconstruction is performed. Many of these complications are not unique to the BII, though the frequency may vary between reconstruction options.

Nutritional Deficiency

Following removal of the stomach or a portion of it, nutritional deficiencies such as iron, calcium, vitamin B12, and folate are common (Table 59.2). Microcytic anemia from iron deficiency is the most common cause of anemia after gastric resection. It is related to bypassing the duodenum which is the primary site of iron absorption and is seen in both BII and REY reconstructions. Decreased gastric acidity is also thought to have a role. Ferritin levels are an accurate indicator of deficiencies and oral supplementation with elemental iron effectively treats the deficit. Megaloblastic anemia can also be seen after gastrectomy. Intrinsic factor (IF) produced in the stomach is decreased after gastrectomy. Decreased availability of IF to bind with B12 leads to malabsorption in the terminal ileum. Folate deficiency, another cause of megaloblastic anemia, can also be seen after gastrectomy, and supplementation of both is recommended to avoid masking a deficiency of the other. The BII and REY reconstructions both lead to increased bone disease like osteoporosis related to impaired calcium absorption when the duodenum is bypassed. Patients should be given calcium supplements as well as vitamin D [6]. Copper deficiency can occur since it is absorbed in the proximal duodenum leading to ataxia, myelopathy, and peripheral neuropathy [7]. Due to the nutritional implications of gastrectomy, close follow-up is necessary, and patients should have baseline nutritional labs checked before surgery with periodic monitoring post-op.

Table 59.2 Nutritional deficiencies
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Dumping Syndrome

Loss of gastric regulation can cause rapid gastric emptying and can occur early or late. Early gastric emptying occurs within 30 min of a meal and manifests as crampy abdominal pain, diarrhea, lightheadedness, and tachycardia. It results from hyperosmolar solute emptying into the small intestine and is reproducible with oral glucose challenge. Late gastric emptying happens approximately 2 h after meal ingestion and is related to hypoglycemia subsequent to inappropriately high levels of insulin secreted in response to ingested glucose loads. This syndrome can occur not just in BII but with any reconstruction, though the incidence may be lower in those with a REY [4]. Patients with dumping syndrome can alleviate symptoms with dietary modifications including small frequent meals, avoiding sweets and avoidance of liquids with meals [1]. Symptoms of hypoglycemia can be managed with medications like acarbose in cases of late dumping. Somatostatin analogs can help both early and late dumping as it has a variety of effects including inhibiting insulin release. Severe cases may require conversion to a REY [7].

Afferent Loop Syndrome

Afferent loop syndrome is unique to BII anatomy. Patients with this rare syndrome present with colicky right upper quadrant pain which progressively worsens and culminates with vomiting that provides instantaneous pain relief. Imaging may demonstrate a chronically dilated afferent limb, or postprandial ultrasound can confirm the diagnosis of acute distension of the afferent limb. Treatment is conversion to Roux-en-Y if technically feasible. An alternative would be Braun enterostomy if revision of the gastrojejunostomy is prohibitively difficult [4].

Delayed Gastric Emptying

Severe delays in gastric emptying are quite rare. In those who undergo a truncal vagotomy in addition to partial gastrectomy, the incidence of gastric stasis is 3–5%. Patients report postprandial bloating and fullness that lasts hours after oral intake. They may also regurgitate undigested food hours to days later. Patients can develop bezoars and bacterial overgrowth and demonstrate intolerance to solids while liquids empty normally or rapidly [6]. Endoscopic evaluation of patients with previous gastrectomy shows retained food in 21% after an overnight fast. The incidence is highest in those with B1 reconstruction, though the significance is unclear. Diet modification or prokinetic drugs can be tried but have variable success. Patients rarely go on to require completion gastrectomy for this condition [4].

Bile Reflux Esophagitis

Patients with this syndrome present with abdominal pain, bilious vomiting, and even weight loss. The symptoms result from the reflux of alkaline fluid into the stomach leading to gastritis. Aside from inflammation seen on endoscopy, the diagnosis can also be made with a technetium biliary scan which demonstrates bile reflux into the stomach. The syndrome is overwhelmingly associated with BII anatomy, occurring in approximately 70% of patients. Repeated studies have shown that bile reflux is significantly decreased in REY reconstruction compared with both BI and BII. Though bile reflux occurs quite frequently, not all patients have debilitating effects related to it. Medical management includes many strategies including bile absorption with cholestyramine, antacid therapy, and coating medications like sucralfate [8]. Symptoms may also be managed by changing bile acid composition with ursodeoxycholic acid [9]. The effectiveness of these treatments is debated, but for patients who suffer significantly, conversion to REY often alleviates their symptoms. Other surgical options include Braun enterostomy and jejunal interposition loop [4].

Ulcers

Anastomotic ulcers can occur in both BII and REY reconstruction. Patients may present with epigastric pain, bloating, and nausea. Bleeding can result in anemia and occult blood in the stool. Recurrent ulcers in patients with peptic ulcer disease are possible and may result from incomplete vagotomy. Nonsteroidal anti-inflammatory drugs (NSAIDs) and exposure to tobacco use can also cause ulcers. Less common reasons include Zollinger-Ellison syndrome and retained antrum. In the latter scenario, antral G cells present in the duodenal stump are bathed in alkaline fluid which results in continued gastrin production. Gastrin prompts parietal cells in the proximal stomach to continuously secrete acid. The jejunal side of the gastrojejunostomy lacks protective agents produced by gastric mucosa and is prone to marginal ulcer formation [4]. The diagnosis can be made by checking serum gastrin levels and a [99mTc] pertechnetate scan. While more invasive, endoscopy with biopsy of the duodenal stump can also establish the diagnosis. Medical treatment focuses on acid reduction with medications such as proton pump inhibitors. In the setting of persistent symptoms, revision may be required in the form of duodenal cuff resection [7]. The retained-antrum syndrome remains quite rare but is a reminder that care should be taken to ensure all gastric tissue is resected. Outside of this condition, ulcers should be managed nonoperatively with acid suppression and avoidance of inciting factors such as very acidic foods, NSAIDs, and tobacco exposure. Symptoms can be managed with coating agents like sucralfate.

Gastric Remnant Carcinoma

The risk of developing gastric remnant cancer has been investigated for many years, and several studies have endeavored to establish a difference in the risk profile for this morbidity between reconstruction types. Though it has been difficult to tease out the true risk associated with each, it does seem that, regardless of reconstruction type, patients who underwent resections performed for ulcer disease are at higher risk compared with other benign indications. A Swedish study did show an increased risk of developing cancer in the remnant when a BII is performed compared with B1. This was thought to be due to alkaline exposure which has been shown to increase risk of cancer in animal models [4].

Conclusion

A review of the recent literature investigating reconstruction options after partial gastrectomy appears to favor Roux-en-Y. Though REY has improved quality of life measures and decreased incidence of certain complications when compared with the BII, it is not always the best option for every patient requiring partial gastrectomy. The Billroth II reconstruction is still a useful adjunct for the foregut surgeon, and in the setting of dense adhesive disease, need for biliary access or other patient-specific circumstances remains a relevant reconstructive option which can be performed with either open or laparoscopic techniques. Furthermore, though REY may be favored in the future, there remains a large patient population with Billroth II anatomy. Understanding the complications seen in Billroth II reconstruction remains relevant to surgeons who may provide care for these patients.