New method for Billroth I reconstruction after distal gastrectomy

Authors report a new technique for Billroth I reconstruction after distal gastrectomy using linear stapling devices, which is easier than conventional methods. The duodenum is divided 0.5 cm distal to the pyrolus ring, with a 55-mm linear stapler. The anterior wall of the duodenum is cut along the planned line of anastomosis with the gastric remnant. The anterior wall of the stomach is cut along the planned suture line having a length similar to that of the duodenum. The posterior walls of the stomach and the duodenum are placed back to back on the planned anastomotic line. End-to-end posterior anastomosis between the gastric remnant and the duodenum is simultaneously performed with gastrectomy using a 100-mm linear stapler. End-to-end anterior anastomosis is performed by hand. This technique has been used in 7 patients, and there have been no complications related to this procedure. Operative time was 152 +/- 16 min (range 130 to 180 min) on average. It is an economical and easy procedure for Billroth I reconstruction.     

Pyloric sphincter reconstruction in Billroth I gastrectomy

AIM To search for a new surgical method which accords with physiologico-anatomical principles, reducethe incidence rate of some postoperative complications in conventional Billroth I (CB1) gastrectomy andraise the life quality of patients after surgery.METHODS Using the blood vessels and innervation of the remaining stomach and duodenum, we designeda new pyloric sphincter reconstruction (PSR) in Billroth I gastrectomy, in which the end of the duodenumremnant is surrounded by the seromuscular valve of 2 cm wide in the end of the greater curvature, thickenedthe muscle of the stoma and reconstructed a similar pylorus with the sphincteric function.RESULTS Eleven patients were treated, 8 males and 3 females, 6 malignant and 5 benign and 1accompanied by mould infection, aged from 33 to 73 years, with 1 to 29 years of gastric disease history(average 7.9 years). The function of gastric emptying was shown to be essentially normal by barium mealstudy with video record one month after the operation. The pyloric-like control effect was present in thereconstructive pylorus. PSR vs CB1 vs NES (P >0.01); PSR vs CB1 (P < 0.01); PSR vs NSE (P >0.05).CONCLUSION The new method of pyloric reconstruction is safer, simpler and more effective thanconventional procedures. This method can be applied to all patients for whom Billroth 1 anastomosis can beperformed regardless of benign or malignant lesion.     

Uncut Roux-en-Y reconstruction after distal gastrectomy for gastric cancer

Introduction: Uncut Roux-en-Y gastrojejunostomy is a modification of the Billroth II procedure with Braun anastomosis, in which a jejunal occlusion is fashioned to avoid the Roux Stasis Syndrome. This review aimed to summarize the current knowledge about the uncut Roux-en-Y anastomosis operation, so that surgeons may be able to make informed decisions about its clinical application. Additionally, we hope that our findings will guide future research on this topic.

Areas covered: The original uncut technique was associated with dehiscence or recanalization of the jejunal occlusion, and was therefore not widely applied. However, with recent improvements in the method of jejunal occlusion, the uncut Roux-en-Y reconstruction may be an appropriate alternative for digestive tract reconstruction after distal gastrectomy. This review summarizes the basic research on and clinical applications of uncut Roux-en-Y gastrojejunostomy from the following several aspects: origin of the uncut reconstruction technique, rationale for uncut reconstruction based on data from animal experiments, clinical results of the uncut reconstruction, recanalization and its countermeasures, and so on.

Expert commentary: The uncut Roux-en-Y gastrojejunostomy is a controversial yet promising method of gastrointestinal reconstruction after distal gastrectomy. Prospective randomized controlled trials and long-term follow-up outcomes are required to support the modified technique in the future.     

Reflux esophagitis in patients with partial gastrectomy and Billroth I or II reconstruction

BACKGROUND: Data on the occurrence of reflux esophagitis and Barrett's esophagus in patients with Billroth I or II resection is sparse. For this reason a cross-sectional study was done in order to assess reflux disease in Billroth resection. METHODS: Consecutive patients were included in the study. Coincidental pathology (hiatus hernia, ulcer, esophagitis, and cancer) was noted. RESULTS: Over a period of 12 years, 370 consecutive patients with a partial gastrectomy were seen (268 Billroth II, 102 Billroth I) and three groups of patients were identified. Group 1 included 64 patients (17%) with a hiatus hernia; group 2, 16 patients (4%) with reflux esophagitis; and group 3, 290 patients (78%) with only a Billroth resection. Reflux disease occurred significantly more often in men than in women (7.5% vs. 2%, p<0.05). There was no difference in type of resection or in the presence of reflux esophagitis. Four patients had an esophageal cancer (only one adenocarcinoma). CONCLUSION: Only a minority of patients with partial gastrectomy has signs of esophagitis in the long term.     

Billroth I versus Billroth II versus Roux-en-Y after subtotal gastrectomy. Prospective [correction of prespective] randomized study

BACKGROUND/AIMS: The aim of this study was to evaluate functional results after Billroth I, Billroth II and Roux-en-Y reconstruction in subtotal gastrectomy. METHODOLOGY: Forty-five patients were randomized between 1990 and 1995 and stratified in 3 different groups: 15 BI, 15 BII and 15 Roux. They were investigated by esophagogastroduodenoscopy with multiple biopsies and upper gastrointestinal scintiscanning, to evaluate gastroesophageal reflux and dynamics of gastric emptying. They also answered a questionnaire: Gastrointestinal Quality of Life. Index. RESULTS: A reflux esophagitis was found in 5 BI, in 7 BII and in 2 Roux (p < 0.001). No gastric lesions were found in 6 BI, in 5 BII and in 12 Roux, (BI vs. Y, p < 0.05; BII vs. Y, p < 0.001). Chronic superficial gastritis was present in 9 BI, in 4 BII and in 3 Roux (BI vs. Y, p < 0.05). Dynamic scintiscan demonstrated the presence of gastroesophageal reflux in 5 BI and gastric emptying was fast (37' < T 1/2 < 86'), but incomplete (60' residual activity: 49-62%). Gastroesophageal reflux was evident in 7 BII with slow (28' < T 1/2 < 143') and incomplete (60' residual activity: 48-72%) gastric emptying. Gastroesophageal reflux was detected in 2 Roux and radioactive bolus progression in the Roux limb was fast (24' < T 1/2 < 53') and complete (60' residual activity: 42-52%) (BI vs. Y; BII vs. Y, p < 0.001). There was no statistical significance between Gastrointestinal Quality of Life Index score in the 3 groups. CONCLUSIONS: The Authors affirm that Roux-en-Y is the technique of choice in subtotal gastrectomy, if compared with BI and BII.     

Digestive and nutritional status after total gastrectomy with a long Roux-en-Y reconstruction

Nineteen patients underwent clinical and nutritional review 1–5.5 years after gastrectomy and long Roux-en-Y jejunal reconstruction. Of these, 79% had little or no restriction of daily activity and only one patient became housebound. Although body weight was only maintained at postoperative levels, body protein status, as measured by arm muscle circumference, creatinine height index and plasma proteins, was normal. Body fat stores were reduced, indicating that fat or carbohydrate digestion was impaired. Mild asymptomatic anaemia in six patients was due to iron deficiency in three and folate deficiency in three. Eight patients had low red cell folate values and these patients had low folic acid intakes. It is concluded that a total gastrectomy using a long Roux-en-Y loop is usually associated with a satisfactory nutritional and digestive outcome but long-term supplements of iron and folic acid should be taken.     

Effect of gastrectomy with either Roux-en-Y or Billroth II anastomosis on small-intestinal function

This prospective study was undertaken in patients scheduled for gastrectomy for peptic ulcer disease to determine the effect of partial gastrectomy with either Roux-en-Y (n = 11) or Billroth II anastomosis (n = 11) on the function of the small intestine. Patients were studied before and at 6 months (blood and small-intestinal function tests) and at 24 months (blood tests) postoperatively. Median postoperative body weights at 6 months (70.5 kg; p less than 0.01) and 12 months (70.3 kg; NS) were lower than preoperatively (73.0 kg). Haemoglobin concentrations at 6 months (8.9 mM; p less than 0.01) and at 24 months (9.1 mM; p less than 0.05) were also significantly reduced compared with the preoperative value (9.5 mM). However, neither at 6 nor at 24 months postoperatively were there significant changes for serum iron, iron saturation, folic acid, vitamin B12, protein, albumin, alkaline phosphatase, and calcium concentrations. Whereas no significant deterioration of the absorption of D-xylose and vitamin B12 or of faecal fat excretion was observed, the orocoecal transit time was significantly shortened from 98 to 50 min (p less than 0.01), the expiratory hydrogen excretion after a 50-g oral glucose load was significantly increased from 8 to 54 ppm (p less than 0.01), as was indicanuria from 257 to 368 mumol/24 h (p less than 0.01). Apart from a lower serum iron concentration and iron saturation index in the Roux-en-Y patients 6 months postoperatively (p less than 0.05), no significant differences between the two types of anastomosis were observed. It is therefore concluded that both in patients with Roux-en-Y and in those with Billroth II anastomosis most abnormalities observed after gastrectomy are secondary to an accelerated small-intestinal transit.     

Roux-en-Y reconstruction does not require gastric decompression after radical distal gastrectomy

AIM: To determine whether routine nasogastric (NG) decompression benefitted patients undergoing radical gastric surgery.METHODS: Between January 1998 and December 2008, 519 patients who underwent distal gastrectomy for gastric cancer were retrospectively divided into 2 time-period cohorts; those treated with Billroth II (BII) reconstruction in the first 6 years and those with Roux-en-Y (RY) reconstruction in the last 5 years. In the latter group, the patients were further divided into 2 subgroups; with and without nasogastric decompression.RESULTS: Postoperatively, there were no significant differences in the number of anastomotic leaks between the 3 groups. In the tubeless RY group, time to semi-liquid diet was significantly shorter than in the other 2 groups (4.4 d ± 1.4 d vs 7.2 d ± 1.3 d and 5.9 d ± 1.2 d, P = 0.005). The length of postoperative stay was significantly increased in patients with BII reconstruction compared with patients with RY reconstruction with/without NG decompression (15.4 d ± 4.3 d in BIIgroup vs 12.6 d ± 3.1 d in decompressed RY and 11.4 d ± 3.4 d in the tubeless RY group, P = 0.035). The postoperative pneumonia rate was lowest in the tubeless group and highest in the BII group (1.4% vs 4.6%, P = 0.01). Severe sore throat was noted in 59 (20.7%) members of the BII group, 18 (17.4%) members of the decompressed RY group and 6 (4.2%) members of the tubeless RY group. Fewer patients in the tubeless group complained of severe sore throat (P = 0.001).CONCLUSION: This study provides support for abandoning routine NG decompression in patients undergoing subtotal gastrectomy with Roux-en-Y gastrojejunostomy.     

Cap-assisted ERCP in patients with a Billroth II gastrectomy

BACKGROUND: ERCP is difficult in patients with a Billroth II gastrectomy because of anatomical changes. OBJECTIVE: Cap-assisted ERCP can improve the cannulation rate and the success rate of stone removal. DESIGN: Case series. SETTING: A tertiary referral center. PATIENTS AND INTERVENTIONS: Ten consecutive patients with bile-duct stones (9) or a distal common bile duct stricture (1), who had previously undergone Billroth II gastrectomy and were referred for ERCP, were analyzed for the outcome of their ERCP. All procedures were carried out with a cap-fitted regular forward-viewing endoscope. MAIN OUTCOME MEASUREMENTS: Ability to perform afferent loop intubation and bile-duct cannulation. RESULTS: Of 10 patients in whom ERCP was attempted, afferent loop intubation and selective bile-duct cannulation were achieved in all patients (100%). Endoscopic sphincterotomy (EST) was successful in all 10 patients (100%). All stones were removed by EST alone in 7 patients and by both EST and endoscopic papillary balloon dilation in 2 patients. There were no serious complications in the patients. LIMITATIONS: Small sample size, single-center experience. CONCLUSIONS: Diagnostic and therapeutic ERCP with a cap-fitted regular forward-viewing endoscope was successful in all patients with a prior Billroth II gastrectomy. The high rate of successful ERCP was achieved by improving afferent loop intubation and bile-duct cannulation with a cap-fitted endoscope.     

Comparison between uncut Roux-en-Y and Roux-en-Y reconstruction after distal gastrectomy for gastric cancer: A meta-analysis

AIM To compare uncut Roux-en-Y(U-RY) gastrojejunostomy with Roux-en-Y(RY) gastrojejunostomy after distal gastrectomy(DG) for gastric cancer.METHODS A literature search was conducted in Pubmed, Embase, Web of Science, Cochrane Library, Science Direct, Chinese National Knowledge Infrastructure, Wanfang, and China Science and Technology Journal Database to identify studies comparing U-RY with RY after DG for gastric cancer until the end of December 2017. Pooled odds ratio or weighted mean difference with 95% confidence interval was calculated using either fixed-or random-effects models. Perioperative outcomes such as operative time, intraoperative blood loss, and hospital stay; postoperative complications such as anastomotic bleeding, stricture and ulcer, reflux gastritis/esophagitis, delayed gastric emptying, and Roux stasis syndrome; and postoperative nutritional status(serum hemoglobin, total protein, and albumin levels) were the main outcomes assessed. Metaanalyses were performed using RevM an 5.3 software.RESULTS Two randomized controlled trials and four nonrandomized observational clinical studies involving 403 and 488 patients, respectively, were included. The results of the meta-analysis showed that operative time [weighted mean difference(WMD):-12.95; 95%CI:-22.29 to-3.61; P = 0.007] and incidence of reflux gastritis/esophagitis(OR: 0.40; 95%CI: 0.20-0.80; P = 0.009), delayed gastric emptying(OR: 0.29; 95%CI: 0.14-0.61; P = 0.001), and Roux stasis syndrome(OR: 0.14; 95%CI: 0.04-0.50; P = 0.002) were reduced; and the level of serum albumin(WMD: 0.71; 95%CI: 0.24-1.19; P = 0.003) was increased in patients undergoing U-RY reconstruction compared with those undergoing RY reconstruction. No differences were found with respect to intraoperative blood loss, hospital stay, anastomotic bleeding, anastomotic stricture, anastomotic ulcer, the levels of serum hemoglobin, and serum total protein. CONCLUSION U-RY reconstruction has some clinical advantages over RY reconstruction after DG.     

Outcomes of endoscopy in patients with iron deficiency anemia after Billroth II partial gastrectomy

GOALS: To determine the frequency of gastrointestinal lesions detected by upper endoscopy and colonoscopy in patients who developed iron deficiency anemia after Billroth II surgery. STUDY: The authors reviewed the medical records of 116 consecutive patients with a Billroth II partial gastrectomy and 232 age- and gender-matched controls without gastric surgery who were referred for endoscopy to evaluate iron deficiency anemia over a 5-year period. RESULTS: Clinically important lesions were detected in 22.4% of the patients with gastric surgery and in 59.5% of those with intact stomachs (p < 0.001). In the gastric surgery group, clinically important lesions were found more often in the upper gastrointestinal tract than in the colon (19.0% vs. 3.4%, p < 0.001). In the nonsurgical group, the diagnostic yields of upper endoscopy and colonoscopy were not significantly different (38.4% vs. 32.8%, p = 0.24). Synchronous lesions in the upper and lower gastrointestinal tract were significantly less common in the group of patients with gastric surgery compared with those without gastric surgery (0.0% vs. 11.6%, p < 0.001). Small bowel biopsies and small bowel follow-through did not identify any additional lesions. In the gastric surgery group, multivariate analysis identified abdominal symptoms (OR = 11.2, 95% CI 3.2-39.2, p < 0.001), a positive result on fecal occult blood testing (OR = 6.4, 95% CI 2.0-20.3, p = 0.002), and Billroth II surgery at least 10 years before evaluation (OR = 5.4, 95% CI 1.7-16.7, p = 0.004) as independent predictors of identifying a clinically important lesion by endoscopy. CONCLUSIONS: Upper endoscopy had a significantly higher diagnostic yield than colonoscopy in patients who developed iron deficiency anemia after Billroth II surgery. Prospective studies are necessary to determine the role and cost-effectiveness of colonoscopy in the evaluation of iron deficiency anemia in this patient population.     

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上胃肠道重建手术是临床的常见术式,其中以胃大部切除BillrothⅡ式(简称毕Ⅱ式)最为常见,并具有代表性。此类病人发生胆道疾病,尤其是胆总管结石的机会较一般人为高,但由于其正常解剖发生改变,且发病年龄相对偏大,因此治疗难度大,本文结合近年来发表的国内外文献及本人临床工作     

Roux-limb motility after total gastrectomy and Roux-en-Y anastomosis in patients with zollinger-ellison syndrome

The Roux-en-Y syndrome was defined as chronic nausea, intermittent vomiting, and chronic abdominal pain worsened by eating in patients who have undergone a gastrojejunostomy Roux-en-Y reconstruction for peptic ulcer. When these patients fasted, the Roux limb showed striking abnormalities in motor function; when postprandial, they failed to convert to normal fed-state motor activity. In contrast, patients with Zollinger-Ellison syndrome do well after similar surgery; they can eat most foods and maintain their body weight. We studied the motility of the Roux limb and jejunum in six patients with Zollinger-Ellison after an esophagojejunostomy Roux-en-Y anastomosis. Roux-limb motor activity in these patients, as characterized by the migrating motor complex, was more frequent, well organized, and in synchrony with the remaining jejunum; most subjects also converted to the fed state after a liquid meal. We suggest that the enteric nervous system is intact and functions normally in patients who have had a Roux-en-Y reconstruction for ulcer disease secondary to Zollinger-Ellison, but not in patients with idiopathic peptic ulcer disease.This work was supported in part by the National Institutes of Health Clinical Research Center grant RR-00073.This material was published in abstract from (Gastroenterology 98:A366, 1990) and presented as posters at the meetings of the American Gastroenterological Association., San Antonio, Texas, 1990, and the North American Conference of Gastroenterology Fellows, San Diego, California, 1991.     

Endoscopic and histopathologic changes in the gastric mucosa in Billroth II gastrectomy and in Roux-en-Y

The gastric mucosa changes induced by enterogastric reflux remain to interest, thus, 20 patients with surgical duodenal ulcer disease were studied, and after raffle, they consisted in 2 groups of 10 patients each, in which were performed antrectomy and truncal vagotomy, with reestablishment of the gastrointestinal continuity, in the group I, through a Billroth II gastrojejunostomy, and, in the group II, by a Roux-en-Y gastrojejunostomy. In the preoperative course, all the patients were undergone to endoscopic and histopathologic studies, when body gastric mucosa biopsies were analysed; after an average time of follow-up about 7.3 months for the group I, and 8.9 months for the group II, these studies were repeated in an attempt to check, in these 2 groups, the presence of gastric mucosa changes on the gastric remnant induced by reflux of alkaline juices. According to Fisher's exact test the outcome of these searches were significants when had compared the bile reflux into the stomach (p = 0.0549), gastritis (p = 0.00) and anastomosis changes (p = 0.0899) at endoscopic study, and were not significants when it comes to the condition of chronic gastritis (p = 0.6672) present at histopathologic study.     

ERCP and sphincterotomy after Billroth II gastrectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) procedures are more difficult in patients who have undergone partial gastrectomy with Billroth II anastomosis. Results improve with experience; we have achieved full diagnostic information in only 52% of 63 attempts, but ultimately in 60% of the 53 patients concerned. Therapeutic endeavours were more successful with useful results in eight of 10 patients during the last two years. Alternative diagnostic and therapeutic techniques should be used wherever possible in these patients.     

Metabolic bone disease in asymptomatic men after partial gastrectomy with Billroth II anastomosis

We sought to determine whether gastric surgery might be associated with metabolic bone disease in a well-characterized population, and if so to explore its etiology. Sixteen asymptomatic middle-aged men who had had partial gastrectomy with Billroth II anastomosis but no other risk factors for metabolic bone disease were compared with unoperated healthy controls. Studies included a dietary survey, biochemical tests of bone and mineral metabolism, radiographs of the spine, determinations of bone mineral content, and bone histomorphometry. The gastric surgery subjects exhibited frequent vertebral fractures and an unusual constellation of bone abnormalities characterized by decreased bone mineral content and hyperosteoidosis without evidence of osteomalacia. Although serum immunoreactive parathyroid hormone and 25-hydroxyvitamin D levels were not different, 1,25-dihydroxyvitamin D levels were significantly higher (p = 0.037), and 24,25-dihydroxyvitamin D levels were significantly lower (p less than 0.0001) in subjects than in controls. Partial gastrectomy with Billroth II anastomosis may be associated with asymptomatic but clinically important metabolic bone disease. The pathophysiology is uncertain, but appears to involve alterations in vitamin D metabolism.