gastrectomy,billroth 1, bilroth 2, polya, subtotal gastrectomy,bookwalter , dumping syndrome, staple anastomosis, sentinel lymph node biopsy in gastrectomy

1. GASTRECTOMY
DR BASHIR BIN YUNUS
GENERAL SUGERY UNIT PRESENTATION
18/02/19

2. OUTLINE
• INTRODUCTION
• HISTORY
• ANATOMY OF THE STOMACH
• TYPES OF GASTRECTOMY
• INDICATION
• PREOPERATIVE PREPARATION
• PROCEDURE
• – SUBTOTAL GASTRECTOMY
• - BILLROTH II
• COMPLICATIONS
• REFERENCES

3. INTRODCTION
• Gastrectomy is the surgical removal of part or the entire stomach.
• The earliest recorded operations on the stomach were performed for
penetrating injuries. Knife from the stomach of a knife thrower 1602
• Late 1800s: Experimental studies by Billroth confirmed the feasibility
of removing the pylorus.
• The last 20 years of the nineteenth century saw the introduction of
many gastric operations, some of which were to become established
and modified during the ensuing years.

4. • Billroth 1881: Performed the first successful pylorectomy –
Duodenum anastomosed to the lesser curvature of the stomach and
the greater curvature oversewn.
• Billroth 1885: Resection of a large pyloric carcinoma, using an anterior
gastrojejunostomy
• Several modifications of where seen over time

5. ANATOMY
PARTS OF THE STOMACH
It is usually J shaped and
located in the left upper
quadrant and epigastrium, and
its distal part can extend to the
level of the umbilicus.
The stomach is divided into;
Fundus,
Body,
Antrum
Pylorus.

8. ANATOMY
TYPES OF CELLS;
• Secretory epithelial cells cover the surface of the stomach;
• Mucous cells: secrete an alkaline mucus that protects the epithelium against
shear stress and acid.
• Parietal cells: secrete hydrochloric acid and intrinsic factor
• Chief cells: secrete pepsinogen, a proteolytic enzyme.
• G cells: secrete the hormone gastrin.
• Enterochromaffin cells- histamine
• D cells somatostatin

9. Arterial blood supply:
COELIAC TRUNK; 3Branches
Left Gastric Artery;
Supplies the cardia of the stomach and distal
esophagus
Splenic Artery;
Gives rise to 2 branches which help supply the
greater curvature of the stomach;
Left Gastroepiploic, Short Gastric Arteries
Common Hepatic ;
2 major branches Right Gastric- supplies a portion of
the lesser curvature
Gastroduodenal artery-Gives rise to Right
Gastroepiploic artery Helps supply greater curvature
in conjunction with Left Gastroepiploic Artery

11. ANATOMY
• INNERVATION

12. ANATOMY
• LYHMPHATIC DRAINAGE
• The lymphatics of the stomach ultimately drain into the coeliac group.
• Zones
• Nodes
• Stations in D1-D4 resection

13. The lymphatics drainage
are grouped into 3 zones
Zone 1 drain via
Left gastric nodes
Right gastric nodes
Zone 2
Gastroepiploic
Suprapyloric
Subpyloric
Zone 3
Splenic, short gastric
Suprapancreatic

14. N1 – First tier – nodes within 3cm
from the primary tumour and are
station 1-6
1. Right cardiac
2. Left cardiac
3. Nodes along the lesser curvature
4. Nodes along the greater curvature
a.Along short gastric -4sa
b. Along left gastroepiploic 4sb
c. Along right gastroepiploic 4sc
5. Suprapyloric nodes
6. Subpyloric nodes

15. N2- Second tier nodes: Nodes
in main and intermediate
arterial trunk stations 7-11
7. Along left gastric artery
8. Along common hepatic artery
9. Along coeliac axis
10. At splenic hilum
11. Along splenic artery

16. N3 - Third tier nodes: Nodes at
stations 12-18 (para-aortic
and above)
12. At hepatoduodenal
ligament
13. Retroduodenal lymph
nodes
14. At root of mesentery
15. Around middle colic artery
16. Para-aortic nodes
17. Around lower oesophagus
18. Supradiaphragmatic

17. • D1—involvement of group I lymph nodes.
• D2—involvement of group I and II lymph nodes.
• D3—involvement of group I, II and III lymph nodes.
• D4—involvement of group I, II, III and para-aortic nodes
• D4 is not commonly advocated. It is removal of stations 1-18.

18. TYPES OF GASTRECTOMY
• Base on the amount of stomach removed
• Total
• Near total >90%
• Subtotal 80-90 %
• Partial 65-75 %
• Hemigastrectomy 50 %
• Antrectomy (distal gastrectomy ) 35-50%
• Base on the method of reconstruction
• Billroth I
• Billroth II
• Roux en Y

19. BILLROTH 1
• Partial gastrectomy with gastro-duodenostomy. It is the most
physiologic type of gastric resection, since it restores normal
continuity.

20. Variations of Billroth I
A. Billroth (1881)
B. Billroth (1881)
C. Kocher (1890)
D. Kutscha-Lissberg (1925)
E. V. Haberer (1920)
F. V. Haberer (1920), Finney (1923)
G. Winkelbauer (1927)
H. Schoemaker (1911)
I. Harkins, Nyhus (1960

23. BILLROTH II
• Partial gastrectomy with gastro-jejunostomy

25. • Extent of lymphadenectomy
• D0 – incomplete D1
• D1; 1-6
• D2; 7-11
• D3; 12-14
• D4; 15, 16
• BASE ON THE RESECTION MARGIN
• R0
• R1
• R2
• BASE ON TECHNIQUE
• OPEN OR LAPAROSCOPIC

26. INDICATION
• PEPTIC ULCER DISEASE
• Intractable PUD
• Recurrent bleeding – for low risk patients
• Cicatrization- GOO
• Gastric ulcer type II and III
• Partial gastrectomy combine with vagotomy has shown less mortility disturbance
and marginal ulcers.
• TUMOURS; benign tumour of antrum, gastric cancer
• OBESITY- sleeve gastrectomy
• TRAUMA;
• STRICTURE

27. Choice for procedure
• Total gastrectomy
• indicated when the extent, or
• location, of the primary tumour is such that adequate margins
• of resection (i.e. 4–6 cm) are not possible by a subtotal
• gastrectomy. proximal gastric
• tumours and extensive lesions, including linitis plastica.
• Subtotal gastrectomy
• particularly suitable for
• small gastric tumours involving the pylorus and distal third
• of the stomach.
• Billroth I;
• benign gastric ulcer (proved by endoscopic biopsy),
• benign tumour of the distal stomach,
• trauma to distal stomach,
• recurrent or bleeding duodenal ulcer,
• if pyloroplasty is not feasible.
• Billroth II
• Gastric ulcer where Billroth I is not possible
• carcinoma pylorus and antrum as a radical or palliative procedure;
• recurrent ulcers;
• Trauma to distal stomach and duodenum.

28. • NB;
• In carcinoma distal stomach, Billroth I anastomosis is usually not done
as recurrence in bed when it occurs will cause obstruction due to
encasement of the relapsed (local) tumour;

29. • The advantage of a Billroth I gastrectomy over a Billroth II procedure
• maintenance of the physiological and anatomical gastroduodenal pathway.
Thus, it offers a lower incidence of post-gastrectomy syndromes.
• minimal disturbance of pancreatic function, and a
• possible lower incidence of late development of carcinoma in the stomach
remnant.

30. PREOPERATIVE PREPARATION
• History – symptoms, risk factor, co-morbidity
• Examination; Epigastric mass, features of advance disease
• UPPER GI ENDOSCOPY AND BIOPSY
• Abdominal CT scan; adjacent structures and liver metastesis
• ENDOLUMINAL USS; infiltration and local nodal involvement
• LAPAROSCOPY is useful for determining tumour spread in the peritoneal cavity and assessing any
fixation of the tumour to surrounding organs.
• Chest X-ray
• ECG, echo
• Optimize derangement; dehydration, dyselectrolytemia, anaemia, GXM, nutritional rehab
• CONSENT
• Preoperative antibiotics

31. PROCEDURE – SUBTOTAL GASTRECTOMY
• For small cancers limited to the distal antrum, the patient can be
offered radical distal or subtotal gastrectomy.
• At initial exploration, determine the resectability.

32. ANAESTHESIA
• General anesthesia with cuffed endotracheal intubation and
adequate muscle relaxation.
POSITION
• As a rule, the patient is laid supine on a flat table, the feet being
slightly lower than the head

33. STEPS
• INCISION
• EXPLORATION
• MOBILIZATION & RESECTION
• ANASTOMOSIS

34. INCISION
• A midline incision extending from the xiphoid skirting the umbilicus
• Additional exposure can be obtained by excising the xiphoid. Bone
wax is applied to the sternal end to control bleeding.
• Further exposure can be obtained by splitting the sternum with a
sternal knife.
• Chevron incision; the exposure provided by midline incision is usually
not as adequate as that provided by a chevron incision.

35. • EXPOSURE
• Self-retaining retractor preferably- Bookwalter

36. BOOKWALTER

38. EXPLORATION
• Do not immediately palpate the stomach.
• Note any ascites and peritoneal deposits.
• Start your complete exploration from the pelvis and work towards
the stomach in order not to disperse malignant cells.
• Examine the greater omentum for deposits and then raise it to feel
the para-aortic nodes and those around the root of the mesentery,
and the right colic and middle colic arteries.
• Examine the full length of the small and then large intestine, seeking
peritoneal deposits on the bowel wall, the mesentery and the parietal
peritoneum.
• Look for incidental disease

39. • Now draw the omentum caudally to examine the upper
compartment.
• Feel both lobes of the liver and adjacent diaphragm, gallbladder and
free edge of the lesser omentum, the spleen, kidneys and adrenal
glands.

40. • Starting at the oesophageal hiatus and working distally, look and feel
for tumour involvement, fixity, glands and also incidental disease.
• Systematically move distally, avoiding handling or squeezing the
tumour if possible.

41. • Palpate the duodenum and feel the pancreas, then the region of the
coeliac axis just above the neck of the pancreas.
• If you are seriously in doubt whether to proceed, incise the lesser
omentum in an avascular area near the liver and examine the coeliac
axis and emerging arteries.

42. MOBILIZATION & RESECTION
• Lift the great omentum and dissect it from the transverse colon at the
bloodless plane of fusion between the folded omentum,

43. • Gently peel off the omentum, taking care not to damage the middle
colic artery

44. • At the left extremity of the greater omentum, Carefully dissect out the
lymph nodes at the origin of the left gastroepiploic artery, then doubly
ligate and divide the artery and vein.

45. • At the right extremity of the greater omentum Carefully isolate the
gastroepiploiec vessels and the subpyloric lymph nodes before doubly
ligating and dividing them at their origins

46. • Now draw the distal stomach caudally to put on stretch the free edge of
the lesser omentum.
• Carefully make a transverse incision in the anterior leaf above the
pylorus extend this towards the cardia, keeping close to the liver, it
reveals the right gastric vessels and the suprapyloric lymph nodes
• Dissect the nodes and doubly ligate and divide the right gastric blood
vessels.

47. • Perform Kocher's mobilization of the duodenum so that the first part
can be dissected from the head of the pancreas.
• Mobilize 5–6 cm of duodenum beyond the pylorus.

48. • Transect the duodenum-use GIA stapler or other mechanical stapler 2-
3cm of the first part.

49. • Elevation and cephalad traction on the stomach exposes the coeliac
axis, the left gastric artery, and the lymph nodes associated with
these vessels.
• The left gastric artery is doubly ligated divided near its origin with
division of the left gastric vein along the superior border of the
pancreas.
• The lymph nodes and fat along the branches coeliac axis, superior
border of the pancreas and infront of the portal veins are removed.

50. • Gastric division; subtotal gastrectomy (80-90%) by dividing the stomach
• 2 cm distal to OG junction along lesser curve and 5 cm distal along the greater
curvature. And at least 5cm resection margin otherwise a total gastrectomy is
done
• Straight occlusion clamp is placed along the greater curvature towards
remnant side and along lesser curve obliquely to create lesser curve.
• Crushing (Payr’s) or Kocher’s clamps are placed towards specimen side.
Stomach is cut using no. 15 blade.
• Specimen is placed in orientation grid. Intraoperative frozen section biopsy
is done to confi rm the clearance at margins.

51. • ANASTOMOSIS
• Polyer
• Hofmyester
• Staple

52. POLYA METHOD
• Unit jejunum with open end of
the stomach.
• Anticolic or retrocolic
• Retrocolic; the jejunum is
brought through a rent in the
mesentry to the left of the
middle colic near the ligament
of treitz
• Grasp the jejunum with babcock
juxtaposition to the lesser
curvature of the stomach
• The jejunal loop is grasped in an
enterostomy clamp and
approximated to the posterior
surface of the posterior of the
stomach adjacent to the
noncrushing clamp by a layer of
closely placed interrupted 2-0
silk suture

53. This posterior layer
should include both
greater curvature and
lesser curvature of the
stomach , otherwise
subsequent closure of
the angle may be
insecure
Apply noncrusing
clamps several cm from
the line of staple on the
stomach – for stability
and prevent gross
soilage

54. Cut-off stapled line with
scissors and jejunum
open approximately
same size
Inner layer thru-and
thru approximating both
mucous membrane of
the stomach and
jejunum

55. • The corners are inverted with a Connell type suture tha is continued
anteriorly and the final knot is tied on the inside of the midline
• The anterior serosal layer are then approximated with interrupted 2-0
silk
• Finally at the upper and lower angles of the new stoma, additional
sutures are placed so that any strain exerted of the stoma is met by
these additional reinforcing serosal suture and not by the sutures of
the anastomosis.

59. Hofmeister Method

63. TA STAPLER

64. GIA STAPLER

71. POSTOPERATIVE CARE
• The patient is placed in a semi-Fowler’s position when conscious.
• Intravenous fluid, antibiotics, analgesics
• Correction of anaemia, electrolyte
• Chest physiotherapy
• Early ambulation, DVT prophylaxis
• NG tube
• Graded oral sips
• Feeding

72. COMPLICATIONS
• EARLY
• Intragastric hemorrhage
• Extragastric hemorrhage
• Duodenal blow out/ stump leakage
• Stomal obstruction
• Afferent loop obstruction
• Jejunal loop herniation
• Gastric remnant necrosis
• Postoperative pancreatitis
• Common bile duct injury or injury to ampula
• Omental infarction

73. COMPLICATIONS
• LATE
• Early dumping syndrome
• Late dumping syndrome
• Recurrent ulcers
• Small gastric remnant syndrome
• Gastric remnant carcinoma
• Roux stasis syndrome
• Gastrojejunocolic fistula
• Chronic afferent loop obstruction
• Chronic efferent loop obstruction
• Internal hernia
• Jejunogastric intussusception

74. FUTURE PROSPECTIVE
• SENTINEL LYMPH NODE BIOPSY
• Injection of isosulfan blue, indocyanine green
• Technetium 99m- radioisotope (standard)
• Intraoperative subserosal injection
• Injection is carried out in 4 quadrant of the tumour

75. • Estern studies node negative T1 and T2 and report accuracy of >98%
particularly in early stage
• Western countries included T3 and the accuracy was about 80%
• Complex lymphatics of the stomach and fear of skip metastesis –
make the selection of patient difficult
• Limited lyphadenectomy base on SLN is cautioned by several authors
and further studies are needed before this method can be introduce
into daily practice.

76. REFERENCES
1. Oliver M, Myles J. Classic operations on the upper gastrointestinal
tract. In; Farquharson's textbook of operative general surgery.
Edward Arnold publ. 9th ed. 272-279.
2. Robert M Z, Christopher E E. Gastrointestinal procedures. In;
Zollinger’s Atlas of surgical operation.Mc Graw Hill. 9th ed 64-79.
3. Winslet M C, Dawas K I. stomach and duodenum. In; Kirk’s General
Surgical operations. Churchill livingstone 6th ed 174-177.
4. SRB’s surgical operation text and atlas. Jaypee Brothers Medical
Publishers. 1st ed. 2014

77. REFERENCES
• 5. Robinson JO. History of gastric surgery. Postgrad Med J. 1960;
36;706-712
• 6. Songun I, et al. Lancet Oncol 2010; 11:439-49
• 7 . Tohru T, Hiromichi S, Masaji T. sentinel lymp node navigation for
gastric cancer: does it really benefit the patient? World J
gastroenterol. 2016 Mar 14; 22(10):2894-2899.
• 8. Arnold S G. The rationale of antrectomy and vagotomy for
duodenal ulcer. AMA Arch Surg. 1956;73(2):364-366