GASTRODUODENOSTOMY RECONSTRUCTION
Category: General Surgery
Abstract : A gastroduodenostomy is a surgical reconstruction procedure by which a new connection between the stomach and the first portion of the small intestine (duodenum) is created.
Purpose A gastroduodenostomy is a gastrointestinal reconstruction technique. It may be performed in cases of stomach cancer, a malfunctioning pyloric valve, gastric obstruction, and peptic ulcers. As a gast
A gastroduodenostomy is a surgical reconstruction procedure by which a new connection between the stomach and the first portion of the small intestine (duodenum) is created.
Purpose
A gastroduodenostomy is a gastrointestinal reconstruction technique. It may be performed in cases of stomach cancer, a malfunctioning pyloric valve, gastric obstruction, and peptic ulcers.
As a gastrointestinal reconstruction technique, it is usually performed after a total or partial gastrectomy (stomach removal) procedure. The procedure is also referred to as a Billroth I procedure. For benign diseases, a gastroduodenostomy is the preferred type of reconstruction because of the restoration of normal gastrointestinal physiology. Several studies have confirmed the advantages of the procedure, because it preserves the duodenal passage.
Compared to a gastrojejunostomy (Billroth II) procedure, meaning the surgical connection of the stomach to the jejunum, gastroduodenostomies have been shown to result in less modification of pancreatic and biliary functions, as well as in a decreased incidence of ulceration and inflammation of the stomach (gastritis). However, gastroduodenostomies performed after gastrectomies for cancer have been the subject of controversy. Although there seems to be a definite advantage of performing gastroduodenostomies over gastrojejunostomies, surgeons have become reluctant to perform gastroduodenostomies because of possible obstruction at the site of the surgical connection due to tumor recurrence.
As for gastroduodenostomies specifically performed for the surgical treatment of malignant gastric tumors, they follow the general principles of oncological surgery,aiming for at least 0.8 in (2 cm) of margins around the tumor. However, because gastric adenocarcinomas tend to metastasize quickly and are locally invasive, it is rare to find good surgical candidates. Gastric tumors of such patients are thus only occasionally excised via a gastroduodenostomy procedure.
Gastric ulcers are often treated with a distal gastrectomy, followed by gastroduodenostomy or gastrojejunostomy, which are the preferred procedures because they remove both the ulcer (mostly on the lesser curvature) and the diseased antrum.
Demographics
Stomach cancer was the most common form of cancer in the world in the 1970s and early 1980s. The incidence rates show substantial variations worldwide. Rates are currently highest in Japan and eastern Asia, but other areas of the world have high incidence rates, including eastern Europesan countries and parts of Latin America. Incidence rates are generally lower in western European countries and the United States. Stomach cancer incidence and mortality rates have been declining for several decades in most areas of the world.
Description
After removing a piece of the stomach, the surgeon reattaches the remainder to the rest of the bowel. The Billroth I gastroduodenostomy specifically joins the upper stomach back to the duodenum.
Typically, the procedure requires ligation (tying) of the right gastric veins and arteries as well as of the blood supply to the duodenum (pancreatico-duodenal vein and artery). The lumen of the duodenum and stomach is occluded at the proposed site of resection (removal). After resection of the diseased tissues, the stomach is closed in two layers, starting at the level of the lesser curvature, leaving an opening close to the diameter of the duodenum. The gastroduodenostomy is performed in a similar fashion as small intestinal end-to-end anastomosis, meaning an opening created between two normally separate spaces or organs. Alternatively, the Billroth I procedure may be performed with stapling equipment (ligation and thoraco-abdominal staplers).
Diagnosis/Preparation
If a gastroduodenostomy is performed for gastric cancer, diagnosis is usually established using the following tests:
• Endoscopy and barium x rays. The advantage of endoscopy is that it allows for direct visualization of abnormalities and directed biopsies. Barium x rays do not facilitate biopsies, but are less invasive and may give information regarding motility.
• Computed tomagraphy (CT) scan. A CT scan of the chest, abdomen, and pelvis is usually obtained to help assess tumor extent, nodal involvement, and metastatic disease.
• Endoscopic ultrasound (EUS). EUS complements information gained by CT. Specifically, the depth of tumor invasion, including invasion of nearby organs, can be assessed more accurately by EUS than by CT.
• Laparoscopy. This technique allows examination of the inside of the abdomen through a lighted tube.
The diagnosis of gastric ulcer is usually made based on a characteristic clinical history. Such routine laboratory tests as a complete blood cell count and iron studies can help detect anemia, which is indicative of the condition. By performing high-precision endoscopy and by obtaining multiple mucosal biopsy specimens, the diagnosis of gastric ulcer can be confirmed. Additionally, upper gastrointestinal tract radiography tests are usually performed.
Preparations for the surgery include nasogastric decompression prior to the administration of anesthesia; intravenous or intramuscular administration of antibiotics; insertion of intravenous lines for administration of electrolytes; and a supply of compatible blood. Suction provided by placement of a nasogastric tube is necessary if there is any evidence of obstruction. Thorough medical evaluation, including hematological studies, may indicate the need for preoperative transfusions. All patients should be prepared with systemic antibiotics, and there may be some advantage in washing out the abdominal cavity with tetracycline prior to surgery.
Aftercare
After surgery, the patient is brought to the recovery room where vital signs are monitored. Intravenous fluid and electrolyte therapy is continued until oral intake resumes. Small meals of a highly digestible diet are offered every six hours, starting 24 hours after surgery. After a few days, the usual diet is gradually introduced. Medical treatment of associated gastritis may be continued in the immediate postoperative period.
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