Billroth I & II Procedure

Also known as Gastroduodenostomy (Billroth I)

Definition

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.

A gastrojejunostomy is a gastrojejunal anastomosis with duodenal closure.

Subtotal excision of the stomach with closure of the proximal end of the
duodenum and side-to-side anastomosis of the jejunum to the remaining
portion ion of the stomach.

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
European 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 tomography (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.

Risks

A gastroduodenostomy has many of the same risks associated with any other major abdominal
operation performed under general anesthesia, such as wound problems, difficulty swallowing,
infections, nausea, and blood clotting.
More specific risks are also associated with a gastroduodenostomy, including:

• Duodenogastric reflux, resulting in persistent vomiting.

• Dumping syndrome, occurring after a meal and characterized by sweating, abdominal
pain, vomiting, lightheadedness, and diarrhea.
• Low blood sugar levels (hypoglycemia) after a meal.
• Alkaline reflux gastritis marked by abdominal pain, vomiting of bile, diminished appetite,
and iron-deficiency anemia.
• Malabsorption of necessary nutrients, especially iron, in patients who have had all or part
of the stomach removed.

Normal results

Results of a gastroduodenostomy are considered normal when the continuity of the

gastrointestinal tract is reestablished.

Morbidity and mortality rates

For gastric obstruction, a gastroduodenostomy is considered the most radical procedure. It is

recommended in the most severe cases and has been shown to provide good results in relieving
gastric obstruction is in most patients. Overall, good to excellent gastroduodenostomy results are
reported in 85% of cases of gastric obstruction. In cases of cancer, a median survival time of 72
days has been reported after gastroduodenostomy following the removal of gastric carcinoma,
although a few patients had extended survival times of three to four years.

Alternatives

In the case of ulcer treatment, the need for a gastroduodenostomy procedure has diminished
greatly over the past 20–30 years due to the discovery of two new classes of drugs and the
presence of the responsible germ (Helicobacter pylori) in the stomach. The drugs are the H2
blockers such as cimetidine and ranitidine and the proton pump inhibitors such as omeprazole;
these effectively stop acid production. H. pylori can be eliminated from most patients with a
combination therapy that includes antibiotics and bismuth.

If an individual requires gastrointestinal reconstruction, there is no alternative to a

gastroduodenostomy

http://emedicine.medscape.com/article/188275-overview