Antrectomy (Distal Gastrectomy) Technique

Updated: May 31, 2019
  • Author: Christa N Grant, MD; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Approach Considerations

Although the preference of the author is for a two-layer handsewn anastomosis, staplers are often used in the creation of the anastomosis after an antrectomy (distal gastrectomy). There are no differences between these two approaches with respect to morbidity. The staplers used for antrectomy and reconstruction are of the gastrointestinal (GI) anastomosis (GIA) and end-to-end anastomosis (EEA) types.

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Excision of Gastric Antrum

An upper midline incision is made, extending from the xiphoid to the umbilicus. This incision may be extended inferiorly as needed to increase exposure. A self-retaining retractor may be used to increase exposure.

Upon entry into the abdomen, a thorough exploration is undertaken to assess the extent of disease and, in the case of gastric carcinoma, to confirm resectability. The gastrocolic ligament is identified and opened at the anticipated area of resection along the greater curvature. A Penrose drain may be placed around the stomach at this point.

Division of the omentum is then continued medially toward the duodenum, staying close to the greater curvature, or extended to include the omentum, depending on whether the procedure is being done for ulcer disease or for carcinoma. [1]

The Billroth I (gastroduodenostomy) reconstruction would proceed at this stage to preparation of the duodenum with the Kocher maneuver, followed by resection of the distal stomach and end-to-end or end-to-side anastomosis.

The author prefers a Roux-en-Y Billroth II (gastrojejunostomy) reconstruction, the operative steps of which are described in the following section.

The duodenum is mobilized with the Kocher maneuver and dissected circumferentially. [1]  The right gastroepiploic artery and vein are identified along the greater curvature, ligated, and cut. Next, the right gastric artery is identified and divided along the lesser curvature. The duodenum is then divided 2 cm distal to the pylorus with a linear cutting stapler. Oversewing the duodenal stump is optional and is carried out in an interrupted fashion with absorbable suture.

The stomach is then transected with a transverse anastomosis (TA) stapler after further dissection along the greater and lesser curvatures. Although the location or extent of ulcer disease sometimes guides the exact area of transection, the standard antrectomy involves removal of the distal third of the stomach, with the landmarks being the incisura on the lesser curvature and the third branch of the right gastroepiploic artery along the greater curvature. [11]  (See the image below.)

Transection of the distal stomach. Transection of the distal stomach.

The first or second loop of jejunum that easily reaches the area of transection is mobilized. After careful inspection of the jejunal arcades in the mesentery, a suitable area is chosen. The vessels of the mesentery are then divided between clamps and cut. Suture ligatures may be required for larger vessels. The jejunum is then transected with a linear TA stapler.

Stay sutures are placed on the proximal divided end. This limb is left open while attention is turned to creation of the gastrojejunostomy. The distal cut end of jejunum is isoperistaltic and thus is used to create the gastrojejunostomy. This limb is brought up to the area of the stomach in a retrocolic fashion through a suitable incision made in the transverse mesocolon.

The jejunum is incised on the antimesenteric border with an electrocautery device. Stay sutures are placed at the corners. A matching incision is made in the posterior wall of the stomach 5 cm proximal to the staple line, starting at the greater curvature. The gastrojejunostomy is fashioned in an end-to-side manner in a single layer with absorbable 3-0 suture.

The posterior wall sutures are full-thickness interrupted mattress sutures, with knots placed intraluminally. The anterior wall is then completed with a single layer of extramucosal stitches after the placement of a gastric tube under direct vision. Alternatively, the gastrojejunostomy can be created with an EEA stapler fired through a separate smaller gastrotomy that is later closed in an interrupted fashion.

The Y limb of the anastomosis is then completed by suturing or stapling the previously transected proximal jejunal loop in an end-to-side fashion to the distal jejunum at least 40 cm aborally to the gastrojejunostomy (see the image below). This distance is important in the prevention of postoperative bile reflux symptoms. At this point, care is taken to reapproximate the opening in the mesentery and to inspect the anastomosis for hemostasis. The abdomen is then closed in the usual fashion.

Roux-en-Y reconstruction. Roux-en-Y reconstruction.
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Postoperative Care

Closed suction drains are usually not indicated, except in the case of perforated ulcers. Similarly, postoperative antibiotics are not indicated in elective cases. Nasogastric tubes may be left in place for decompression and are usually removed by postoperative day 2. A prospective randomized study by Kimura et al suggested that routine 1-day nasogastric decompression after distal gastrectomy may not be necessary. [12]

A clear diet is initiated soon thereafter. A contrast swallow study to confirm anastomotic integrity is optional before the start of oral feedings. In some cases, depending on underlying disease, parenteral nutrition may be necessary to supplement oral intake.

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Complications

Complications after antrectomy can occur at any point. The most common complications and steps to avoid them are discussed here.

Anastomotic leakage

Anastomotic leaks that present in the first few days postoperatively represent technical errors and should be managed by means of reoperation. Although reoperation is also warranted in cases of brisk, difficult-to-control bleeding, endoscopic approaches are usually attempted initially in the hemodynamically stable patient.

Patients with anastomotic leaks present with tachycardia, fever, or a change in the effluent of closed suction drains. Radiographic studies using water-soluble oral contrast are helpful in the diagnosis. Closed suction or gastric drainage tubes may increase the healing rate of anastomotic leaks by diverting flow across the healing tissue. Percutaneous drains may be placed minimally invasively if large collections are seen on imaging.

Oral intake is not permitted, and parenteral alimentation is used adjunctively. Although some success has been seen with the use of endoscopically placed stents across anastomoses, large leaks, worsening of sepsis, and prolonged time to healing warrant reoperation.

Risk factors associated with anastomotic leakage include malnutrition, smoking, steroids, and the use of alcohol or tobacco. Identification and elimination of these risk factors preoperatively may decrease the leak rate. Intraoperative factors that contribute to increased leak rates include long operating time and gross spillage. [11]

Gastric outlet obstruction

Anastomotic edema or hematoma can cause early outlet obstruction and manifests as vomiting and early satiety. This diagnosis is usually made clinically or on endoscopy. No treatment is necessary, because the condition resolves over time. [1]  In contrast, a late presentation of these symptoms could represent anastomotic stricture from scarring, cancer recurrence, or external adhesions. Endoscopic dilation is used initially, but in cases of cancer recurrence or strictures refractory to dilation, anastomotic revision becomes mandatory.

Recurrent ulcer disease

Antral tissue may be present up to 0.5 cm past the pylorus. [11]  Retained antral tissue may cause symptoms of gastritis or recurrent ulcer disease. This complication is prevented by performing a sufficient resection at the level of the duodenum. Incomplete vagotomy may also explain recurrent ulcer disease. Zollinger-Ellison syndrome must also be ruled out in the case of recurrent or multiple intractable ulcers. [4]

Pancreatitis

Postoperative pancreatitis may be caused by edema and in this instance is usually self-limiting. However, if dissection was difficult or encroached on the pancreas, ductal injury must be suspected. Hemorrhagic and necrotizing pancreatitis carry a much higher morbidity and mortality. [1]

Duodenal stump blowout

Duodenal stump leak or blowout is a severe complication that presents early with peritonitis and varying degrees of sepsis. This complication is most common in cases where the duodenum is chronically ulcerated or edematous; it always warrants reexploration. A thorough washout of the right upper quadrant is followed by definitive repair. In some cases, primary closure reinforced with a patch of omentum may suffice, but this should not be attempted if the duodenum still appears friable and is difficult to reapproximate.

Tube duodenostomy is recommended in this situation. Duodenal stump blowout can be prevented by placement of a tube duodenostomy or distal tube jejunostomy at the time of the initial operation if the integrity of the tissues or the anastomosis is in question. [11]  Alternatively, the Bancroft closure can be used during the initial operation (see the image below).

Bancroft procedure for closure of the duodenal stu Bancroft procedure for closure of the duodenal stump.

A Bancroft closure involves transection of the stomach above the pylorus followed by dissection and removal of the mucosal layer of the stomach and duodenum. The duodenal closure is then reinforced by invaginating the duodenum within the submucosal and muscularis layers of the stomach.

Dumping syndrome

Dumping syndrome is a common complication after distal gastrectomy. The early stage is characterized by cramping abdominal pain and diarrhea following meals secondary to the hyperosmotic load delivered to the small intestine. Late dumping is caused by hyperinsulinemia and presents with hypoglycemic symptoms such as lightheadedness and diaphoresis.

Dumping is more prevalent in Billroth II than in Billroth I reconstruction, with a frequency in the range of 7-29%, [1]  and is treated conservatively by consuming high-protein, high-fiber, low-carbohydrate meals and by avoiding having liquids with meals. Octreotide is often used with good results. Surgical revision is rarely necessary and is carried out by either an antiperistaltic jejunal interposition or conversion to a Roux-en-Y reconstruction.

Atrophic gastritis

Atrophic gastritis is more common with Billroth II than with Roux-en-Y and Billroth I reconstructions and results from enterogastric reflux. As previously discussed, this complication can be minimized by fashioning an appropriately long Roux limb. Conversion of a Billroth II to a Roux reconstruction can alleviate symptoms related to gastritis.

Afferent loop syndrome

Afferent loop syndrome is caused by a closed loop obstruction of the afferent limb of a Billroth II reconstruction and manifests as epigastric pain, nausea, and feeling of fullness followed by projectile vomiting. The most common causes are adhesions, stasis, internal hernias, and volvulus. Closure of the mesocolon and retrocolic position of the loop at the time of initial operation can minimize this complication. Revision to a shorter afferent loop or conversion to a Roux-en-Y reconstruction usually results in symptom resolution.

Efferent loop syndrome

Efferent loop syndrome presents with nausea, vomiting, and abdominal pain from a partial obstruction. Common causes include adhesions and intussusception at the gastrojejunostomy or jejunojejunostomy.

Roux stasis syndrome

Roux stasis syndrome is unique to patients with Roux-en-Y gastrojejunostomies and manifests with symptoms similar to those of afferent loop syndrome. It is thought to be secondary to aperistalsis of the Roux limb and may be relieved by administering promotility agents such as erythromycin or metoclopramide.

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