Partial Gastrectomy: Bilroth Procedures

Published on 19/07/2015 by admin

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Last modified 19/07/2015

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 Antrectomy with gastroduodenostomy

• Billroth 2 (B2) procedure

image Distal gastrectomy with gastrojejunostomy
• Surgery for gastric cancer

image May be some variant of B1 or B2, up to total gastrectomy
• Complications include recurrent tumor and acute or chronic sequelae of surgery
• Recurrent or new carcinoma

image Local, lymph node, peritoneal, hematogenous
• Bezoar formation

image Conforms to shape of stomach, traps air within
• Anastomotic leak

image CT may detect indirect signs of leaks missed on upper gastrointestinal (GI) series (up to 50% of cases)
• Duodenal stump leakage

image Loculated collection of fluid in subhepatic space
image Rarely diagnosed on upper GI
• Jejunogastric intussusception

image Rare complication of B2 procedure
• Afferent loop syndrome

image Obstruction of afferent loop at or near anastomosis → dilation of duodenum

DIAGNOSTIC CHECKLIST

• Upper GI series is 1st-line test for detecting mechanical complications of gastric surgery
• CT is optimal test for general surveillance for postoperative complications
• PET/CT is optimal imaging test for surveillance of recurrent gastric carcinoma
• Abscessogram may identify leak as source of infection
image
(Left) Graphic depicts an isoperistaltic Billroth 2 gastrojejunostomy. The afferent limb image, composed of the duodenum and a variable length of jejunum, carries pancreaticobiliary secretions toward the stomach, while the efferent limb image carries fluid and food downstream.

image
(Right) Graphic depicts an antiperistaltic Billroth 2 procedure, in which the afferent loop image enters the anastomosis from a left-to-right direction. This procedure is intended to reduce the prevalence of bile gastritis.
image
(Left) Film from a small bowel follow-through (SBFT) shows evidence of a prior Billroth 2 procedure and complete obstruction of antegrade flow of barium in the mid jejunum image. At surgery, a phytobezoar was removed, which corresponded to the shape and size of the gastric remnant.

image
(Right) Film from an upper GI series shows evidence of a prior Billroth 1 procedure, along with persistent filling defects within the stomach that conform to the shape of the stomach, a bezoar.

IMAGING

General Features

• Many to most fluoroscopic exams of esophagus, stomach, and duodenum are now performed for patients who have surgically altered anatomy
• Some procedures are so common they are discussed separately

image Postoperative state, esophagus

– Includes esophagectomy with gastric pull-through
image Fundoplication complications
image Bariatric surgery
• Goal for evaluating remaining procedures

image Define expected postoperative anatomy
image Describe imaging approaches to evaluation of postoperative patients
image Describe imaging and clinical findings for various complications

Surgical Procedures

• Billroth 1 (B1)  procedure

image Antrectomy with gastroduodenostomy
image Polya variation: Entire excised end of gastric stump is used for anastomosis
image Hofmeister: Only a portion (usually greater curvature portion) is used
• Billroth 2 (B2)  procedure

image Distal gastrectomy with gastrojejunostomy

– Stomach may be anastomosed to Roux limb or loop of jejunum
– Anastomosis is side to side
– Variable length of duodenum and jejunum forms proximal or afferent loop

image Carries pancreaticobiliary secretions toward stomach
– Distal or efferent loop carries food and fluid downstream
– Isoperistaltic anastomosis (right to left)

image Afferent limb 1st contacts lesser curve side of anastomosis; efferent limb contacts distal side
– Antiperistaltic (left to right)

image Opposite configuration
– Duodenal stump is closed by sutures

image Usually filled with gas bubble on postoperative CT
image Located in subhepatic space
– Anastomotic loop may be brought to gastric remnant in antecolic or retrocolic position

image Antecolic: Results in longer afferent loop
image Retrocolic: Shorter afferent loop; considered more “physiological” and usually preferred
• Surgery for gastric cancer

image Varies according to site and size of tumor
image May be some variant of B1 or B2, up to total gastrectomy

– Gastrectomy usually results in creation of esophagojejunal anastomosis
image Usually involves extensive denervation of stomach

– Alters gastric and intestinal motility and absorption

Complications

• Recurrent or new carcinoma

image Patients who have had partial gastrectomy for gastric cancer have high risk of recurrent tumor

– May occur in gastric remnant or anastomosis (often causes bowel thickening or obstruction)
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