Introduction
Gastrectomies can also be defined further by the type of reconstruction used to resume gastrointestinal continuity. Billroth I procedure is a gastroduodenostomy, which can be done either end-to-end or in an end-to-side manner. Billroth II or gastrojejunostomy reconstruction is usually performed end-to-side, or a roux-en-Y gastrojejunostomy can be performed.
What Are the Indications for Distal Gastrectomy?
The prevalence and indications of gastric ulcers, particularly perforated ulcers, need the intervention of surgical treatment modality was reduced after the discovery of antacids. At present, Helicobacter pylori infection and NSAID (non-steroidal anti-inflammatory drug use are the most common etiologic factors for ulcer disease. A study reviewing hospitalization trends from 1993 to 2006 reported an overall decrease in the prevalence of gastric ulcer disease, with duodenal ulcers showing a steeper decline when compared to gastric ulcers. There has been a remarkable rise in therapeutic endoscopy and a fall in the trend for surgical intervention, which is commonly the approach of choice for complications like persistent bleeding or perforation.
Distal gastrectomy is indicated in the treatment of gastric ulcers that are:
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Obstinate to medical therapy.
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Complicated by perforation, bleeding, or obstruction.
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Recurrent after treatment of H. pylori.
Ulcer location and pathophysiology predict the appropriate therapy, which does not always involve surgery.
What Are the Types of Gastric Ulcers?
Type I ulcers occur along the lesser curvature or around the incisura. Type II ulcers lie along the lesser curvature and the duodenum. Type III ulcers are found in the prepyloric region, whereas Type IV ulcers are seen proximally on the lesser curvature. Type V ulcers can be seen anywhere in the stomach.
Type I, IV, and V are caused due to a state of under protection from acid, whereas types III and II are sequelae of acid hypersecretion. They are best treated with distal gastrectomy. Removal of the antrum allows the possibility to rule out carcinoma and decreases the rate of ulcer recurrence due to the removal of gastrin-secreting G cells.
Selective vagotomy or truncal vagotomy is almost always performed to decrease the likelihood of ulcer recurrence. Distal gastrectomy is also a procedure of choice for small or benign, well-differentiated tumors on the distal stomach. Lymphadenectomy is mandatory in such cases.
What Is the Contraindication for Distal Gastrectomy?
With the proper case selection, there should be a few relative contraindications for the procedure before duodenal surgery, which precludes a Billroth I reconstruction, as does an inflamed or ulcerated duodenum which makes a secure anastomosis unlikely. Poor nutritional status hampers healing and may contribute to postoperative complications such as anastomotic leaks.
What Are the Periprocedural Steps?
Patient Education and Consent:
Individuals undergoing the procedure should be counseled preoperatively about the frequent and common complications of distal gastrectomy (antrectomy) and how they may be recognized, alleviated, and avoided. Lifestyle modification more likely prevents reoperation. Emphasizing the significance of postoperative follow-up tests and imaging specific to individuals condition.
Preprocedural Planning:
Esophagogastroduodenoscopy or upper gastrointestinal endoscopy is performed in people with ulcer disease to check the extent of the disease and to obtain biopsies to rule out cancer. The ulcer location determines the level of resection. In individuals with cancer of the stomach, endoscopic ultrasonography is often used in conjugation with computed tomography to check for the tumor's extent and respectability, which is an advantage for providing biopsy specimens. In H pylori cases, repeat testing is done to document the refractory nature of the disease.
Equipment:
Gastrointestinal anastomosis (GIA) and end-to-end anastomosis staplers are used in creating the anastomoses.
Patient Preparation:
General endotracheal anesthesia is administered. The individual is placed in a supine position. Reverse Trendelenburg positioning may improve exposure.
Monitoring and Follow-Up:
Upper gastrointestinal endoscopy is used routinely to screen for recurrent ulcer disease. It is used diagnostically and potentially therapeutically in case of complications, along with surveillance for signs of recurrent ulcer disease, as well as postoperative complications such as stricture or bleeding. Individuals undergoing resection for cancer undergo annual screening postoperatively.
What Are the Complications of Distal Gastrectomy?
Complications post-procedure can occur at any point.
The most common complications are as follows:
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Anastomotic Leakage: Anastomotic leaks that occur in the first few days postoperatively are caused due to technical errors and should be managed by reoperation. Endoscopic approaches are considered in hemodynamically stable individuals. Individuals with anastomotic leaks and tachycardia, fever, or change in the effluent of suction drains. Risk factors that come along with anastomotic leakage include smoking, malnutrition, steroids, and the use of alcohol or tobacco.
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Gastric Outlet Obstruction: Anastomotic hematoma or edema can lead to early outlet obstruction and manifests as vomiting. The diagnosis is achieved either clinically or endoscopically. No treatment is required as the condition resolves over time. In contrast, the late appearance of these symptoms could be an anastomotic stricture from cancer, scarring, or external adhesions.
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Recurrent Ulcer Disease: Antral tissue present 0.5 cm from the pylorus is excised, and retaining the antral tissue may cause recurrent ulcer disease or gastritis symptoms. The resection is performed at the level of the duodenum. Zollinger-Ellison syndrome should be ruled out in cases of intractable or recurrent ulcers.
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Pancreatitis: Postoperative pancreatitis may be caused due to edema, and most of the time, it is self-limiting. If the dissection encroached or dissection was difficult, there might be a possible ductal injury. Necrotizing and hemorrhagic pancreatitis carries a much higher mortality and morbidity rate.
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Dumping Syndrome: It is a common complication after distal gastrectomy. The early signs include cramping, abdominal pain, and diarrhea after meals secondary to hyperosmotic load to the small intestine. Late dumping may be caused by hyperinsulinemia and hypoglycemic symptoms such as diaphoresis and lightheadedness. Dumping syndrome is common in Billroth II reconstruction and is treated conservatively by consuming high protein, low carbohydrate, high fiber meals and by avoiding liquids during meals.
Conclusion
Distal gastrectomy or antrectomy is a procedure in which the distal third of the stomach is excised. In recent years, distal gastrectomy has become common for treating early-stage stomach cancer.
