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MINI SYMPOSIUM: GASTROINTESTINAL
Year : 2012  |  Volume : 49  |  Issue : 2  |  Page : 251-253
 

The feasibility and advantages of billroth-I reconstruction in distal gastric cancers following resection


1 Department of Surgical Oncology, Vydehi Institute of oncology, Bangalore, India
2 Department of Surgical Oncology, Viswabharathi cancer hospital, Kurnool, India

Date of Web Publication25-Oct-2012

Correspondence Address:
M S Ganesh
Department of Surgical Oncology, Vydehi Institute of oncology, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.102922

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 » Abstract 

Background: Gastric carcinomas are common malignancies in southern India and distal stomach remains the commonest site in low socio economic groups. Surgery still remains an important modality of treatment to achieve local control and also relieve obstructive symptoms. In this study we investigated the feasibility of performing a gastrectomy and billroth-1 type of anastomosis in a rural cancer center setting, with parameters like adequacy of margins, ease of anastomosis and its functional results were analysed Materials and Methods: Eight patients presenting to a rurally based cancer center underwent a distal gastrectomy and billroth-1 type of anastomosis for continuity restoration Results: All the patients had adequate proximal and distal marg. The surgical time varied between-hrs. The anastomosis was constructed without any tension on bowel ends in all patients. The average time to start oral feeds varied between- None of the patients showed symptoms of bile reflux nor dumping. The average hospital stay varied between- Conclusions: Billroth-1 anastomosis is a physiologically more natural way of restoring continuity following a gastrectomy and it is a procedure which would be technically more simpler and decrease per and post operative complications and allow speedier post operative recovery following surgery on distal gastric cancers.


Keywords: Distal gastric cancer, billroth-1 anastomosis, gastrectomy


How to cite this article:
Ganesh M S, Reddy K G, Venkata Subbareddy D S. The feasibility and advantages of billroth-I reconstruction in distal gastric cancers following resection. Indian J Cancer 2012;49:251-3

How to cite this URL:
Ganesh M S, Reddy K G, Venkata Subbareddy D S. The feasibility and advantages of billroth-I reconstruction in distal gastric cancers following resection. Indian J Cancer [serial online] 2012 [cited 2019 Nov 22];49:251-3. Available from: http://www.indianjcancer.com/text.asp?2012/49/2/251/102922



 » Introduction Top


Gastric cancers are common in south Indian population and remain a significant cause for cancer induced mortality. The type of diet; smoking and alcohol and low socio economic status are the main reasons for this preponderance. Distal stomach represented by pyloric antrum and part of body of the stomach remain common site for most of the gastric malignancies in this group. Due to late presentation most patients present with some form of gastric outlet obstruction/symptoms related to the tumor like bleeding from the ulcerated lesions. Surgery remains an important modality of treatment apart from chemotherapy and radiation therapy which have adjuvant role.

Distal gastrectomy with clearance of lymph nodes to various extent remains the standard surgical approach and restoration of continuity can be achieved by two or three methods. In India the billroth- type-II anastomosis is commonly carried out in many centers wherein there is closure of duodenal stump and a gastrojejunostomy fashioned.

This study is carried out in a cancer center which caters mainly to patients hailing from rural Andhra pradesh. The aim of our study was to look for the benefits and feasibility of carrying out restoration by billroth-1 anastomosis for distal gastric cancers keeping in view the need to hasten post operative recovery and commence early oral feeding. Another long term goal is to standardize the procedure and extend it for suitable patients, as an alternative to billroth-II anastomosis


 » Materials and Methods Top


Between November 2010 and February 2011 seven patients diagnosed with gastrc cancers underwent distal gastrectomy for adeno carcinoma of distal stomach and had continuity restored by billroth-I anastomosis. We evaluated the per operative findings, procedural details and post operative recovery and pathological adequacy following the procedures.

The age of the patients ranged from 19 years to 62 years. Median age of presentation was 53 years. All of the patients had epigastric pain and loss of appetite at presentation. Three patients gave history of episodic vomiting though not typical of Gastric outlet obstruction. Two patients presented with typical features of gastric outlet obstruction. Four patients were anaemic with Hb% levels less than 8 gm/dl and needed pre surgery transfusion. The OGD scopy revealed ulcero proliferative lesions in the pyloric antrum in four and antrum and body in three patients. One patient had lesion extending along lesser curve to involve incisura. Four out of seven patients had significant food residue and needed gastric lavage prior to scopy. The ultrasonography revealed thickening of antral region in one patient and normal in others. CT scan revealed thickening of antral region in all patients and perigastric nodes were identified in two patients pre operatively. No distant metastasis was identified in any of the patients.

After adequate preparation, all patients were taken up for exploratory laparotomy and possible resection. Per opereative findings included mobile nodular growth in antral region in all patients. In all patients the tumor was involving the serosal surface. The tumor was extending to proximal body in one patient and along lesser curvature till incisura in another. Perigastric nodes were found in four out of seven patients. The stomach was distended in two patients and showed features of chronic obstruction. In two patients the tumor was adherent to the surface of pancreas superficially and could be dissected free. In one patient the mesocolon was densely adherent but could be removed without resorting to doing a colectomy since the middle colic vessels were free.


 » Results Top


A distal radical gastrectomy was possible in six out of seven patients and in one patient the tumor was relatively densely adherent to pancreatic surface and this type of resection we consider as palliative. Though we had the know-how to do a D2 resection keeping in view various factors associated with patients and available evidence, we confined ourselves to carrying out a D-1 resection in all patients. We could achieve good grossly free margins proximally and a 1-1.5 cm margin at duodenal end. To facilitate this and have an adequate duodenal stump for anastomosis we had to mobilize the entire first part of duodenum and also kocherise it in all patients. A gastro duodenal anastomosis was carried out in two layers using interrupted sutures and a nasogastric tube was passed thro in to duodenum. The anastomosis was comfortably done in all except in one patient where in we felt that it was under little stretch. This was the patient in whom we excised significant part of body and lesser curvature as well. The average blood loss was around 400 ml and mean operative time was 2.5 hours. All patients had uneventful recovery from surgery

The post operative period recovery was something we analysed in more detail. The stay till discharge from the day of surgery ranged from 7-11 days. None of the patients had features suggesting gastric atony /bile reflux symptoms. The mean aspirate from Ryles tube was around 150 ml per day and was bilious. By 5 th postoperative day all patients could get their naso gastric tubes removed and had commencement of oral feeds by 7 th postoperative day. None of the patients had any serious postoperative complications, which warranted repeat exploration. None of the patient despite poor nutritional status had postoperative wound infection.

The postoperative pathological results were as follows. All were adeno carcinomas with varied differentiations. Two patients had a diffuse type of gastric cancer. The tumor was involving the serosa in four-patients and involving beyond muscularis till serosa in others. Lymphatic emboli were present in six out of seven patients and vascular and perineural invasion was not evident in any. The resected margins were microscopically free in all the patients. The gross unstretched distal macroscopic margin ranged from 0.5 cm in three patients to 1 cm in four patients. The proximal resected margin varied between 3-6 cms. On average 10-19 lymph nodes were isolated and studied by the pathologist for evidence of metastasis. Three patients were node positive with number of nodes involved ranging from 1-8.


 » Discussion Top


Distal gastric cancers are still common in rural south Indian population. The crude incidence rates of gastric cancer are highest reported in Chennai and it ranks as the second commonest digestive tract cancer in India. [1] Most of the cancers are either T3 or T4 and present with symptoms like epigastric pain, early satiety and vomiting when gastric outlet obstruction sets in.

Surgery remains an important modality in achieving reasonable local control. It is accepted that a D1 type of gastrectomy with a minimum of 12 nodes constitutes adequate resection in most circumstances. Most distal gastric cancers due to their location are amenable for a surgical resection. Restoration of continuity following gastrectomy can be achieved by couple of procedures, but in India a billroth-II type of gastrojejunal anastomosis after closure of duodenal stump is the most common procedure performed. Billroth-I anastomosis is an alternative type of reconstruction most commonly performed by Japanese surgeons. The obvious advantages include- a simplified anastomosis, shorter surgical time and more physiological restoration of continuity. In most of the reviews the post operative recovery is faster and smoother. [2] The incidence of bile reflux and gall stone formation is also less though in some studies a rou-en-y billroth-II anastomosis is supposed to be more advantageous and less complicated. [3] Incidence of dumping also is low in comparison to billroth-II type reconstruction. This type of reconstruction is preferred in laparoscopic gastrectomies as well which are shown to have many potential benefits over open gastrectomies. [4] Other modifications to billroth-1 anastomosis include pylorus preserving gastrectomy which results in even lesser dumping syndrome. [5] In our study, this reconstruction did not in any way hamper with the oncological soundness of gastrectomies performed. We plan to offer this procedure to most of the patients presenting with distal gastric cancers who can be potential candidates for surgical resection.

 
 » References Top

1.Pavithran K, Doval DC, Pandey KK. Gastric cancer in India. Gastric Cancer 2002;5:240-3.  Back to cited text no. 1
[PUBMED]    
2.Sah BK, Chen M-M, Yan M, Zhu Z-G. Gastric cancer surgery: Billroth I or Billroth II for distal gastrectomy? BMC Cancer 2009;9:428.  Back to cited text no. 2
    
3.Nunobe S, Okaro A, Sasako M, Saka M, Fukagawa T, Katai H, et al. Billroth 1 versus Roux-en-Y reconstructions: A quality-of-life survey at 5 years. Int J Clin Oncol 2007;12:433-9.   Back to cited text no. 3
[PUBMED]    
4. Huscher CG, Mingoli A, Sgarzini G, Sansonetti A, Di Paola M, Recher A, et al. Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: Five-year results of a randomized prospective trial. Ann Surg 2005;241:232-7.  Back to cited text no. 4
[PUBMED]    
5.Park do J, Lee HJ, Jung HC, Kim WH, Lee KU, Yang HK. Clinical outcome of pylorus preserving gastrectomy in gastric cancer in comparison with conventional distal gastrectomy with billroth-I anastomosis. World J Surg 2008;32:1020-36.  Back to cited text no. 5
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