Gastric reconstruction

Following distal gastric resection, the continuity of the small bowel with the stomach must be reestablished. The goal is to accomplish this in a way that will minimize the risk of postoperative complications. A thorough knowledge of the physiology of vagal innervation and gastric emptying are the main factors that will determine optimal gastric reconstruction. The condition of the patient, the extent of gastric resection, and surgeon preference may also play a role.

Reconstruction following resection of the stomach is accomplished in three general manners: 1) Billroth I (gastroduodenostomy); 2) Billroth II (loop gastrojejunostomy); 3) Roux-en-Y (end gastrojejunostomy). Modifications of the Roux-en-Y to create a reservoir include the Hunt-Lawrence pouch and the Tanner Roux-19 pouch. Each of the different reconstructions, and the extent of gastric resection, produces specific early and late postoperative complications.

The extent of distal gastric resection can vary (Fig. 1) depending on the pathology and goals of the procedure. An antrectomy removes 40-50% of the distal stomach and includes a greater portion of the lesser curvature where gastrin producing cells extend more proximally. A partial distal gastrectomy removes 50-80% of the stomach. A subtotal gastrectomy removes 80-99% of the stomach, but preserves the fundus. A near-total gastrectomy removes 99% of the stomach including the fundus, leaving a rim of gastric tissue attached to the esophagus to be used for the anastomosis.

Subtotal Gastrectomy
Fig. 1. Nomenclature for gastric resections and percentage of stomach removed. The antrum extends proximally on the lesser curvature and must be removed in all gastrectomies.
Billroth Reconstruction
Fig. 2. Antrectomy with Billroth I reconstruction.

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