Modifications according to Billroth 2. Gastric resection: indications, types, implementation, recovery and diet after. Sample menu after gastrectomy

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All recommendations are indicative in nature and are not applicable without consulting a doctor.

Gastric resection is an operation to remove a part of the stomach affected by a chronic pathological process with the subsequent formation of an anastomosis (connection of various parts of the digestive tube) to restore adequate passage of food.

This operation is considered difficult and traumatic and is undoubtedly a last resort. However, often for the patient it is the only way to cure a number of diseases, the conservative treatment of which clearly will not produce results.

Today, the technique of this operation has been thoroughly developed and simplified, and therefore has become more accessible to surgeons and can be performed in any general surgical department. Gastric resection now saves those patients who were previously considered inoperable and incurable.

The method of gastric resection depends on the location of the pathological focus, histological diagnosis, and the size of the affected area.

Indications

development of stomach cancer

Absolute readings:

• Malignant tumors.
• Chronic ulcers with suspected malignancy.
• Decompensated pyloric stenosis.

Relative readings:

1. Chronic gastric ulcers with poor response to conservative treatment (within 2-3 months).
2. Benign tumors (most often multiple polyposis).
3. Compensated or subcompensated pyloric stenosis.
4. Severe obesity.

Contraindications

Contraindications to surgery are:

• Multiple distant metastases.
• Ascites (usually occurring due to cirrhosis of the liver).
• Open form of pulmonary tuberculosis.
• Liver and kidney failure.
• Severe diabetes mellitus.
• The patient's condition is serious, cachexia.

Preparing for surgery

If the operation is carried out as planned, a thorough examination of the patient is first prescribed.

1. General blood and urine tests.
2. Study of the coagulation system.
3. Biochemical parameters.
4. Blood type.
5. Fibrogastrodudodenoscopy (FGDS).
6. Electrocardiogram (ECG).
7. X-ray of the lungs.
8. Ultrasound examination of the abdominal organs.
9. Examination by a therapist.

Emergency resection is possible in case of severe bleeding or perforation of the ulcer.

Before the operation, a cleansing enema is applied and the stomach is washed. The operation itself usually lasts no more than three hours using general anesthesia.

How is the operation performed?

An upper midline laparotomy is performed.

Gastric resection consists of several mandatory steps:

• Stage I – revision of the abdominal cavity, determination of operability.
• II – mobilization of the stomach, that is, giving it mobility by cutting off the ligaments.
• Stage III – direct cutting off of the necessary part of the stomach.
• Stage IV – creation of an anastomosis between the stump of the stomach and intestines.

After all stages are completed, the surgical wound is sutured and drained.

Types of gastric resection

The type of resection in a particular patient depends on the indications and location of the pathological process.

Based on how much of the stomach is planned to be removed, the patient can undergo:

1. Economical resection those. removal of one third to half of the stomach.
2. Extensive or typical resection: removal of about two-thirds of the stomach.
3. Subtotal resection: removal of 4/5 of the stomach volume.
4. Total resection: removal of more than 90% of the stomach.

According to the location of the excised section:

• Distal resections(removal of the final portion of the stomach).
• Proximal resections(removal of the inlet of the stomach, its cardiac part).
• Middle(the body of the stomach is removed, leaving its inlet and outlet sections).
• Partial(removal of only the affected part).

Based on the type of anastomosis being formed, there are 2 main methods: resection according to BillrothI And BillrothII, as well as their various modifications.

Operation BillrothI: after removing the outlet section, the gastric stump is connected by a direct connection “output end of the stump - inlet end of the duodenum.” Such a connection is the most physiological, but technically such an operation is quite difficult, mainly due to poor mobility of the duodenum and the discrepancy in the diameters of these organs. Rarely used nowadays.

Billroth resectionII: involves suturing the stump of the stomach and duodenum, forming a side-to-side or end-to-side anastomosis with the jejunum.

Gastric ulcer resection

In case of peptic ulcer, in order to avoid relapses, they strive to resect from 2/3 to 3/4 of the body of the stomach along with the antrum and pylorus. The antrum produces the hormone gastrin, which increases the production of hydrochloric acid in the stomach. Thus, we perform anatomical removal of the area that contributes to increased acid secretion.

However, surgery for gastric ulcers was popular only until recently. Resection began to be replaced by organ-preserving surgical interventions, such as excision of the vagus nerve (vagotomy), which regulates the production of hydrochloric acid. This type of treatment is used in those patients who have increased acidity.

Gastric resection for cancer

If a malignant tumor is confirmed, a volumetric resection is performed (usually subtotal or total) with the removal of part of the greater and lesser omentum to prevent relapse of the disease. It is also necessary to remove all lymph nodes adjacent to the stomach, as they may contain cancer cells. These cells can metastasize to other organs.

Removing lymph nodes significantly lengthens and complicates the operation, but ultimately reduces the risk of cancer recurrence and prevents metastasis.

In addition, when cancer spreads to neighboring organs, there is often a need for a combined resection - removal of the stomach with part of the pancreas, esophagus, liver or intestines. In these cases, it is advisable to perform resection as a single block in compliance with the principles of ablastics.

Longitudinal gastrectomy

longitudinal gastrectomy

Longitudinal gastrectomy(PRG, other names - “drain”, sleeve, vertical resection) is a surgical operation to remove the side of the stomach, accompanied by a decrease in its volume.

Longitudinal gastrectomy is a relatively new method of resection. This operation was first performed in the USA about 15 years ago. The operation is rapidly gaining popularity around the world as the most effective treatment for obesity.

Although during prostate cancer a significant part of the stomach is removed, all its natural valves (cardiac sphincter, pylorus) are left, which allows the physiology of digestion to be preserved. The stomach is transformed from a voluminous bag into a fairly narrow tube. Satisfaction occurs fairly quickly with relatively small portions; as a result, the patient consumes much less food than before surgery, which contributes to sustainable and productive weight loss.

Another important feature of PRG is that the area in which the hormone ghrelin is produced is removed. This hormone is responsible for the feeling of hunger. When the concentration of this hormone decreases, the patient stops experiencing constant cravings for food, which again leads to weight loss.

The functioning of the digestive tract after surgery quickly returns to its physiological norm.

The patient can expect a weight loss equal to about 60% of the excess weight they had before surgery. PGR is becoming one of the most popular surgeries to combat obesity and diseases of the digestive tract.

According to reviews from patients who have undergone prostate cancer, they literally have a new life. Many who gave up on themselves and tried unsuccessfully to lose weight for a long time gained self-confidence, began to actively engage in sports, and improved their personal lives. The operation is usually performed laparoscopically. Only a few small scars remain on the body.

Laparoscopic gastrectomy

This type of surgery is also called “minimal intervention surgery.” This means that surgery is performed without large incisions. The doctor uses a special instrument called a laparoscope. Through several punctures, surgical instruments are inserted into the abdominal cavity, with which the operation itself is performed under the control of a laparoscope.

A specialist with extensive experience using laparoscopy can remove some part of the stomach or the entire organ. The stomach is removed through a small incision no more than 3 cm.

There is evidence of transvaginal laparoscopic resections in women (the stomach is removed through an incision in the vagina). In this case, no scars remain on the anterior abdominal wall.

Gastric resection performed using laparoscopy undoubtedly has great advantages over open one. It is characterized by less severe pain, a milder course of the postoperative period, fewer postoperative complications, as well as a cosmetic effect. However, this operation requires the use of modern suturing equipment and the surgeon's experience and good laparoscopic skills. Typically, laparoscopic gastrectomy is performed when the course of a peptic ulcer is complicated and the use of antiulcer drugs is ineffective. Also, laparoscopic resection is the main method of performing longitudinal resection.

For malignant tumors, laparoscopic surgery is not recommended.

Complications

Among the complications that arise during the operation itself and in the early postoperative period, it is necessary to highlight the following:

1. Bleeding.
2. Infection in the wound.
3. Peritonitis.
4. Thrombophlebitis.

IN later In the postoperative period, the following may occur:

• Anastomotic failure.
• The appearance of fistulas at the site of the formed anastomosis.
• Dumping syndrome (discharge syndrome) is the most common complication after gastrectomy. The mechanism is associated with the rapid entry of insufficiently digested food into the jejunum (the so-called “food failure”) and causes irritation of its initial section, a reflex vascular reaction (decreased cardiac output and dilation of peripheral vessels). It manifests itself immediately after eating with epigastric discomfort, severe weakness, sweating, increased heart rate, dizziness and even fainting. Soon (after about 15 minutes) these phenomena gradually disappear.
• If gastric resection was performed for peptic ulcer disease, then it may recur. Almost always recurrent ulcers localized on the intestinal mucosa, which is adjacent to the anastomosis. The appearance of anastomotic ulcers is usually a consequence of a poorly performed operation. Most often, peptic ulcers form after Billroth-1 surgery.
• Recurrence of a malignant tumor.
• Weight loss may occur. Firstly, this is caused by a decrease in the volume of the stomach, which reduces the amount of food taken. And secondly, the patient himself strives to reduce the amount of food eaten in order to avoid the appearance of unwanted sensations associated with dumping syndrome.
• When performing Billroth II resection, the so-called adductor loop syndrome, the occurrence of which is based on violations of the normal anatomical and functional relationships of the digestive tract. It manifests itself as bursting pain in the right hypochondrium and bilious vomiting, which brings relief.
• Iron deficiency anemia may be a common complication after surgery.
• Much less common is B12 deficiency anemia due to insufficient production of Castle factor in the stomach, through which this vitamin is absorbed.

Nutrition, diet after gastrectomy

The patient's nutrition immediately after surgery is carried out parenterally: saline solutions, glucose solutions and amino acids are administered intravenously.

After surgery, a nasogastric tube is inserted into the stomach to suction out the stomach contents, and nutritional solutions can also be administered through it. The tube is left in the stomach for 1-2 days. Starting from the third day, if there is no congestion in the stomach, you can give the patient a not too sweet compote in small portions (20–30 ml), or a rosehip decoction about 4–6 times a day.

In the future, the diet will gradually expand, but an important condition must be taken into account - patients will have to follow a special diet, balanced in nutrients and excluding coarse, indigestible foods. The food that the patient takes must be thermally processed, consumed in small portions and should not be hot. Complete exclusion of salt from the diet is another condition of the diet.

The volume of a serving of food is no more than 150 ml, and the frequency of intake is at least 4-6 times a day.

This list contains products, strictly prohibited after operation:

1. Any canned food.
2. Fatty dishes.
3. Marinades and pickles.
4. Smoked and fried foods.
5. Baking.
6. Carbonated drinks.

The hospital stay is usually two weeks. Complete rehabilitation takes several months. In addition to following the diet, it is recommended:

• Limiting physical activity for 2 months.
• Wearing a postoperative bandage for the same time.
• Taking vitamin and mineral supplements.
• If necessary, take hydrochloric acid and enzyme preparations to improve digestion.
• Regular monitoring for early detection of complications.

Patients who have undergone gastrectomy must remember that the body’s adaptation to new digestive conditions can take 6-8 months. According to reviews from patients who have undergone this operation, weight loss and dumping syndrome are most pronounced at first. But gradually the body adapts, the patient gains experience and a clear understanding of what diet and what foods he tolerates best.

After six months to a year, the weight gradually returns to normal, and the person returns to normal life. It is not at all necessary to consider yourself disabled after such an operation. Many years of experience with gastric resection proves that it is possible to live without part of the stomach or even completely without the stomach.

If indicated, gastric resection surgery is performed free of charge in any abdominal surgery department. However, it is necessary to take a serious approach to the issue of choosing a clinic, because the outcome of the operation and the absence of postoperative complications depend to a very large extent on the qualifications of the operating surgeon.

Prices for gastric resection, depending on the type and volume of the operation, range from 18 to 200 thousand rubles. Endoscopic resection will cost slightly more.

Sleeve resection for the treatment of obesity is, in principle, not included in the list of free medical care. The cost of such an operation is from 100 to 150 thousand rubles (laparoscopic method).

Video: longitudinal gastrectomy after surgery

Video: laparoscopic sleeve gastrectomy – medical animation

Currently, conservative therapy has achieved great success, which is especially significant in the treatment of diseases of the gastrointestinal tract. However, it is not always possible to start treatment on time; many diseases have a latent period and remain undetected for many years, after which it is no longer possible to save the organ, and further delay threatens even more serious problems. In some cases, resection is the only (albeit quite traumatic) way to save the patient’s life or significantly increase his chances of a normal standard of living.

Gastric resection is a surgical method for treating many diseases of the stomach, in which part of this organ is removed and the subsequent restoration of the integrity of the gastrointestinal tract with the formation of an anastomosis. If the stomach is completely removed without leaving a gastric stump, the operation is called a total gastrectomy.

Nowadays, gastric resection is a common and quite effective operation, which provides a wide range of possibilities for its implementation, and, therefore, for an individual approach to the patient and his disease. It’s hard to believe, but the first such operation took place in 1881 under the leadership of Theodor Billroth, whose name is given to one of the subtypes of resections used to this day.

Resection with preservation of the pylorus

Gastric resection usually takes place under endotracheal inhalation anesthesia. During the operation, the surgeon removes a strictly specific area of ​​the stomach, which he had previously identified, and according to indications, both a more gentle resection (removal of a small area, most often the middle third) and a subtotal resection (in which almost the entire stomach and duodenum are removed) connects to the esophagus).

The variety of resection methods can create a false impression of prosperity in this branch of surgery, but only the imperfection of methods can stimulate the creation of new modifications of the operation. In the human body, everything is arranged harmoniously, and the removal of any part of an organ is not physiological and leads to corresponding consequences. Only vital necessity can be a serious reason for gastric resection.

Indications for the procedure

Overweight and obesity are modern pandemics that are difficult to treat and sometimes require surgical intervention. The generally accepted basis for resection for the purpose of weight loss is a body mass index of 40 kg/m2 or higher (in the absence of concomitant diseases) and 35 kg/m2 or higher (for example, with diabetes mellitus or other severe pathology). Increased body weight contributes to rapid fatigue and high blood pressure, which is especially dangerous in later life. As weight loss occurs, concomitant symptoms (arterial hypertension, type 2 diabetes, etc.) decrease, which significantly prolongs the life of such patients.

This branch of medicine is called bariatric (metabolic) and has existed since 1966. The effectiveness of resection aimed at weight loss directly depends on the size of the removed area of ​​the stomach. By reducing the volume of the organ, the surgeon achieves a smaller capacity and a quicker feeling of saturation. By consuming less food, the patient loses weight.

Despite many plastic surgeries performed to eliminate stenosis of any part (for example, the pylorus), additional resection of the area is still resorted to. Resection is also used for organic lesions, for example, peptic ulcers (peptic ulcers directly caused by the digestive process in the stomach). In addition, an absolute indication for surgical intervention will be penetration (transition of the ulcerative process) to other nearby organs and perforation with bleeding. The operation is also performed in cases of long-term non-healing ulcers in elderly people.

Since the ulcer does not have the correct geometric shape, it is necessary to remove an area significantly larger than the size of the lesion. Despite many techniques aimed at maintaining normal digestion of food, resections are sometimes complicated by scarring and stenosis of the lumen. In this case, the surgeon must completely remove the ulcerative defect and stitch it in the most physiological position. In addition to surgical treatment, peptic ulcer requires long-term follow-up therapy due to the tendency to relapse.

Resection is the only truly effective treatment for stomach cancer in the early stages. Cancer (or carcinoma) can be found in any part of the stomach, which is a fundamental factor in choosing resection. If the lesion is located, distal resection is preferred. If in the cardiac (or subcardial), then they make a choice in favor of the proximal one.

The stomach has an extensive network of lymphatic vessels, which ensures the rapid spread of cancer metastases inside the wall, into the peritoneum and lymph nodes. That is why in case of cancer, subtotal resection is most often performed, always giving preference to a more radical method.

Classification of intervention methods

Depending on the location of the operated part of the stomach, proximal (cardial or subcardial) and distal (antrum) resections can be distinguished. With the development of endoscopy, more and more people are trying to resort to laparoscopic surgery, bypassing wide incisions.

The volume of intervention performed also matters; there are:

• economical resection of a third or half of the stomach;
• extensive resection of 2/3 of the stomach;
• subtotal resection of the stomach with preservation of 1/5 of the organ.

Theodor Billroth is the founder of gastric surgery; the invented method of resection is known and is still used in two versions. Billroth-1 is a less radical operation in which the anastomosis is formed “end to end”. Billroth-2 provides convenient suturing of the gastric stump without tension on the sutures and narrowing of the opening with greater possibilities for removal. Statistics confirm the fact that Billroth-1 is more dangerous than Billroth-2. Since there is no difference in the postoperative period, and in case of cancer early metastasis must be taken into account, Billroth-2 is preferred.

Billroth-2 underwent numerous modifications. For example, when modifying according to Balfour, an anastomosis is applied between the stomach and intestines on the jejunum, additionally forming an interintestinal anastomosis (using the Brown method). The Hoffmeister-Finsterer method is used more often, since a kind of artificial valve is formed, replacing the previously removed antral valve. In this case, food is not thrown into the intestines too quickly, and dumping syndrome does not occur.

Other operation modifications

Longitudinal gastrectomy has a short history; the first such operation was performed in 2000. The purpose of resection, unlike other types, is not organic damage to the stomach, but to improve the quality of life. As part of bariatric medicine, gastrectomy is effective for weight loss.

The operation is performed under general anesthesia and lasts several hours (usually 2-3 hours). The surgeon removes most of the stomach along its side, ensuring the safety of the valves and areas of production of hydrochloric acid, pepsin, and the area of ​​absorption of vitamin B12. By removing the side wall of the stomach, the surgeon also affects the feeling of hunger and satiety, since the side wall contains the production zone of the hormone ghrelin, which is responsible for the feeling of hunger.

Consequences of gastrectomy

As mentioned earlier, removal of part of the stomach is not a physiological situation, which, although therapeutic in nature, has associated complications. The strength and severity depend on the volume of the intervention performed and the volume of tissue removed: the larger the area that was resected, the sooner the patient will encounter a disorder in the gastrointestinal tract. Not everyone experiences such complications, but the frequency of such cases has made it possible to identify a whole separate group of post-gastroresection syndromes.

Dumping syndrome

The most specific complication of gastric resection is dumping syndrome (failure syndrome). Patients report characteristic symptoms after eating:

• palpitations, dizziness;
• dyspeptic disorders (nausea, vomiting);
• weakness and neurotic signs (tic, etc.).

Due to the fact that the stomach is reduced, its shape changes slightly, and this leads to the rapid passage of food through the stomach into the intestines. The osmotic characteristics of such food, which has not actually gone through the stage of digestion in the stomach, differ from those usual in the intestines, which leads to inadequate absorption of fluid and resulting hypovolemia.

There are three stages of dumping syndrome severity, determined by the condition's impact on organ systems.

1. In mild cases, only rare attacks accompanied by dyspepsia are observed.
2. With a moderate degree, blood pressure, tachycardia, and dyspeptic symptoms increase.
3. The third degree is characterized by regular attacks with loss of consciousness, severe metabolic disorders, and cachexia.

Treatment in mild cases can be carried out conservatively, by normalizing the diet (eating in small portions and often, diet therapy), the third degree is subject to surgical treatment.

Anastomasis

Anastomositis is inflammation at the site of anastomosis, the formed junction of cut sections of the gastrointestinal tube. Often, such inflammation is accompanied by a pathological narrowing of the stomach and difficulty in passing the bolus of food further through the intestines, which causes stretching of the gastric wall, pain, nausea and vomiting. If left untreated, anastomositis leads to deformation of the stomach and the need for repeated surgery.

When forming gastroenteroanastomoses on a long loop, the food bolus passes mainly through the pyloric part of the stomach, and the food bolus, squeezing the efferent intestine, ensures difficult passage in it. A kind of vicious circle is formed, giving symptoms of nausea, vomiting, and exhaustion. The condition is diagnosed by X-ray examination and subsequently requires surgical intervention (removal of the anastomosis and part of the stomach, application of an additional anastomosis).

Diet and nutrition after surgery

During the first time after surgery, the patient is given intravenous parenteral nutrition solutions containing amino acids, carbohydrates and small amounts of fats. Two days after resection, the patient can drink liquids (decoctions, tea, compote) in small portions and often. Baby formulas begin to be administered through a tube. Gradually, the diet expands, and after two weeks the patient can independently adhere to a gentle diet, the purpose of which is to prevent inflammatory processes and complications (for example, dumping syndrome).

In the late postoperative period, it is better to give preference to purees and soups based on vegetables or cereals (but without cabbage or millet). The method of preparing other dishes can be steamed, oven-baked or boiled; fried foods should be avoided. You need to refrain from eating baked goods during the first month, and after that, control your consumption within reasonable limits. It is also better to limit plant foods containing a coarse fibrous structure. You can only eat lean meat; give preference to poultry (turkey, chicken). The fish consumed should also not contain large quantities of fat (bream, hake, cod, pike perch). Dairy products, milk and eggs can be eaten in limited quantities and not earlier than 2 months after surgery.

After removing part of the stomach, the patient will have to eat small portions and quite often (up to 5 times a day). Small portions will not cause discomfort, since the feeling of hunger does not form if the stomach is full. You should not try to increase single servings; this can lead to stretching of the gastric wall and the formation of an overly large stomach, which is undesirable for patients with existing obesity, which was the reason for seeing a doctor.

That is why, when forming a diet, they pay attention to the primary reason for visiting a doctor.

If the patient has suffered from a peptic ulcer for a long time, then the diet after gastrectomy in the postoperative period should limit the consumption of acidic foods, include the intake of mineral water and antacid and antibacterial (targeted Helicobacter Pylori) drugs.

Indications for gastrectomy

Absolute: malignant neoplasms of the stomach, suspicion of malignant degeneration of an ulcer, repeated ulcer bleeding, pyloric stenosis. Relative: long-term non-healing ulcers of the stomach and duodenum (especially in older people), perforated ulcers in good condition of the patient admitted in the first 6 hours after perforation.

If resection is performed for a peptic ulcer, then in order to avoid relapse, they strive to resect 2/3 – 3/4 of the body of the stomach along with the pyloric region. With a smaller volume of resection, the main goal is not achieved - a decrease in the secretory activity of the gastric stump, which can lead to relapse of the ulcer or the formation of a peptic ulcer of the jejunum. In case of stomach cancer, 3/4 - 4/5 of the stomach must be removed, sometimes the organ is removed subtotally or even a gastrectomy is performed with the lesser and greater omentum. The scope of resection expands not only due to the stomach itself, but also due to regional lymphatic collectors, where tumor metastasis is possible.

The operation includes 2 main stages:

1) excision of the affected part of the stomach (resection of the stomach itself), and it is desirable to remove the area of ​​the stomach in which gastrin is secreted to reduce the acidity and amount of gastric juice;

2) restoration of the continuity of the gastrointestinal tract by applying an anastomosis between the stump of the stomach and the duodenum or jejunum.

Types of gastric resections

​According to the volume of intervention: economical - removal of 1/3 - 1/2 of the stomach volume, extensive - removal of 2/3 of the stomach volume, subtotal - removal of 4/5 of the stomach volume, total - removal of 90% of the stomach volume.

​According to the sections excised: distal resections (removal of the distal part of the stomach), proximal resections (removal of the proximal part of the stomach along with the cardia), pylorectomy, anthrumectomy, cardioectomy, fundectomy.

With extensive resection of the stomach, the level of dissection of the lesser curvature is 2.5–3 cm distal to the esophagus, at the point where the 1st branch of the left gastric artery enters the stomach; on the greater curvature, the line passes to the lower pole of the spleen, at the level of the origin of the 1st short gastric artery, which goes to the gastric wall as part of the gastrosplenic ligament. When resection of 1/2 of the stomach, dissection of the lesser curvature is performed at the level of entry into the stomach of the 2nd branch of the left gastric artery; the greater curvature is dissected at the place where both gastroepiploic arteries anastomose with each other. Antrumectomy along a broken line allows you to reduce the size of the removed part of the organ in case of a gastric ulcer located high. Depending on the method of restoring the continuity of the gastrointestinal tract, the variety of options for gastrectomy can be represented by 2 types:

---------------- gastric resection operations based on the principle of restoration of direct gastroduodenal anastomosis according to the Billroth-1 type;

---------------- gastric resection operations based on the principle of creating a gastroenteroanastomosis with unilateral exclusion of the duodenum according to the Billroth-2 type.

Mobilization of the stomach

The abdominal cavity is opened with an upper midline incision. Mobilization of the stomach along the greater curvature is carried out by dissecting the gastrocolic ligament. Start from the middle third of the greater curvature in a relatively avascular place between the branches of the gastroepiploic arteries. A curved clamp is inserted into the hole made and the adjacent section of the ligament is clamped. Distal from the 1st clamp, a 2nd clamp is applied and the compressed part of the gastrocolic ligament is dissected. So, in small portions, the greater curvature is first mobilized to the left and up to the upper third of the stomach, freeing the avascular portion of the greater curvature in the proximal direction. You need to be especially careful when mobilizing the pyloric part of the stomach, since in this area the mesentery of the transverse colon with the vessels feeding it is adjacent directly to the gastrocolic ligament. At the pylorus, the right gastroepiploic arteries and vein are separately ligated. Having completed the mobilization of the greater curvature, they begin to mobilize the lesser curvature of the stomach. Using a curved clamp held behind the stomach, a hole is made in the avascular area of ​​the lesser omentum, and then, grasping the lesser omentum in separate sections, they cut it up and to the left. When mobilizing the lesser curvature of the stomach, one should beware of damage to the accessory hepatic artery, which often arises from the left gastric artery (a. gastrica sinistra) and goes to the left lobe of the liver. The main point of this stage is the ligation of the left gastric artery in the gastropancreatic ligament. After crossing the left gastric artery, the stomach acquires significant mobility, remaining fixed only by the right part of the lesser omentum with the branches of the right gastric artery passing through it. Then they continue to mobilize the lesser curvature in the area of ​​the pylorus, where the right gastric arteries and vein are ligated and crossed. If gastric resection is supposed to be performed according to the Billroth-1 type, in some cases it is necessary to mobilize the duodenum according to Kocher.

Mobilization of the duodenum

To do this, the anterior and posterior layers of the gastrocolic ligament are dissected and, by pulling the pyloric section of the stomach upward, the branches of the right gastroepiploic artery and veins going to the initial part of the duodenum are exposed. They are crossed between the clamps and bandaged. The transection of the gastrocolic ligament is usually performed below the gastroepiploic arteries with ligation of the omental branches of these arteries. The transverse colon, together with the greater omentum, is lowered into the abdominal cavity and, pulling the stomach upward, several small branches are tied at the posterior wall of the duodenum, coming from the gastroduodenal artery.

Gastric resection according to Billroth type-1

After mobilization of the stomach, the distal cut-off border of the stomach is determined. In all cases, it should pass below the pylorus, which is determined by the characteristic thickening of the wall in the form of a roller and the corresponding pre-pyloric vein of Mayo, running in a transverse direction relative to the axis of the stomach. An intestinal sponge is applied to the duodenum below the pylorus. A crushing clamp is placed above the pylorus and the duodenum is crossed with a scalpel along the upper edge of the clamp. A Payra press is applied to the middle third of the stomach and 2 clamps parallel to it. After this, the stomach is brought to the duodenum and, stepping back 0.7–0.8 cm from the sphincter, the posterior wall of the stomach is sutured with seromuscular sutures to the posterior wall of the duodenum. The threads of the applied sutures are cut off, with the exception of the extreme ones, which later serve as holders when applying an anastomosis. Then the stomach is crossed between the sphincter and the drug is removed. A stay suture is placed on the lesser curvature above the remaining sphincter and the edge of the gastric wall is cut off along with the upper sphincter. First, a continuous catgut suture is placed on the stomach stump, which passes through all layers of the stomach wall, and then an interrupted seromuscular suture. Having finished suturing the upper part of the stump, cut off the edges of the wall of the stomach and duodenum under the pulp. A continuous catgut suture is applied to the posterior lips of the anastomosis, starting from the bottom up. At the upper edge of the anastomosis, the thread is wrapped and the suture is continued on the anterior lips. On top of the 1st row of sutures, a 2nd row of seromuscular sutures is placed on the anterior wall of the anastomosis. In this case, special attention should be paid to suturing the anastomosis in the upper corner at the junction of 3 sutures, where it is advisable to apply several additional sutures. After anastomosis, the thread-holders are cut and the defects in the gastrocolic and hepatogastric ligaments are sutured.

Direct gastroduodenal anastomosis. Depending on the method of forming the anastomosis between the stump of the stomach and the duodenum, Billroth-1 type options can be divided into 4 groups:

1. Gastroduodenal anastomosis of the end-to-end type:

In the greater curvature of the stomach;

At the lesser curvature of the stomach;

With narrowing of the lumen of the gastric stump.

2. Gastroduodenal anastomosis of the end-to-side type with the entire lumen of the stomach.

3. Gastroduodenal anastomosis of the side-to-end type.

4. Side-to-side gastroduodenal anastomosis has not become widespread due to technical complexity.

Gastric resection according to Billroth-1, modified by Haberer

After resection of the stomach, the lumen of its stump is narrowed with a series of corrugated sutures to the circumference of the duodenum, with the stump of which an anastomosis is placed end-to-end.

Advantages and disadvantages . Functionally, the operation is most complete. The great advantage of the Billroth-1 operation is that the entire intervention occurs above the mesentery of the transverse colon. However, Billroth-1 resection in the classical form is rarely performed, mainly due to the difficulty of mobilizing the duodenum and the discrepancy between the lumens of the stomach and duodenum.

Gastric resection according to Billroth type-2

The differences between Billroth-1 and Billroth-2 resection are:

​in the method of closing the gastric stump;

- suturing a loop of jejunum to the stomach (anterior or posterior gastroenterostomy);

。 in the way of its location in relation to the transverse colon (anterocolic or retrocolic gastroenteroanastomosis).

The classical method of gastric resection according to the Billroth-2 type has only historical significance. In modern surgery, various modifications are usually used.

Indications. Localization of the ulcer in the pyloric or antrum of the stomach, absence of cicatricial changes in the duodenum.

Classic method of gastric resection according to Billroth-2 consists in the subsequent application of a side-to-side gastrojejunostomy after gastric resection.

Hoffmeister-Finsterer method- one of the most common methods of surgery. The essence of the operation is the resection of 2/3 - 3/4 of the stomach, suturing the lumen of the gastric stump along the lesser curvature, immersing it in the form of a keel into the lumen of the stump and applying a retrocolic gastrojejunostomy between the short loop of the adductor section of the jejunum at a distance of 4 –6 cm from the ligament of Treitz in an end-to-side manner with the remaining lumen of the stomach. In this case, the afferent loop is fixed above the anastomosis for 2.5–3 cm to the newly created lesser curvature. The “spur” formed in this way prevents the reflux of gastric contents into the afferent loop. After the stomach is mobilized and the duodenal stump is processed, the stomach is cut off and anastomosis is performed. To do this, 2 straight gastric sphincters are placed on the stomach along the line of future intersection. One press is applied from the side of greater curvature, and the second - from the side of lesser curvature so that the ends of the presses touch; Next to them, a crushing gastric sponge is applied to the removed part of the stomach. Then, having stretched the stomach, the surgeon cuts it off with a scalpel along the edge of the crushing sphincter and removes the drug.

Since the anastomosis according to this modification is applied only to a part (about 1/3) of the lumen of the gastric stump, it is necessary to suturing the rest of it, in other words, it is necessary to form a new lesser curvature of the gastric stump. Most surgeons close the stump with a 2- or 3-row suture. The first suture is placed around the gastric sphincter in the same way as on the duodenal stump. The suture is tightened and a continuous suture is applied with the same thread through all layers of the gastric stump in the opposite direction. Starting from the deserosed area, a 2nd row of interrupted serous-muscular sutures is applied along the lesser curvature so that the previous suture is completely immersed, especially in the area of ​​the upper corner. The threads of the last seam are not cut, but are taken onto a clamp, using them as a holder. Having finished suturing the upper part of the gastric stump, they begin to apply the gastroenteroanastomosis itself. To do this, the gastric stump is turned with a Kocher clamp with the posterior wall anterior, and the jejunal loop, previously prepared and passed through the window of the mesentery of the transverse colon, is pulled to the gastric stump and positioned so that the adducting end of the loop is directed to the lesser curvature, and the abducent end - to greater curvature of the stomach. The length of the afferent loop from the duodenum-jejunal flexure to the beginning of the anastomosis should not exceed 8–10 cm. The afferent loop of the intestine is sutured to the stump of the stomach with several interrupted silk sutures for 3–4 cm above the stay suture, and the efferent loop with one suture to the large curvature. First, the posterior wall of the stomach is sutured with interrupted seromuscular sutures across the entire width of the anastomosis to the greatest curvature with the free edge of the jejunum. The distance between the seams is 7–10 mm. All seams are cut off except the last one (at the greater curvature). It is necessary to suture the intestine to the stomach so that the anastomosis line runs in the middle of the free edge of the intestinal loop. Each suture captures at least 5–6 mm of the serous and muscular membranes of the intestine and stomach. All ends of the threads, with the exception of the holders, are cut off. After this, stepping back from the suture line by 6–8 mm and parallel to it, the intestinal lumen is opened to a length corresponding to the lumen of the gastric stump. The contents of the intestine are removed with an electric suction.

After this, a continuous catgut suture is applied to the posterior lips of the anastomosis through all layers of the intestine and stomach. Using a long catgut thread, starting from the greater curvature, the posterior walls of the stomach and intestines are sutured with a continuous continuous suture up to the upper corner of the anastomosis. Having reached the corner of the anastomosis, the last stitch of the suture is overlapped and the anterior lips of the anastomosis are sewn with the same thread. In this case, the Schmieden suture is often used. When tightening each stitch of this suture, make sure that the mucous membranes of the stomach and intestines are immersed inside the anastomosis, helping with tweezers. Using this technique, they reach almost the lower corner of the anastomosis and move to the front wall, where the initial and final threads of the continuous suture are tied and cut off. Change instruments, napkins, wash hands and apply a 2nd row of interrupted seromuscular sutures on the anterior wall of the anastomosis. After this, the adductor section of the jejunum is sutured to the suture line of the lesser curvature to prevent food from being thrown into this loop and to strengthen the weakest point of the anastomosis. To do this, 2–3 sutures are placed, capturing the seromuscular membrane of both walls of the stomach directly at the sutures of the lesser curvature and adductor section of the intestine. If necessary, the anastomosis is strengthened with additional interrupted sutures in the area of ​​greater curvature. The patency of the anastomosis is checked and it is sutured to the edges of the incision in the mesentery of the transverse colon. To do this, the transverse colon is removed from the abdominal cavity, slightly pulled upward, and an anastomosis is performed through the window of its mesentery. Then the edges of the mesentery are sutured to the wall of the stomach above the anastomosis with 4-5 interrupted sutures so that there are no large gaps left between the sutures. Insufficient fixation of the anastomosis can cause the penetration of loops of the small intestine into the mesenteric window with subsequent strangulation.

Reichel-Polya method used to avoid stenosis of the exit from the gastric stump. The essence of the operation is to apply a retrocolic gastroenteroanastomosis between the entire lumen of the gastric stump and a short loop of the jejunum (end-to-side type) at a distance of 15 cm from the ligament of Treitz.

Gastric resection according to Billroth-2 modified by Spasokukotsky

After resection of the stomach, 1/3 of the lumen of the stump from the side of the lesser curvature is sutured and an anastomosis is applied to the remaining 2/3 of the stump into the side of the jejunal loop.

Treatment of the duodenal stump

An important stage of gastrectomy is suturing the duodenal stump. When surgical sutures diverge, the duodenal stump accounts for 90%, and only in 10% of cases does the gastroenteroanastomosis sutures fail.

1. Doyen's method - apply a crushing clamp, bandage the intestine with thick catgut, and cut it. The stump is immersed in the purse-string suture.

2. Schmieden method - a Schmiden screw-in suture is applied, and a Lambert suture is applied on top.

3. Moynigen-Mushkatin seam - a through enveloping suture over the clamps, which is immersed in the seromuscular purse-string suture.

Radical operations include gastric resection and gastrectomy. The main indications for performing these interventions are: complications of gastric and duodenal ulcers, benign and malignant tumors of the stomach.

Classification

Depending on the location of the part of the organ being removed:

1. proximal resections (the cardiac part and part of the body of the stomach are removed);

2. distal resections (the antrum and part of the body of the stomach are removed).

Depending on the volume of the stomach part being removed:

1. economical– resection of 1/3–1/2 of the stomach;

2. extensive– resection of 2/3 of the stomach;

3. subtotal- resection of 4/5 of the stomach.

Depending on the shape of the part of the stomach being removed:

1. wedge-shaped;

2. stepped;

3. circular.

Stages of gastric resection

1. Mobilization (skeletonization) of the removed part of the stomach - intersection of the gastric vessels along the lesser and greater curvature between ligatures throughout the resection area. Depending on the nature of the pathology (ulcer or cancer), the volume of the removed part of the stomach is determined.

2. Resection – the part of the stomach intended for resection is removed.

3. Restoring the continuity of the digestive tube (gastroduodenoanastomosis or gastroenteroanastomosis).

In this regard, there are two main types of surgery:

1. Operation according to the Billroth-1 method– creation of an end-to-end anastomosis between the stump of the stomach and the stump of the duodenum.

2. Operation according to the Billroth-2 method– formation of a “side to side” anastomosis between the gastric stump and the jejunal loop, closure of the duodenal stump (not used in the classical version).

The operation using the Billroth-1 method has an important advantage compared to the Billroth-2 method: it is physiological, because The natural passage of food from the stomach to the duodenum is not disrupted, i.e. the latter is not excluded from digestion.

However, the Billroth-1 operation can be completed only with “small” gastric resections: 1/3 or antrum resection. In all other cases, due to anatomical features (retroperitoneal location of most of the duodenum and fixation of the gastric stump to the esophagus), it is very difficult to form a gastroduodenal anastomosis (there is a high probability of suture divergence due to tension).

Currently, for resection of at least 2/3 of the stomach, the Billroth-2 operation in the Hofmeister-Finsterer modification is used.

The essence of this modification is as follows:

1. the stump of the stomach is connected to the jejunum using an “end to side” anastomosis;

2. the width of the anastomosis is 1/3 of the lumen of the gastric stump;

3. the anastomosis is fixed in the “window” of the mesentery of the transverse colon;

4. The afferent loop of the jejunum is sutured with two or three interrupted sutures to the stump of the stomach to prevent the reflux of food masses into it.

The most important disadvantage of all modifications of the Billroth-2 operation is the exclusion of the duodenum from digestion.

In 5–20% of patients who have undergone gastrectomy, diseases of the “operated stomach” develop: dumping syndrome, afferent loop syndrome (reflux of food masses into the afferent loop of the small intestine), peptic ulcers, cancer of the gastric stump, etc.

Often such patients have to be operated on again - to perform reconstructive surgery, which has two goals: removal of the pathological focus (ulcer, tumor) and inclusion of the duodenum in digestion.

For advanced stomach cancer, a gastrectomy is performed - removal of the entire stomach. Usually it is removed along with the greater and lesser omentum, spleen, tail of the pancreas and regional lymph nodes. After removal of the entire stomach, the continuity of the alimentary canal is restored through gastric plastic surgery. Plastic surgery of this organ is performed using a loop of the jejunum, a segment of the transverse colon, or other parts of the colon. The small or large intestinal insert is connected to the esophagus and duodenum, thus restoring the natural passage of food.

The principle of the operation is to excise the affected part of the stomach and restore the continuity of the gastrointestinal tract by creating an anastomosis between the stump of the stomach and the duodenum or jejunum.

There are two main methods of gastric resection. The first method (Billroth I) involves circular excision of the pyloric and antral parts of the stomach and anastomosis between the duodenum and the lower part of the gastric stump in an end-to-end fashion.

Currently, when connecting the stomach stump with the intestine end-to-end, the Billroth I method and its modification Haberer II are most often used.

During the Billroth I-Haberer operation, after mobilization and resection of 2/3 of the stomach, its lumen is narrowed with corrugated sutures to the width of the lumen of the duodenum. After this, an anastomosis is placed between the duodenum and the stomach.

The second method - Billroth II - differs from the first in that after resection of the stomach, the stump is sutured tightly and the continuity of the gastrointestinal tract is restored by applying an anterior or posterior gastroenteroanastomosis.

Gastric resection– removal of part of the stomach:

a) distal – 2/3 of the stomach is removed

b) proximal – 95% of the stomach is removed

Indications:

1. operable malignant tumor of the pyloric region

2. complicated forms of gastric and duodenal ulcers (perforated, bleeding, malignant, stenotic, penetrating, chronic callous, ulcer refractory to drug therapy)

Contraindications:

1. old age

3. pathological changes in the kidneys and liver

Gastric resection according to Billroth-1:

1. Access: upper median laparotomy

2. Within the resection, the stomach is mobilized along the greater and lesser curvature.

3. Clamps are applied to the stomach and duodenum. Between the clamps, the stomach is crossed, turned to the left and resected.

4. The upper part of the gastric stump is sutured with a double-row suture (continuous through catgut suture + pure Lambert seromuscular sutures). At the greater curvature, an area with a diameter of the duodenum is left unsutured to form a gastroduodenoanastomosis.

5. The unsutured part of the stomach is brought to the duodenum. The posterior walls of the stomach and duodenum are sutured with seromuscular sutures. Using a long catgut thread, a through continuous catgut suture is applied to the posterior lip of the anastomosis, starting from bottom to top; the same thread is passed to the anterior lip of the anastomosis and a Schmieden screw-in suture is applied.

6. After changing instruments and linen, a seromuscular suture is applied and the formation of the anastomosis is completed. The wound of the anterior abdominal wall is sutured in layers.

Advantages of the method: the most physiological, passage of food occurs through the duodenum, dumping syndrome is not expressed. Flaws: difficulty mobilizing the duodenum; discrepancy between the lumens of the stomach and duodenum.

Gastric resection according to Billroth-2. The bottom line: if the duodenum is immobile, we sutured both stumps tightly and performed a side-to-side gastroenteroanastomosis. Currently running in Hoffmeister-Finsterer modifications (end-to-side anastomosis):

1. Access: upper median laparotomy.

2. Mobilization of the stomach by freeing the part to be removed from the ligaments with simultaneous ligation of the vessels.

3. We find the initial loop of the jejunum and pass it through a hole made in the avascular zone of the mesentery of the transverse colon to the upper floor, where we hold it by applying an elastic sphincter to its mesentery.

4. We place a Payra sponge on the upper part of the duodenum, a sponge on the stomach below the pylorus and cross it between the sponges.

5. Close the duodenal stump:

a – placing a continuous suture on the stump around the clamp

b – tightening the thread

c – loading of the intestinal stump with a serous-serous purse-string suture

d – tightening the purse-string suture

6. Two straight gastric sphincters are placed on the stomach along the line of future intersection on the left: one from the side of the greater curvature, the second from the side of the lesser curvature so that they touch. Next to them, a crushing press called Payra is applied to the part of the stomach that is being removed. The stomach is cut off between two straight sphincters and Payra's sphincter.

7. The upper part of the gastric stump is sutured using a clamp applied from the lesser curvature.

8. We bring the prepared loop of jejunum to the stump of the stomach so that its adducting end corresponds to the lesser curvature, and the efferent end corresponds to the greater curvature of the stomach. The intestine is fixed to the posterior wall of the unsutured part of the gastric stump with holders so that the line of the future anastomosis falls on the antimesenteric edge of the intestine.

9. Posterior seromuscular sutures are placed between the holders at intervals of 0.5 cm. The surgical field is covered with napkins. The intestine is cut open.

10. A continuous wrapping Multanovsky catgut suture is applied to the posterior lip of the anastomosis, the same thread is passed to the anterior lip of the anastomosis and it is sutured with a continuous continuous screw-in Schmieden suture. A second row of seromuscular sutures is placed on top. Monitor the patency of the anastomosis.

11. To prevent the reflux of gastric contents into the afferent loop, it is sutured with several sutures above the anastomosis zone to the gastric stump.

Gastrectomy– complete removal of the stomach.

Indications: cancer of the cardia of the stomach or its upper half.

1. Upper midline laparotomy.

2. We mobilize the stomach by freeing the part to be removed from the ligaments with simultaneous ligation of the vessels.

3. The initial section of the duodenum is crossed between the clamps, and the duodenal stump is sutured.

4. We mobilize the esophagus, separating the esophagus from the peritoneum, ligating the vessels, dissecting the nerves.

5. We create an esophagojejunostomy of the “end to side” type (according to Gilyarovich, according to Lagay) with Brown’s anastomosis between the afferent and efferent loops of the intestine or of the “end to end” type (according to Laska-Tsatsanidi).