What You Need To Know About Gastroduodenostomy

Introduction

A brief explanation of what gastroduodenostomy is:

A gastroduodenostomy (GAS-troe-dew-oe-deen-OS-toe-mee) involves the partial removal (resection) of the stomach and reconnecting the remaining stomach tissue to part of the small intestine, either the duodenum (Billroth-I surgery) or the jejunum (Billroth-II surgery) using the Billroth technique. This approach is used to address various medical conditions that may affect the digestive system.

The importance of the procedure:

Gastroduodenostomy is a life-saving procedure that is often necessary for people who do not have normal digestive function, such as those with chronic gastritis, peptic ulcers, stomach cancer, gastric outlet obstruction, and pyloric valve dysfunction.¹

What is gastroduodenostomy?

Definition

Gastroduodenostomy is, strictly speaking, a surgery that creates a new connection (anastomosis) between the stomach and the duodenum, the first part of the small intestine. A range of medical ailments can be treated with this procedure. 

Types

There are two types of Billroth procedure - Billroth-I and Billroth-II.^1,3 The Billroth-I procedure involves the partial or total removal of the stomach, while the Billroth-II procedure creates a new connection between the stomach and the jejunum, bypassing the duodenum.^1,3 The Billroth-I procedure enables food to pass from the stomach into the duodenum.

Conditions that lead to a requirement for gastroduodenostomy

This procedure is recommended for a range of medical ailments, including:

• Stomach cancer: for malignant growth in the stomach, it is best to remove the tumour via this procedure, especially if the tumour is located in the lower part (antrum) of the stomach.¹
• Severe stomach or duodenum injuries from traumas or a previous surgical procedure.
• Peptic ulcers: if these ulcers cannot be treated with regular treatments, this procedure might be the best option to remove the stomach/duodenum lesion in the organ lining.^1,2,3
• Gastric outlet obstruction: when the stomach cannot correctly empty food into the duodenum due to a full or partial obstruction.

The gastroduodenostomy procedure

Before undergoing the gastroduodenostomy procedure, you will be asked to provide an extensive medical history and undergo a health assessment. This procedure is not suitable for patients with larger tumours because the surgery requires a minimum 5 cm margin of non-cancerous tissue to be removed around the tumour. In the case of a large tumour, it would leave a very small amount of stomach tissue and make it difficult to reattach the remaining stomach to the duodenum without tension.^2,3,4 

A successful procedure requires precise surgical techniques and tension-free stitching, ensuring a heavily vascularised connection (anastomosis) between the two pieces of healthy, uninflamed, and cancer-free tissue.³  Malnourishment and anaemia can be treated before the procedure with IV nutrition and blood transfusions. Gastric decompression is achieved using a nasogastric tube, which removes the stomach's content to relieve pressure and improve anaesthesia safety.

Pre-procedure preparation

Before a gastroduodenostomy procedure, several pre-procedure preparations are required, especially if the procedure is for gastric cancer. Various diagnostic tests such as CT scans, endoscopic ultrasounds, endoscopy, X-rays, and laparoscopy may be used to assess the extent of the tumour, its nodal involvement, and its invasiveness. Additionally, certain medications may need to be stopped before the procedure. It is crucial to ensure that you are healthy enough to undergo the procedure, and if you suffer from malnutrition, which is especially common for those with gastric outlet obstruction, it should be addressed before the procedure.²

Anaesthesia used during the procedure

Before the gastroduodenostomy procedure, general anaesthesia is administered by an anaesthesiologist, and a nasogastric tube is put in place.^2,3 Throughout the procedure, your vital signs will be carefully monitored to ensure your safety. The type and amount of anaesthesia used are dependent on various factors, such as your medical history, age, weight, and the length of the procedure. The anesthesiologist will conduct a thorough evaluation of your health and develop a personalised anaesthesia plan to ensure that you are comfortable and unaware of the surgical procedure.

Surgical techniques used for gastroduodenostomy

Surgical techniques used for gastroduodenostomy vary depending on different factors, such as medical history, the condition being treated, and the surgeon's expertise.² Typically, these days, the operation is carried out laparoscopically through several small incisions in the abdomen into which are passed cameras, lights and special surgical instruments to remove the lower portion (antrum) of the stomach. ⁴ Laparoscopic surgery has the benefits of reduced scarring and trauma and simpler infection control. ⁴

The surgeon then explores the abdomen and enters the lesser sac, located between the omentum and the transverse colon. After locating the correct gastroepiploic blood vessels, the surgeon proceeds to join the stomach body to the duodenum. Finally, the incisions are closed using either stitches or staples.² After the procedure, it is important to regularly inspect the surgical site for infection and ensure that it is correctly healing. Additionally, compatible blood may be given intravenously, and postoperative care may involve regularly monitoring your condition and vital signs.

Duration of the procedure

The duration of gastroduodenostomy can vary depending on several factors, such as the underlying condition, the surgeon's experience, and your medical history. Typically, the procedure can take anywhere from 2 to 4 hours to complete, but this may vary based on the complexity of the case and the presence of any complications. After the surgery, you will need to stay in the hospital for monitoring and recovery. The length of the hospital stay will depend on your individual needs and the surgeon's recommendations.

Post-operative care and recovery

After the gastroduodenostomy procedure, you will be taken to the recovery room, where your vital signs will be monitored, and electrolytes and fluids will be given intravenously. You will initially remain in the hospital under observation, receiving antibiotics and medication to manage any pain. Regular checks for infection, pain, and bleeding will be conducted. Due to the procedure, you will be restricted to a liquid diet initially, and solid foods will be slowly introduced later. You might experience paralytic ileus after surgery, which means slow-moving bowels, as it takes a while for the stomach's contents to move through the new connection.⁴

You will need to avoid strenuous activity for the first few weeks after the procedure. Recovery time typically takes around 6 weeks, but this can vary depending on the extent of the surgery.

Risks and complications

Common risks and complications

Abdominal surgeries are known to carry several risks and complications, including wound healing difficulties, postoperative bleeding, appetite loss, gastric reflux, trouble swallowing, post-surgery infections, blood clotting, and nausea.¹ These complications can often be attributed to patient malnourishment, which can hinder the healing process ² Invasive abdominal surgeries also carry the potential risk of excessive internal scar tissue and damage to nearby organs.

Serious risks and complications

The gastroduodenostomy procedure carries several specific risks, including hypoglycaemia, nutrient malabsorption, alkaline or bile reflux gastritis, dumping syndrome, and duodenogastric reflux, as well as anastomotic leak, bowel obstruction, and the potential development of marginal ulcers in the jejunum. Duodenogastric reflux can result in persistent vomiting, while an anastomotic leak refers to a rare but serious complication that can lead to infection in the abdominal cavity, and bowel obstruction is a blockage that occurs between the stomach and the duodenum. 

Alkaline reflux gastritis is characterised by symptoms such as bile vomiting, reduced appetite, anaemia, and abdominal pain. Bile reflux is a potential risk as the new connection may not be as successful in keeping bile and digestive juices out of the stomach, which can cause bile reflux.⁴ Dumping syndrome may lead to vomiting, sweating, abdominal pain, diarrhoea, and lightheadedness, but it is a common but usually short-term complication.  

Marginal ulcers may also develop in the jejunum due to stomach acid bypassing the duodenum, which is responsible for neutralising any remaining stomach acid. However, compared to a gastrojejunostomy, the gastroduodenostomy procedure is less invasive and involves fewer changes to normal physiological conditions, which may result in fewer long-term complications.

Outcomes of gastroduodenostomy

The success rate of the procedure

Gastroduodenostomy is an invasive procedure that is usually recommended for severe cases. However, the good news is that the procedure has been shown to offer favourable outcomes, with 85% of gastric obstruction cases experiencing good to excellent results after gastroduodenostomy.

Long-term outcomes of gastroduodenostomy

Gastroduodenostomy is an invasive procedure that alters one's digestion, but it has excellent long-term outcomes in the majority of cases. However, there may be long-term complications from the procedure. Anaemia and hypoalbuminaemia have been associated with postoperative morbidity. Preoperative weight loss and a diagnosis of malignant neoplasia are risk factors that reduce the success of the gastroduodenostomy procedure. Patients who have gastroduodenostomy instead of gastrojejunostomy experience fewer long-term complications such as pancreatic function impairment, gastritis, and lower oesophageal sphincter impairment.

Summary

Gastroduodenostomy is an invasive abdominal surgical procedure that involves the partial removal of the stomach to form a new connection to the intestines. It is used to treat a range of conditions, including stomach cancer, gastric outlet obstruction, peptic ulcers and gastritis.