Pediatrics. Medicine and law. Oncology. Infection » Mammalogy » Gastric resection according to Billroth-II as modified by Hofmeister-Finsterer. Technique of gastric resection for peptic ulcer Subtotal distal gastrectomy according to Billroth 2

Gastric resection according to Billroth-II as modified by Hofmeister-Finsterer. Technique of gastric resection for peptic ulcer Subtotal distal gastrectomy according to Billroth 2

A surgical operation during which 2/3 or 3/4 of the affected stomach is removed is called resection. This procedure is traumatic, so it is prescribed only in the most extreme cases when other treatment cannot help. When a gastrectomy occurs, the affected part of the organ is excised, and then the continuity between the duodenum and the stump is restored. Let's see how effective this operation is.

What is gastrectomy?

Resection (removal) of the stomach (code according to the international classification of diseases K91.1) is necessary when conservative treatment methods become powerless. It is prescribed to patients diagnosed with cancer, peptic ulcers, polyps and other diseases of the gastrointestinal tract. Gastric surgery is performed in several ways:

  1. Partial resection of the lower part of the stomach, when the preserved part is connected to the duodenum.
  2. Partial resection of the upper part of the stomach, when the upper area, which is involved in the pathological process, is excised, and then a subsequent connection of the esophagus is made to the lower part of the organ.
  3. Sleeve (longitudinal) gastroplasty. This type of operation is used in the treatment of obesity, when most of the stomach is removed while preserving the natural connections of the duodenum and esophagus.
  4. Complete gastrectomy, when the entire organ is removed and then a connection is made between the duodenum and the final part of the esophagus.

Indications for surgery

Absolute indicators for resection are malignant tumors of the stomach, when surgery gives the patient a chance to prolong life. Doctors prescribe surgical intervention when ulcers do not heal for a long time, the acidity of gastric juice is reduced, or severe scar changes occur that give a pronounced clinical picture.

Stomach cancer

All organs of the human body are made up of cells that grow and divide when new cells are needed. But sometimes this process is disrupted and begins to proceed differently: cells begin to divide when the body does not need it, and old cells do not die. Additional cells accumulate, forming tissue that doctors call a tumor or neoplasm. They can be benign or malignant (cancerous).

Stomach cancer begins in the inner cells, but over time invades the deeper layers. In this case, the tumor can grow into neighboring organs: the esophagus, intestines, pancreas, liver. The causes of malignant neoplasms of the stomach are divided into several types:

  • poor nutrition, especially associated with the abuse of fried, canned, fatty and spicy foods;
  • smoking and alcohol;
  • chronic diseases of the gastrointestinal tract: ulcers, gastritis;
  • hereditary predisposition;
  • hormonal activity.

Severe stomach ulcer

An ulcer is a defect in the gastric mucosa. Peptic ulcer disease is characterized by periodic exacerbations, especially in the spring and autumn. The main reason for the development of the disease is frequent stress, which strains the nervous system, which causes muscle spasms in the gastrointestinal tract. As a result of this process, a malfunction in the nutrition of the stomach occurs, and gastric juice has a detrimental effect on the mucous membrane. Other factors leading to the development of peptic ulcers:

  • disrupted diet;
  • chronic gastritis;
  • genetic predisposition;
  • long-term medication use.

With a chronic gastric ulcer, the formation of ulcerative defects occurs on the mucous membrane of the organ. Resection of these pathologies is performed when complications of the disease develop, when there is no effect from conservative therapy, bleeding occurs, and stenosis develops. This is the most traumatic type of surgery for stomach ulcers, but also the most effective.

Laparoscopic resection for obesity

Laparoscopic surgery is an endoscopic method of gastric surgery, which is performed through punctures in the abdominal cavity with a special instrument without a wide incision. This resection is carried out with the least trauma for the patient, and the cosmetic postoperative result is much better. The indication for laparoscopic gastrectomy is the extreme stage of obesity, when neither medication nor a strict diet helps the patient.

With obesity, a metabolic disorder occurs, and when the process of losing weight can no longer be controlled, doctors have to remove part of the stomach, after which the patient gets rid of the problem, loses weight and gradually returns to everyday life. But the biggest advantage of laparoscopy is the restoration of normal metabolism, reducing the risk of atherosclerosis and coronary heart disease. Watch the video to see how laparoscopic gastrectomy is performed:

Operation technique

Carrying out gastric resection is a technically complex process, and in order to avoid postoperative inflammation, scarring and other complications, you should take seriously the choice of a medical institution and the qualifications of surgeons. The choice of surgical technique depends on the degree of organ damage, the patient’s condition, his age, anatomical and other characteristics. All types of resection are performed under general anesthesia, and the duration of surgical intervention on the stomach does not exceed three hours.

Basic methods of performing the operation

There are many different options for gastric resection and reconstruction. Theodor Billroth first performed such an operation back in 1881, and in 1885 he also proposed another way to restore the functioning of the gastrointestinal tract. These gastric surgeries are still used today, but today they have been modernized and simplified, so they are available to a wide range of practicing surgeons. The doctor selects the type of operation individually in each case, but more often they use:

  1. Subtotal distal resection, when the lesion is located in the pyloroantral part of the lower third of the stomach (the entire lesser curvature).
  2. Subtotal proximal resection, performed for stage 1 and 2 gastric cancer, when the lesser omentum, lymph nodes, lesser curvature and a section of the greater omentum are removed.
  3. Gastrectomy, which is performed in the presence of a primary multiple tumor or infiltrative cancer located in the middle part of the stomach. The entire organ is removed, and an anastomosis is performed between the esophagus and the small intestine.

By Billroth 1

Gastric resection according to Billroth 1 is the excision of 2/3 of the organ, when the physiological path of food movement with the participation of pancreatic excretion and bile is preserved. During surgery, the anastomosis of the duodenum and stomach is connected end to end. This method is used for polyps, malignant ulcers, and small cancerous tumors of the gastric antrum.

By Billroth 2

During Billroth 2 resection, a large part of the blind stump of the duodenum and stomach, anterior and posterior anastomosis (connection of two organs) are removed. After this operation, the physiological path of food movement is disrupted - it enters directly into the jejunum, and bile reflux is possible and the anastomosis is disrupted. Resection according to Billroth 2 has more indications, since it is performed on gastric ulcers of any location and for cancer, since it gives the doctor the opportunity to perform extensive removal of the organ up to 70%.

According to Hofmeister-Finsterer

The Hofmeister-Finsterer technique is a modified version of Billroth 2, which provides for resection of at least 2/3 of the organ for peptic ulcer disease. During the operation, the entire secretory zone is removed, after which the motor function of the stomach undergoes significant changes: peristalsis weakens, the function of the pylorus, which ensures the gradual evacuation of food, disappears altogether.

By Ru

The Roux method is the removal of part of an organ with a Y-shaped gastroenteroanastomosis. In this case, the jejunum is divided, and its distal end is sutured and connected to the lower third of the gastric stump. This is also a modification of Billroth 2, which is indicated for duodenogastric reflux esophagitis, which is characterized by the reflux of the contents of the duodenum into the stomach.

According to Balfour

The Balfour method involves placing a gastrointestinal connection on a long loop of jejunum. This method prevents pathological changes in the organs of the gastrointestinal tract, and is also used for very high resection due to peptic ulcer or the impossibility of suturing in another way due to the anatomical features of the gastric stump. Balfour resection eliminates the gap between the knees of the jejunum, which eliminates the future occurrence of intestinal obstruction.

Rehabilitation process after surgery

As after any surgical intervention, so after gastrectomy, all sorts of complications and risks of developing negative symptoms arise: peritonitis, bleeding, anemia, reflux esophagitis, dumping syndrome. The average length of a patient's stay in the hospital after surgery is from 2 to 3 weeks, and the patient can sit as early as 5-6 days after resection. According to the doctor's recommendation, physical activity should be limited for some time, and a bandage should be worn for 4-6 months. Complete restoration of gastrointestinal functions occurs after 3-5 years.

Diet and nutrition after resection

After removal of part of the stomach, nutrition must be adjusted, because food very quickly after resection comes from the esophagus into the small intestine, so complete absorption of nutrients will not always occur during meals. The following nutritional rules will help you avoid complications after gastric surgery:

  • eat up to 6 times a day;
  • eat slowly, chewing food thoroughly;
  • limit dishes containing easily digestible carbohydrates: honey, sugar, jam;
  • tea, milk, kefir and other drinks should be consumed no earlier than 30 minutes after meals, so as not to overload the stomach;
  • Particular importance should be given to animal proteins, which are found in chicken, eggs, fish, cheese, cottage cheese and vitamins contained in vegetables, fruits, berries, and herbal infusions.

In the first 3 months after resection, special emphasis should be placed on nutrition, because at this time the digestive system adapts to new living conditions. At this time, you should eat mainly mashed or chopped steamed foods. Recommended dishes: vegetable broth soups, pureed milk porridges, vegetable soufflés, fruit puddings, steam omelettes, whole milk, sour cream sauces, weak coffee with cream and tea with milk.

Sample menu

  • Day 1: complete fasting;
  • Day 2: fruit jelly, unsweetened tea, still mineral water, 30 ml every 3 hours;
  • Days 3 and 4: soft-boiled egg, 100 ml of unsweetened tea, rice porridge, meat cream soup, rosehip decoction, curd soufflé;
  • Days 5 and 6: steam omelette, milk tea, pureed buckwheat porridge, pureed rice soup, steamed meat dumplings, carrot puree, fruit jelly;
  • Day 7: liquid rice porridge, 2 soft-boiled eggs, sugar-free cottage cheese soufflé, pureed vegetable soup, steamed meat cutlets, steamed fish fillet, mashed potatoes, jelly, white bread crackers.

There are various diseases of the stomach or duodenum. One of the methods of treatment by surgical intervention is Billroth gastrectomy. In this case, part of it is removed, but thanks to the gastrointestinal connection, the gastrointestinal tract gradually restores its integrity.

The use of arthrotomy depends on the type of pathology, its size and location. This procedure is performed by two currently known methods 1 and 2. The history of the appearance of the technique.

Like many other operations, subtotal gastrectomy using the method described below appeared after lengthy experiments on animals, because first it was necessary to prove the possibility of removing part of the epigastrium from a physiological point of view. So in 1810, the operation was carried out by Professor Merrem on several dogs, and was successful.

For a long time, the experiments remained in the shadows and were forgotten, but half a century later (1876), on behalf of the doctor-inventor, they risked repeating the experiments. This is how the idea emerged that abdominal cancer could be cured. However, the first experiments with patients ended fatally, since the surgeons did not have such experience. So, when trying to repeat the operation in Russia, the patient died and success was achieved only in 1882.

In 1885, the second method was invented, unexpectedly for the discoverer himself. Another experimental subtotal gastrectomy was underway; it was planned to perform an anterior colonic gastroenteroanastomosis, but then he changed his mind after seeing that the patient’s condition was good. Aesculapius decided to simply cut off the affected part, tightly suturing the remains.

Method 1

The scheme of gastric resection using this technique involves the circular removal of the pyloric and antral parts of the stomach and the subsequent “end to end” placement of parts of the operated organs. Now this effect is carried out with Haberer modification number 2.

Pros of use:

  • Anatomical changes in the body do not occur and the functions of the gastrointestinal tract do not change, its acidity is normalized;
  • surgical intervention using the first method is much easier and is tolerated;
  • Gastric resection according to Billroth 1 does not provoke the development of hernias;
  • Dumping syndrome is found very rarely.

More on the topic: Heartburn in the stomach: how to get rid of it?

Disadvantages of use:

  • high probability of ulcers;
  • narrowing of the lumen of the interior, which in turn will complicate food intake and the processes of its digestion;
  • cannot be performed for cancer of this viscera.

Method 2

The scheme of gastric resection using this technique involves suturing it with anterior or posterior gastroenteroanastomosis. There is no one specific modification. All of them are used depending on the situation: suturing an organ, suturing the gastrointestinal tract to the remaining part of the epigastrium, etc.

Pros of use:

  • there is no tension on the seams;
  • peptic ulcers of the anastomosis occur much less frequently;
  • suturing of the stump is easier than anastomosis in the case of a complex duodenal ulcer;
  • Only after resection using method 2 can the gastrointestinal tract be started after excision of the ulcer using the “off” technique. Disadvantages of use:
  • there is a high risk of dumping syndrome;
  • complications in the form of internal hernias and adductor loop syndrome.

Indications for use

Gastric resection according to Billroth 1 is recommended by doctors for use in situations with benign stenoses. It cannot be used in cases of stomach cancer, because it reduces the boundaries of the invasion. This means that the proper radicalism will not be implemented.

Indications for the process increased in the 50s of the last century, because it began to be used not separately, but together with vagotomy in the treatment of ulcers.

Gastric resection according to Billroth 2 is used in modern medicine when pyloric-antral resection alone is not enough. For example, when removing more than half of the inside, when removing polyps that are located throughout the abdominal cavity, as well as with moderate and severe cicatricial deformities.

This resection method is mandatory in the presence of malignant epigastric tumors.

Today, scientists have developed a large number of stapling devices for gastric resections according to Billroth, the purpose of which is to maintain asepsis and speed up the surgical process.

Complications after surgery

Despite the fact that the operation was invented 2 centuries ago, complications of Billroth resection still occur. These include peritonitis, pancreatitis, problems with the respiratory system, heart disease and even bleeding.

More on the topic: Erosive gastritis: how to be and what to do?

The most dangerous of all of the above is peritonitis. It causes death in 50% of patients. This often happens due to failure of the joint sutures or their divergence after resection using this technique. Doctors call infection the main cause of peritonitis. This happens during surgery if maximum sterility of the instruments has not been ensured.

Contact your doctor immediately if you experience persistent, unrelenting abdominal pain after surgery. This may be accompanied by hiccups and brown vomit. Peritonitis does not appear out of nowhere. It either gradually increases over 3-4 days after the Billroth resection operation, or is detected from time to time, but in a weak form, and only then the patient’s condition sharply deteriorates.

Providing qualified assistance should be as quickly as possible. The victim is sent for relaparotomy, where he is removed from exudate and fluid that has leaked from the organs. If possible, the defect is sutured, and the abdominal cavity is dried with napkins and tubes. The patient is given antibiotics through the same tubes, and dressings are also made 3 times a day.

The doctor’s unwillingness to take decisive and radical action can be disastrous in this situation.

The second important problem after resection can be anastomositis. They are not amenable to conservative treatment and require intensive anti-inflammatory therapy. In medical practice, there are cases of the formation of extensive infiltrates that spread to the entire abdominal cavity and lead to the death of the patient.

Complications in the form of motor disorders of the stomach after surgery occur very rarely. Of the 200 surgeries performed recently, only one woman developed these symptoms.

A common abnormality is disturbances in the functioning of the pancreas. Various disorders of this organ were registered in 85% of patients. Doctors explain this phenomenon by the fact that the pancreas reacts very sharply to any surgical intervention in the body, provoking physiological changes.

A) Indications for Billroth II gastrectomy (gastrojejunostomy):
- Relative indications: if the creation of gastroduodenostomy is impossible for anatomical reasons.
- Alternative operations: Billroth I, so-called combined resection, gastrectomy.

b) Preoperative preparation:
- Preoperative studies: transabdominal and endoscopic ultrasound, endoscopy with biopsy, radiography of the upper gastrointestinal tract, computed tomography.
- Patient preparation: nasogastric tube.

V) Specific risks, informed consent of the patient:
- Damage, splenectomy (0.5% of cases)
- Bleeding (2% of cases)
- Homologous blood transfusion
- Anastomotic failure (gastroenterostomy - in 1%, duodenal stump - in 2% of cases)
- Impaired passage of food (5-15% of cases; dumping syndrome, afferent loop syndrome)
- Damage to the common bile duct
- Damage to the middle colic artery
- Anastomotic ulcer
- Gastric stump cancer
- Pancreatitis (less than 2% of cases)

G) Anesthesia. General anesthesia (intubation).

d) Patient position. Lying on your back.

e) Access. Upper midline laparotomy.

For partial gastrectomy, the incision is usually made between X-X1 and Z-Z1; for more localized anterectomy, the resection is limited to between Y-Y1 and Z-Z1.
The anastomosis is performed according to the standard Billroth I or Billroth II schemes. Published with permission of Professor M. Hobsly

and) Stages of gastric resection according to Billroth II:
- Gastrojejunostomy according to Billroth II: sutures of the posterior wall
- Gastrojejunostomy according to Billroth II: sutures of the anterior wall
- Billroth II: enteroenteroanastomosis according to Brown
- Billroth II with enteroenteroanastomosis according to Brown

h) Anatomical features, serious risks, surgical techniques:
- The fundus of the stomach and spleen (short gastric vessels), greater curvature and transverse colon/mesentery, distal lesser curvature and hepatoduodenal ligament, as well as the posterior wall of the stomach and pancreas are located close to each other.
- There are several important vascular connections: between the left gastric artery and the right gastric artery from the hepatic artery - along the lesser curvature; between the left gastroepiploic artery from the splenic artery and the right gastroepiploic artery from the gastroduodenal artery - along the greater curvature; between the short gastric arteries from the splenic artery - in the area of ​​the fundus of the stomach. An important venous trunk along the lesser curvature (gastric coronary vein) drains into the portal vein.
- Warning: rupture of blood vessels.
- In approximately 15% of cases, an additional left hepatic artery is found in the lesser omentum, coming from the left gastric artery.

And) Measures for specific complications:
- Bile duct injury: Place a primary suture with absorbable material (4-0 PDS) after insertion of the T-tube.
- Splenic injury: Attempt to preserve the spleen by electro/sapphire/argon plasma coagulation hemostasis and application of hemostatic material.
- Rupture of the duodenal stump: if repeated secure sutures are not possible, either provide a Roux-en-Y jejunal vent, or create a controlled duodenal fistula by inserting a thick, soft catheter (e.g., urinary) into the duodenal stump, covering the omentum with a strand, and removing the catheter through the abdominal wall.

To) Postoperative care after gastrectomy according to Billroth 2:
- Medical care: remove nasogastric tube on days 3-4, remove drains on days 5-7.
- Resumption of nutrition: small sips of clean liquid from 4-5 days, solid food - after the first independent stool.
- Bowel function: enema from the 2nd day, oral laxatives - from the 7th day.
- Activation: immediately.
- Physiotherapy: breathing exercises.
- Period of incapacity: 2-4 weeks.


1. Gastrojejunostomy according to Billroth II: sutures of the posterior wall. Restoring the continuity of the gastrointestinal tract after gastrectomy can be achieved by Billroth II gastrojejunostomy. To do this, the stomach is anastomosed with a loop of jejunum, which is carried anteriorly or retrocolicly. The anastomosis begins from the posterior wall, with separate sutures (3-0 PGA). The width of the anastomosis should be approximately twice the width of the duodenal lumen.

2. Gastrojejunostomy according to Billroth II: sutures of the anterior wall. Once the posterior suture line is completed, the anterior wall is created with separate sutures. Particular attention should be paid to the junction of the gastrointestinal anastomosis and the resected lesser curvature. Both corner flaps of the stomach and the edge of the anastomosis are closed with U-shaped sutures. Otherwise, anastomotic failure may occur in the so-called “sorrow angle.”


3. Billroth II: enteroenteroanastomosis according to Brown. With a long jejunal loop, an enteroenteroanastomosis according to Brown is required to connect the afferent and efferent loops. The anastomosis can be performed with a manual or hardware suture.

4. Billroth II with enteroenteroanastomosis according to Brown. Restoring the continuity of the gastrointestinal tract after gastrectomy using Billroth II anastomosis involves closing the duodenal stump and applying an enteroenteroanastomosis according to Brown in an anterior colon modification.

5. Video of gastric resection technique according to Billroth 2 .

Today, modern techniques are used during gastric resection. One of the most famous techniques is Billroth. There are two options for carrying out such an operation. They have certain differences. Those who are faced with serious stomach diseases should know the differences between Billroth 1 and 2. The features of these methods will be discussed further.

General definition

Billroth-1 and 2 techniques are types of gastric resection. This is a surgical operation used to treat serious diseases. These include pathologies of the stomach and duodenum. The technique involves removing part of the stomach. At the same time, the integrity of the digestive tract is restored. For this purpose, this connection of tissues is created using a certain technology.

Billroth is a fairly serious operation. It was the first successful surgical intervention of this type. Nowadays the technique is being improved. There are other ways to successfully remove part of the stomach. However, Billroth is still actively used in world-famous clinics. Surgical operations performed using the presented method in Israel are especially known for their high quality.

It is worth noting that the method of resection largely depends on the location of the pathological process. The type of disease also influences this. Most often, Billroth-1 and 2 are prescribed for stomach ulcers or cancer. Before the operation, the size of the excised area is assessed. Next, a decision is made on the method of resection.

The Billroth technique is one of the most frequently used during gastric resection. There are a number of differences between these techniques. They appeared at different times. However, Billroth-1, although it is the first technique of its kind, is still quite effective today.

Historical reference

Gastric resection according to Billroth was first successfully performed on January 29, 1881. The author and performer of this technique is Theodor Billroth. This is a German surgeon, a scientist who was able to restore the patency of the gastrointestinal tract by performing an anastomosis of the lesser curvature of the stomach with the duodenum. The operation was performed on a 43-year-old woman who suffered from stenotic type cancer. The pathology developed in the pyloric part of the stomach.

In the same year in November, the first successful resection of a peptic pyloric ulcer was performed using the same technique. The patient survived after such surgical intervention. This technique was called Billroth-1. After the first operation, the German surgeon himself began to create a connection not in the lesser, but in the greater curvature of the stomach.

Of course, the technology of that time could not be called flawless. At the end of the 19th and beginning of the 20th century, the gastroduodenal suture line caused a lot of trouble for surgeons when using the presented technique. Often they turned out to be insolvent. During this time, 34 patients were operated on according to Billroth-1. 50% of patients died.

To reduce mortality due to suture failure, it was proposed in 1891 that the end of the stomach be sutured, creating a connection to the duodenum and the posterior wall of the stomach. A little later, they began to create an anastomosis with the anterior wall of the stomach. It was also proposed to mobilize the duodenum (in 1903). This maneuver was invented by the scientist, surgeon Kocher.

As a result, in 1898, at the Congress of German Surgeons, 2 main methods of gastric resection according to Billroth 1 and 2 were established.

Features and benefits of Billroth-1

To understand how Billroth-1 differs from Billroth-2, you need to consider the features of each of these operations. They are used for various stomach diseases. The first technique is characterized by a circular type of excision of parts of the gastrointestinal tract that are affected by pathology. Subsequently, during this operation, an anastomosis is performed. It is located between the duodenum and the rest of the stomach and is created according to the “ring to ring” principle.

However, the anatomy of the esophagus remains unchanged. The preserved part of the stomach performs a reservoir function. During gastric resection according to Billroth-1, contact between the mucous membranes of the intestine and stomach is excluded. The advantages of this technique are:

  1. The anatomical structure does not change. The functioning of the gastrointestinal tract and its digestive tract is preserved.
  2. Technically, performing such a surgical intervention is much easier. In this case, the operation is performed in the upper part of the peritoneum.
  3. According to statistics, dumping syndrome (dysfunction of the intestine) after the presented intervention is very rare.
  4. There is no syndrome of adductor loop formation.
  5. The method does not lead to the subsequent development of hernias.

It is also worth noting that the path that food takes after surgery becomes shortened, but the duodenum is not excluded from it. If some part of the stomach can be left, it will be able to fulfill its natural function - to be a reservoir for food.

This operation is carried out quite quickly. The consequences are much better tolerated by the body. The risk of peptic ulcers at the anastomosis site is also eliminated.

Billroth-1: disadvantages

Operations according to Billroth 1 and 2 also have certain disadvantages. They must be taken into account when choosing a surgical procedure. During the Billroth-1 operation, duodenal ulcers may be observed.

With this method of surgical intervention, it is not possible to qualitatively mobilize the intestine in all cases. This is necessary to create an anastomosis without tension on the suture. This problem occurs especially often in the presence of duodenal ulcers that penetrate into the pancreas. Also, severe scarring and narrowing of the intestinal lumen can lead to the inability to properly mobilize the duodenum. The same problem occurs when ulcers develop in the proximal stomach.

Some surgeons enthusiastically insist on performing Billroth-1 resection, even if there are a number of unfavorable conditions for its implementation. This significantly increases the likelihood of suture failure. Therefore, in some cases it is necessary to abandon the Billroth-1 operation. If there are significant difficulties, it is better to give preference to surgical intervention using the second method.

It is extremely important that the technique of the surgeon who will perform the operation be carefully honed and practiced as much as possible. Although Billroth-1 is considered an easier, faster technique, it is performed exclusively according to strict indications. The decision to conduct it is made only if certain factors are present and certain obstacles are absent.

In some cases, this operation requires mobilizing not only the duodenum, but also the spleen and intestinal stump. In this case, it is possible to create a seam without tension. Extensive mobilization greatly complicates the operation. This unnecessarily increases the risk during its implementation.

It is also worth noting that resection using the Billroth-1 technique is not performed during the treatment of gastric cancer.

Billroth-2 technique

Considering briefly Billroth-1 and 2, it is worth paying attention to the second type of resection technique. During this operation, the part of the stomach remaining after excision is sutured using the technique of applying a posterior or anterior gastroenteroanastomosis. Billroth-2 has many modifications.

In this case, anastomosis is performed according to the “side to side” principle. The remaining part of the organ is sutured to the jejunum. Often used modifications of Billroth-2 are methods for closing the stump of the stomach, suturing its remaining part with the jejunum, etc. This technique is used in this case. If there are contraindications to Billroth-1.

It is worth noting that Billroth-2 is prescribed for ulcers and stomach cancer, and other diseases of the organ. In this case, a resection of the organ is performed in an amount determined by the condition of the stomach and the type of disease. The organ is sutured after excision in a special way. For some diagnoses, this operation is the only option. Billroth-2 allows you to make the gastrointestinal tract passable.

Billroth-2: positive and negative sides

Resection according to Billroth 1 and 2 has a number of positive and negative qualities. The second technique has a number of advantages. When performing Billroth-2, it is possible to perform an extensive resection without tension on the gastrojejunal sutures. If a patient is diagnosed with a duodenal ulcer, when performing an operation using this technique, the occurrence of a peptic ulcer at the junction occurs much less frequently.

Also, if a patient has a duodenal ulcer, which is accompanied by the presence of gross pathological defects in the duodenum, suturing the organ stump is much easier than creating an anastomosis with the stomach.

If a patient has a duodenal ulcer that cannot be resected, it becomes possible to restore the patency of the gastrointestinal tract only with the help of Billroth-2. These are the main advantages of the presented method.

The disadvantages of the method are the following:

  • increased risk of developing dumping syndrome;
  • the operation is accompanied by difficulties and requires more time;
  • there is a possibility of occurrence;
  • in some cases, after Billroth-2, an internal hernia occurs.

However, this technique has its place. Billroth-2 is sometimes the only possible solution for the development of certain pathologies. Therefore, doctors carefully study the characteristics of the disease before prescribing one or another type of operation.

Differences between methods

It should be noted that the techniques of Billroth 1 and 2 are significantly different. The connection point in the first case is called “ring into rings”. With Billroth-2, the anastomosis has a side-to-side appearance. Accordingly, due to such intervention, complications may develop in both cases. However, in both cases they are not similar.

It is worth noting that the degree of expression of dumping syndrome in Billroth-2 is more pronounced. The work of the stomach itself and the entire gastrointestinal tract after these operations is also different. With Billroth-1, the patency of the intestinal tract is preserved. However, this operation is not performed for stomach cancer, extensive ulcers and gross changes in stomach tissue. In these cases, the Billroth-2 technique is indicated.

Indications for Billroth-1 are the following conditions:

  • Peptic ulcers of the stomach. This is the least controversial indication. In this case, resection of 50-70% of the stomach gives a good result. In this case, an addition in the form of a truncal vagotomy is not required. The only exception is surgery for prepyloric ulcers and pathologies in the area of ​​the turn in the case of increased gastric secretion.
  • For duodenal ulcers, resection of 50-70% of the stomach is indicated, but only when using truncal vagotomy.

Indications for Billroth-2 can be stomach ulcers, which have almost any localization. If half of the stomach is excised, truncal vagotomy is used.

Also, for stomach cancer, the only possible option for excision of the affected tissue is Billroth-2. This is explained by the ability to perform extensive resection not only of the stomach, but also of regional lymph nodes and the duodenum. In this case, the occurrence of anastomotic obstruction is less likely than in the case of the first technique.

Modifications of the first technique

The differences between Billroth 1 and 2 are significant. These techniques have modern modifications. The second method has more of them. With Billroth-1, the modifications differ only in the method of creating the anastomosis. The fact is that the size of the diameters that connect to each other is different. This leads to a number of difficulties. Only with a very limited resection in the pyloric part of the stomach, which is carried out according to the Pean technique, can it be connected to the duodenum “end to end” without preliminary suturing or narrowing.

One of the main modifications of Billroth-1 is the Haberer technique. It allows you to eliminate the discrepancy in organ diameters after resection without suturing part of the lumen of the gastric stump. In this case, a corrugated suture is applied. After this, an end-to-end anastomosis can be performed. Haberer's method has been significantly improved today. Previously, it often led to narrowing of the anastomosis and its obstruction.

There are other ways to narrow the lumen. They differ from the Haberer method in the way they create corrugated seams.

Modifications of the second technique

During Operation Billroth 2, many modifications are used. The main one is the technique proposed by Hoffmeister-Finsterer. Its essence is as follows. After excision of damaged tissue, part of the stomach is connected according to the “end to side” principle. In this case, the width of the anastomosis should be 1/3 of the total lumen of the gastric stump.

The connection is fixed transversely in the artificially created lumen. In this case, the afferent loop of the jejunum is sutured with two or three sutures. They are performed according to the type of nodules in the stump. This feature allows you to prevent food from entering the reduced area of ​​the gastrointestinal tract.

Other Resection Improvements

Having considered the differences between Billroth 1 and 2, it should be noted that although there is a big difference between these methods, they have been significantly improved since their discovery. Therefore, today the resection procedure is performed with less risk for the patient. In specific conditions, certain techniques are used.

Thus, surgeons can perform distal excision of the diseased area of ​​the organ with the formation of an artificial pyloric sphincter. In some cases, in addition to this, an invagination valve is installed. It is formed from the tissues of the mucous membrane.

Resection can be carried out with the creation of a pyloric sphincter, type. An artificial valve can be formed at the entrance to the duodenum. In this case, the pyloric sphincter is preserved.

Sometimes distal resection can be subtotal. In this case, primary type jejunogastroplasty is performed. Some patients are indicated for subtotal, complete gastrectomy. In this case, an intussusception valve is formed at the outlet portion of the jejunum.

If the patient is indicated for proximal resection, an esophagogastroanastomosis and an invagination valve are installed. Existing techniques make it possible to perform resection of the diseased area of ​​the organ as accurately as possible. In this case, the risk of complications will be minimal.

Having examined the differences between Billroth 1 and 2, one can understand the basic principles of such surgical interventions. Both methods have been greatly improved. Today they are used in a modified form.

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.



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