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 Table of Contents     
UNUSUAL CASE
Year : 2019  |  Volume : 15  |  Issue : 2  |  Page : 161-163
 

Total laparoscopic Billroth-I gastrectomy for corrosive-induced antropyloric stricture


Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission22-May-2018
Date of Acceptance23-May-2018
Date of Web Publication12-Mar-2019

Correspondence Address:
Dr. Raja Kalayarasan
Department of Surgical Gastroenterology, JIPMER, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_132_18

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 ¤ Abstract 

Antro-pyloric stricture with gastric outlet obstruction is a common manifestation of corrosive-induced gastric injury. Surgical management is the only curative option as endoscopic dilatation usually fails in the long term. Billroth I gastrectomy with gastroduodenostomy is the preferred surgery as it restores normal alimentary pathway, reduces dumping and does not complicate colon mobilisation for the future oesophageal bypass. Conventionally, it is performed by the open approach. The present report is the first technical description of total laparoscopic Billroth-I gastrectomy using the laparoscopic linear cutter for corrosive-induced antropyloric stricture. The two patients who underwent this procedure had patent gastroduodenal anastomosis on the post-operative contrast study and tolerating normal diet at 9 and 6 months follow-up, respectively.


Keywords: Antropyloric stricture, Billroth I gastrectomy, corrosive, laparoscopic


How to cite this article:
Nagaraj K, Kalayarasan R, Gnanasekaran S, Pottakkat B. Total laparoscopic Billroth-I gastrectomy for corrosive-induced antropyloric stricture. J Min Access Surg 2019;15:161-3

How to cite this URL:
Nagaraj K, Kalayarasan R, Gnanasekaran S, Pottakkat B. Total laparoscopic Billroth-I gastrectomy for corrosive-induced antropyloric stricture. J Min Access Surg [serial online] 2019 [cited 2019 May 23];15:161-3. Available from: http://www.journalofmas.com/text.asp?2019/15/2/161/235401



 ¤ Introduction Top


The corrosive gastric stricture is late sequelae of corrosive-induced gastric injury and is commonly associated with acid ingestion.[1] The antropyloric region of the stomach is frequently affected due to reflux pylorospasm which, in turn, leads to prolonged contact time. In the absence of oesophageal stricture patients with antropyloric stricture present with features of gastric outlet obstruction. Surgery is required in most of the patients as endoscopic treatment approaches are associated with poor long-term results.[2] Limited gastrectomy with gastroduodenal reconstruction is the preferred treatment for corrosive-induced antro-pyloric stricture.[1] Conventionally, it is performed by the open approach. This is the first report of totally laparoscopic distal gastrectomy with gastroduodenal anastomosis for corrosive gastric stricture using the laparoscopic linear cutter.


 ¤ Case Reports Top


Patient 1

A 34-year-old male patient presented 1 month after accidental corrosive acid ingestion with progressive dysphagia. On evaluation with barium meal, he was found to have both oesophageal and antropyloric stricture. He underwent laparoscopic feeding jejunostomy and multiple sessions of endoscopic dilatation for oesophageal stricture. After 9 months, with the oesophageal stricture manageable with endoscopic dilatation, the patient underwent laparoscopic Billroth-I gastrectomy. He had an uneventful post-operative course with a patent gastroduodenal anastomosis on the oral contrast study. At 9 months follow-up, the patient is tolerating the normal diet.

Patient 2

A 22-year-old female with a history of acid ingestion presented with postprandial abdominal pain and distention of 1-year duration. Barium meal revealed antropyloric stricture with the dilated stomach. There was no evidence of oesophageal stricture. After nutritional optimisation, she underwent laparoscopic distal gastrectomy with Billroth I reconstruction. Post-operative contrast study revealed patent anastomosis and the patient was discharged on the 4th postoperative day. At 6 months follow-up, the patient is tolerating a normal diet.

Technical description

Under general anaesthesia, the patient is placed in supine position. Six laparoscopic ports were placed in the following order-one 12-mm camera port at infraumbilical region, two 5-mm ports in the right and left pararectal region 5 cm above the camera port, a 5-mm port in the right subcostal region at midclavicular line and a 12-mm port at a corresponding location on the left side. For liver retraction, one 5-mm port was placed only below the xiphisternum. The primary surgeon stands on the left side of the patient. Assistant surgeon and the camera surgeon stands on the right side of the patient. Gastrocolic omentum was divided with Harmonic Scalpel™ (Ethicon Endosurgery, Cincinnati, OH, USA) and lesser sac entered. Right gastroepiploic vessels were ligated with Hem-o-lok clips ® (Weck Closure System; Research Triangle Park, Durham, NC, USA) and divided [Figure 1]a. Gastrohepatic ligament and branches of the right gastric artery are divided with Harmonic Scalpel™. An umbilical tape was passed through the retrogastric tunnel and tied over the distal portion of the stomach to provide traction [Figure 1]b and [Figure 1]c. Pylorus was lifted using umbilical tape and the proximal portion of the duodenum was mobilised to facilitate application of stapler. The healthy portion of distal stomach proximal to stricture was divided using two 60-mm green laparoscopic linear cutter (Echelon Flex TM Ethicon Endosurgery, Cincinnati, OH, USA) inserted through the left subcostal port [Figure 1]d. After gastric transection, a small gastrotomy was made on the greater curvature side of the remnant stomach and another gastrotomy was made at the level of the pylorus. One jaw of the 60-mm blue laparoscopic linear cutter was placed through greater curve gastrotomy and the stomach was brought anterior to the duodenum. The other jaw of the stapler was introduced into the duodenum through the gastrotomy made at the level of the pylorus [Figure 2]a. Proximal traction using umbilical tape facilitate the introduction of the stapler jaw into the duodenum. The firing of stapler creates a V-shaped gastroduodenostomy between posterior wall of the stomach and anterior wall of the duodenum [Figure 2]b. Through the common gastroduodenotomy, the staple line was checked for haemostasis. The common gastroduodenotomy was closed using a 60-mm green laparoscopic linear cutter and the gastroduodenostomy is completed by double-stapled technique [Figure 2]c and [Figure 2]d. Traction on the duodenum using the specimen which was kept in continuity until the end facilitates the stapling manoeuvre.
Figure 1: (a) Right gastroepiploic vessels isolated and ligated. (b) Retrogastric tunnel created after division of right gastroepiploic and right gastric vessels. (c) Umbilical tape tied at the level of distal stomach for traction. (d) Healthy stomach proximal to the level of stricture divided with stapler

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Figure 2: (a) The jaws of the laparoscopic linear cutter in the stomach and duodenum with the stomach brought anterior to the duodenum. (b) Stapled gastroduodenostomy completed with the specimen in continuity. (c) Final stapler simultaneously close the gastroduodenotomy and transects duodenum. (d) Completed anastomosis

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 ¤ Discussion Top


Ananthakrishnan et al. had classified corrosive-induced gastric stricture into five types based on the extent of involvement of stomach.[1] Type I and type II gastric strictures that involve the distal portion of the stomach are amenable for Billroth I reconstruction. Billroth I gastrectomy with gastroduodenostomy is preferred over gastrojejunostomy as it restores normal alimentary pathway, reduces bile reflux and dumping syndrome. Furthermore, Billroth I gastrectomy does not interfere with colon mobilisation for future oesophageal bypass in patients with coexistent oesophageal stricture.[1] Various techniques of laparoscopic Billroth-I gastrectomy have been described in patients with gastric cancer.[3],[4],[5] As the use of circular stapler for gastroduodenal reconstruction often requires a minilaparotomy modification using linear stapler was reported. The most common technique using linear stapler is delta-shaped gastroduodenostomy which is technically demanding.[4] Application of traction and alignment of the gastric remnant and the duodenal stump are the important reasons for the technical difficulty in doing a totally laparoscopic gastroduodenal anastomosis. In the present technique, duodenum was not transected until the end. This helps to provide traction using umbilical tape during the stapling manoeuvre. Furthermore, the number of staplers required is less compared to the delta-shaped gastroduodenostomy as the final stapler simultaneously close the gastroduodenostomy and transects duodenum. The technique described is best suited for benign antropyloric stricture as in patients with gastric cancer gastrotomy at the level of pylorus may not be oncologically acceptable. The present report is the first technical description of total laparoscopic Billroth-I gastrectomy for the management of corrosive antro-pyloric stricture. At 6 and 9 months follow-up, both patients are doing well and tolerating a normal diet.

The present technique of total laparoscopic Billroth-I gastrectomy using laparoscopic linear cutter is a simple and effective treatment for corrosive-induced antro-pyloric stricture.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Ananthakrishnan N, Parthasarathy G, Kate V. Chronic corrosive injuries of the stomach – A single unit experience of 109 patients over thirty years. World J Surg 2010;34:758-64.  Back to cited text no. 1
    
2.
Ray D, Chattopadhyay G. Surgical management of gastric outlet obstruction due to corrosive injury. Indian J Surg 2015;77:662-5.  Back to cited text no. 2
    
3.
Kitano S, Iso Y, Moriyama M, Sugimachi K. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc 1994;4:146-8.  Back to cited text no. 3
    
4.
Kanaya S, Gomi T, Momoi H, Tamaki N, Isobe H, Katayama T, et al. Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy: New technique of intraabdominal gastroduodenostomy. J Am Coll Surg 2002;195:284-7.  Back to cited text no. 4
    
5.
Tanimura S, Higashino M, Fukunaga Y, Takemura M, Nishikawa T, Tanaka Y, et al. Intracorporeal billroth 1 reconstruction by triangulating stapling technique after laparoscopic distal gastrectomy for gastric cancer. Surg Laparosc Endosc Percutan Tech 2008;18:54-8.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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