Laparoscopic Distal Gastrectomy With Billroth I Reconstruction

John H Rodriguez, MD, Kevin M El-Hayek, MD, Andrea Zelisko, MD, Matthew Kroh, MD. Cleveland Clinic Foundation.

Introduction
Peptic ulcer disease requiring surgical intervention has become a rarity in the era of proton pump inhibitors.

Methods
We present the case of a 71 year old female who was referred to our institution for evaluation of a pyloric stricture secondary to chronic non-steroidal anti-inflammatory use. Her symptoms were consistent with gastric outlet obstruction and included bloating, nausea and failure to thrive. She had been followed for the past 6 years with serial upper endoscopies and balloon dilatation with partial improvement of her symptoms.

Results
We performed an upper gastrointestinal contrast study that revealed a high grade stricture at the pylorus. This was followed by an upper endoscopy that confirmed the findings. We dilated the stricture and were able to pass the endoscope distally. Biopsies were taken and found to be consistent with a chronic inflammatory process. Unfortunately she developed recurrent symptoms for which surgical intervention was recommended. A laparoscopic distal gastrectomy with a Billroth I reconstruction was performed. While constructing the anastomosis, the anvil migrated distally into the duodenum. We performed an intraoperative endoscopy through a 15 mm port and retrieved the anvil with a snare. The remaining of the operation was uncomplicated. Length of stay was 2 days. The patient was discharged home and has been doing well and remains asymptomatic after a 6 month follow-up.