Fabio Garofalo, MD, Omar Abouzahr, MD, Henri Atlas, MD, Ronald Denis, MD, Pierre Garneau, MD, Hai Huynh, MD, Radu Pescarus, MD. Sacré-Coeur Hospital
INTRODUCTION: Various reconstructions of the gastro-intestinal tract have been described in the past after distal gastrectomy. Among these, a Billroth II (BII) anastomosis can be performed with the addition of the Braun entero-enterostomy that may theoretically reduce the alkaline reflux. Given the significant complications associated with this procedure such as biliary reflux, marginal ulceration and afferent loop syndrome, a revision into a Roux-en-Y anatomy is generally recommended.
METHODS AND PROCEDURES: A 73-year-old healthy male was referred to our foregut surgery service for treatment of severe biliary gastritis. The patient previously underwent an open distal gastrectomy with a BII reconstruction followed by a Braun-type entero-enterostomy 6 months later. His main complaint was worsening daily biliary reflux with constant regurgitations, which were non-responsive to medical treatment. Initial investigations included an upper endoscopy, barium study, CT abdomen and pelvis and nutritional work-up. Based on these exams the diagnosis of severe alkaline reflux secondary to his BII reconstruction was established.
RESULTS: The pre-operative endoscopic evaluation revealed severe biliary gastritis and LA grade B esophagitis. The CT scan of the abdomen and upper GI study confirmed a distal gastrectomy with a BII reconstruction with a distal entero-enterostomy in the right hypochondrium. Intra-operatively, the patient was positioned in a standard foregut surgery position. Two 12 mm trocards and two 5 mm trocards were used for the laparoscopic procedure. First, an extensive lysis of adhesions was necessary to find the gastro-jejunostomy and jejuno-jejunostomy. Identification of the afferent and efferent limb was complicated by the patient’s incomplete intestinal malrotation with the angle of Treitz being present in the right hypochondrium. Intra-operative gastroscopy enabled visualization of the jejuno-jejunostomy and ensured correct interpretation of the anatomy. Subsequently, resection of the right-sided afferent limb completed the revision into a Roux-en-Y anatomy. The patient recovered well after the surgery and was discharged home on post-operative day 2. At 3 months follow-up, the patient’s reflux symptoms have completely disappeared.
CONCLUSION: BII reconstruction with or without Braun entero-enterostomy is a classic historical option following distal gastrectomy. Surgical revision of a BII into a Roux-en-Y anatomy is a good solution for severe biliary reflux and other long-term complications. Intra-operative endoscopy is a great adjunct to laparoscopic exploration as it greatly facilitates the accurate identification of the surgical montage, especially in cases with intestinal malrotation.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80927
Program Number: V013
Presentation Session: Gastric
Presentation Type: Video