Gastrectomy for benign lesions: classic partial gastrectomy, variation: antrectomy

作者群

摘要

The description of the classic partial gastrectomy for benign lesions and its variation: antrectomy covers all aspects of the surgical procedure used for the management of benign gastric tumors.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: surgical approach, principles, mobilization of greater curvature, mobilization/transection, gastrojejunal anastomosis, gastroduodenal anastomosis, difficult duodenums, freeing of the curvature, transection of the stomach, restoration/continuity, Billroth I anastomosis, Billroth II anastomosis.
Consequently, this operating technique is well standardized for the management of this condition.

媒體類型

刊物

2001-09

普通的

最愛

音訊

數位出版

WeBSurg.com, Sept 2001;1(09).
URL: http://www.websurg.com/doi-ot02en170a.htm

Gastrectomy for benign lesions: classic partial gastrectomy, variation: antrectomy

1. Introduction

Historically, gastrectomy was indicated for benign lesions and in the radical treatment of gastric ulcers.
A significant decrease in the indications for gastrectomy has been observed in Western countries due to:
- the practice of vagotomy;
- the administration of anti-ulcer medications such as H2-blockers, proton pump inhibitors (PPI);
- the eradication of Helicobacter pylori with antibiotics.
Today, therapeutic failure for gastric ulcers is seen in less than 5% of the cases and gastrectomy represents less than 1% of surgical interventions for gastric ulcers.

Surgery is only indicated in patients who either do not respond to medical therapy or have a poor compliance record (Michot and Fraleu-Louer, 1996). Other indications are benign tumors and/or certain functional disorders.
Gastrectomy may be performed via the open approach and, more recently, via the laparoscopic approach.

2. Definitions/resection

• Two-thirds gastrectomy

A partial gastrectomy (usually indicated for benign lesions) consists of the resection of a defined part of the stomach. Rarely, a proximal resection is performed, but more commonly performed is a distal resection with or without the pylorus, an antrectomy, or a two-thirds resection of the stomach.
The line of transection through the stomach is oblique.
It starts on the lesser curvature 2 fingerbreadths (4 cm) below the cardia at the level of the left gastric artery to finish at the level of the first short gastric vessel located in the avascular zone of the greater curvature.

• Antrectomy

The line of transection through the stomach is oriented in a horizontal direction.
It starts one fingerbreadth (2 cm) above the angulus (junction between the horizontal and vertical regions of the lesser curvature), to finish on the midpoint of the gastroepiploic artery of the greater curvature.

• Distal gastrectomy

The correct landmark for the distal gastrectomy is also the landmark between the mobile part of the duodenum and the fixed duodenum. It is located below the pylorus, at the level of the duodenal bulb, 1 cm to the left of the gastroduodenal artery.

• Restoration of continuity

Restoration of gastrointestinal tract continuity is established:
- with a gastroduodenal anastomosis (performed manually or by a mechanical stapler),
or
- with a gastrojejunal anastomosis where the remaining gastric stump is united to the first jejunal loop (as above).

3. General anatomy

• Anatomical description

• Landmarks

The stomach is a J-shaped sac located between 2 fixed anatomical landmarks:
1. the cardia: junction between the abdominal esophagus and stomach,
2. the pylorus: junction between the stomach and duodenum.

• Division

The stomach is composed of 2 parts:
3. the vertical part inclines over the vertebral column to the left and is composed of both the fundus and the body of the stomach;
4. the horizontal part heads to the right beyond the linea alba.

• Duodenal bulb

The duodenal bulb, often resected during gastrectomies due to its proximity to the stomach, is:
5. the first mobile segment of duodenum. It is separated from the pancreas by the omental bursa, which extends from the right to the gastroduodenal artery.

• Physiological description

From a physiological standpoint, the stomach is composed of:
6. a gastrin-producing zone called the antrum,
7. the fundus.
The junction between these functional regions does not correspond to the junction between the horizontal and vertical regions of the stomach.

4. Vascular anatomy

• Pedicles

Gastric arterial blood supply comes from the celiac trunk.
It divides into 4 pedicles, 2 each at the level of the:
1. lesser curvature,
2. greater curvature.
The pedicles then join a wide anastomotic network that supplants vascular blood supply when one of the main trunks is either obstructed or ligated.

• Celiac trunk

The celiac trunk supplies the stomach.
It originates from the anterior aspect of the aorta above the superior aspect of the pancreas.
The trunk is 1 to 3 cm long and divides into 3 branches:
1. the left gastric artery;
2. the common hepatic artery;
3. the splenic artery.

5. Lesser curvature

• Left gastric artery

• Origin

The left gastric artery originates from the celiac trunk in 90% of cases.

• Variations

Alternatively, it originates either:
1. directly from the aorta;
2. from the inferior phrenic artery;
3. from the gastrosplenic trunk;
4. from the gastrohepatic trunk.

• Division

The left gastric artery forms an arch before joining and running along the lesser curvature 2 fingerbreadths below the cardia. It then divides into an anterior (1) and posterior (2) branch that both run down along the lesser curvature to join the terminal branches of the right gastric artery (or pyloric artery).

• Other branches

The left gastric artery gives off several branches:
1. the hepatic artery (present and functional in 30% of cases);
2. the anterior and posterior cardioesophageal arteries (that supply the cardia and abdominal esophagus).

• Right gastric artery

• Origin

The right gastric artery usually originates from the common hepatic artery.

• Variations

Alternatively, it originates directly from:
1. the gastroduodenal arteries;
2. the left hepatic artery;
3. the proper hepatic artery.

• Vascular arch

The right gastric artery approaches the pylorus, giving off one of its main terminal branches. It then divides into anterior and posterior gastric branches that join the terminal endings of the left gastric artery at the level of the angulus, the junction between the horizontal and vertical regions of the stomach.
The right and left gastric arteries comprise the vascular arch of the lesser curvature.

• Gastroduodenal junction

The free duodenum is vascularized by branches mainly originating from the gastroduodenal artery.

6. Greater curvature

• Definition

The greater curvature of the stomach is bordered by the greater omentum and gastrosplenic ligament. Each is composed of 2 layers in continuum with the gastric visceral peritoneum. The greater omentum spreads over the transverse colon and extends beyond it inferiorly at the level of the body and horizontal region of the stomach where it forms the gastrosplenic ligament at the level of the fundus. The right and left gastroepiploic arteries and the short gastric vessels form the vascular arch that runs through the anterior fold of the greater omentum.

• Right gastroepiploic artery

The right gastroepiploic artery:
1. originates from the division of the gastroduodenal artery at the inferior aspect of the duodenum;
2. runs along the greater curvature of the stomach from right to left at an average distance of 1 cm;
3. the branches originating from the right gastroepiploic artery run along the anterior and posterior aspects of the stomach and into the omentum.

• Left gastroepiploic artery

The left gastroepiploic artery originates from the division of the splenic artery. It supplies the middle part of the greater curvature and runs through the gastrocolic ligament to join the terminal branches of the right gastroepiploic artery.
The right and left gastroepiploic arteries thus form the vascular arch of the greater curvature.

• Short gastric vessels

The short gastric vessels originate from the terminal branches of the splenic artery.
Alternatively, they originate directly from the trunk of the splenic artery or from its terminal branches.
There are 2 to 6 vessels that run from the splenic hilum to the stomach via the gastrosplenic omentum.
The largest vessel – the posterior gastric artery – joins the posterior aspect of the stomach and divides to supply the fundus and the cardia.

• Vascular window

An avascular window consisting of 2 peritoneal folds is situated between the last short gastric vessel and the origin of the left gastroepiploic artery. These peritoneal folds split to form the omental bursa opposite the splenic artery.

7. Operating room set-up

• Patient

The operation is performed under general anesthesia.
The patient is administered antibiotic prophylaxis (systematically) and put in supine position.
A nasogastric tube is inserted to fully decompress the stomach.
Padding (preferably inflatable) is set underneath the patient to obtain better exposure of the intra-abdominal anatomy. The operating table may be bent posteriorly at the level of the inferior angle of the scapula in order to obtain the same result. This angle must be straightened before parietal closure, at the end of the procedure.

• Team

1. The surgeon stands on the patient’s right.
2. The first assistant stands opposite the surgeon.
3. The second assistant stands on the surgeon’s left.
4. The scrub nurse stands opposite the surgeon and on the first assistant’s left.
5. The anesthesiologist is at the head of the patient.

• Equipment

1. Anesthetic equipment
2. Electric device
3. Operating table
4. Instrument table

8. Surgical approach

• Midline incision

The midline incision extends from the xiphoid process to the umbilicus.
The upper part of the abdominal incision clearly reveals the xiphoid process and provides good visualization of the upper part of the stomach. In obese patients, the inferior part of the abdominal incision extends slightly to the left of the umbilicus. The round ligament remains undisturbed to facilitate exposure.
The parietal wall is protected using a plastic “skirt” and a “Gosset” abdominal retractor.
Subcostal retraction is not necessary.

• Horizontal incision

A horizontal bilateral subcostal incision can also be utilized.

9. Principles

1. Dissection of the greater curvature
2. Dissection of the duodenum
- Billroth II operation (closed duodenal stump)
- Billroth I operation (opened duodenal stump)
3. Dissection of the lesser curvature
4. Transection of the stomach
5. Restoration of the gastrointestinal tract continuity
- Billroth II anastomosis
- Billroth I anastomosis

10. Mobilization/curvature

• Exposure/greater curvature

The aim of this operative step is to free the posterior aspect of the stomach, key to a successful distal gastrectomy.
The stomach is retracted cephalad using either 1 or 2 Babcock clamps or a gauze pad to prevent the organ from slipping.
The transverse colon is lifted up slightly, to expose the vessels between itself and the stomach.

• Ligature and dissection

The vessels are all ligated either using ligatures, clips, or an automatic device that divides vessels after applying 2 staples. The dissection begins between the gastric wall and the gastroepiploic vessels. It extends from the middle part of the stomach up to the end of the gastroepiploic arch. The left gastroepiploic artery running along the stomach is ligated at this point.
The posterior adhesions between the stomach to the pancreas are dissected to the right down to the pylorus using an electrocautery device.

• Variation

In case of an antrectomy:
To perform an antrectomy (without vagotomy), the dissection only extends up to the middle part of the gastroepiploic arch.
In this case, the vascular arch - supplied by the left gastroepiploic artery - must be preserved since it will be supplying the remainder of the body of the stomach.

11. Mobilization/transection

• Distal dissection

The vasculature of the duodenum must be preserved when dissecting the organ.
The posterior adhesions of the pylorus are preferably transected using an Argon electrical device since it guaranties hemostasis and thus obviates having to perform numerous ligatures of the fine venous networks.
The right gastroepiploic vein that joins the gastrocolic trunk is ligated.
Care must be taken to preserve the right gastroepiploic artery.

• Proximal dissection

The stomach is retracted caudally to expose the lesser omentum.
The pars flaccida of the lesser omentum is incised down to the pylorus. This allows passage of the left hand behind the pylorus for better exposure. It allows:
- the dissection and ligature of the right gastric artery that runs along the pylorus thus presented (pyloric artery),
- the preservation of the hepatic artery, posteriorly.
The ligature or electrocauterization of 1 or 2 small supraduodenal vessels completes the dissection of the mobile duodenum.
The gastroduodenal artery constitutes the lateral landmark for the dissection of the duodenal bulb.

• Duodenal transection

The duodenal transection is carried out just to the left of the gastroduodenal artery. From 2 to 4 cm of duodenum are resected during this maneuver. About 1 cm of mobile duodenum must be preserved to ensure adequate surgical management of the stump.

• Danger

The gastric tube must be removed from the stomach to prevent it from coming in the way of the transection line. Surgical management of the stump depends on the type of anastomosis intended. Both the gastrojejunal and gastroduodenal anastomoses are described in this chapter.

12. Gastrojejunal anastomosis

• Principles

a. In the gastrojejunal anastomosis, the duodenal stump must be closed immediately since this anastomosis is achieved under the condition that the stump be closed.
b. In the gastroduodenal anastomosis, the duodenal stump must be preserved.
In certain cases, the duodenal stump cannot be utilized for an anastomosis, nor can it be adequately closed.
If a gastrojejunal anastomosis is intended, the duodenal stump is closed.

• Transecting linear stapler

The use of a transecting linear stapler (55 mm, blue cartridge) is simple, quick and secure.
The stapler achieves hemostasis, water-tightness and duodenal transection, and avoids contamination of the operative field since the organ is not opened.

• Non-transecting linear stapler

With the use of a non-transecting linear stapler (55 mm, blue cartridge), closure of the duodenal stump is performed in a single operative step. An extra running suture is not necessary since this stapler applies 3 rows of staples. The stapler is fired and a clamp is placed at stomach level.

• Manual transection/suture

The transection and suture of the duodenum may both be performed manually.
Two rigid right-angled clamps are applied on both sides of the transection line. An interrupted or extra-mucosal running suture is performed to close the stump.
Most authors further bury the suture line by applying a second row of interrupted sutures or fashioning a purse-string closure. In this case, the duodenal wall must be at least 2.5 cm long (which is more than that required for the use of a stapling device).

• Dangers and variations

• Danger

The transecting linear stapler only applies 2 rows of staples. An extra running suture must be performed to bury the staples applied on the stump.
Although the rate of postoperative fistulas is low (about 4.5% according to Kyzer et al. 1997), extreme care must be taken to prevent this grave type of surgical complication.

• Variation

Fibrin glue:
Fibrin glue can be used to reinforce suturing.
No study has demonstrated so far that the rate of postoperative fistulas significantly decreases when fibrin glue is used.

13. Gastroduodenal anastomosis

• General surgical conditions

If a gastroduodenal anastomosis is intended, the duodenal stump is preserved.
A healthy duodenal stump must be preserved.
Anastomosis of the gastric and duodenal segments must be tension-free.
Posterior adhesions of both the duodenum and pancreas must be detached before performing the anastomosis (Kocher maneuver) in order to gain a few millimeters.
An automatic linear stapler can be placed 1cm above the transection area. The stapled fragment is transected a second time just before proceeding to the anastomosis.

• Variations

• 1

Circular stapler:
A circular stapler can be used for the gastroduodenal anastomosis to help fashion a purse-string type closure. The duodenal stump is transected and the anvil of the circular stapler set in place (see Billroth I anastomosis, step 17).

• 2

Anastomosis with preservation of the pylorus :
Preservation of the pylorus and vagal nerve in the anastomosis is thought to reduce the functional sequelae caused by gastrectomy. Yet this type of surgery is rarely practiced (Yunfu et al., 1998).

14. Difficult duodenums

• Peptic ulcer development

Surgical management of duodenal stumps with advanced peptic ulcer growth is possible, yet it remains difficult to perform the transection of these duodenums.
Peptic ulcer development posterior to the duodenum affects the pancreas, the common bile duct and the accessory pancreatic duct. The sclerosis provoked by the ulceration process results in the destruction of the plane of dissection between the duodenum and the common bile duct. Transection of the duodenum may therefore injure the biliary tract.

• Protected duodenal closure

We feel that it is preferable to leave ulcerated tissues untouched and to perform a protected duodenal closure.
When the duodenum is unhealthy and/or the duodenal segment is too short, it may be impossible to utilize a linear stapler to transect both walls of the duodenum. In such cases, transverse interrupted sutures may be applied to close the duodenum.
When it is impossible to dissect the posterior aspect of the duodenum, interrupted sutures are applied longitudinally.

When it is impossible to apply secure sutures to the duodenum, a duodenostomy must be performed with the use of a probe. Three to four centimetres of a multi-perforated or “Pezzer” rubber catheter are introduced into the lumen of the duodenal stump. The stump is closed around the catheter with a running suture line or a purse-string closure. A lamina is also placed with the catheter that comes out of the patient’s right flank. The duodenostomy will retrieve 300 to 600mL of liquid per day, be maintained for 8 to 15 days, and then be progressively removed (in most cases, the opening will close by itself).

15. Freeing of the curvature

• Left lobe retraction

The left lobe of the liver is retracted cephalad and to the right using a valve retractor.

• Left gastric artery exposure

The distal part of the stomach is retracted cephalad and to the left to expose the origin of the left gastric artery.

• Left gastric artery ligature

The left gastric artery is first ligated at its point of entry over the lesser curvature. Its anterior and posterior branches are then successively ligated.
This ligature allows preservation of:
- a collateral branch of the celiac trunk that heads to the liver;
- the left accessory hepatic artery (or hepatic artery);
- and the “cardio-fundic” branch of the left gastric artery that supplies the cardia of the stomach.

16. Transection of the stomach

• Gastric tube retraction

The dual lumen gastric tube is retracted to lie at the junction between the abdominal esophagus and the cardia.

• Transection line

In performing a two-thirds gastrectomy, the left side of the transection line starts on the greater curvature where the first short gastric vessels appear.

• Stapling device

The automatic stapler is considered the most simple, quickest and efficient method for transection and closure of the stomach.
A 90 mm linear stapler using 2.5 mm green staples is applied to the stomach and fired.
An extra cartridge can be used to finish the entire transection line in order to perform the gastric transection in one operative step.

• Transection

A right clamp is placed below the staple line. The stomach is transected as close as possible to the clamp.
An extra running suture is performed along the staple line to ensure hemostasis.

• Variation

• Antrectomy

In performing an antrectomy, the gastric transection line ends on the greater curvature at the terminal end of the right gastroepiploic artery.

• Manual transection

Manual transection may be performed using either a scalpel or an electrocautery device.
The serous and muscular planes are gradually incised to expose the submucosal plane with its rich vasculature. A thin 3.0 or 4.0 absorbable suture is used to ligate the submucosal vessels.
The transection line is closed in two planes using interrupted or running absorbable sutures.

17. Restoration/continuity

Two major modalities exist for restoring gastrointestinal tract continuity after partial gastrectomy:
- the gastroduodenal anastomosis (Billroth I);
- the gastrojejunal anastomosis (Billroth II).
These procedures, first described in 1881 (Lau & Leow, 1997; Trias et al., 1996), both allow for restoring digestive tract continuity following gastric resection.

They are performed in comparable overall operative times (Kyzer et al., 1997). In the surgical literature, neither technique has been reported as giving better results (as far as secondary complications are concerned).
Secondary complications:
- late occurrence of gastric stump cancer;
- calcium and hormone metabolism alterations;
- hemorrhage;
- reflux;
- cholecystokinin secretion (Kyzer et al., 1997; Oka et al., 1995).

18. Billroth I anastomosis

• Advantages and drawbacks

Billroth I anastomosis is an end-to-end gastroduodenal anastomosis between the distal part of the stomach remnant and duodenal stump. This simple, quick, and easy-to-perform anastomosis restores the physiologic continuity of the digestive tract.
However, this anastomosis may lead to fistula formation which is particularly serious in this area, since it may prevent the patient from resuming normal dietary habits.

• General conditions

The duodenum must be healthy and well vascularized.
The suture line must be tension-free.
Gastrointestinal tract restoration using the Billroth I anastomosis should only be performed after an antrectomy.
The remaining stomach and duodenum are anastomosed manually, starting from the posterior wall, using absorbable sutures.
Danger: Because of the risk of secreting cells remaining in the stomach remnant, the Billroth I anastomosis must be performed in conjunction with a truncal vagotomy.

• Variation

Among the many variants of the Billroth I gastroduodenal anastomosis are:
a. the end-to-side gastroduodenal anastomosis (Von Haberer technique, Patel-Lataste-Noack anastomosis);
b. the anastomosis starting from the right aspect of the stomach;
c. the anastomosis starting from the posterior aspect of the gastric stump using a circular stapler.
A purse-string suture line is fashioned and the duodenal stump is resected. The anvil of the circular stapler is placed into the duodenal lumen and the purse-string tightened. One corner of the staple line resulting from the gastric resection is excised and opened to introduce the circular stapler into the gastric lumen. The posterior aspect of the stomach is perforated by the center of the circular stapler. The anvil is closed and the stapler fired to perform the anastomosis. The orifice created for entry of the circular stapler is closed using a linear stapler.
It is possible to perform the anastomosis with the circular stapler before transecting the stomach. The antrum is preserved. The circular stapler is introduced into the pylorus. The posterior aspect of the stomach is perforated by the center of the circular stapler. The stomach and duodenum are then anastomosed using an automatic stapler before proceeding to the gastric resection (Oka et al., 1995).

19. Billroth II anastomosis

• Advantages and principles

Billroth II anastomosis is a gastrojejunal anastomosis.
The main advantage of this type of anastomosis is that it can be performed regardless of the condition of the duodenum. This procedure is quick and offers good functional results.
Certain general rules should be followed:
- it is preferable to perform a mechanical anastomosis;
- the posterior aspect of the stomach and the first jejunal loop are anastomosed using a side-to-side anastomosis;
- the jejunal loop used for the anastomosis must be only 20 to 40 cm long to preserve the physiology of the digestive tract.
- the anastomosis is antiperistaltic -- the afferent loop is approximated to the lesser curvature of the stomach. The lesser curvature hence becomes the point of entry of the biliopancreatic secretions discharged into the stomach. The secretions clear the gastric pouch at the lowest point of the greater curvature.
- the anastomosis is performed below the mesocolon to prevent loop stricture at that level.

• Preparing the anastomosis

• Lifting/colon

The transverse colon is lifted and exteriorized by the assistant. It is stretched and transilluminated to find an avascular zone in the mesocolon between its origin and Riolan's vascular arcade. A 5 to 7 cm opening is fashioned at the origin of the transverse mesocolon in this avascular zone.
The part of the jejunum chosen for the anastomosis is brought closer to the stomach by using Babcock clamps placed on the staple line under the mesocolic incision.

• Suture

The posterior fold of the mesocolic opening is first sutured to the posterior aspect of the stomach about 4 cm from the staple line. Care must be taken to preserve enough tissue for the anastomosis.
The posterior fold must be fixed at this point of the operative step since access to this area is impossible once the small bowel is sutured to the stomach.

• Mechanical anastomosis

The gastric wall and small bowel are each incised for 1 cm. The jaws of the automatic mechanical stapler are inserted into these incisions to perform the side-to-side anastomosis.
The stapler is removed and its introduction site is closed with absorbable interrupted sutures or with a 55 mm linear stapler whose opening is triangulated to prevent the staple lines from being in approximation when the stapler is fired.
The anterior fold of the mesocolic opening is closed at stomach level, anterior to the anastomosis. The stomach can, therefore, still move cephalad and the anastomosis will remain in a submesocolic position.

• Manual anastomosis

• Step 1

The stomach is completely dissected free and the transection line defined but at this point, the stomach is not yet transected.
Once the mesocolic opening is fashioned and the posterior fold is sutured, the small bowel is approximated to the stomach. First, a posterior seromuscular running suture is placed to secure the small bowel to the stomach and then both the stomach and the small bowel are opened on either side of the posterior suture line. Next, a through and through, 3.0 absorbable running suture is placed across the stomach (from the lesser curvature to the greater curvature) prior to transection, as a hemostatic measure.

• Step 2

The stomach is completely transected. Another through-and-through suture is placed between the stomach and the anterior aspect of the small bowel. The suture line is completed by a second sero-serous anterior running suture.
The mesocolon is next sutured to the anterior aspect of the stomach so that the anastomosis always remains in submesocolic position.

• Dangers and variations

• Danger

Hemorrhage at the transection line of a mechanical stapler:
The transection line is inspected interiorly prior to closing the anstomosis, to make sure that the transection lines are not bleeding.

• Variations

Other types of gastrojejunal anastomosis:
1. The gastrojejunal anastomosis can be performed on the posterior aspect of the stomach. The stomach is transected using a 90 mm linear stapler and its posterior aspect approximated to the small bowel (as in an end-to-end anastomosis). The side-to-side anastomosis is performed in 4 ways:
2. Isoperistaltic anastomosis
3. Precolic anastomosis
4. Loop anastomosis forming a Y-shaped pattern
5. Anastomosis to the anterior aspect of the stomach (may impair the functional aspect of the stomach)

Finsterer anastomosis:
This type of anastomosis is also submesocolic.
The main difference between the Finsterer and Billroth II anastomoses concerns the length of the anastomosis. Billroth II anastomosis is an end-to-end anastomosis whereas the Finsterer anastomosis is an end-to-side anastomosis performed on the left part of the gastric transection line. The small bowel is sutured to the corner of the inferior gastric pouch. This creates an angle preventing biliary secretions from discharging into the stomach. It is fashioned by applying 3 to 4 stitches to the anterior and posterior aspects of the stomach and eventually the small bowel.

20. Postop management

Postoperative management following a Billroth I anastomosis:
A drain is placed in the abdominal cavity near the anastomosis.
The nasogastric tube is placed by direct palpation opposite the anastomosis. It is maintained for 2 to 5 days at a low suction (less than 30 mm Hg) before retrieval.
Evaluation of the anastomosis (esogastroduodenal gastrograffin swallow) is recommended before resuming PO intake.
The drain is removed on the fifth postoperative day.

Postoperative management following a Billroth II anastomosis:
Billroth II anastomosis is a particularly safe procedure; anastomotic failures are rare.

Danger:
“Marginal ulcer” associated with hematemesis, melena and possible transitory anemia may be observed after mechanical anastomosis. In some cases, it is necessary to re-operate to complete hemostasis of the resection line (Kyzer et al., 1997).

Conclusion
Today, gastrectomies for benign lesions are rarely performed. Some authors contest their utility. (Witte, 1997; Witte, 1995).
Yet they remain useful for the treatment of gastric ulcers (Lacaine, 1996), especially in areas where the availability of medical treatment is inconsistent and the costs are high (Balafrej et al.). The benefits of this type of procedure must be weighed against the risks of failure which could greatly affect the quality of life of the patient (Gertsch et al. 1996; Jordan & Thornby, 1994), for example, as in the dumping syndrome.

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