What is the procedure for a Billroth I (partial gastrectomy) surgery?

Billroth I Procedure: Surgical Technique and Considerations

The Billroth I procedure is a type of partial gastrectomy with direct gastroduodenal anastomosis that maintains physiological continuity of the digestive tract and is primarily used for distal gastric cancers and peptic ulcer disease. 1

Surgical Procedure

Preparation and Resection

• The procedure begins with adequate lymph node dissection when performed for gastric cancer 2
• After appropriate exposure, the distal portion of the stomach is resected along with the pylorus 1
• For tumors located in the lower third of the stomach, the extent of resection must ensure adequate margins 1

Anastomosis Technique

• The remnant stomach is directly anastomosed to the duodenum, creating a gastroduodenal connection 1, 2
• Several techniques can be used for the anastomosis:
  • Traditional hand-sewn technique
  • Stapled anastomosis using linear staplers 3, 4
  • Semi-hand-sewn technique which combines stapling and hand suturing 3

Modern Variations

• Laparoscopic Billroth I reconstruction has become increasingly common 3
• Intracorporeal triangular anastomosis technique:
  • Small incisions are made in the remnant stomach and duodenum
  • Linear stapler is used to create the bottom of a triangular anastomosis
  • The common hole is closed with additional stapling to complete the anastomosis 4
• Semi-hand-sewn technique:
  • Posterior walls attached with linear stapler
  • Anterior wall completed with laparoscopic hand-sewn technique
  • This approach is economical as it requires fewer staplers 3

Clinical Considerations

Indications

• Primarily used for distal gastric cancers, particularly those located in the antrum 5
• Suitable for peptic ulcer disease, especially bleeding duodenal ulcers 1
• Ideal when there is availability of a large stomach remnant post-resection 2

Advantages

• Maintains physiological continuity of the digestive tract 2
• Simpler and more time-efficient than other reconstruction methods 2
• Associated with lower incidence of recurrence in some studies 5
• Economical when using modified techniques that require fewer staplers 3

Limitations and Complications

• May not be suitable for tumors invading the pylorus and duodenum, where Billroth II is preferred 1
• Potential complications include anastomotic leak, stricture, and intra-abdominal abscess 3
• Higher bile leak rate has been reported with gastrectomy procedures 1

Long-term Outcomes

Oncological Outcomes

• No significant difference in overall survival between Billroth I and Billroth II for non-early gastric adenocarcinoma 5
• Some studies suggest lower local recurrence rates with Billroth I anastomosis 5

Bone Health Considerations

• No difference in risk of postgastrectomy bone disease between Billroth I and Billroth II procedures 1
• Postgastrectomy patients should be evaluated for underlying bone disease due to increased fracture risk 1

Follow-up Care

• Patients who have undergone Billroth I for gastric cancer should receive appropriate follow-up 1
• For gastric ulcers, endoscopic confirmation of healing approximately six weeks after surgery is recommended 1
• H. pylori eradication therapy should be considered for patients with ulcer disease 1

Surgical Expertise

• The procedure should be performed by experienced surgeons, particularly when using laparoscopic approaches 1, 6
• Complex variations such as the jejunal interposition method should be carried out in large experienced medical centers 1