What is the Billroth II surgical procedure?

Billroth II Surgical Procedure

The Billroth II procedure is a type of partial gastrectomy where the distal portion of the stomach is resected, and the remnant stomach is anastomosed to the jejunum rather than the duodenum, creating a gastrojejunal connection that bypasses the duodenum. 1

Surgical Technique

• The procedure begins with resection of the distal portion of the stomach along with the pylorus, ensuring adequate margins, especially for tumors located in the lower third of the stomach 1
• After resection, the duodenal stump is closed, and an anastomosis is created between the remnant stomach and a loop of jejunum (gastrojejunostomy) 2, 3
• The gastrojejunal anastomosis can be performed in an antecolic fashion (bringing the jejunum anterior to the transverse colon) 4
• Modern techniques often utilize stapling devices for both resection and anastomosis, which has made the procedure faster and more efficient 2, 3
• Laparoscopic approaches have been developed, offering minimally invasive options with benefits of reduced postoperative pain, quicker mobilization, fewer wound problems, better cosmesis, and shorter hospital stays 2, 4

Clinical Indications

• Billroth II is particularly recommended for tumors located in the lower third of the stomach, especially those invading the pylorus and duodenum 1
• This approach is preferred over Billroth I for distal gastric tumors with duodenal involvement because it allows for a second chance at surgery in case of tumor recurrence 1
• The procedure is also indicated for completely stricturing duodenal ulcers causing gastric outlet obstruction 4

Technical Considerations

• When performing endoscopic procedures on patients with Billroth II anatomy, the "upside-down" (5 o'clock) orientation of the papilla requires significant alteration in technique 1
• For endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II patients, a side-viewing duodenoscope may facilitate cannulation and therapy due to its elevator and large accessory channel 1
• However, forward-viewing endoscopes have advantages in flexibility and luminal visualization, with one RCT showing higher success rates (87% vs 68%) compared to duodenoscopes 1
• A reasonable strategy is to attempt with a duodenoscope first, followed by a forward-viewing endoscope if initial approach fails 1

Modifications and Variations

• A Braun anastomosis (enteroenterostomy) can be added to the standard Billroth II procedure, creating a side-to-side jejunojejunostomy between the afferent and efferent limbs 5
• This modification may reduce bile reflux and serve as a good alternative to Roux-en-Y reconstruction, with shorter operation times (134.6 min vs 157.3 min) and similar complication rates 5

Potential Complications

• Billroth II reconstruction is associated with a risk of bile reflux into the gastric remnant 5
• The altered anatomy creates challenges for future endoscopic access to the biliary system 1
• Patients with Billroth II anatomy have a higher risk of perforation during ERCP procedures (reported rates of 2.7-10%) 1
• Other potential complications include dumping syndrome due to rapid gastric emptying and bacterial overgrowth in the afferent limb 1

Historical Context

• The Billroth II procedure was first performed by Theodor Billroth on January 15,1885, at the Second Surgical Clinic of the University of Vienna 6
• It represented one of the starting points of modern gastric surgery and has remained conceptually similar since its introduction, though techniques have evolved 2, 6

Comparison with Other Reconstruction Methods

• Compared to Billroth I (gastroduodenostomy), Billroth II is preferred for tumors invading the pylorus and duodenum 1
• Roux-en-Y reconstruction can effectively reduce bile reflux and prevent remnant gastritis compared to Billroth II, but is more complex and associated with a higher risk of postoperative retention syndrome 1
• For total gastrectomy, Roux-en-Y is the preferred reconstruction method rather than Billroth II 1