Distal Gastrectomy with Reconstruction

Procedure Snapshot

• Indication: Distal gastric cancer, refractory ulcer, outlet obstruction.
• Expected duration: ___
• Special instruments: Staplers, energy device, retractors.

Step Workflow

1. Midline incision; explore for metastases.
2. Mobilize stomach; ligate right gastric and gastroepiploic arteries.
3. Divide duodenum 1–2 cm distal to pylorus.
4. Divide stomach proximally.
5. Reconstruction:
   • Billroth I: gastroduodenostomy.
   • Billroth II: gastrojejunostomy.
   • Roux-en-Y: for reflux control.
6. Leak test; drain placement.

Key Pimp Questions

• Q: When to choose Billroth I vs II?
  A: Billroth I for benign, II/Roux for malignant or short duodenal stump.
• Q: Common post-gastrectomy syndromes?
  A: Dumping, bile reflux (PMID 34780105).
• Q: D2 lymphadenectomy includes?
  A: Celiac, splenic, hepatic nodes (PMID 32053261).

Critical Anatomy

• Landmarks: Celiac trunk, left/right gastric and gastroepiploic vessels.
• Danger zones: Pancreas, portal triad.

Informed Consent Highlights

• Risks:
  • Leak ___ (PMID 35635268)
  • Dumping syndrome ___ (PMID 34780105)
  • Stricture ___
  • Nutritional deficiency ___

Post-op Considerations

• NGT until flatus.
• Gradual diet; B12 and iron supplementation.
• Monitor for leak or ileus.

References

• Chassin’s, Gastric section.
• Clinical Scenarios, Upper GI.
• Japanese Gastric Cancer Guidelines 2020 (PMID 32053261).