Antrectomy

Updated: May 09, 2017
  • Author: Christa N Grant, MD; Chief Editor: Kurt E Roberts, MD  more...
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Overview

Background

Antrectomy (distal gastrectomy) is a procedure in which the distal third of the stomach (the gastric or pyloric antrum). Gastrectomies are further defined by the type of reconstruction used to reestablish gastrointestinal (GI) continuity. A Billroth I procedure is a gastroduodenostomy, which can be fashioned in either an end-to-end or an end-to-side manner. A Billroth II or gastrojejunostomy reconstruction is usually fashioned in an end-to-side manner. [1]  Alternatively, a Roux-en-Y gastrojejunostomy can be performed, and this version of the procedure is the focus of this topic.

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Indications

The incidence and prevalence of gastric ulcers, particularly perforated ulcers necessitating surgical intervention, fell dramatically after the 1970s, when antacids were discovered. [2]  Currently, Helicobacter pylori infection and nonsteroidal anti-inflammatory drug (NSAID) use are the most common etiologic factors for ulcer disease.

A review analyzing hospitalization trends between 1993 and 2006 revealed an overall decrease in the prevalence of ulcer disease in the United States, with duodenal ulcers showing a steeper decline than gastric ulcers. [3]  Overall inpatient mortality has also decreased. There has been a significant rise in the use of therapeutic endoscopy and a concurrent fall in the use of definitive surgery, which remains the therapy of choice for complications such as perforation or persistent bleeding.

Antrectomy is indicated in the treatment of gastric ulcers that are (a) refractory to medical therapy; (b) complicated by perforation, [4]  bleeding, or obstruction; or (c) recurrent after adequate treatment of H pylori. Ulcer location and pathophysiology (see the image below) dictate the appropriate intervention, which does not always involve surgery.

Types of gastric ulcers. Types of gastric ulcers.

Type I ulcers lie along the lesser curvature at or around the incisura. Type II ulcers involve the lesser curvature as well as the duodenum. Type III ulcers are prepyloric, whereas type IV ulcers are located proximally on the lesser curvature. Type V ulcers can be located anywhere in the stomach but are associated with NSAID use.

Types I, IV, and V ulcers represent a state of underprotection from acid, whereas types II and III ulcers are sequelae of acid hypersecretion. These are best treated with antrectomy. Removal of the antrum allows pathologic examination of antral/prepyloric ulcers to rule out carcinoma, and it decreases the rate of ulcer recurrence by removing the gastrin-secreting G cells. Truncal vagotomy or highly selective vagotomy is almost always performed simultaneously to decrease the likelihood of ulcer recurrence. This procedure will not be described here.

Antrectomy is also the procedure of choice for benign or small, well-differentiated tumors of the distal stomach. As with any GI neoplasm, lymphadenectomy is mandatory in such cases.

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Contraindications

With proper patient selection, there should remain few relative contraindications for the procedure. Prior duodenal surgery precludes a Billroth I reconstruction, as does a “woody,” inflamed, or ulcerated duodenum, which makes a secure anastomosis unlikely. Poor nutritional status impairs healing and may contribute to postoperative complications such as anastomotic leaks.

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Outcomes

In a prospective randomized trial comparing Billroth II and Roux-en-Y anastomosis after partial gastrectomy plus vagotomy for duodenal ulcers after an average follow-up of 15 years, the latter was found to be significantly better. [5]  Although patients who had a Billroth II anastomosis had significantly more frequent chronic fundic gastritis and intestinal metaplasia of the remnant stomach, those who had Roux-en-Y reconstruction were significantly more asymptomatic and were more likely to have normal esophageal and gastric histology.

Chen et al carried out a systematic review and meta-analysis aimed at comparing the safety and efficacy of hand-assisted laparoscopic distal gastrectomy and open distal gastrectomy for gastric cancer, [6]  focusing on operating time, incision length, blood loss, number of harvested lymph nodes, time to flatus, hospital stay, postoperative complications, and long-term outcomes. They concluded that the laparoscopic approach, though associated with smaller incisions and quicker recovery and having comparable short-term efficacy to conventional open surgery, lacked multicenter data to confirm long-term efficacy.

Park et al conducted a randomized phase II multicenter clinical trial evaluating laparoscopy-assisted distal gastrectomy with D2 lymph node dissection against open distal gastrectomy for the treatment of advanced gastric cancer. [7]  On the basis of the primary endpoint, the noncompliance rate of the lymph node dissection, they found the laparoscopy-assisted procedure to be feasible for treatment of advanced gastric cancer, though findings from subgroup analysis data suggested that further research is warranted for stage III cancer.

Kim et al compared the short-term surgical outcomes of laparoscopy-assisted distal gastrectomy with those of totally laparoscopic distal gastrectomy with Billroth II anastomosis in the treatment of gastric cancer. [8]  They found that the totally laparoscopic approach was feasible in this setting and had advantages over the laparoscopy-assisted approach in terms of incision size, duration of hospitalization, and intraoperaive convenience; however, additional data from propsective randomized controlled trials will be required before it can be regarded as a standard procedure in this setting.

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