Today, modern techniques are used during the resection of the stomach. One of the most famous techniques is Billroth. There are two options for conducting such an operation. They have certain differences. Those who have encountered serious diseases of the stomach should know the differences between Billroth-1 and 2. The features of these methods will be discussed later.
General definition
Methods Billroth-1 and 2 are varieties of gastric resection. This is a surgical operation that is used to treat serious diseases. These include pathologies of the stomach, as well as the duodenum. The technique involves the removal of part of the stomach. At the same time, the integrity of the digestive tract is restored. For this, a gastrointestinal anastomosis is created. This is a combination of tissues according to a certain technology.
Billroth is a fairly serious operation. She became the first successful surgical intervention of this type. Now the technique is being improved. There are other ways to successfully remove part of the stomach. However, Billroth is still actively used in clinics with a worldwide reputation. Surgical operations performed according to the presented technique in Israel are especially known for their high quality.
It is worth noting that the method of resection largely depends on the location of the pathological process. It also affects the type of disease. Most often, Billroth-1 and 2 are prescribed for stomach ulcers or cancer. Before the operation, the size of the excised site is estimated. Next, a decision is made on the method of resection.
The Billroth technique is one of the most commonly used during gastrectomy. There are a number of differences between these techniques. They appeared at different times. However, Billroth-1, although it is the first of its kind technique, and today is quite effective.
Historical reference
Billroth's gastrectomy was first successfully performed on 01.29.1881. The author and performer of this technique is Theodore Billroth. This is a German surgeon, a scientist who was able to restore the patency of the gastrointestinal tract by performing an anastomosis of the lesser curvature of the stomach with the duodenum. The operation was performed on a 43-year-old woman who suffered from stenosing type of cancer. Pathology developed in the pyloric stomach.
In the same year, in November, the first successful resection with peptic ulcer of the pylorus was performed using the same technique. The patient survived such surgery. This technique is called Billroth-1. After the first operation, the German surgeon himself began to create a connection not in the small, but in the large curvature of the stomach.
Of course, the technique of that time could not be called perfect. At the end of the 19th - beginning of the 20th century, a lot of troubles when using the presented technique delivered the gastroduodenal suture line to surgeons. Often they turned out to be insolvent. During this time, 34 patients were operated on Billroth-1. 50% of patients have died.
To reduce mortality due to inconsistency of sutures, in 1891 it was proposed to suture the end of the stomach, creating a connection with the duodenum and posterior wall of the stomach. A little later, anastomosis began to be created with the front wall of the stomach. It was also proposed to mobilize the duodenum (in 1903). This maneuver was invented by the scientist, surgeon Kocher.
As a result, in 1898, at the Congress of German Surgeons, 2 main methods of stomach resection according to Billroth-1 and 2 were established.
Features and benefits of Billroth-1
To understand the difference between Billroth-1 and Billroth-2, you need to consider the features of each of these operations. They are used for various diseases of the stomach. The first technique is distinguished by the circular type of excision of the digestive tract, which are affected by pathology. Subsequently, with this operation, an anastomosis is superimposed. It is located between the duodenum and the remaining part of the stomach and is created on a ring-to-ring basis.
In this case, the anatomy of the esophagus remains unchanged. The surviving part of the stomach performs a reservoir function. During resection of the stomach by Billroth-1, contact of the mucous membranes of the intestine and stomach is excluded. The advantages of this technique are:
- The anatomical structure does not change. The work of the digestive tract and its digestive tract is preserved.
- Technically, such surgery is much easier. In this case, the operation is performed in the upper part of the peritoneum.
- According to statistics, dumping syndrome (intestinal dysfunction) after the intervention is very rare.
- There is no syndrome of the formation of adherent loops.
- The method does not lead to the subsequent development of hernias.
It is also worth noting that the path that food passes after the operation becomes shortened, but the duodenum is not excluded from it. If you manage to leave some of the stomach, it will be able to fulfill its natural function - to be a reservoir for food.
This operation is carried out quite quickly. The consequences are much better tolerated by the body. The risk of peptic ulcers at the site of the anastomosis is also excluded.
Billroth 1: disadvantages
Billroth-1 and 2 operations also have certain disadvantages. They must be taken into account when choosing a surgical procedure. During Billroth-1 surgery, duodenal ulcers may be observed.
With this method of surgical intervention, not in all cases it is possible to qualitatively mobilize the intestine. This is necessary to create an anastomosis without tensioning the seam. Especially often, a similar problem occurs in the presence of duodenal ulcers, which penetrate into the pancreas. Also, pronounced scarring, narrowing of the lumen of the intestinal passage can lead to the inability to properly mobilize the duodenum. The same problem occurs with the development of ulcers in the proximal stomach.
Some surgeons are very enthusiastic in insisting on a Billroth-1 resection, even if there are a number of adverse conditions for it. This greatly increases the likelihood of developing joint failure. Therefore, in some cases, it is required to abandon the Billroth-1 operation. If there are significant difficulties, it is better to give preference to surgical intervention according to the second technique.
It is imperative that the technique of the surgeon who will conduct the operation, be carefully honed, worked out as much as possible. Although Billroth-1 is considered a lighter, faster technique, it is performed exclusively according to strict indications. The decision on its implementation is taken only in the presence of certain factors and the absence of certain obstacles.
In some cases, this operation requires mobilization of not only the duodenum, but also the spleen and stump of the intestine. In this case, it is possible to create a seam without tension. Extensive mobilization greatly complicates the operation. This unnecessarily increases the risk during its implementation.
It is also worth noting that resection according to the Billroth-1 technique is not performed during the treatment of gastric cancer.
Billroth-2 technique
Considering briefly Billroth-1 and 2, it is worth paying attention to the second variety of resection techniques. During this operation, the part of the stomach remaining after excision is sutured using the method of application from the posterior or anterior gastroenteroanastomosis. Billroth-2 has many modifications.
Anastomosis in this case is superimposed on a side-by-side basis. The rest of the organ is sutured to the jejunum. Frequently used modifications of Billroth-2 are methods of closing the stump of the stomach, stitching the remaining part with the jejunum, etc. This technique is used in that case. If there are contraindications to Billroth-1.
It is worth noting that Billroth-2 is prescribed for ulcers and cancer of the stomach, and other diseases of the organ. In this case, an organ resection is performed in the volume indicated by the state of the stomach, the type of disease. An organ is sutured after excision in a special way. For some diagnoses, this operation is the only way out. Billroth-2 allows you to make the gastrointestinal tract passable.
Billroth-2: positive and negative sides
Resection by Billroth-1 and 2 has a number of positive and negative qualities. The second technique has a number of advantages. When performing Billroth-2, it is possible to conduct an extensive resection without tensioning the gastrojejunal sutures. If a patient is diagnosed with a duodenal ulcer, during surgery using this technique, the occurrence of peptic ulcers at the junction is much less common.
Also, if a patient has a duodenal ulcer, which is accompanied by the presence of gross pathological defects in the duodenum, suturing the organ stump is much easier than creating an anastomosis with the stomach.
If a patient has a duodenal ulcer that cannot be resected, it is possible to restore gastrointestinal patency only with Billroth-2. These are the main advantages of the presented method.
The disadvantages of the technique are the following:
- increased risk of dumping syndrome;
- the operation is accompanied by difficulties, requires more time;
- there is a likelihood of a leading loop syndrome ;
- in some cases, an internal hernia occurs after Billroth-2.
However, this technique has a place to be. Billroth-2 is sometimes the only possible solution in the development of certain pathologies. Therefore, doctors carefully study the features of the course of the disease before prescribing this or that type of operation.
Method differences
It should be noted that the technology of Billroth-1 and 2 is significantly different. The junction in the first case is called “ring to ring”. With Billroth-2, the anastomosis has a side-to-side appearance. Accordingly, due to such an intervention, complications can develop in both cases. However, in both cases they are not similar.
It should be noted that the degree of expression of dumping syndrome with Billroth-2 is more pronounced. The work of the stomach itself and the entire digestive tract after these operations is also different. With Billroth-1, patency of the intestinal tract is maintained. However, this operation is not performed for stomach cancer, extensive ulcers and gross changes in the tissues of the stomach. In these cases, the Billroth-2 technique is indicated.
Indications for Billroth-1 are the following conditions:
- Peptic ulcers of the stomach. This is the least controversial testimony. In this case, resection of 50-70% of the stomach gives a good result. In this case, an addition in the form of a stem vagotomy is not required. The only exception is surgery for prepyloric ulcers and pathologies in the area of the converter in the presence of increased secretion of the stomach.
- Duodenal ulcer resection of 50-70% of the stomach is indicated, but only when using stem vagotomy.
Indications for Billroth-2 can be stomach ulcers, which have almost any location. If half of the stomach is excised, stem vagotomy is used.
Also, with gastric cancer, the only possible option for excising the affected tissue is Billroth-2. This is explained by the ability to perform an extensive resection not only of the stomach, but also of the regional lymph nodes, the duodenum. In this case, the occurrence of obstruction of the anastomosis is less likely than in the case of the first technique.
Modifications of the first technique
The differences between Billroth-1 and 2 are significant. These techniques have modern modifications. The second methodology has more of them. With Billroth-1, modifications differ only in the way the anastomosis is created. The fact is that the size of the diameters that are interconnected is different. This leads to a number of difficulties. Only with a very limited resection in the pyloric section of the stomach, which is carried out according to the method of Pean, can it be connected with the duodenum "end to end" without preliminary suturing or narrowing.
One of the main modifications of Billroth-1 is the Gaberera technique. It allows you to eliminate the mismatch of the diameters of the organs after resection without suturing of the lumen of the stump of the stomach. In this case, a corrugated seam is applied. After this, an end-to-end anastomosis can be applied. The Gaberer method is significantly improved today. Previously, it often led to a narrowing of the anastomosis and its obstruction.
There are other ways to narrow the lumen. They differ from the Gaberer method in the way of creating corrugating seams.
Modifications of the second technique
During the operation Billroth-2, many modifications are used. The main one is the technique proposed by Hoffmeister-Finsterer. Its essence is as follows. Part of the stomach after excision of damaged tissue is connected according to the principle of "end to side". In this case, the width of the anastomosis should be 1/3 of the total lumen of the stomach stump.
The connection in this case is fixed transversely in the artificially created lumen. The lead loop of the jejunum in this case is sutured with two or three sutures. They are performed by the type of nodules in the cult. This feature allows you to prevent food from entering the stripped section of the digestive tract.
Other resection enhancements
Having considered the differences between Billroth-1 and 2, it should be noted that although there is a big difference between these methods, they have improved significantly since their discovery. Therefore, today the resection procedure is performed with less risk for the patient. In specific conditions, certain techniques are used.
So, surgeons can perform distal excision of a diseased area of an organ with the formation of an artificial pyloric sphincter. In some cases, in addition to this, an invagination valve is installed. It is formed from the tissues of the mucous membrane.
Resection can be carried out with the creation of pyloric pulp, valve type flap . An artificial valve may form at the entrance to the duodenum. In this case, the pyloric sphincter is preserved.
Sometimes distal resection may be subtotal. In this case, primary gastroplasty is performed. Some patients are shown subtotal, complete resection of the stomach. In this case, an invagination valve is formed on the discharge section of the jejunum.
If the patient is shown a resection of the proximal type, an esophagogastroanastomosis and an invagination valve are established. Existing techniques allow the most accurate resection of a diseased area of an organ. In this case, the risk of complications will be minimal.
Having examined the differences between Billroth-1 and 2, we can understand the basic principles of such surgical interventions. Both methods have been greatly improved. Today they are used in modified form.