Angeles University Foundation

College of Nursing

Case Report:

BILLROTH’S PROCEDURES

(I and II)

Submitted to:
Glenth Fermin, R.N., M.N.
OR in JBL- MGH

Submitted by:
Marie Catherine Galang
Sarabjit Hampal
Bryan Mendiola
Mardielene Mercado
BSN III- 10, group 40

March 6, 2008

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 I. INTRODUCTION

Related and current statistical evidence or critical findings

The proper reconstructive technique after partial gastrectomy for

adenocarcinoma of the stomach is often debated, but few data exist to clarify the issue.
The evaluated outcomes after different anastomoses used during partial gastrectomy for
gastric adenocarcinoma. A review of the hospital records of all 277 patients who
underwent operation for gastric cancer at our institution from 1970 to 1996. Of 118
partial gastrectomies performed with curative intent 57 anastomoses were Billroth II
gastrojejunostomies, 22 were Billroth I gastroduodenal reconstructions, and 39 were
Roux-en-Y gastrojejunostomies. There was no difference in the incidence of early gastric
emptying problems or early or late postoperative obstruction among the groups. Average
hospital stay was 14 days for the Billroth I group, 15 days for those with Billroth II
reconstructions, and 22 days for the Roux-en-Y cohort. Documented late gastric outlet
obstruction occurred in 29 per cent of patients having Billroth I and in 33 per cent of
those with Billroth II anastomoses. Antecolic anastomoses represented 30 (53 per cent)
and retrocolic 27 (47 per cent) of the 57 Billroth II reconstructions performed. Late
gastric outlet obstructions occurred in seven (23 per cent) patients who had antecolic
reconstructions and in just one (4 per cent) with a retrocolic anastomosis (P < 0.05).
Five-year cumulative survival was lower for patients having Billroth I reconstructions than
for those with Billroth II (P < 0.05). Among patients with Billroth II reconstructions, 5-year
cumulative survival was lower for those with antecolic reconstructions compared with
those with retrocolic anastomoses (P < 0.05). Although conventional teaching dictates
otherwise our data indicate that retrocolic Billroth II anastomoses are preferable to
antecolic Billroth II reconstructions after partial gastrectomy for adenocarcinoma of the
stomach, as there is a diminished risk of late gastric outlet obstruction and a greater 5-
year survival among patients having the former procedure. Survival is unacceptably low
after Billroth I anastomoses. Eighty-eight patients operated during the years 1991 to
1994 underwent distal gastric resection (41 had BI, and 43 had BII resections). The
indications for BI resections were gastric tumors in 39 patients (95%) and duodenal ulcer
in 2 (5%). The indications for BII resection were malignancy in 28 patients (65%) and
duodenal ulcer disease in 15 (35%). The average duration of the procedure was 147 +/-
28 minutes for the BI resection and 175 +/- 38 minutes for the BII resection (p < 0.05).

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No patient in the BI group developed anastomic leakage. Two patients who underwent
BII resection developed duodenal stump leakage (4.7%). Relaparotomy was indicated in
five patients, two from the BI group (malignant cells in the resection margins) and three
from the BII group (one due to duodenal stump leakage and two for bleeding). There
was no postoperative mortality in the BI group. The postoperative mortality in the BII
group was 7.1% (p < 0.05). The average proximal gastric resection margins were
significantly smaller in the BI group than in the BII group (3.65 +/- 2.83 cm and 5.18 +/-
2.57 cm, respectively; p < 0. 05). The number of lymph nodes found in the resected
specimen did not differ significantly between the two groups. Recurrent tumor at the
gastric remnant developed in two patients in the BI group but not in the BII group. The
results of our study revealed that the BI procedure is accompanied by significantly lower
postoperative complication and mortality rates than the BII procedure in cases of gastric
malignancy. BI resection performed for malignancy seems to achieve smaller proximal
gastric resection margins, which may influence the recurrence rate

Recent trends, refinements, and/or innovations in treatment

The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a

prospective randomized multicenter trial with special focus on assessment of quality of
life.

OBJECTIVE: To evaluate the effect of a prophylactic gastrojejunostomy on the

development of gastric outlet obstruction and quality of life in patients with unresectable
periampullary cancer found during explorative laparotomy.
SUMMARY BACKGROUND DATA: Several studies, including one randomized trial,
propagate to perform a prophylactic gastrojejunostomy routinely in patients with
periampullary cancer found to be unresectable during laparotomy. Others suggest an
increase of postoperative complications. Controversy still exists in general surgical
practice if a double bypass should be performed routinely in these patients.
METHODS: Between December 1998 and March 2002, patients with a periampullary
carcinoma who were found to be unresectable during exploration were randomized to
receive a double bypass (hepaticojejunostomy and a retrocolic gastrojejunostomy) or a
single bypass (hepaticojejunostomy). Randomization was stratified for center and
presence of metastases. Patients with gastrointestinal obstruction and patients treated

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endoscopically for more than 3 months were excluded. Primary endpoints were
development of clinical gastric outlet obstruction and surgical intervention for gastric
outlet obstruction. Secondary endpoints were mortality, morbidity, hospital stay, survival,
and quality of life, measured prospectively by the EORTC-C30 and Pan26
questionnaires. It was decided to perform an interim analysis after inclusion of 50% of
the patients (n = 70).
RESULTS: Five of the 70 patients randomized were lost to follow-up. From the
remaining 65 patients, 36 patients underwent a double and 29 a single bypass. There
were no differences in patient demographics, preoperative symptoms, and surgical
findings between the groups. Clinical symptoms of gastric outlet obstruction were found
in 2 of the 36 patients (5.5%) with a double bypass, and in 12 of the 29 patients (41.4%)
with a single bypass (P = 0.001). In the double bypass group, one patient (2.8%) and in
the single bypass group 6 patients (20.7%) required (re-)gastrojejunostomy during
follow-up (P = 0.04). The absolute risk reduction for reoperation in the double bypass
group was 18%, and the numbers needed to treat was 6. Postoperative morbidity rates,
including delayed gastric emptying, were 31% in the double versus 28% in the single
bypass group (P = 0.12). Median postoperative length of stay was 11 days (range 4-76
days) in the double versus 9 days (range 6-20 days) in the single bypass group (P =
0.06); median survival was 7.2 months in the double versus 8.4 months in the single
bypass group (P = 0.15). No differences were found in the quality of life between both
groups. After surgery most quality of life scores deteriorated temporarily and were
restored to their baseline score (t = -1) within 4 months.
CONCLUSIONS: Prophylactic gastrojejunostomy significantly decreases the incidence
of gastric outlet obstruction without increasing complication rates. There were no
differences in quality of life between the two groups. Together with the previous
randomized trial from the Hopkins group, this study provides sufficient evidence to state
that a double bypass consisting of a hepaticojejunostomy and a prophylactic
gastrojejunostomy is preferable to a single bypass consisting of only a
hepaticojejunostomy in patients undergoing surgical palliation for unresectable
periampullary carcinoma. Therefore, the trial was stopped earlier than planned.

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Implications of the above information for Nurses as a productive member of society.

In this procedure, nursing care focuses more in providing the patient with
comfort, preventing him from acquiring complications and assists the patient in regaining
his optimum health, wellness and being. A careful monitoring of the patient’s intake and
output must be thoroughly done preoperatively in order to ensure patient’s assurance of
being subjected to operation. In the postoperative care, rehabilitation via assist to regain
independence and patient health teaching must be done in order to hasten recovery
physically, physiologically and psychologically. Support from the mutual connections
must be imparted in order for the patient to gain self-esteem and reduce anxiety due to
the recent operation. As nurses and member of the health care team, it is our primary
responsibility to give utmost assistance and continuity of quality care to the patient until
his discharged from the hospital As a nursing student being knowledgeable about
Billroth I and II, this will enable us to assist in some operations concerning about this
procedure where gastric cancer treatment is first and foremost favored with early
detection. Many studies have demonstrated stage dependent survival ratios. Knowing all
of the complications that they may bring to the patient we as student nurse must be
aware of those complication to cater our patients a better health.

1.1 Description of prescribed surgical treatment performed

Billroth partial gastrectomies

consist in the removal of the distal
portion of the stomach. According to
the type of disease (ulcer or
carcinoma) and the location of the
basic disease (duodenal ulcer,
gastric ulcer, high-gastric ulcer),
they are performed as an antral,
tw0-thirds, four-fifths, or subtotal
gastrectomy. The distal partial
gastrectomy is named in according to the type of anastomosis between the small
intestine and the gastric remnant, regardless of the extent of the gastrectomy.

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 Billroth I (also known as Billroth's gastrectomy I, Billroth's anastomosis I, Rydigier's
resection) operation is a gastroduodenostomy that can be performed both end-to-end
and end-to-side. It is the removal of lower portion of stomach (pylorus) with end to end
anastomosis of the remaining stomach with the duodenum. A decisive difference
between this method and the Billroth II procedure is that the duodenal passage remains
intact in the former method. Because of anastomotic requirements, the Billroth I
operation is, as a rule, performed as an antral or a two-thirds gastrectomy.
Gastroduodenostomy is a different after extended gastrectomies. Direct anastomoses of
this kind between gastric findus and duodenum are followed by postoperative
complications in a large number of patients.

Billroth II (Billroth's gastrectomy II, Billroth's anastomosis II) is a standard treatment

for ulcer disease, stomach cancer, injury and other diseases of the stomach. It is
gastrojejunal anastomosis with duodenal closure. An international consensus
conference of gastric cancer specialists express consensus about the use of the Billroth
II for the treatment of Gastric Cancer. Subtotal excision of the stomach with closure of
the proximal end of the duodenum and side-to-side anastomosis of the jejunum to the
remaining portion ion of the stomach. The Billroth II connects the stomach to the
jejunum, the middle portion of the small intestine. The Billroth II is a gastrectomy, that is,
a surgical procedure used in the treatment of stomach cancer and peptic ulcers.

Surgical Treatment/Technique

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 END-TO-END GASTRODUODENOSTOMY

In intricate dudodenal ulcers, it is impossible to preserve enough duodenal wall to

be able to construct a tension-free anastomosis. In this situation, it is safer to cut the
duodenum without clamps and then to close the duodenal stump in the usual way. The
reconstruction of the intestinal passage can proceed by end-to-side anastomosis. For
this purpose, the stomach is removed; the dissected stomach lumen is then
anastomosed onto the front wall of the duodenum. Usually, an oblique incision should be
made on the duodenal front wall so that the incision level starts from oral-medial and
goes to aboral-lateral. The suturing technique is the same as for the end-to-end
anastomosis. The back wall is also sutured in two rows, and the front wall is sutured with
one row of interrupted sutures through all layers. In technically difficult duodenal stump
closures, additional covering of the stump with the back wall of the stomach may be
obtained.

ANASTOMOSIS USING STAPLER TECHNIQUE

After the duodenum is cut, the EEA stapler is introduced transpylorically into the
stomach. A small incision is made on the stomach back wall selected for the
anastomosis within pursestring suture. The head of the EEA stapler is brought through
the pursestring. The pursestring suture is tied above the staple cartridge. The anvil of the
EEA is then led into the duodenum after pursestring suture has been made there, as

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near to the end as possible. After these pursestring sutures are tied, the stapler can be
closed and the anastomosis performed.

After the anastomosis has been positioned between the duodenum and the back
wall of the stomach, the stapler is removed and the stomach resection is performed
aborality to the anastomosis after closure of the proximal stomach with the TA90 stapler.
The cut surface of the stomach can but need not to sewn over.

1.2 Indications of prescribed surgical treatment

Arteriovenous malformations

 Arteriovenous malformations (AVMs) of the stomach. AVMs are collections of

small blood vessels that may develop in various parts of the digestive system.
AVMs can cause bleeding into the gastrointestinal tract, resulting in hematemesis
(vomiting blood) or melena (black or tarry stools containing blood). The type of
AVM most likely to occur in the antrum is known as gastric antral vascular
ectasia (GAVE) syndrome. The dilated blood vessels in GAVE produce reddish
streaks on the wall of the antrum that look like the stripes on a watermelon.

Prepyloric ulcers

 prepyloric ulcers represent a good indication for Billroth I resection. Because of

its secretory behavior this ulcer type was, as far as the surgical and therapeutic
consequences were concerned, previously included with the duodenal ulcers
and, thus, normally represented an indication for vagotomy. However, results
after 5 years of using this procedure show relatively high recurrence rates, so
that it may be concluded that prepyloric ulcers would better be regarded as
gastric ulcers as far as surgical treatment is concerned.

Gastric outlet obstruction

 Gastric outlet obstruction (GOO). GOO is not a single disease or disorder but a
condition in which the stomach cannot empty because the pylorus is blocked. In
about 37% of cases, the cause of the obstruction is benign—most often PUD,

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 gallstones, bezoars, or scarring caused by ingestion of hydrochloric acid or other
caustic substance. The other 63% of cases are caused by pancreatic cancer,
gastric cancer, or other malignancy that has spread to the digestive tract.

Gastric ulcer

 Gastric ulcer. The main indication for Billroth I operation is gastric ulcer, which
gives evidence of a high recurrence rate after vagotomy. The following
arguments favor Billroth I resection: (1) the gastric ulcer is removed into during
distal resection and can be examined histological. (2) The point of least
resistance of the antrium-corpus border of the lesser curvature is eliminated. (3)
The number of chief cells is reduced by removal of a part of the fundus. (4) The
antrum as a point for the formation of gastrin in eliminated. (5) The remainder of
the stomach is partly vagotomized by dissection of the lesser curvature from
above the resection border.

Risk associated with Billroth I & II:

A gastroduodenostomy and gastrojejunostomy has many of the same risks associated

with any other major abdominal operation performed under general anesthesia, such as
wound problems, difficulty swallowing, infections, nausea, and blood clotting.

More specific risks:

 Duodenogastric reflux, resulting in persistent vomiting.

 Dumping syndrome, occurring after a meal and characterized by sweating,

abdominal pain, vomiting, lightheadedness, and diarrhea.

 Low blood sugar levels (hypoglycemia) after a meal.

 Alkaline reflux gastritis marked by abdominal pain, vomiting of bile, diminished
appetite, and iron-deficiency anemia.
 Malabsorption of necessary nutrients, especially iron, in patients who have had
all or part of the stomach removed.

1.3Required instruments, devices, supplies, equipments and facilities

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Devices:
• Suction machine
• Electrosurgical Unit

Facilities:
• Operating Room

Supplies:
• Dissectors • Mask
• Suction tubing • Sponges
• Drainage (e.g. Hemovac) • Surgical caps
• Blades (2) No. 10, (1) No.15 • Abdo Pack
• Hemoclips, variety of size • Dextrose (D5LRS)
• Electrosurgical pencil • Needles
• Sterile Gloves

Equipments:
• Operating table
• Operating Lights

Instruments
Forceps
• adson tissue forceps (1 x 2 ) • 2 thumb tissue forceps with teeth
• Ferris-smith tissue forceps ( 1 x (1 x 2)
2) • 2 DeBakey vascular Autraugrip
• 2 Russian tissue forceps tissue forceps

Scissors
• 1 Wire cutter • 1 Metzenbaum 7”
• 2 straight & 1 Curved Mayo 6 ¼” • 2 Snowden-pencer

Retractors

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 • Goelet • 2 Army-Navy
• Gelpi • Deaver (1) narrow, (1) medium,
(1) wide

Suction Tubes or Tips:

• 1 Poole
• 1 Yankauer 10 3/8”

Miscellaneous • 1 Probe, malleable

• Knife handles (2) No. 3, (1) No. 7 • 1 Grooved director

Clamps:
• 4 Tonsil (Shnidt) 7 ½” • 12 Curved Pean (6) 6 ¼”, (6) 8”
• Right angle 8” • Needle Holder (2) 6”, (2) 7”, (2)
• Allis 6” 8”

• 18 Curved Crile 5 ½” • 10 Towel clips 5 ½”

• 6 Straight Crile 5 ½” • Straight Kocher 6 ¼”

• Bobcock 6 • 4 Sponge forceps 10”

GASTRO-DUODENUM PROCEDURE
• 2 Bobcock • 2 Adson tissue forceps
• 1 metzenbaum dissecting • 2 Curved clamps
scissors • 1 thumb forceps
• 2 mayo dissecting scissors

GASTRO-JEJUNUM PROCEDURE
• Straight & Curved
intestinal 9 ¼”
• 2 Bobcock 10”
• 12 Pean (8) 6 ¼”, (4) 10”
• 1 Metzenbaum scissors
• 2 Mayo dissecting scissors
Doyen • 2 allis tissue forceps
• 2 mixter hemostatic forceps
• 2 bard parker needle holder
• 2 Army Navy retractors
• 2 Yankauer suction
• 1 poole abdominal suction tube

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IMAGES:

Devices:

> Suction machine > Electrosurgical unit

Facilities:

> Operating Room

Supplies:

• Dissectors

• Suction
tubing
• Drainage (e.g. Hemovac)

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 • Blades (2) No. 10, (1) No.15 • Sterilegloves

• Hemoclips, variety of sizes

• Sponges

• Electrosurgical pencil

• Surgical caps

Equipments:

• Operating table • Operating lights

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Instruments:

MAJOR PROCEDURES TRAY

Forceps
• adson tissue forceps (1 x 2 )

• Ferris-smith tissue forceps

• 2 Russian tissue forceps

• 2 thumb tissue forceps with teeth (1 x 2)

• 2 DeBakey vascular Autraugrip tissue forceps

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Scissors • 1 Metzenbaum 7”
• 1 Wire cutter

• 2 straight & 1 Curved Mayo 6 ¼” • 2 Snowden-pencer

Retractors

• Goelet • 2 Army-Navy

• Gelpi
• Deaver (1) narrow, (1) medium,
(1) wide

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Suction Tubes or Tips:
• 1 Poole

Miscellaneous
• Knife handles (2) No. 3, (1) No. 7

• 1 Probe, malleable

• 1 Grooved director

Clamps:

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• 4 Tonsil (Shnidt) 7 ½”
• Right angle 8”
• Needle Holder (2) 6”, (2) 7”, (2)
8”

• Allis 6”

• 10 Towel clips 5 ½”

• 6 Straight Crile 5 ½”

• Straight Kocher 6 ¼”

• Bobcock 6”

• 12 Curved Pean (6) 6 ¼”, (6) 8” • 4 Sponge forceps 10”

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1.4 Perioperative tasks and responsibilities of the Nurse

Preoperative Preparation
Restoration of the blood volume is especially important in patients who have lost
considerable weight. Low values of sodium chloride and potassium must be corrected,
and the carbon dioxide combining power and blood urea nitrogen return to normal before
operation. Secondary anemia and protein and vitamin deficiencies should be corrected
insofar as possible before operation. Their correction aids in healing and contributes to
the proper emptying of the stomach after operation. The large atonic stomach is emptied
by constant gastric suction for several days before operation. The stomach is emptied by
gastric lavage, usually the night preceding operation, to make certain that all coarse
particles of food have been removed and that gastric tension is relieved. The lavage is
repeated 1 to 2 hours before operation. Constant gastric suction with a Levin tube is
maintained. Blood must be available for transfusion during the operation.

Pre-operative

 avoid consuming alcohol and substances that contain caffeine or chocolate

 avoid smoking

 avoid aspirin or NSAIDS

 obtain adequate rest and reduce stress

Intraoperative

 monitor v/s closely

 assess for signs of dehydration, hypovolemic, shock, sepsis, and respiratory

insufficiency

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  maintain NPO status and administer intravenous fluid ,replacement as
prescribed, monitor intake and output

 monitor hemoglobin and hematocrit

 administer blood transfusion as prescribed

 assist with the insertion of Nasogastric tube for decompression and for lavage
access

 assist with normal saline or tap water lavage at room temp to reduce active
bleeding

 prepare to assist with administering vasopressin(pitressin) intravenously as

prescribed to induce vasoconstriction and reduce bleeding

Post-operative

 monitor v/s

 position patient in fowlers for comfort and to promote drainage

 administer fluids and electrolyte replacements intravenously as prescribed

 monitor intake and output

 assess bowel sounds

 monitor Nasogastric suction as prescribed

 do not irrigate or remove Nasogastric tube

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  assist the physician with Nasogastric irrigation or removal of Nasogastric tube

 maintain NPO status as prescribed for 1 to 3 days until peristalsis return

 progress the diet from NPO to sips of clear water to small, bland meals a day as
prescribed when bowel sounds return

 monitor postoperative complications of hemorrhage, dumping syndrome,

diarrhea, hypoglycemia and Vitamin B 12 deficiency

Preoperative Preparation
The patient’s eating habits should be evaluated and the relationship between his
preoperative and ideal weight should be determined. The retention of an adequate
gastric capacity as well as reestablishment of a normal continuity tends to give the best
assurance of a satisfactory nutritional status in undernourished patients.

Pre-operative Responsibilities:

 Upon admission of the patient, obtain the vital signs. History of past and present
illness of the patient should also be taken.

 The nurse should serve as a witness when the client signs the surgical consent.
The nurse has to make sure that the client really understood the content of the
consent and the procedure.

 Advise patient to discontinue Drugs/medications such as aspirin/ NSAIDS

several days before the operation to avoid excessive bleeding during the
procedure. The discontinuation of any medication must be discussed with the
doctor when the surgery is scheduled.

 Advise patient that the stomach must be completely empty.

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  The nurse has to review the orders made by the doctor and carry out pre-
operative medications as well as prepare the patient before transferring the
patient to the operating room.

 Encourage patient to void before transferring to the operating room.

 Any prosthesis and nail polish should also be removed before the surgery.

 Tie the hair of the patient if it is long or let her/him use a hair net.

 Accompany the patient in going to the operating room for proper endorsement of
the things done to the patient prior to the operation.

Preoperative Responsibilities of the Circulating Nurse:

 The circulating nurse must know and be familiar to all information about the
operation, (operating room, schedule, operation to be performed, and the
instruments to be used)

 Prior to transferring the patient to the operating room, the circulating nurse shall
check the chart of the patient

 The circulating nurse is responsible for the arrangement of all instruments to be

use in operation

 The circulating nurse should test all facilities and equipments to be use in
operating room.

 The circulating nurse is responsible for opening all sterile supplies that will be
used in operation.

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  Check with the scrub nurse and anesthesiologist the instruments that will be
used, confirm the scrub nurse if they need more supplies or instruments are
needed.

 The circulating nurse shall assist in transferring the patient to the operating table.

 The circulating nurse should be responsible for the turning on of the lights.

 The circulator helps the surgeons and scrub nurse into their gowns by pulling the
gowns over their shoulders and tying the back ties.

 The circulator shall also help scrub nurse if he/she needs more OS or other
equipments. And help in arranging the back table

 Prior the surgery the circulating nurse together with the scrub nurse shall count
all the instruments and supplies to be use in the operation.

Intraoperative Responsibilities of the Scrub Nurse:

 The scrub nurse should be familiar with the procedure to be done and the
materials, equipments, and supplies needed.

 The scrub nurse shall check all the instruments and supplies to be used by
surgeon in operation.

 The scrub nurse assists the surgeon and assistant surgeon into their gowns and
gloves.

 The scrub nurse is the responsible in draping the operative site.

 The scrub nurse assist the surgeon all through out the procedure as required.
The nurse should listen carefully to what the surgeon is saying.

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  As the patient leaves the room, the scrub nurse gathers all the instruments ready
for terminal cleaning.

 The scrub nurse is responsible in cleaning all the instruments used in operation.

Intraoperative Responsibilities of Circulating Nurse:

 The circulating nurse shall be responsible for the recording of the cutting time.

 The circulating nurse must be alert of the needs of the scrub nurse and the
anesthesiologist.

 Be aware of the emergency procedures.

 Keep the operating room neat.

 Observe the scrub team for perspiration and wipe team members’ forehead as
necessary.

 Give any medication as requested by the surgeon.

 Get supplies as they are requested during an operation.

 Count sponges and have them available so the anesthesiologist can see them
and estimate the blood loss.

Post-operative Responsibilities of the Circulating Nurse:

 The circulating nurse is responsible for the recording of closing time of the
surgery.

 The circulating nurse assists with dressings as needed.

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  After the surgery has been completed the circulator is in charge in assisting the
scrub team on taking off their gowns and in bringing the post anesthesia recovery
stretcher into the room.

 The circulator checks to see that any catheters, suctions, IVF poles are
transferred with the patient.

 The circulator should be available to assist the anesthesiologist to move the

patient to the post anesthetic recovery room if necessary.

 After taking the patient to the recovery room, the scrub nurse and the circulating
nurse should clean up the operating room.

 The circulating nurse shall complete all paperwork.

Postoperative Care

 Nurse shall monitor vital sign immediately

 Nurse shall position patient in fowlers for comfort and to promote drainage

 Administer fluids and electrolyte replacements intravenously as prescribed

 Nurse shall monitor intake and output

 Assess bowel sounds

 Monitor Nasogastric suction as prescribed

 Do not irrigate or remove Nasogastric tube

 Assist the physician with Nasogastric irrigation or removal of Nasogastric tube

24
  Maintain NPO status as prescribed for 1 to 3 days until peristalsis return

 Progress the diet from NPO to sips of clear water to small, bland meals a day as
prescribed when bowel sounds return

 Monitor postoperative complications of hemorrhage, dumping syndrome,

diarrhea, hypoglycemia and Vitamin B 12 deficiency

1.5 Expected outcomes of surgical treatment performed

Expected outcomes of Billroth I & II depend on the reasons for the surgery. These
procedures are performed to reduce acid secretion in PUD or to remove premalignant
tissue to prevent gastric cancer are over 95% successful. The success rate is even
higher in treating watermelon stomach. Billroth I & II performed to treat gastric cancer or
penetrating abdominal trauma are less successful, but this result is related to the
severity of the patient's illness or injury rather than the surgical procedure itself.

Overall survival after gastrectomy for gastric cancer varies greatly by the stage of
disease at the time of surgery. For early gastric cancer, the five-year survival rate is up
to 80-90%; for late-stage disease, the prognosis is bad. For gastric adenocarcinomas
that are amenable to gastrectomy, the five-year survival rate is 10-30%, depending on
the location of the tumor. The prognosis for patients with gastric lymphoma is better, with
five-year survival rates reported at 40-60%.

For gastric obstruction, a gastroduodenostomy is considered the most radical

procedure. It is recommended in the most severe cases and has been shown to provide
good results in relieving gastric obstruction is in most patients. Overall, good to excellent
gastroduodenostomy results are reported in 85% of cases of gastric obstruction. In
cases of cancer, a median survival time of 72 days has been reported after
gastroduodenostomy following the removal of gastric carcinoma, although a few patients
had extended survival times of three to four years. Results of a gastroduodenostomy are
considered normal when the continuity of the gastrointestinal tract is reestablished.

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 A gastroduodenostomy has many of the same risks associated with any other major
abdominal operation performed under general anesthesia, such as:

• Wound problems • Nausea

• Difficulty swallowing • Blood clotting

• Infections

More specific risks associated with a gastroduodenostomy include:

• Duodenogastric reflux - resulting in persistent vomiting

• Dumping syndrome - occurring after a meal and characterized by sweating,

abdominal pain, vomiting, lightheadedness, and diarrhea

• Low blood sugar levels (hypoglycemia) after a meal

• Alkaline reflux gastritis - marked by abdominal pain, vomiting of bile, diminished

appetite, and iron-deficiency anemia

• Malabsorption of necessary nutrients - especially iron, in patients who have had

all or part of the stomach removed

1.6 Medical management of physiology outcomes

A. Fluid Therapy
1. D5LRS
• It is a hypertonic solution which is used to replace acute fluid and
electrolyte losses and for correcting mild acidosis. Provide fluid
replacement and electrolytes

B. Pharmacologic Therapy

1. Narcotic Analgesics

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 • e.g. meperidine (Demerol), fentanyl (Sublimaze), pentazocine
(Talwin).
• Meperidine is usually effective in relieving pain and may be
preferred over morphine. Paravertebral block has been used to
achieve prolonged pain control.

2. Sedatives
• e.g. diazepam (Valium), antispasmodics; e.g. atropine
• Potentiates action of narcotic to promote rest and to reduce
muscular/ ductal spasm, thereby reducing metabolic needs,
enzyme secretions.

3. Foley Catheter
• Foley catheter is a double-lumen catheter. The larger lumen drains
urine from the bladder. A second, smaller lumen is used to inflate a
balloon near the tip of the catheter to hold the catheter in place within
the bladder. The balloons of retention catheters are sized by the
volume of fluid used to inflate them.

4. Nasogastric tube
• Is inserted by way of nasopharynx and is placed directly into the
client’s stomach and provides another route for administering
medications and nutrition

5. Vitamin B12, iron, and folate, Vitamin D and calcium

• replacement required because fat metabolism is altered, reducing
absorption/ storage of fat-soluble vitamins.
• Help in preventing anemia, osteoporosis and osteomalacia

6. Anti-infectives and aminoglycosides

• e.g. imipinem/ cilastatin (Primaxin), metronidazole (Flagyl),
levofloxan (Levoquin), cephalosphorins, cefoxitin sodium
(Mefoxin)

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 • e.g. gentamicin (Garamycin), tobramycin (Nebcin)
• decreases bacterial count

Pre-op Medication
Name of Drugs General Indication(s) or Purpose(s)
Classification
1. Antiinfectives, Prophylactic treatment.
Metronidazole antiprotozoal,
antiulcer

2. Ranitidine Anti-ulcer Short-term treatment of active duodenal ulcers and

benign gastric ulcers, Prevention of heartburn, acid
indigestion and sour stomach. Decreased symptoms of
GERD. Decreased secretion of gastric acid.
3. Clindamycin Anti infectives Treatment of skin and skin structure infections, Resp
tract infections, intraabdominal infections.

4. Halothane
General Controlling pain and making the patient unconscious,
anesthesia(inha general anesthesia control the body's reaction to stress
lation) and relieves fear and anxiety associated with surgery
5. Ancef 1
gram Antibiotic Used to treat a wide variety of bacterial infections. It
may also be used before and during certain surgeries
to help prevent infection. This medication is known as
a cephalosporin antibiotic. It works by stopping the
growth of bacteria.

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Post-op Medication
Name of Drugs General Indication(s) or Purpose(s)
Classification
1. Demerol 75 narcotic This medication is used to treat moderate to severe
analgesic pain. Meperidine acts on certain centers in the brain to
give you pain relief. This medication is a narcotic pain
reliever similar to morphine.

2. Non-opioid Mild pain.fever. inhibits the synthesis of prostaglandins

Acetaminophen analgesic, that may serve as mediators of pain and fever,
anti-pyretics primarily in the CNS.
3. Antiinfectives,
Metronidazole antiprotozoal,
antiulcer

4. Ranitidine Anti-ulcer Decreased symptoms of GERD. Decreased secretion

of gastric acid.

Nursing Responsibilities:

Metronidazole
1. Alcohol should be avoided because metronidazole and alcohol together can cause
severe nausea, vomiting, cramps, flushing, and headache

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2. can increase the blood thinning effects of warfarin (Coumadin) and increase the risk of
bleeding probably by reducing the break down of warfarin.
3. Metronidazole is not used in early pregnancy because of potential adverse effects on
the fetus.
4. Metronidazole is excreted in breast milk. Nursing mothers, because of potential
adverse effects on the newborn, should not use metronidazole.
5. Metronidazole is a valuable antibiotic and is generally well tolerated with appropriate
use. Minor side effects include nausea, headaches, loss of appetite, a metallic taste, and
rarely a rash. Serious side effects of metronidazole are rare. Serious side effects include
seizures and damage of nerves resulting in numbness and tingling of extremities
(peripheral neuropathy). Metronidazole should be stopped if these symptoms appear.

Ranitidine
1. May be taken with or without food.
2. Since ranitidine is excreted by the kidney and metabolized by the liver, dosages of
ranitidine need to be lowered in patients with significantly abnormal liver or kidney
function.
3. Antacids may decrease the absorption of ranitidine.
4. Safety of ranitidine in children has not been established.
5. Ranitidine is not habit forming.
6. Ranitidine can interfere with the metabolism of alcohol.
7. Patients taking ranitidine who drink alcohol may have elevated blood alcohol levels.
8. Take note of the Minor side effects include constipation, diarrhea, fatigue, headache,
insomnia, muscle pain, nausea, and vomiting. Major side effects are rare; they include:
agitation, anemia, confusion, depression, easy bruising or bleeding, hallucinations, hair
loss, irregular heartbeat, rash, visual changes, and yellowing of the skin or eyes.

Clindamycin
1. Do not use this medication if allergic to clindamycin or lincomycin (Bactramycin, L-
Mycin, Lincocin)
2. Do not take clindamycin together with erythromycin (E-Mycin, E.E.S., Eryc, Ery-Tab,
Robimycin, and others).

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3. Before using clindamycin, remind patient to tell the doctor if he have kidney disease,
liver disease, an intestinal disorder such as colitis or Crohns disease, or a history of
asthma, eczema, or allergic skin reaction.
4. Clindamycin will not treat a viral infection such as the common cold or flu.
5. Antibiotic medicines can cause diarrhea, which may be a sign of a new infection.
6. If patient have diarrhea that is watery or has blood in it, call the doctor. Do not use any
medicine to stop the diarrhea unless prescribed by the doctor.

Halothane
1. Tell the doctor if the patient has
• Irregular heartbeat
• History of malignant hyperthermia
• Liver disease
• Myasthenia gravis
• pheochromocytoma
• Previous exposure to halothane anesthesia
• An unusual or allergic reaction to halothane, or other anesthetics
• Pregnant or trying to get pregnant
• breast-feeding
2. Tell the HCP all the medications that the patient is taking as this may interact with
halothane.
3. Tell the patient that the anesthesiologist will closely monitory all body systems and
treat any serious side effects.

Ancef
1. Prophylactic administration of cefazolin should usually be discontinued within a 24-
hour period after the surgical procedure.
2. In surgery where the occurrence of infection may be particularly devastating (e.g.,
open-heart surgery and prosthetic arthroplasty), the prophylactic administration of
cefazolin may be continued for 3 to 5 days following the completion of surgery.

Demerol

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1. Do not use this medicine if allergic to meperidine, or if client used an MAO inhibitor
such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline
(Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days.
2. Demerol may be habit-forming and should be used only by the person it was
prescribed for.
3. Demerol should never be given to another person, especially someone who has a
history of drug abuse or addiction.
4. Before using Demerol, tell the doctor if the patient is allergic to any drugs, or if the
patient has:
• low blood pressure;
• asthma, COPD, sleep apnea, or • gallbladder disease;
other breathing disorders; • Addison's disease or other
• liver or kidney disease; adrenal gland disorders;
• under active thyroid; • enlarged prostate, urination
• curvature of the spine; problems;
• a history of head injury or brain • mental illness; or
tumor; • history of drug or alcohol
• epilepsy or other seizure addiction.
disorder;

5. Contraindicated to pregnant women

Acetaminophen
1. Acetaminophen is not particularly effective against pain from inflammatory disorders,
since it doesn't reduce the underlying inflammation.
2. It should not be used for over two weeks without seeking medical advice.
3. It is essential to avoid excessive amounts of acetaminophen as this may cause
damage to the liver or kidneys
4. Overdose of acetaminophen is serious and can be fatal from liver toxicity

1.7 Nursing management of physiologic, physical and psychosocial outcomes

Risk for ineffective breathing pattern r/t abdominal incision pain

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 • Evaluate respiratory rate and depth and note for respiratory effort.
-Rate and effort may be increased by pain. Early recognition and treatment of abnormal
ventilation may prevent complications.

• Auscultate breath sounds. Note areas of diminished/ absent breath sounds and
presence of adventitious sounds.
-Loss of active breath sounds in an area of previous ventilation may reflect atelectasis.
Crackles or rhonchi may be indicative of fluid accumulation.

• Encourage client participation/ responsibility for deep breathing exercises, use of

adjuncts, and coughing as indicated. Reposition frequently.
-Stimulates respiratory function/ lung expansion. Effective in preventing and resolving
pulmonary congestion. Coughing is not necessary unless wheezes or rhonchi are
present, indicating retention of secretions.

• Reinforce splinting abdomen with pillow during deep breathing or coughing.

-this may enhance effectiveness of cough effort.

• Note increasing restlessness, confusion and lethargy.

-this may indicate impaired gas exchange.

• Administer supplemental oxygen if indicated.

-increases available oxygen for optimal oxygenation.

Risk for deficient fluid volume

• Auscultate heart sounds; note rate and rhythm.

-Cardiac changes may reflect hypovolemia or electrolyte imbalance.

• Monitor blood pressure and heart rate.

-Dropping blood pressure and tachycardia may indicate fluid volume deficit.

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 • Monitor and report any postoperative bleeding. Mark extension of drainage from
incisions.
-outlining the stain on the surface of the dressing and indicating the time of assessment
allow staff to quantify amount of drainage and severity of bleeding later.

• Record color and character of gastric drainage, measure pH, and note presence
of occult blood.
-indicates risk for gastric bleeding or hemorrhage is high.

• Check mucous membranes and skin turgor.

-Moist mucous membranes and good skin turgor are signs of adequate hydration.

• Weigh patient daily at the same time, using the same scale.
-Changes in the patient’s body weight can be an indicator of fluid balance changes.

• Observe or report coarse muscle tremors and twitching.

-Symptoms of calcium imbalance. Calcium binds with free fats in the intestine and is lost
by excretion in the stool.

Risk for infection r/t surgical incision

• Monitor Vital signs esp. temperature.

-For the first 48 to 72 hours postoperatively, temperatures of up to 38.5°C are expected
as normal stress response after major surgery. Beyond 72 hours, temperature should
return to patient’s baseline. Temperature spikes, usually occurring in the later afternoon
or night, are often indications of infection.

• Monitor white blood cell count.

-Elevated WBC count is typically an indication of infection; however in elderly patients,
infection may be present without a rise in WBC because of normal changes in the
immune system.

• Assess incision and wound for redness, drainage, swelling and increased pain.

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-Redness, drainage, swelling and increased pain indicate the presence of infection.

• Use strict aseptic technique when changing surgical dressing or working with IV
lines, indwelling catheter/ tubes, drains. Change soiled dressing promptly.
-Limits sources of infection, which can lead to sepsis in a compromised client.

• Stress importance of good hand washing.

-Reduces risk of cross-contamination.

• Assess quality of breath sounds, cough, and sputum production.

-The presence of adventitious breath sounds can indicate a respiratory infection.

• Encourage frequent position changes, deep breathing, and coughing. Assist with
ambulation as soon as stable.
-Enhances ventilation of all lung segments and promotes mobilization of secretions.

• Obtain culture specimens; e.g., blood, wound urine or sputum.

-Identifies presence of infection and causative organism.

Acute pain r/t abdominal incision pain

• Assess nature of pain (location, quality, onset, frequency, radiation, and

duration). Have patient rate pain intensity of a scale (1 to 10).
-Some pain is expected after abdominal surgery; appropriate pain management will
provide comfort and enable the patient to move and rest.

• Monitor change in perception of pain associated with abdominal distention.

-Distention of the abdomen by accumulation of gas and fluid occurs postoperatively
because normal peristalsis does not return until the third or fourth day after surgery;
distention stresses the suture line/s and causes pain.

• Promote position of comfort; e.g., on one side with knees flexed, sitting up and
leaning forward.

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-Reduces abdominal pressure/ tension, providing some measure of comfort and pain
relief.

• Provide alternative comfort measures; e.g. back rub.

-Promotes relaxation and enables client to refocus attention; may enhance coping.

• Administer analgesics in timely manner, smaller, more frequent doses, during

acute episode as ordered.
-Severe or prolonged pain can aggravate shock and is more difficult to relieve, requiring
larger doses of medication, which can mask underlying problems/ complications and
may contribute to respiratory depression.

• Document patient’s response to pain-relieving measures.

-Patients have individualized pain tolerance levels and all patients will not be made
comfortable with standard doses.

Nutrition imbalance: less than body requirements r/t inability to ingest adequate
nutrients.

• Discuss eating habits, including food preferences, intolerances.

-To appeal to client’s likes/ dislikes.

• Ascertain understanding of individual nutritional needs.

-To determine what information to provide client/ SO.

• Assess drug interactions, disease effects, allergies, use of laxatives, diuretics.

-These factors may be affecting appetite, food intake, or absorption.

• Evaluate impact of cultural, ethnic, or religious desires/ influences.

-To determine factors that may affect food choices.

• Assess weight, age, body build, strength, activity/ rest level.

-Provides comparative baseline.

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 • Promote relaxing and pleasant environment.
-To enhance food intake.

• Promote adequate and timely fluid intake.

-To replace fluid loss.

• Note total daily intake. Maintain diary of caloric intake, patterns and times of
eating.
-To reveal changes that should be made in client’s dietary intake.

• Prevent/ minimize unpleasant odors/sights.

-May have a negative effect on appetite/ eating

III. Conclusion

Through this case report, the group has learned how the surgery is done that will
greatly assist them when given the chance to handle such procedure. During the
surgery, the group will be able to anticipate the next procedure that will be done thus
increasing the awareness of the instruments to be prepared and the kind of assistance
to be given. Postoperatively, the group will be able to render optimum assistance in
gaining the client’s health and well-being through rehabilitation and health teachings.

Gastroduodenostomy (Billroth I) and Gastrojejunostomy (Billroth II) are surgical

procedures which are considered palliative measures which remove any obstructions or
malignancy from the gastrointestinal. In the actual OR setting, the group has not yet
been given the chance to perform the said surgery but it is an assurance that this
procedure will bring about interesting experience and knowledge.

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 Furthermore, the group has learned what are the different risks and benefits
involved in partaking with this surgery. Complications postoperatively will be much more
controlled.

REFERENCES:

Black, Joyce, et. al. Medical-Surgical Nursing: Clinical Management for Positive
Outcomes 6th Edition. Philadelphia, Pennsylvania: W.B. Saunders Company, 2002
Bare, Brenda G., et al. Brunner and Sudddarth’s Textbook of Medical-Surgical
Nursing 11th Edition. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins, 2004.

Retrieved at:
http://www.answers.com/topic/gastroduodenostomy)
http://www.answers.com/topic/gastrojejunostomy)
www.whonamedit.com/synd.cfm/2730.html
en.wikipedia.org/wiki/Gastrectomy
cancerweb.ncl.ac.uk/cgi-bin/omd?Billroth's+i+operation
http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?
requestURI=/healthatoz/Atoz/ency/gastrectomy.jsp

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