Billroth II subtotal gastrectomy

The Billroth II subtotal gastrectomy is to suture the duodenal stump after partial resection of the distal part of the stomach, and the residual stomach is anastomosed to the jejunum. This kind of reconstruction method can directly enter the upper jejunum from the stomach, and the duodenal ulcer lesion can be removed without resection. It can remove more stomach tissue without excessive anastomotic tension, so it is more suitable for treatment. Duodenal ulcer is also suitable for the reconstruction of gastric ulcer and radical resection of gastric cancer. However, the anatomical and physiological changes caused by this method are large, and the incidence of surgical complications is high. Treatment of diseases: stomach cancer Indication Billroth II subtotal gastrectomy is applicable to: 1. Duodenal ulcer is mainly used for patients with acute perforation of ulcer, acute massive hemorrhage, pyloric obstruction, and poor medical treatment and multiple ulcer recurrence. The basic theory of partial gastrectomy for duodenal ulcer is to reduce the number of parietal cells and primary cells, reduce the secretion of gastric acid and pepsinogen, and remove the gastric antrums rich in gastrin cells. Reduce serum gastrin; remove or treat ulcer lesions. 2. Gastric ulcer with high gastric acid secretion. 3. The tumor at the distal end of the stomach is mainly gastric cancer. Radical subtotal resection should be performed according to the principle of treatment of cancer. Semi-gastrectomy is suitable for patients with gastric ulcer and low stomach acid. Because of the absence of high acid stimulating factors, anastomotic ulcers do not occur after surgery. A lot of treatment experience in China has proved this. Gastric ulcer has a tendency to malignant. Patients with gastric ulcer who are over 40 years old should undergo surgical treatment after regular medical treatment for 4 to 6 weeks. Semi-gastrectomy can also be used as an additional procedure for selective vagotomy or vagus nerve ablation to treat duodenal ulcers. Preoperative preparation 1. Patients with poor general condition and nutritional status should improve their general condition before surgery to correct malnutrition, anemia and hypoproteinemia. A diet high in protein and sufficient vitamins should be given. If necessary, transfusion or plasma transfer should increase the levels of hemoglobin and plasma protein. 2. Patients with dehydration and electrolyte imbalance should be properly infused and supplemented with electrolytes before surgery to correct water and electrolyte disturbances. 3. Patients with pyloric obstruction should start fasting, gastrointestinal decompression, infusion, daily gastric lavage 2 or 3 times before surgery, emptying the food and secretions in the stomach, reducing inflammation of the gastric mucosa. And edema to facilitate recovery after surgery and surgery. 4. Patients with ulcer bleeding should take various anti-shock measures before surgery to actively transfuse blood and try to make up the blood volume. 5. Patients undergoing elective surgery performed soapy water enema 1 day before surgery, and fasted in the morning on the day of surgery. Surgical procedure 1. Freeness of the stomach and duodenum The method was the same as the Billroth I subtotal gastrectomy. 2. Cutting the duodenum and suturing the stump Two vascular clamps were placed on the duodenum under the pylorus, and the duodenum was cut between the two clamps, and the stomach was turned to the left. Closed duodenal stump can be sutured with non-absorption line, or continuous suture can be used. Intermittent suture method is to make a row of full-thickness sutures along the right side of the vascular clamp with non-absorbent lines, without knotting, loosening the vascular clamp, and then tightening the suture one by one. Ligation, and then a layer of pulp muscle suture. The continuous suture method uses a non-absorbent wire-wound vascular clamp to make a full-layer continuous suture. The suture is not tightened for the time being. After the suture is completed, loose the vascular clamp and then tighten the suture from both ends and knot. Then use one end of the suture to make a continuous musculotomy. When the duodenal stump is long, a bowel forceps can be placed on the distal end of the duodenum. After the duodenum is crossed, the stump is opened, and the non-absorbent line is used as the stump full-thickness muscle suture. The muscle layer is sutured. Duodenal ulcer has a wide range of lesions. When there are many scar tissue or there is a posterior wall penetration, it is difficult to suspend the stump, and special treatment should be done. 3. Gastric left artery severance and gastric resection The method steps were the same as the Billroth I procedure. 4. Post-colon stomach and jejunum anastomosis Lift the transverse colon to reveal the mesentery and its blood vessels. A cross-shaped incision is made on the transverse aorta of the avascular region on the left side of the middle cerebral artery, and the length is about 5 to 7 cm. Find the proximal end of the jejunum. The two-needle traction line was sutured to the mesenteric side of the jejunum of 5 to 10 cm under the ligament of the ligament, and the incision and anastomosis were between the two lines. The stomach stump is turned upside down to expose the posterior wall of the stomach. The posterior half of the transverse mesenteric incision and the posterior wall of the stomach were fixed and sutured 5-6 needles, and the suture should be 5-6 cm from the gastric stump. The jejunal traction line is passed through the transverse mesenteric orifice to the jejunum onto the transverse mesentery and close to the gastric stump. Gastric jejunal anastomosis, the toothed vascular clamp of the gastric stump is turned forward to reveal the posterior wall of the gastric stump, and close to the jejunum. Intermittent sutures were performed with the No. 0 non-absorbable line. The suture is about 0.5 to 1 cm from the vascular clamp. The muscle wall of the posterior wall of the stomach was cut along the vascular clamp, the blood vessels of the gastric mucosa were sutured, and the muscle layer of the anterior wall of the stomach was cut, the submucosal blood vessels were sutured, and the edge of the gastric stump was clamped. These steps are the same as the Billroth I style. A pair of intestinal clamps on the stomach and jejunum side. The jejunal wall was cut approximately 0.5 cm from the suture of the sarcoplasmic layer. The length of the incision should be equal to the length of the gastric stump. The anastomosis posterior wall was then sutured and a full-thickness suture was performed with a 3-0 non-absorbent line. The anterior wall of the anastomosis was also treated with a 3-0 non-absorbent line for full-thickness suture. Loosen the jejunum and the intestinal clamp on the stomach. Then use the No. 0 non-absorption line to make the anterior wall of the anastomotic stoma intermittent suture, and strengthen the suture at the two corners. The match has now been completed. The anastomosis is placed under the transverse mesenteric orifice, and the leading edge of the transverse mesenteric orifice is sutured and fixed to the anterior wall of the stomach. The suture should be 5 to 6 cm from the anastomosis. 5. The colon before the colon and the jejunum Lifting the transverse colon along the root of the mesentery is equivalent to the left side of the first lumbar vertebrae to find the ligament of the ligament and the beginning of the jejunum. The two-needle traction line of the mesenteric side of the jejunal wall of the ligament of the flexor ligament is used as an anastomosis. The jejunum is lifted in front of the colon close to the stomach stump. The lower part of the jejunum and transverse mesenteric membranes were sutured with 3 to 4 needles with non-absorbent lines to prevent the formation of internal hemorrhoids. The toothed vascular clamp of the gastric stump is turned to the front to expose the posterior wall of the gastric stump. The jejunum is brought close to the posterior wall of the stomach, and the jejunal input section is slightly curved to the stomach. The No. 0 non-absorbable line was used to suture the posterior wall of the stomach and the sarcolemma of the jejunum. The suture should be 0.5 to 1 cm from the vascular clamp. The muscle wall of the gastric wall was cut along the vascular clamp, the submucosal vessels were sutured, and the tissue clamped by the gastric stump was removed with the Billroth I procedure. A small intestine forceps on the stomach and jejunum side temporarily clamped the gastrointestinal cavity, 0.3 cm from the suture of the muscle layer and paralleled the jejunal wall. Its length should be equal to the gastric residual port. The anastomosis posterior wall was then sutured, and the 3-0 non-absorbent line was used to suture the entire layer of the posterior wall. The needle can not exceed the suture of the muscle layer. Turning to the anterior wall of the anastomosis, the 3-0 non-absorbent line is also used for full-thickness suture. The intestinal clamp was removed, and the sutured muscle layer of the anterior wall was sutured with a non-absorbent line No. 0. The triangular region of the junction of the anastomosis and the suture of the gastric stump is sutured with a needle muscle layer. complication Partial resection of the stomach has some special complications in addition to the complications of general abdominal surgery. Some complications are related to surgical technique operations, and some are related to anatomical changes in the gastrointestinal tract. Generally can be divided into recent complications and long-term complications. 1. Recent complications of partial gastrectomy (1) bleeding Hemorrhage after gastric surgery can occur in the stomach or in the abdominal cavity. Most of the intra-abdominal hemorrhage is caused by imperfect hemostasis or ligature ligature of a certain blood vessel. The main clinical manifestations are hemorrhagic shock symptoms early in the operation, such as pale skin, cold sweat, shortness of breath, rapid pulse and blood pressure. There may be a full stomach, and there are mobility dullness in the percussion. Abdominal puncture aspiration of a large amount of blood can be a clear diagnosis. Once diagnosed, surgery should be stopped immediately. Common intragastric bleeding sites are in the gastrointestinal anastomosis, gastric stump suture and duodenal stump. The latter occurs mostly after duodenal ulcer surgery. It is common to aspirate a small amount of bloody fluid from the nasogastric tube after a gastrectomy, which will gradually decrease or even disappear. If the gastrointestinal decompression tube draws more blood, it should be closely observed. If a large amount of blood is continuously sucked out, indicating that there is active bleeding in the stomach, the stomach should be infused with a solution of norepinephrine aqueous solution in the stomach, blood transfusion and intravenous drip hemostatic agent. Most of the bleeding after these treatments can be gradually stopped. If the bleeding is not enough or the symptoms of shock occur, the operation should be stopped in time to stop bleeding. During the operation, the anterior wall of the stomach can be cut open to remove the blood and blood clots in the stomach cavity. Examine carefully and look for the bleeding site. Most of them are sutured or anastomotic at the stump of the stomach. Suture ligation with non-absorbent lines to stop bleeding. If the bleeding originates from the duodenal stump, the stump suture should be removed and re-sewed after hemostasis or via the duodenal stump. (2) Duodenal stump or anastomotic fistula Most of the duodenal stumps occur in cases where the duodenal stump is difficult to treat. The input of jejunal stenosis or obstruction is also an important factor contributing to the rupture of the duodenal stump. The clinical manifestations of duodenal stump fistula are early symptoms of peritoneal inflammation, such as upper right abdominal pain, abdominal distension, fever, and peritoneal irritation. Abdominal puncture sucks out the biliary fluid to confirm the diagnosis. Once the duodenal stump fistula occurs, it must be surgically treated in time. After the abdomen, the abdominal cavity was absorbed, and the abdominal cavity was flushed with a large amount of physiological saline. The double cannula and the irrigation tube were placed near the mouth of the fistula to continue the vacuum suction. Continued gastrointestinal decompression after surgery, give total parenteral nutrition support or surgery while jejunal suture for enteral nutrition, and give broad-spectrum antibiotics. After the above treatment, the mouth will gradually shrink and heal. In order to prevent duodenal stump paralysis, the duodenal stump should be properly treated during the Billroth II gastric resection. If the stump is difficult to handle or the suture of the stump is estimated to be unreliable, the stump should be intubated into the duodenum for external drainage. The catheter can be removed after the sinus wall has been formed around the catheter 10 to 14 days after surgery. Anastomotic fistula often occurs in the triangle of the junction of the gastrointestinal anastomosis and the suture of the gastric stump. Adding a pocket to the suture at the site during surgery is an essential step. Excessive anastomotic tension is also one of the causes of paralysis. Therefore, care should be taken during surgery to make the anastomosis mouth free of tension. In the case of Billroth I, if the anastomotic tension is too large, the peritoneum of the duodenum should be opened to move the duodenum to the midline to reduce the tension of the anastomosis. The clinical manifestations and treatment of anastomotic leakage The principle is basically the same as the duodenal stump. (3) Obstruction Obstructive complications of partial gastrectomy include gastric emptying disorders, jejunal obstruction, jejunal obstruction, and internal hemorrhoids. Gastric emptying disorder: Gastric retention occurs after the partial gastric resection of the residual stomach contents can not enter the intestine through the anastomosis. Functional or mechanical factors are collectively referred to as gastric emptying disorders. Mechanical obstruction due to too small anastomosis, excessive varus or distortion caused by anastomotic obstruction. Obstruction due to tension-free gastric or anastomotic inflammation edema is often functional. The cause of no tension in the stomach is not fully understood. It is generally considered to be related to the following factors. 1 bile reflux causes acute reflux gastritis, anastomotic and gastric mucosal edema, erosion; 2 vagus nerve branches with the stomach are cut off, the peristaltic function of the stomach is reduced; 3 electrolyte disorders, such as hypokalemia and hyponatremia; 4 mental factors and other unexplained reasons. The main clinical manifestations of gastric emptying disorders are upper abdominal fullness and vomiting. Mechanical anastomotic obstruction often occurs after stopping gastrointestinal decompression. Functional emptying disorders occur mostly 7 to 10 days after surgery. After the patient began to enter the semi-liquid diet, he developed upper abdominal fullness and vomiting. Gastrointestinal examination showed that the contrast agent was retained in the stomach and could not pass through the anastomosis. Fiberoptic endoscopy is important for identifying mechanical or functional obstructions. As long as it is not a mechanical anastomotic obstruction, it should adhere to non-surgical treatment, continue gastrointestinal decompression, gastric lavage with normal saline or 2% sodium bicarbonate solution, inhibit gastric acid secretion by H2 receptor antagonist, maintain water and electrolyte balance To correct anemia and hypoproteinemia. For more than 1 week, all parenteral nutrition support should be given. After 2 to 4 weeks of treatment, it can generally be gradually restored. A small number of patients also need longer treatment time, do not rush to surgical exploration. If surgical exploration is performed because the possibility of mechanical anastomotic obstruction cannot be ruled out, it is found that the anastomosis is smooth and there is no mechanical obstruction factor. It is feasible to use the gastrostomy tube decompression and jejunal suture to maintain the intestine. Nutrition, do not easily add a gastrointestinal anastomosis or other complicated surgery, making the condition more complicated. Gastroscopic examination confirmed that the mechanical anastomosis or stenosis of the anastomosis should be re-synthesized by re-excision of the obstruction site. Entering jejunal obstruction: Common causes of jejunal obstruction in the input segment after partial partial resection of Billroth II are: 1 input jejunum segment is too short, and the jejunum and stomach anastomosis form an acute angle to cause obstruction (the proximal jejunum is easy for the stomach to bend slightly) Occurred); 2 colonic jejunal anastomosis when the colon collapsed into the jejunum segment; 3 input jejunum segment is too long to produce distortion, torsion or adhesion; 4 colonic jejunal anastomosis when the transverse mesenteric hole slid into the jejunum segment caused by obstruction. The input segment of jejunal obstruction is divided into acute and chronic. Acute obstruction is mostly complete obstruction, which usually occurs within a few days after surgery, but also after several years. The main clinical manifestations are severe abdominal pain, fullness, and mass in the right upper abdomen. Entering the jejunal obstruction is closed obstruction, vomit and gastrointestinal decompression abundance often does not contain bile, often accompanied by serum amylase, increased blood bilirubin, easily misdiagnosed as pancreatitis. Further development of the lesion can cause duodenal stump rupture or intestinal necrosis, and severe peritonitis symptoms. Chronic obstruction is often a partial obstruction. The typical performance is that the upper abdomen is full and nausea 10 to 20 minutes after eating. This is due to the accumulation of bile and pancreatic juice in the duodenum, enlargement of intestinal fistula and increased intestinal pressure. The intracavitary pressure is increased to a certain extent to overcome the obstruction disorder, and a large amount of duodenal juice is rapidly poured into the stomach to cause a large amount of vomiting. A vomiting amount can reach more than 500ml, and the symptoms are relieved after vomiting. This kind of vomiting is light once every few days, and severe cases can be several times a day. Symptoms of light input of jejunal obstruction can be treated with dietary adjustment or application of antispasmodic agents. After a certain period of time, the symptoms can be alleviated or disappeared. Severe symptoms should be treated surgically. Acute closed fistula obstruction should be treated urgently. The surgical procedure is based on the findings of the surgical exploration. If the jejunum segment is too short, the ligament ligament lysis can be performed. The duodenal jejunum is freed to lengthen the jejunal input segment. If the jejunum segment is too long, the gastrojejunostomy can be repeated. The anastomosis is moved to the proximal end of the jejunum or the jejunum of the input section is resected, and the side-to-side anastomosis can be performed between the input and output sections of the jejunum. Selective vagus nerve ablation should be performed at the same time as the above short-circuit surgery to prevent anastomotic ulcer. Output of jejunal obstruction: common causes are adhesion of the jejunum, distortion, compression of the omental mass, and compression of the transverse mesenteric orifice. It may also be caused by inflammation, edema and spasm in the jejunum segment. Clinical manifestations of high intestinal obstruction. Non-surgical treatment should be used to treat such obstruction. If the symptoms are not relieved, surgery should be performed. During the operation, the corresponding treatment is done according to different reasons. Guilin: There is a gap between the mesentery and the transverse colon and its mesentery in the jejunal input section after the partial resection of the stomach. The small intestine can enter this gap from left to right or from right to left to form an internal hemorrhoid. It is more likely to occur when the jejunal segment is too long, and the time is often in the early postoperative period, and may occur several months or years after surgery. The clinical manifestations are typical high acute intestinal obstruction, which is prone to intestinal necrosis. In the event of internal hemorrhoids, surgery should be performed promptly. Reset the internal hemorrhoids and suture the pupil. If the invaded small intestine is necrotic, an intestinal resection should be performed. (4) common bile duct injury Duodenal ulcer changes the normal relationship between the duodenum and the common bile duct due to local inflammation and edema and scar tissue hyperplasia. It is easy to damage the common bile duct if it is not taken care of when separating and excising the ulcer site. If a common bile duct injury has been found during surgery, a T-tube drainage should be performed. If no injury is found during surgery, severe peritonitis will occur early in the postoperative period. Abdominal puncture and suction of bile can confirm the diagnosis and timely surgical exploration. In order to prevent the damage of the common bile duct, it is not necessary to forcibly remove the duodenal ulcer with severe local lesions and severe adhesion. It is feasible to perform Bancroft placement. When the duodenal ulcer lesion must be removed, the common bile duct can be inserted into a catheter. The lower end of the common bile duct is used as a guide and a marker, and a T-shaped tube is placed at the end of the operation. (5) Gastric ileal mismatch It is a rare and serious mistake to misalign the stomach with the ileum during the Billroth II partial gastrectomy. After the stomach and the ileum are anastomosed, a large number of small intestines are placed, and the food directly enters the lower ileum to cause short bowel symptoms. The severity of the symptoms is related to the length of the anastomosis from the ileocecal area. The shorter the distance, the heavier the symptoms. The main clinical manifestation is severe diarrhea. Defecation occurs shortly after eating. The stool contains a large amount of undigested food, and the vomit of the vomiting person has a fecal odor. As time goes on, there will be serious malnutrition and water and electrolyte imbalance. Digestive tract barium meal examination found that the sputum can be clearly diagnosed by the residual stomach directly into the distal small intestine. The patient should be treated promptly to correct the error. In order to prevent this mismatch, the site of the duodenal jejunum must be confirmed before the gastrointestinal anastomosis. The small intestine that cannot be fixed with the posterior peritoneum is the beginning of the jejunum. The beginning of the jejunum should be on the left side of the transverse mesenteric spine. The upper end is continuous with the duodenum, and the right side is called the duodenal jejunum. The upper edge is the flexor ligament, and the inferior mesenteric vein passes through the lower left of the flexor ligament. After determining the proximal end of the jejunum, the 2-needle traction line should be marked at the predetermined anastomotic site for marking. 2. Long-term complications of partial gastrectomy (1) recurrent ulcer Ulcer recurrence or anastomotic ulcer after partial gastrectomy occurs mostly in patients with duodenal ulcer. Billroth II surgery is more than I surgery. The cause of ulcer recurrence is that gastric acid has not been effectively reduced after surgery. There are several reasons for the high gastric acid status after the operation: 1 The amount of gastrectomy is not enough, and the distal part of the stomach is not removed as required. More than 70% of the stomach is retained, and 2 parts of the duodenal stump are retained. Gastric antrum mucosa remains. Under the influence of alkaline bile and pancreatic juice environment, G cells of gastric antrum mucosa secrete a large amount of gastrin, which stimulates parietal cells to secrete gastric acid; 3 pancreatic ulcer is also known as Zollinger-Ellison syndrome, ie in pancreas or ten Gastrinoma is present near the duodenum. Because this tumor secretes a large amount of gastrin, it constantly stimulates parietal cells to secrete gastric acid in a large amount, resulting in peptic ulcer. This type of patient often presents with symptoms of ulcer disease. Most of the patients who underwent the treatment of ulcer disease were treated with partial gastrectomy. They quickly relapsed after surgery and were prone to bleeding or perforation. Some patients had only a few stomachs after repeated operations, but the ulcers still relapsed. Recurrent ulcers after partial gastrectomy are mostly located in the jejunum near the anastomosis, and can also occur in the anastomosis. The treatment of recurrent ulcers is poor, and more surgery is needed. Gastric acid secretion and serum gastrin determination, barium meal X-ray and gastroscopy should be performed before surgery to further analyze the causes of ulcer recurrence. The manner of surgery is determined for different reasons. Recurrent ulcers caused by insufficient gastric resection, the surgical methods are: 1 re-surgical partial resection (including resection of recurrent ulcers) re-gastrointestinal anastomosis; 2 selective vagus nerve cutting; 3 partial gastric resection plus vagus nerve cutting. Residual gastric mucosa should be examined for duodenal stump, residual antral mucosa, re-sewed stump or vagus nerve. Patients with gastrinoma should be carefully examined for the pancreas and duodenum. If the tumor can be found, it should be removed. However, gastrinomas are generally small, some may be multiple, often difficult to find in the pancreatic parenchyma, and it is often difficult to completely remove the tumor, so a total gastrectomy is appropriate. (2) dumping syndrome Some patients after abdominal resection have abdominal discomfort, palpitation, dizziness, sweating, weakness, nausea, diarrhea, and vascular nervous system after eating. Symptoms that appear within a few minutes after eating are called early dumping syndrome. Especially when eating in a diet, sweets or standing position, the symptoms are more obvious. The patient must be supine after eating to relieve the symptoms. The cause of early dumping syndrome is not fully understood. It is generally considered to be related to the following comprehensive factors: 1 The function of the pylorus is lost after partial resection of the stomach, and the capacity of the stomach is significantly reduced. After eating, the food rapidly enters the small intestine and causes sudden expansion of the small intestine, accelerating the peristalsis and pulling the mesentery. The celiac plexus; 2 high-tension food into the small intestine, the water in the tissue is inhaled into the intestinal lumen, so that the systemic blood circulation capacity is suddenly reduced; 3 the jejunal mucosa of the jejunum cells stimulated to release a large amount of serotonin, resulting in Angiogenesis, intestinal peristalsis is accelerated. Those who develop symptoms 1 to 1.5 hours after eating are called late dumping syndrome. Since a large amount of carbohydrates are decomposed into glucose after being in the small intestine and quickly absorbed by the small intestine, the rapid increase of blood sugar stimulates the secretion of endogenous insulin and the blood sugar is lowered. After the blood sugar is lowered, the insulin continues to be secreted, resulting in hypoglycemia and hypoglycemia. Most dumping syndromes are mildly symptomatic and can be treated non-surgically. Strengthen dietary regulation, give a small amount of low-sugar, high-fat and semi-solid diet to avoid fluidity and sweets, and give symptomatic treatment. If the peristalsis function is hyperthyroidism, the antispasmodic agent can be given. Those with obvious vascular neuromotor dysfunction can give serotonin drugs such as blood and blood equality, and those who are nervous can give sedatives. After treatment and adaptation for a certain period of time, the symptoms will gradually ease. Only those patients whose symptoms are severely inoperable for a long period of time and non-surgical treatment is ineffective are considered for remedial surgical treatment. Various surgical methods are designed around increasing the volume of the stomach and delaying the emptying time of the stomach. There are mainly the following: In the first case, the Billroth II type was changed to the I type plus the peristaltic jejunal section (Henley's original method): the duodenal stump was cut and trimmed. The jejunal input section was cut near the anastomosis, the anastomosis end was sutured closed, and the jejunal output section was transected 10 to 15 cm from the anastomosis. The proximal end was anastomosed with the duodenal stump, and the distal end was inserted into the end of the jejunum segment. Matches end to end. To prevent anastomotic ulcer formation and add vagus nerve cutting (Hedenstedt's method). The second type, the reverse motility and jejunal interposition between the stomach and the duodenum: the intestine vascular pedicle was preserved in the proximal jejunum 10 cm, and the mesenteric vascular pedicle was rotated 180°, and placed in the stomach and duodenum. between. The third type, the gastric and duodenal double jejunal bag interposition (Poth's method): Take the jejunum with the mesenteric vascular pedicle, each length 10 ~ 12cm. One segment is sutured in the direction of the peristaltic direction and juxtaposed in a reverse creep direction to form a jejunal pocket. The jejunal pouch is placed between the stomach and the duodenum and a vagus nerve is removed. The fourth type, Billroth II plus empty intestine bag and Roux-Y anastomosis: suitable for long cases of jejunal input. The jejunum of the input section was transected 8 to 10 cm from the anastomosis. The jejunal input and output sections under the anastomosis were made into a jejunal pocket, and the proximal jejunum and the jejunum of the output section were end-to-side anastomosis. The mouth should be 50 ~ 60cm away from the gastrointestinal anastomosis, plus vagus nerve cutting. The fifth type, other methods: 1 Place a 6 cm long inverted (reverse peristaltic) jejunum section between the middle of the output jejunum of the Billroth II (Christeas method). Or between the Billroth II type stomach and the output segment jejunum, a 6 cm long inverted (inverse peristaltic) jejunum segment is placed (Jordan method. 2) The jejunal input segment of the Billroth II proximal anastomosis is used as the inverse peristaltic segment. The jejunum output segment is anastomosis. The proximal jejunum is then anastomosed to the distal jejunum (Kennedy and Green method). 3 Change the Billroth II type to Roux-Y anastomosis, and invert an 8 cm long intestine between the jejunum and the stomach in the output section (Kenndy method). (3) Bile reflux gastritis Due to the loss of pyloric function after partial gastrectomy, the duodenal contents are easily refluxed into the stomach. Some patients have symptoms of reflux gastritis. Both Billroth I or II can occur, with Billroth II being more common. The main clinical manifestations were upper abdominal pain and burning sensation. The pain increased after eating, and often vomiting bile-like fluid. The patient did not dare to eat more, and lost weight, malnutrition, and weight loss. People with severe symptoms cannot work properly. The pathogenesis of reflux gastritis is due to bile acid destroying the gastric mucosal barrier, and the reverse dispersion of H+ ions in gastric juice produces gastric mucosal inflammation. The manifestation of bile reflux into the stomach and inflammation of the gastric mucosa can be directly observed by gastroscopy. The diagnosis of bile reflux gastritis must be combined with clinical symptoms, because almost all of the gastro-intestinal resection will have different degrees of reflux, there may not be reflux gastritis in reflux, and only a few clinical symptoms appear. Most of the bile reflux gastritis after mild gastrectomy is mild, and after medical treatment, the symptoms will gradually improve over time. Severe symptoms should also be treated first in internal medicine. Surgical treatment should be cautious. Only when the symptoms are particularly serious and long-term medical treatment is ineffective, surgery should be considered. So far, the basic principles of various procedures for treating reflux gastritis have focused on how to prevent reflux of duodenal juice to the stomach. The common surgical methods are as follows: In the first case, the Billroth II formula is changed to the I type to reduce backflow. But this method is less effective. In the second type, the type of Billroth II is changed to type I, and a smooth jejunum is placed between the stomach and the duodenum. In the third type, the Billroth II formula is changed to Roux-Y anastomosis, and the length of the upper jejunum segment should be 50-60 cm to effectively prevent reflux. In order to prevent the occurrence of anastomotic ulcer, vagus nerve cutting should be added. The fourth type, Tanner "19" surgery, if the original is done with high gastrectomy, the anastomosis can be retained if the anastomosis is removed again. Only the jejunal input section is cut and the two broken ends of the input section are respectively aligned with the output jejunal section. (4) Anemia and nutritional disorders After the gastrectomy, the volume of the stomach becomes smaller, the patient's food intake is reduced, and the food is accelerated in the gastrointestinal tract. It cannot be fully mixed with the digestive enzymes, resulting in digestion and malabsorption. Vitamin B1 deficiency and vitamin B12 malabsorption after gastric acid reduction, these factors cause about 40% to 50% of patients with different degrees of anemia and nutritional disorders in the long-term after surgery. It is characterized by iron deficiency anemia, weight loss, weight loss and diarrhea. Osteoporosis occurs in a small number of patients due to fat malabsorption and the lack of fat-soluble vitamins (A, D, E), which affect the absorption of calcium and phosphorus. It is advisable to treat these long-term complications with symptomatic treatment of internal medicine. Such as strengthening dietary regulation, the use of iron and vitamins and other treatments.