SURGICAL COMPLICATIONS OF

GASTRECTOMY

Balasankar S

INTRA-OPERATIVE COMPLICATIONS:

Hemorrhage

Acute ischemia of Left lobe of Liver (aberrant Left Hepatic artery)

Injury to Spleen, Pancreas, Common Bile duct.

Disruption of Ampulla of Vater.

POST- OPERATIVE COMPLICATIONS:

IMMEDIATE (within 30 days of Surgery)

EARLY ( within 6 months)

LATE ( after 6 months)

IMMEDIATE COMPLICATIONS:

Atelectasis(12-20%)Pneumonia(9%)Respiratory Failure(3%)Pulmonary Embolism(0.05%)Venous thrombosis of Lower limbsWound infectionSub-phrenic abscessAcute Pancreatitis

EARLY COMPLICATIONS:

Post operative Anastomotic Hemorrhage

Anastomotic LeakDuodenal Stump LeakSmall Bowel ObstructionStomal Obstruction

Post Operative Anastomotic Hemorrhage:

It can be *Intra-abdominal *Intra-luminalBloody fluid from drain, tachycardia,

fall in Hb level, haemetemesis, melena.

Substantial: Open/ Laparoscopic re-exploration

Remove clots; identify & control site of bleeding.

Anastomotic Leak:

Frequently at Gastro-jejunal anastomosis.

Intra-abdominal leak > peritonitis > sepsis > multi-organ failure.

Early signs: Fever, persistent tachycardia >120/min, worsening abdominal pain.

Testing integrity:

*Instillation of methylene blue

*Air insufflation

Meticulous repair of anastomosis remains primary method of prevention.

IV Antibiotic therapy

Percutaneous drainage

Fully/ Partially covered Self Expanding Metal Stents( SEMS) help in sealing of the leaks.

Persistent : Abdominal washout and repair of anastomosis.

Duodenal Stump Leak:

‘Blown’/Difficult Duodenal Stump.Follows Billroth II Gastrectomy. Incidence: 3-5%.Commonest cause: excessive dissection of

duodenal stump; compromises blood supply.Other causes include *ischemia and necrosis (over zealous

suturing) *increased tension on duodenal stump caused by acute afferent loop obstruction.

4th or 5th post-operative day with severe Right upper quadrant pain, fever, tachycardia, jaundice, bile-stained discharge from incision; Biliary Peritonitis.

Prevention: *Duodenostomy- Foley catheter

*Nissen or Bancroft closure. *Purse-string suturing.

Conservative: *Per-cutaneous drainage * Afferent loop decompression by Nasogastric tube. *Broad-spectrum antibiotics.Surgical: Thorough peritoneal lavage,

duodenostomy.

Small Bowel Obstruction:

Internal Hernias through potential mesenteric defects.

Retrocolic > AntecolicColicky abdominal pain, nausea,

vomiting, distensionRisk of strangulation & perforation.Diagnosed by CT / serial small bowel

contrasts.Laparoscopic repair.

Stomal Obstruction:

Obstruction of efferent stomaInflammatory adhesionsDysphagia, nausea, vomiting,

abdominal pain.Options: -Endoscopic balloon dilatation -Surgical release of adhesions.

LATE COMPLICATIONS:

Anastomotic StrictureMarginal Ulcer BleedingGastro-gastric FistulaPost Gastrectomy SyndromeSmall stomach syndromeRemnant carcinoma

Anastomotic Stricture:

Gastro-jejunal anastomosis

Tension / Ischemia

Progressive dysphagia, vomiting, minimal abdominal pain.

Endoscopic dilatation.

Marginal Ulcer Bleeding(MUB):

Ulceration around gastro-duodenal or gastro- jejunal anastomotic site.

Chronic irritation by suture materials at the anastomosis, use of electrocautery, ischemic injury and anastomotic stricture.

Epigastric painEndoscopy is diagnosticPPIs, discontinue NSAIDsEndoscopic coagulation or clipping.

Gastro- gastric Fistula(GGF):

Abnormal connection between gastric pouch and excluded stomach.

Incomplete gastric transection

Inadequate Weight gain

Asymptomatic: PPIs

Symptomatic: Surgical correction

POST GASTRECTOMY SYNDROME:

3 main types:

1.Gastric reservoir dysfunction 2. Vagal dennervation 3. Aberrations in surgical

reconstruction.

Gastric Reservoir Dysfunction:

DUMPING SYNDROME

METABOLIC ABERRATIONS

Dumping Syndrome:

Frequently attributed to the rapid emptying of gastric content into the small bowel.

2 types • Early • Late

Early Dumping Syndrome:

15 minutes to 1 hour after a meal.

due to rapid release of hyperosmolar food into small bowel > rapid shift in extracellular fluid > systemic hypotension.

Nausea, vomiting, epigastric fullness, abdominal cramping and diarrhea, palpitation, diaphoresis.

Relieved by lying down.

Late Dumping Syndrome:

1 to 3 hours after a meal.

Carbohydrates absorbed quickly > blood sugar level rises > hyper-insulinemia and consequent hypoglycemia.

Fainting, tremor, prostration, decreased consciousness.

Relieved by food.

Management:

• CONSERVATIVELow carbohydrate diet (prefer complex

carbohydrate)

Small meal with solid and liquid food

Somatostatin analogues; Octreotide100 mcg IV 15-60 minutes before meal to slow transit time.

Alpha glucosidase inhibitor medication in late dumping

• SURGICAL:

Iso/anti peristaltic segment of jejunum interposed between stomach and small bowel (10-20 cm)

Conversion to Roux-en-Y gastro-jejunostomy.

Metabolic Aberrations:

Anemia: *Iron Deficiency( reduced absorption) *Pernicious anemia( reduced intrinsic

factor) *Folate deficiency (malabsorption).

Metabolic Bone disease( decreased Vit.D & Ca absorption)

* Unexplained aches and pains in back or long bones

*Rx : Ca and Vit D supplements.

Vagal Denervation:

Diarrhea

Gastric stasis

Gallstone

Diarrhea:Uncontrolled bowel movement >>

increased stool frequency .Conservative Rx :

CholestyraminCodeineLoperamide

Surgical : 10 cm segment of reversed jejunum anastomosis placed 70-100 cm from ligament of Treitz .

Gastric Stasis:

Conservative Rx :

MetoclopramideDomperidoneErythromycin

Naso jejunal tube feed

Gall Stone:

Division of hepatic branches of anterior Vagal trunk.

Gallbladder dysmotilitySurgery indicated only if pathological.No indication for prophylaxis

cholecystectomy.

Aberrations in Reconstruction:

Alkaline reflux gastritisAfferent and efferent loop obstructionRoux syndrome

Alkaline Reflux Gastritis:

Reflux of alkaline secretions into gastric remnant.

Reflux symptoms: epigastric pain, bilious vomiting

Clinical + evidence of bile reflux on endoscopy.

Roux en Y Gastro- jejunostomy with afferent limb measuring at least 40cm.

Afferent and Efferent Loop Obstruction:

Loop of bowel passing through the hiatus between anastomosis in front & transverse colon behind.

Severe postprandial epigastric pain(30-60 mins),projectile vomiting & dramatic clinical relief after vomiting.

Avoid excess length of afferent loopRelease trapped loop.

Roux Syndrome:

Symptom complex characterized by chronic postprandial epigastric pain, fullness, and vomiting after gastric reconstructive surgery with vagotomy and Roux-en-Y gastroenterostomy.

Post Vagotomy gastric atony. Medical treatment is successful in

only about half of cases.Surgical :remove most or all of the

gastric remnant is usually successful.

TO SUMMARIZE…

High index of suspicion

DO NOT skeletonize >2cm of Duodenum: simple duodenostomy

Late Complications >6months

Counsel properly to prevent Dumping syndrome & nutritional deficiencies.