surgical complications of gastrectomy
TRANSCRIPT
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.