Surgical complications of Gastrectomy

1. SURGICAL COMPLICATIONS OF GASTRECTOMY Balasankar S

2. 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.

3. POST- OPERATIVE COMPLICATIONS: IMMEDIATE (within 30 days of Surgery) EARLY ( within 6 months) LATE ( after 6 months)

4. IMMEDIATE COMPLICATIONS: Atelectasis(12-20%) Pneumonia(9%) Respiratory Failure(3%) Pulmonary Embolism(0.05%) Venous thrombosis of Lower limbs Wound infection Sub- phrenic abscess Acute Pancreatitis

5. EARLY COMPLICATIONS: Post operative Anastomotic Hemorrhage Anastomotic Leak Duodenal Stump Leak Small Bowel Obstruction Stomal Obstruction

6. It can be *Intra-abdominal *Intra-luminal Bloody fluid from drain, tachycardia, fall in Hb level, haemetemesis, melena. Substantial: Open/ Laparoscopic re-exploration Remove clots; identify & control site of bleeding.

7. Frequently at Gastro- jejunal anastomosis. Intra-abdominal leak > peritonitis > sepsis > multi-organ failure. Early signs: Fever, persistent tachycardia >120/min, worsening abdominal pain.

8. Testing integrity: *Instillation of methylene blue *Air insufflation

9. 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.

10. ‘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.

11. 4 th or 5 th post-operative day with severe Right upper quadrant pain, fever, tachycardia, jaundice, bile-stained discharge from incision; Biliary Peritonitis.

12. Prevention: * Duodenostomy - Foley catheter *Nissen or Bancroft closure. *Purse-string suturing.

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

14. Internal Hernias through potential mesenteric defects. Retrocolic > Antecolic Colicky abdominal pain, nausea, vomiting, distension Risk of strangulation & perforation. Diagnosed by CT / serial small bowel contrasts. Laparoscopic repair.

15. Obstruction of efferent stoma Inflammatory adhesions Dysphagia, nausea, vomiting, abdominal pain. Options: -Endoscopic balloon dilatation -Surgical release of adhesions.

16. LATE COMPLICATIONS: Anastomotic Stricture Marginal Ulcer Bleeding Gastro-gastric Fistula Post Gastrectomy Syndrome Small stomach syndrome Remnant carcinoma

17. Gastro- jejunal anastomosis Tension / Ischemia Progressive dysphagia, vomiting, minimal abdominal pain. Endoscopic dilatation.

18. 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 pain Endoscopy is diagnostic PPIs, discontinue NSAIDs Endoscopic coagulation or clipping.

19. Abnormal connection between gastric pouch and excluded stomach.

20. Incomplete gastric transection Inadequate Weight gain Asymptomatic: PPIs Symptomatic: Surgical correction

21. 3 main types: 1.Gastric reservoir dysfunction 2. Vagal dennervation 3. Aberrations in surgical reconstruction.

22. DUMPING SYNDROME METABOLIC ABERRATIONS

23. Frequently attributed to the rapid emptying of gastric content into the small bowel. 2 types Early Late

24. 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.

25. 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.

26. CONSERVATIVE Low 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

27. SURGICAL: Iso/anti peristaltic segment of jejunum interposed between stomach and small bowel (10-20 cm) Conversion to Roux-en-Y gastro- jejunostomy .

28. 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.

29. Diarrhea Gastric stasis Gallstone

30. Diarrhea: Uncontrolled bowel movement >> increased stool frequency . Conservative Rx : Cholestyramin Codeine Loperamide Surgical : 10 cm segment of reversed jejunum anastomosis placed 70-100 cm from ligament of Treitz .

31. Gastric Stasis: Conservative Rx : Metoclopramide Domperidone Erythromycin Naso jejunal tube feed

32. Gall Stone: Division of hepatic branches of anterior Vagal trunk. Gallbladder dysmotility Surgery indicated only if pathological. No indication for prophylaxis cholecystectomy .

33. Alkaline reflux gastritis Afferent and efferent loop obstruction Roux syndrome

34. 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.

35. 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 loop Release trapped loop.

36. 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.

37. High index of suspicion DO NOT skeletonize >2cm of Duodenum: simple duodenostomy Late Complications >6months Counsel properly to prevent Dumping syndrome & nutritional deficiencies.