surgery

1. Post Gastrectomy Syndrome
Madusha premamali
Group 04
6th year 1st semester

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. Post Operative Anastomotic Hemorrhage:
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. 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.

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. 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.

11.  4th or 5th 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. Small Bowel Obstruction:
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. Stomal Obstruction:
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. Anastomotic Stricture:
Gastro-jejunal anastomosis
Tension / Ischemia
Progressive dysphagia, vomiting, minimal
abdominal pain.
Endoscopic dilatation.

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

19. Gastro- gastric Fistula(GGF):
Abnormal connection between gastric pouch
and excluded stomach.

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

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

22. Gastric Reservoir Dysfunction:
DUMPING SYNDROME
METABOLIC ABERRATIONS

23. Dumping Syndrome:
Frequently attributed to the rapid emptying of
gastric content into the small bowel.
2 types
• Early
• Late

24. 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.

25. Late Dumping Syndrome:
1 to 3 hours after a meal.
Carbohydrates absorbed quickly > blood sugar
level rises > hyper-insulinemia and consequent
hypoglycemia. (catacholamine stimulation)
Fainting, tremor, prostration, decreased
consciousness.
Relieved by food.

26. Management:
• CONSERVATIVE
Low carbohydrate diet (prefer complex
carbohydrate)
Small meal with solid and liquid food
Avoid some sort of food such as ice cream.
Somatostatin analogues; Octreotide100 mcg IV
15-60 minutes before meal to slow transit time.
Alpha glucosidase inhibitor medication in late
dumping

27. Dumping syndrome : Rx

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

30. Metabolic aberration
• B II > B I
• Anemia
• Bone disease
• Weight loss

31. Metabolic Aberrations:
Anemia:
*Iron Deficiency( reduced absorption)
*Pernicious anemia( reduced intrinsic factor)
*Folate deficiency (malabsorption).

32. IDA
• Most common anemia in anemia post gastric
procedure
• Fe decreased absorption (Prefered acidic
state)
• Rx : Iron supplement

33. B12 deficiency
• Decreased in absorption
– Intrinsic factor from parietal cell
– Acidic environment
• Rx :
– B12 supplement

34. B12 deficiency

35. Folate deficiency
• Impaired digestion
• Malabsorption (duodenum)
• Rx :
– Folate supplement

36. Metabolic Bone disease
• Vit D absorption decreased in fat
malabsorption
• Ca decreased absorption (mostly at
duodenum)
• Unexplained aches and pains in back or long
bones
• Monitor BMD q 1-2 Yr : Osteoporosis, penia
and malacia
• Rx : Ca and Vit D supplement

37. Metabolic Bone disease
Prevent Dose
250 mg calcium
400 mg IU vitamin D OD

38. Weight loss
• Thin woman
• Causes
– Not adequate caloric intake
– Malabsorption

39. Vagal Denervation
• 30% of patients
• Diarrhea
• Gastric stasis
• Gallstone

40. Vagal Denervation : Diarrhea
• Presented with diarrhea
• Mostly diarrhea from dumpling syndrome, but
some may not
• Post vagal resection >> uncontrolled bowel
movement >> increased stool frequency
• Other machanism: bile acid malabsorption,
rapid gastric emptying time and bacterial
overgrowth

41. Vagal Denervation : Diarrhea
• Conservative Rx :
– Cholestyramin
– ATB
– Codeine
– Loperamide
• Sx Rx : 10 cm segment of reversed jejunum
anastomosis placed 70-100 cm from ligament
of Treitz

42. Vagal Denervation : Gastric stasis
• Conservative Rx :
– Metoclopramide
– Domperidone
– Erythromycin
• NJ (naso jejunal) tube feed

43. Vagal Denervation : Gallstone
• Division of hepatic branches of anterioe vegal
trunk
• Gallbladder dysmotility
• Sx indicated only if have pathology
• No indication for prophylaxis cholecystectomy

44. Abberation in Reconstruction
• Bile(alkaline) reflux gastritis
• Afferent and efferent loop obstruction
• Jejunogastric intussusception
• Roux syndrome

45. Bile Reflux Gastritis
• Reflux of alkaline secretions into gastric remnant
• Most patient no symptoms
• Reflux symptoms: epigastric pain, N/bilious
vomiting
• Dx by clinical + evidence of bile reflux (scope or
scan)
• Scope :
– mucosal erythema that involve parastomal region
– bile staining or pooling
– observed enterogastric reflux

46. Bile Reflux Gastritis
• Rx : no significant medication benefit
• Sx : divert bile and pancreatic secretion from
stomach
– Roux-en-Y gastrojejunostomy (Roux limb at least 45
cm)
– Interposition 40 cm of isoperistaltic jejunal loop
– Braun enteroenterostomy

47. Bile Reflux Gastritis

49. Afferent and Efferent Loop Obstruction
• Afferent loop syndrome
– Afferent limb length > 30-40 cm can be
obstruction
– Chronic > acute
– Some can be presented with diarrhea

50. 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.

51. Afferent and Efferent Loop Obstruction

52. Afferent and Efferent Loop Obstruction

53. Afferent and Efferent Loop Obstruction

54. Jejunogastric Intussusception
• Rare complication
• Simple gastroenterostomy > B II
• E limb intussuscepted into stomach
• Came with upper gut obstruction symptoms
• Sx treatment in Rx of choice

55. 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.(promotality agents)
Surgical :remove most or all of the gastric
remnant is usually successful.

56. Thank You