gastric surgery and its complicatons

1. Dr.Prakash Patel
Department of surgery
Government Medical College , Surat

2. Objectives
 To know the various surgeries performed for gastric
pathology .
 To know to basic principle for gastric surgery
 To know the complications of gastric surgery
 To know the management of complications

3. GASTRIC SURGERY
 Common surgeries performed on stomach are:
 Gastrotomy
 Gastrostomy
 Gastrectomy
 Vagotomy, surgeries for peptic ulcers and perforation
 Drainage procedures
 Pyloroplasty
 Gastrojejunostomy
 pyloromyotomy

4. Indications for gastric surgery
 Complicated peptic ulcers
 Surgical management of duodenal ulcers
 Ca.stomach
 Obesity
 Gastro intestinal stromal tumors (GIST)
 Corrosive stricture of stomach
 Zollinger Ellison syndrome

5. Complicated peptic ulcers
 Indications for Surgical procedures
 Refractory to medical management
 Hemorrhage
 Perforation
 Obstructive symptoms

6.  Surgical procedures for complicated peptic ulcer
disease
 Vagotomy with drainage
 Billroth II gastrectomy
 Gastrectomy with hemostasis

7.  Surgery for Ca. stomach
 Radical total gastrectomy
 Radical partial gastrectomy
 Palliative resection
 Bypass

8.  Surgery for Obesity
 Malabsortives types
 Restrictive types
 Gastric band
 Sleeve gastrectomy
 Gastroplasties
 Mixed
 Gastric bypass
 Biliopancreatic diversion with duodenal switch

9. SURGICAL MANAGEMENT OF
DUODENAL ULCERS
 Principles
 Reduce acid secretion by dividing vagus nerve-
vagotomy
 Vagotomy denervate stomach and pylorus which will
lead to gastric outlet obstruction.
 So drainage procedure is performed called as
pyloroplasty.
 Two types of surgical procedures
 Truncal vagotomy with pyloroplasty
 Selective vagotomy with pyloroplasty

10.  Billroth-I
 Remove of distal
part of stomach
and
anastomosis of
stomach
with duodenum.

11.  Billroth II
 Remove distal part of
stomach and perform
gastro – jejunostomy.

12. Roux en Y anastomosis

13. Complications of gastric surgery
 Early
 late

14. Early complications
 Gastrointestinal haemorrhage
 Anastomotic leak
 Pulmonary embolism
 DVT( Deep vein thrombosis)
 Wound infection
 Respiratory insufficiency , pneumonia
 Acute gastroparesis
 Ischemic necrosis of gastric ramnant or anstomotic
site.
 Duodenal stump blow out

15. Late complications
 Stomal stenosis
 Bowel obstruction, small bowel obstruction
 Internal hernia
 Cholelithiasis
 Micronutrient deficiencies
 Marginal ulcer
 Staple line disruption
 Ventral hernia formation
 Post vagotomy diarrhoea

16.  Malabsorption of fat soluble vitamins ( vitamin A, D, E
,K )
 Vitamin A deficiency, which causes night blindness
 Vitamin D deficiency , which causes osteoporosis
 Iron defiiciency
 Protein energy malnutrition
 Afferent loop syndrome
 Blind loop syndrome

17.  Alkaline gastritis
 Stomal ulcers
 Gastrojejunocolic fistula

18. Vagotomy complications
 Decreased acid secretion
 Faster gastric emptying
 Diarrhoea
 Dumping syndrome
 Gastric outlet obstruction

19.  Vagotomy denervates from stomach to distal
transverse colon including pancreas and gall bladder.
 Gall bladder denervations leads to stasis and which
increase the chance of gall stones
 Decrease in pancreatic and gallbladder secretions
leads to undigested fat steatorrhoea

20.  DUMPING SYNDROME
 Early
 Late
 Cardiovascular and GI symptoms due to vagotomy and
pyloroplasty or gastrectomy
 Early dumping syndrome due to Hypovolemia
 Late dumping syndrome due to Hypoglycemia

21. Complications of gastrectomy
 Anaemia ( intrnsic factor essential for binding of vit
B12 for absorption in terminal ileum)
 Early satiety
 Hypocalcaemia – reduced HCL production interferes
with absorption of calcium and Fe in the duodenum
 Gastric stump carcinoma – due to chronic irritation of
stunp by duodenul secretions

22. Early Dumping Syndrome
 No intact pylorus leads to dumping of large amount of
chymes , billiary and pancreatic secretions in to the
duodenum at once
 Results in large amount of fluid shift
 Occurs within 40 minutes of ingestion
 Symptoms
 Tachycardia
 Diaphoresis
 Palpitations
 Diarrhoea
 Abdominal pain

23. Late Dumping Syndrome
 Due to rebound hypoglycaemia
 Occurs 2-4 hours post op
 Symptoms
 tachycardia
 Palpitations
 Diaphoresis
 Dizziness

24. Afferent Loop Syndrome
 Symptoms show immediately after meal
 Occurs only with billroth II reconstruction.
 Obstruction of afferent loop adjcent to anastomosis.
 Cramping pain
 Vomiting of dark brown bitter tasting material
 Symptoms resolves with vomiting

25. Blind Loop Syndrome
 After Billroth II than roux en y gastrojejunostomy , also
seen after irradiation or morbid obesity
 Associated with bacterial overgrowth in the limb of
intestine excluded from flow of chyme.
 This limb has bacteria which proliferate and interfere with
folate and vit B12 metabolism, also bacterial overgrowth
causes deconjugation of bile salts – steatorrhoea
 vit B12 deficiency lead to megaloblastic anaemia
 Diarrhoea
 Weight loss
 weakness

26. Treatment of Blind Loop
Syndrome
 Antibiotics
 Revison surgery or conversion of Billroth I may be
required for some patients

27. Reccurent Ulcer Disease
 Incomplete vagotomy , posterior vagal trunk or a
branch of this trunk (Criminal nerve of grassi) is left
intact
 Truncal vagotomy + antrectomy ( lowest rate 2%)
 Proximal gastric vagotomy ( highest rate 12%)

28.  Treatment –
 Endoscopy + congo red dye ( to demonstrate area of
pH drop in gastric mucosa )
 PPI(proton Pump Inhibiter) for long term
 Re operative vagotomy
 Recurrent ulceration despite of verified complete
vagotomy  look for endocrine etiology like family
history of MEN I syndrome , also look for
hyperparathyroidism and Gastrinoma as possible
cause.