SEQUELAE OF GASTRIC

SURGERY
 SEQUELAE OF GASTRIC SURGERYA
(sequela, plural sequelæ) is a pathological
condition resulting from a disease, injury, or other
trauma

Minor postprandial complaints are commonly

after gastric operations
These usually improve with time- dietary
adjustments
5-20% of gastric surgery patients- severe
symptoms- altered anatomy and physiology of
the upper GI tract
 SEQUELAE OF GASTRIC
SURGERY
1. Recurrent ulcer
2. Dumping symptoms
3. Reactive hypoglycemia
4. Bile vomiting
5. Diarrhea
6. Small stomach syndrome
7. Mechanical complications
8. Other: cholelithiasis, bezoar formation, gastric
stump carcinoma
 DUMPING
Systemic symptoms:
– Weakness, tiredness, dizziness
– Headache, fainting, warmth, palpitations
– Dyspnea, sweating
Gastrointestinal symptoms:
– Fullness, epigastric discomfort, heaviness
– Nausea, vomiting
– Excessive distension, diarrhea
 DUMPING
Dumping syndrome is associated with
rapid gastric emptying
The systemic symptoms occur within
minutes of eating- hypovolemia- massive
outpouring of fluid from vessels into the
bowel lumen
Hyperosmolar nature of the intestinal
contents secondary to rapid gastric
emptying
 Dumping
Kinines, enteroglucagon- vasoactive
peptides responsible for systemic and
digestive symptoms

Gastrointestinal symptoms occur later

during the course of a dumping attack
 DUMPING- TREATMENT

Small dry meals rich in protein and fat but

low in carbohydrate
Additive which slow gastric emptying such
as pectin or bran
Remedial gastric surgery for patients with
severe dumping syndrome
REACTIVE HYPOGLYCEMIA

Rare complication, incidence of 1-6%

Occur 2-3 hours after meal
Sweating, tremor, difficult concentration
Reactive hypoglycemia may coexist with
vasomotor dumping and diarrhea
REACTIVE HYPOGLYCEMIA
Diagnosis – oral glucose tolerance test
Initial hyperglycemia- exagerated insulin
release- elevated plasma insulin and
enteroglucagon- hypoglycemia
It responds to dietary measures, including
low-carbohydrate and high protein meals
 BILE VOMITING
Vomiting of bile or bile-stained fluid before
or after meals- common after gastric op.
It may be due to:
- recurrent ulcer
- enterogastric reflux,
- intermittent obstruction of the afferent or
efferent loop of gastroenterostomy,
- cardioesophageal incompetence
ENTEROGASTRIC REFLUX
Causes a reflux erosive Gastritis and bile
vomiting
Symptoms: epigastric pain, nausea, bile
vomiting in the early postprandial period
The pain- burning in nature, aggravated by food
and not relieved by antacids
The attack culminates in the vomiting of bile-
stained fluid 1-2 hours after a meal
The erosive gastritis leads to chronic blood loss
with iron-deficiency anemia
ENTEROGASTRIC REFLUX
Treatment:
– bile salt-binding agents- cholestiramine,
– remedial surgical intervention
Prolonged enterogastric reflux can result
in atrophic gastritis and intestinal
metaplasia
This is a risk factor for gastric stump
carcinoma
 EXTRINSIC LOOP
OBSTRUCTION
The causes are:
- internal herniation,
- kinking of the anastomosis,
- adhesions,
- volvulus,
- stenosis,
- intussusception
Disorders that can develop after resection of the stomach,
as a result of the technique used to re-establish
gastrointestinal continuity
 EXTRINSIC LOOP
OBSTRUCTION

Symptoms- upper GI obstruction

Diagnosis- rx. contrast study of the GI

tract

Treatment- surgical correction

 Complications after Billroth II
First successful gastfrectomy-Theodor
Billroth- 1881
 DIARRHEA
Severe intractable diarrhea- 2% of pts. after
truncal vagotomy
Characterized by extreme urgency and often
causes incontinence during an acute attack
Malabsorbtion of bile salts and fatty acids
secondary to intestinal denervation is implicated
The sma;ll bowel transit is accelerated
Treatment: low fat diet, codeine phosphate,
imodium, cholestyramine
SMALL STOMACH SYNDROME
It appears after extensive gastrectomy
and GI disfunction after truncal vagotomy

The condition leads to gross malnutrition

Surgical treatment- reconstruct a gastric

reservoir and restore duodenal continuity
 OTHER COMPLICATIONS
Formation of gall stones and bezoars due
to:
– Hypoacidity
– Impaired proteolytic activity
– Loss of antral pump

Development of gastric stump carcinoma

after 15-20 years postoperatively
BENIGN GASTRIC TUMORS
Gastric polyps- benign adenomas
– Solitary or multiple
– Sessile or pedunculated
– Usually asymptomatic
– Found incidentally on rx.or endoscopic exam.
– 20% show histological features of dysplasia
– Treatment- endoscopic excision biopsy, follow-up
BENIGN GASTRIC TUMORS
Leyomyomas- smooth muscle tumors
– May arise anywhere in the muscle wall of GI
– Common in the stomach and small bowel
– Discovered incidentally- rx, endoscopy
– Large lesions may cause chronic blood loss
or intermittent gastric outlet obstruction
– Sessile or pedunculated, covered by normal
mucosa
MALIGNANT GASTRIC TUMORS
Lymphomas- 10% of gastric malignancies
– May present as a bulky ulcerated mass or
diffusely infiltrating the gastric wall
– Diagnosis- barium meal, endoscopy with bx.
– Treatment- total gastrectomy,
radio/chemotherapy
– Better prognosis than gastric adenocarcinoma
ENDOSCOPIC VIEW OF
GASTRIC LYMPHOMA
GASTRIC LYMPHOMA OF THE
GASTRIC FUNDUS
 GASTRIC
ADENOCARCINOMA
90% of gastric malignant tumors
Better outcome when diagnosed early
Risk factors:
– atrophic gastritis,
– pernicious anemia,
– previous partial gastrectomy,
– polyps
ATROPHIC GASTRITIS
 GASTRIC CARCINOMA
Three morphological forms
– Fungating tumor
– Ulcerated tumor- necrosis at the centre of the
tumor, large, heaped-up indurated margin
with no surrounding mucosal puckering
– Infiltrating tumor- diffusely invades the
muscular wall of the stomach- wall thickening
and rigidity- linita plastica “lether bottle”
LINITA PLASTICA
 EARLY GASTRIC CANCER
Cancer limited to the mucosa and
submucosa
Prognosis with adequte resection
excellent with 5-year survival rates of
more than 80%
10-15% of early gastric cancers have
positive regional lymph nodes- this
subgroup is referred to as early-simulating
advanced gastric cancer
EARLY GASTRIC CANCER
ADVANCED GASTRIC CANCER

Tumor which has involved the muscular

layer of the stomach

Positive lymph nodes, peritoneal and

hepatic deposits (secondaries)
 TNM STAGING SYSTEM
T1- tu.limited to the mucosa, submucosa
T2- tu. involves the muscular layer
T3- tu. penetrates the serosa
T4- tu.invades the adjacent structures
N0- no positive lymph nodes
N1- positive perigastric lymph nodes within 3
cm. of the primary tu.
N2- positive lymph nodes more than 3 cm.
M0- no distant metastases
M1- evidence of distant metastases
SPREAD OF GASTRIC CANCER
Direct spread through the gastric wall
Extragastric lymphatic spread- perigastric
and regional
Vascular spread-distant metastases
Serosal peritoneal spread-
carcinomatosis, Blummer tu., Krukenberg
tu.
 GASRIC CANCER
CLINICAL FEATURES
Early gastric cancer- asymptomatic or dyspepsia
simulating an gastric ulcer
Malaise, postprandial fullness, loss of appetite
Cardia cancer-dysphagia
Antral cancer- obstructive symptoms
Hematemesis/melena
The most frequent reason for the delayed dg. Is a
period of symptomatic therapy with antacids
before referral for endoscopy
 GASTRIC CANCER
CLINICAL FEATURES
Anemia- chronic blood loss
Weight loss- persistent skin fold, low
serum albumin
Enlarged left supraclavicular lymph node
Palpable epigastric mass
Jaundice- liver metastases or biliary
compressive lymphadenopathy in the
porta hepatis
 GASTRIC CANCER
DIAGNOSIS
GI endoscopy with biopsy and brush
cytology
Radiological contrast study- barium meal
Abdo CT
CXR

USS of the abdomen

Laparoscopy
 GASTRIC CANCER
TREATMENT
Only effective treatment which offer a
chance for cure- adequate surgical
resection
A palliative resection whenever feasible is
more effective in relieving sy.than by-pass
procedures.
Radio/chemotherapy useless
 GASTRIC CANCER
TREATMENT

Principles of potentially curative resection:

– Resection with tumor-free margins

– Lymph node clearance according to the
location of the primary tu. in the stomach
– Safe and well functioning reconstruction
 GASTRIC CANCER
TREATMENT

Classification of gastric resection

– R0- complete resection, no microscopic tu.left

– R1- residual microscopic tu.

– R2- residual macroscopic tu.

 GASTRIC CANCER
TREATMENT
Total gastrectomy is necessary:

– To achieve a safe tumor free margin

– When the neoplasm involves 2 or 3 regions of

the stomach

– Diffuse carcinoma
 GASTRIC CANCER
TREATMENT
Omentectomy- the lesser and greater
omentum removed for a better
lymphadenectomy
Lymph node clearance:
– D1 resection- perigastric lymphadenectomy
– D2 resection- along left gastric, hepatic,
celiac, splenic arteries nodes
– D3 resection- hepatoduodenal,
retropancreatoduodenal, root of the
mesentery, middle colic, paraaortic nodes
 CURATIVE RESECTION

There is no peritoneal or hepatic

metastases

The serosa is not involved by the tumor

The resection level exceeds the level of

nodal involvement
 RECONSTRUCTION

Subtotal gastrectomy with Roux-en Y

procedure

Total gastrectomy with eso-jejunal

anastomosis
 PALLIATIVE SURGICAL
TREATMENT

Gastroenterostomy- by-pass op. for

obstructing antral carcinoma

Intubation for the cardia carcinoma

Feeding jejunostomy
 Gastric stump
adenocarcinoma
Case report
 Gastric stump adenocarcinoma

Male, MV, 56-year of age, retired brick mason

2002- 3 months history of epigastric pain, vomiting

after meals, asthenia, weight loss

Habits: smoking, heavy alcohol drinking

PMH- partial gastric resection for gastric ulcer-20

years ago
 Physical signs
General: underweight, palor, inelastic skin fold

Abdominal examination
Flat abdomen moving with respirations
Post. Op.scar- median xypho- ombilical
Moderate tenderness in epigastrium
Succusion splash

NG aspiration- 100o ml. Gastric fluid non-bile

stained with undigested food
 What is the clinical suspicion?

Previous partial gastric resection- stump problem

Frequent vomiting- undigested food- stenosis

Anemia- chronic blood loss

Weight loss- bad nutrition

Succusion splash- stenosis

 Clinical diagnosis

Cancer of the gastric stump ?

 Investigations
Lab. Tests- NAD except a moderate anemia
Barium meal- partial gastric resection Billroth I, gastric stump
dilated, desorganized mucosal folds
Endoscopy- stenotic gastro-duodenal anastomosis , multiple
gastro-duodenal polyps
Biopsy- adenocarcinoma of the gastric stump of papillary type
Abdominal USS- absent liver MTS
CXR- NAD
 Operative findings
Gastric stump tumour staring from the
gastro-duodenal anastomosis

Invasion of the D1 and D2

Perigastric lymphadenopathy

Liver and peritoneum intact

 What to do?
Frozen section from the a perigastric lymph
node negative for tumour cells

Mobile tumour on adjacent planes

Age

Absent comorbidities
 Operative decision
Completion gastrectomy
D2 lymphadenectomy: loco-regional
Tactic splenectomy
Cephalic duodenopancreatectomy
Digestive continuity:
– Eso-jejunal anastomosis
– 60 cm distal to it- Wirsungo-jejunal anastomosis
– 20 cm distal to it- biliary-jejunal anastomosis
 Case report
Operative time- 6 hours
Postoperative course- uneventful
Contrast medium eso-jejunal
radiological check-up- intact
anastomosis without any leak
Hospital stay- 26 days
 Case report
Operative time- 6 hours
Postoperative course- uneventful
Contrast medium eso-jejunal
radiological check-up- intact
anastomosis without any leak
Hospital stay- 26 days
 Pathological report
of the surgical specimen
Polipoyd adenocarcinoma
Lymph nodes: perigastric,
retroduodenal, celiac trunk, hilum of
the spleen were negative for tumour
cells
pTNM- T2 N0 M0
2003-1 year post-operatively

10 Kg weight gain
Good digestive tolerance
Symptoms-free
Normal hematological and
biochemistry tests
 Next post-operative course
2005- acute appendicitis- appendectomy

2007-routine endoscopic check-up

eso-jejunal anastomotic recurrence

 2007- further investigations

Endoscopic biopsy- adenocarcinoma

CXR- NAD
Abdominal USS-slightly enlarged liver,
pneumobilia, normal remnant pancreas,
no ascites, no lombo-aortic lymph nodes
Respiratory tests- WNL
 2007- further investigations
Barium meal: eso-jejunal anastomosis T-
L, anastomotic lacunar image- 2cm in
size

Abdominal CT- thickening at the level of

the anastomosis with esophageal extent
 What to do?
Surgical options:
– Partial esophagectomy with
intrathoracic graft interposition
– Esophageal stripping with colic graft
Small eso-jejunal tumour
Absence of mediastinal lymph nodes-
CT
Avoidance of left thoracotomy
 Decisions
Surgical resection
– Esophageal stripping
– Proximal jejunostomy
Digestive reconstruction
– Left colon graft
– Colo-jejunal anastomosis
– Colo-colic anastomosis
– Cervical eso-colic anastomosis
Nutrition
– TPN
– Jejunostomy tube
 Pathology report

Colloid adenocarcinoma invading the

digestive wall thickness till subserosa

3 out of 4 jejunal mesentry limph nodes

positive

Periesophageal lymph nodes negative

 Early morbidity

Cervical eso-colic fistula

– Small output
– Conservative treatment
– Oral hygene
– Spontaneous closure in 2 weeks
– Radiological check-up before oral intake
Eso-colic fistula-jan.2008
 Late morbidity

Colic fistula due to forcibly coughing episodes

after quit smoking

Relaparotomy-transverse colon fistula

– Colo-jejunal and colo-colic anastomoses intact
– Coloraphy and abdominal drainage
– Good recovery
– Discharged after 9 days
Patent eso-colic anastomosis,
may 2008
Intact colo-jejunal anastomoses,
may 2008
 2009

Multiple pulmonary metastases