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Leaks and obstruction after gastric resection
Leaks and Obstruction After Gastric Resection
Wahwd Ahmad, MD, Louisville, Kentucky Phil J. Ha&m&t,
MD, Louisville, Kentucky
Hiram C. Polk, Jr., MD, Louisville, Kentucky
There has been a decrease in the use of gastric resection for the treatment of peptic ulcer disease. Less frequent occurrence of the disease and the widespread use of HZ receptor antagonists [I] may be responsible in part, but the type of primary operation has also changed since the introduction of various kinds of vagotomies [2,3]. Despite these changes, gastric resection is still a proved modality for the treatment of recalcitrant peptic ulcer disease and of neoplasms of the stomach. Leaks and obstructions are dreaded complications of gastric resection [4,5] but are seldom described in the current literature. In addition, what is found in the older literature is often controversial. Herein, we present a review of these complications of gastric resection to update the literature and to clarify some of the controversial issues. Material and Methods A retrospective review was undertaken at the Veterans Administration Medical Center in Louisville, Kentucky, to study 312 gastric resections (307 partial and 5 total) performed between 1968 and 1978. All patients were men, and their ages ranged from 30 to 70 years. Operative data are summarized in Table I.
Of these 312 gastric resections, the most frequent indications (listed in order) were duodenal ulcer, gastric ulcer, prepyloric ulcer, and gastric cancer. Vagotomy was performed in 181 patients, and continuity was restored with a Billroth II anastomosis in 193 patients, a Billroth I anastomosis in 114 paFrom the Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky. Requests for reprints should be addressed to Waheed Ahmad, MD, Department of Surgery, Ambulatory Care Building, University of Louisville, Louisville. Kentucky 40292.
Volume 152, September 1986
and esophagojejunostomy in 5 patients. Billroth II reconstructions were associated with vagotomy in 64 percent of the patients. The Hoffmeister modification was often used and was placed in the antecolic position in 82 percent of the patients. Billroth I reconstructions were divided equally into those with and without vagotomy. In most instances, the Shoemaker modification was used. Indications for gastric resection in patients with duodenal ulcers were perforation (11 patients), obstruction (23 patients), bleeding (26 patients), and intractability (124 patients); for patients with gastric ulcers, obstruction (1 patient), perforation (2 patients), bleeding (15 patients), and intractability (16 patients); and for patients with prepyloric ulcers, perforation (1 patient), obstruction (3 patients), bleeding (10 patients), and intractability (16 patients). Mortality rates were highest when resection was necessitated by cancer (10 percent), bleeding (15 percent), and perforation (28 percent) (Table II). The mortality rate for elective operations in patients with benign duodenal ulcers was 3.2 percent, and it was exactly half that for elective operations on benign gastric and prepyloric ulcers when the duodenum appeared normal. The mortality rate for emergency resections for benign disease was 12 percent. Early complications after gastric resection included leaks in 19 patients; obstruction in 12 patients; pneumonia, myocardial infarction, peritonitis, and intraperitoneal bleeding in 3 patients each; splenic injury in 2 patients; and gastrointestinal bleeding and gastrocolic fistula in 1 patient each. Late postoperative complications and treatments required are listed in Table III. Leaks: Nineteen leaks (6 percent) were observed after gastric resection, 14 of which occurred after Billroth II anastomosis and were from the duodenal
tients,
301
Ahmadet al
TABLE I
Management of 312 Patients With Gastric Resections
n
Billroth II With Vagotomy
Lesion
184 65 30 2 1 1 29
Duodenal ulcer Gastric ulcer Prepyloric ulcer Combined ulcer Gastrinoma Gastritis (portal hypertension) Cancer
Total
. .
TABLE II
37 13 5 1 0 0
99 7 15 1 0 0
n
Elective Intractable ulcer Gastric cancer Emergency Perforation Bleeding Obstruction
39 8 9 0 0 0
Billroth I Without Vagotomy
Total Gastrectomy
9 37 1 0 0 0
0 0 0 0 1 1
2
13
1
10
3
124
69
57
57
5
187 29 14 52 27
Cancer (n = 29)
n
Medical
Bile gastritis
7
3
Dumping
5
3
Diarrhea Bezoar Gallstones Recurrent peptic ulcer Pancreatic pseudocysts Adhesions with bowel
-
Duodenal Ulcer (n = 184)
Deaths Gastric Ulcer (n = 65)
Preplyoric Ulcer (n = 30)
Gastritis (n= 1)
...
4
...
1
3
...
...
. .
..
...
4 4
..
...
...
... ... ...
...
2
. . ..
Complications and Treatments ol Late Postgastric Resection
Complications
Treatment Surgical 2, Tanner Roux-Y 2, Roux-Y 2, 10 cm antiperistaltic loop
1 1 2, cholecystectomy 1, transthoracic vagotomy 1, cyst gastrostomy 2, laparotomy
obstruction
stump (Table IV). Eleven leaks occurred in patients with duodenal ulcers. Thus, 73 percent of the leaks occurred after Billroth II reconstructions, which were selected for 63 percent of the patients with duodenal ulcer. There were also three leaks after Billroth I anastomosis, and two leaks in the five patients who had esophagogastrectomy. Four of the patients with cancer (14 percent) had leaks, two after total gastrectomy (one did not require reoperation) and two after Billroth II reconstruction. In the patients with benign disease, 13
302
Operative Procedure Billroth I With Vagotomy
Relatlonshlp ot Mortality to Presentation
Operative Indications
TABLE Ill
Billroth II Without Vagotomy
...
1
...
patients with duodenal ulcer (7 percent) had leaks compared with only 2 patients (1.6 percent) in whom the duodenum was normal. In patients with benign disease who had a gastrectomy, there were six leaks (3 percent) among patients operated on for intractability, compared with nine leaks (10 percent) in patients who underwent emergency gastrectomy. After Billroth II anastomosis, 1 of 35 retrocolic anastomoses (3 percent) was associated with a duodenal stump leak, compared with 13 of 158 antecolic anastomoses (8 percent). Two of the 13 patients with duodenal ulcers and stump leaks had undergone previous operations for duodenal ulcer. Twenty-six patients (8 percent) were considered to be at high risk for leaks at gastrectomy and were treated with preventive or protective measures such as duodenostomy with drainage (14 patients), drainage alone (8 patients), or placement of a nasogastric tube secured in the afferent limb (2 patients). Leaks developed in eight of these patients, two with duodenostomies, four with drainage alone, and both patients who had drainage of a nasogastric tube in the afferent limb. Ten patients with leaks had documentation of a difficult stump closure due to posterior or penetrating duodenal ulcer disease. Two patients had undergone duodenal invagination to close the duodenal stump. In one patient, a staple line had been invaginated and oversutured. In no
The American Journal of Surgery
Leaks and Obstruction After Gastric Resection
TABLE IV
Relationshlp of Leaks to Operatlve Procedure and Inltlal Disease’
Operative Indications Duodenal ulcer Elective Emergency Gastric ulcer Elective Emergency Prepyloric ulcer Elective Emergency Cancer Elective l
Bilkoth II
Procedure Performed Billroth I Procedures Leaks
Total Gastrectomies Procedures Leaks
Pts (n)
Leaks
Procedures
124 60
5 6
84 52
0 2
40
..~ ...
. ...
47
18
0 0
16 4
1 0
31 14
.., ...
.. ...
16 14
0 1
11 9
0 0
5 5
.., ...
.
29
2
26
*. .
...
2
a
3
No leaks were found after operations for combined ulcers in two patients, gastrinoma in one patient, and gastritis in one patient.
was a mechanical defect identified at the termination of the afferent limb. Evidence of the leak occurred within 5 to 21 days in 18 patients (average 10 days). Curiously, one patient presented 1 year later with a subphrenic abscess at the duodenal stump which represented chronic leakage. In 14 patients, the presenting symptoms were high fever, leukocytosis, and abdominal pain. Pleural effusion was the initial sign in three patients, and jaundice was the initial sign in one patient. One patient with an esophagojejunostomy had a controlled leak that was treated conservatively, and the patient recovered. The other 18 patients all needed drainage or improvement of drainage, and 6 needed more than one reoperation. Two patients had a duodenostomy in addition to external drainage. The total duration of hospital stay for surviving patients was 1 to 2 months for 12 patients and more than 2 months for 2 patients. Five of the patients with leaks (26 percent) died as a result of uncontrolled sepsis, and these accounted for one fourth of the postoperative deaths after gastrectomy. Two of the surviving patients had persistent duodenal fistulas which needed excision at later elective operation. Data regarding the 19 patients with leaks are listed in Table V. Gastric retention and obstruction: Twelve cases of postoperative gastric outlet obstruction [6-8] were observed for an overall incidence of 4 percent (Table VI). Four obstructions occurred after Billroth I reconstruction without vagotomy, four after Billroth I reconstruction with vagotomy, and four after Billroth II reconstruction with vagotomy. There was no incidence of obstruction after Billroth II reconstruction without vagotomy or after total gastrectomy. All but one of the obstructions followed operation for duodenal ulcer. Four patients had emergency operations. Three of four patients with obstruction after Billroth II reconstruction with vagotomy and all of the patient
Volume 152, September 1986
patients with retrocolic anastomoses had a mechanical cause for their complications and required early reoperation. In two of the three patients, sutures from the mesocolon to the stomach had disintegrated and the gastrojejunostomy was pulled up and twisted. Another patient was found to have a twisted gastrojejunostomy caused by a different mechanism. The fourth patient of this group with a vagotomy and an antecolic anastomosis was conservatively treated, which resulted in remission. Three of eight patients had early obstruction after Billroth I anastomosis with vagotomy and responded to prolonged nasogastric suction. Five other patients presented at 7 months postoperatively or longer and required reoperation. Two-layer anastomoses had previously been performed for duodenal ulcers that were not resected; in three, the anastomoses included the edge of the ulcer and in another, the duodenum was noted as narrow. Four of these patients had conversion to a Billroth II anastomosis, and one had revision of a gastroduodenostomy. Twenty-seven patients who previously had undergone operation for duodenal ulcer with preoperative obstruction underwent gastric resection as follows: 1 Billroth I procedure, 2 Billroth I procedures with vagotomy, 7 Billroth II procedures, and 17 Billroth II procedures with vagotomy. Postoperative obstruction occurred in none of these patients, although vagotomy had been included in 19 of the operations. Gastric retention and obstruction did not contribute to mortality in this series. All patients survived and eventually improved after appropriate corrective treatment. Data regarding the 12 patients with impaired gastric emptying are summarized in Table VII. Comments
The use of surgery for the treatment of peptic ulcer disease was decreasing before the advent of the Hz receptor antagonists, although the latter ap-
303
Obstruction
Intractability
Bleeding
Intractability
Obstruction
Perforation
Intractability
Intractability Intractability
Intractability
Intractability
Intractability
DU
DU
RDU
DU
DU
DU
GU
CA CA
CA
DU
DU
Intractability
Obstruction
Intractability
Perforation
CA
PU
DU
RDU
Billroth II, antecolic Billroth II, antecolic Billroth II, antecolic Billroth II, antecolic vagotomy
vagotomy
vagotomy
vagotomy
Billroth II, antecolic Billroth II, antecolic vagotomy
Billroth II Total gastrectomy Total gastrectomy Billroth II, antecolic vagotomy Billroth II, antecolic retrocolic vagatomy Billroth II, antecolic vagotomy
Billroth II, antecolic vagotomy Billroth I leak; Billroth II, antecolic Billroth I
10 7
21
7 9 12 10
No Yes
No
No No No Yes
Penrose Sump
. .
.. Difficult closure
Difficult closure
.
Omental cover, difficult closure Difficult closure
Difficult closure, omental cover
..
Posterior ulcer, needed Nissen maneuver, omental pouch
. .
... ..
.
Penrose
...
...
Nasogastric limb
. . ... Sump
.. Nasogastric tube, efferent limb Yes
Penrose
.
. . .
Management
21
1 yr
Drainage, twice Drainage
Drainage
Drainage
8 7
Drainage Drainage
Drainage, twice Drainage twice
Drainage
Expectant
Drainage, colostomy for colon fistula, gastrojejunostomy for obstruction Drainage Drainage
End DD 8 drainage
Billroth II, drainage. DD for leak Drainage, 12th rib
Drainage
Drainage
Drainage
7 7
9
10
5
No
... Mass around duodenum Difficult closure
6
No
... ..
7
No
Penrose
Time to Leak (d) 10
DD No
Posterior ulcer, required Nissen maneuver Scarring, difficult closure
Billroth II, antecolic Billroth II, antecolic vagotomy Billroth II, antecolic Billroth I
Drain No
Comments
Operation
CA = cancer; DD = duodenostomy; DU = duodenal ulcer; GU = gastric ulcer; PU = prepyloric ulcer; RDU = recurrent duodenal ulcer.
Intractability Obstruction
DU DU
DU
Indication
Details of 10 Leaks in 19 Patients
Diagnosis
TABLE V
Fistula,
Recovered
Recovered
Recovered Recovered
Recovered
Died
Died
Recovered
Recovered Died
Recovered
Recovered
Fistula, excised Fistula, excised Died from sepsis Recovered
Recovered
Outcome
Leaks and Obstruction
TABLE VI
After Gastric
Resection
Relationship ol Gastric Retention to Operative Procedure and lnltlal Disease* Billroth II With Vagotomy Patients With GR Procedures
Condition Duodenal ulcer Elective (n = 124) Emergency (n = 60) Gastric ulcer Elective (n = 47) Emergency (n = 16) Prepyloric ulcer Elective (n = 16) Emergency (n = 14)
Billroth II Without Vagotomy Patients Procedures With GR
Billroth I With Vagotomy Patients With GR Procedures
Billroth I Without Vagotomy Patients With GR Procedures
1
64
0
20
3
33
3
7
2
35
0
17
1
6
1
2
1
5
0
11
0
6
0
25
0
2
0
2
0
2
0
12
0
8
0
3
0
4
0
1
0
7
0
2
0
5
0
0
There was no retention after operation for cancer in 29 patients, combined ulcer in 2 patients, gastrinoma in 1 patient, or gastritis in 1 patient. GR = gastric retention. l
TABLE VII Diagnosis
Details of Postoperatlve Obstructions In 12 Patients Presentation
DU DU
Bleeding
DU
Intractability
DU
Intractability
DU
Intractability
DU DU
intractability Bleeding
DU DU
Intractability Bleeding
GU
Intractability
DU
Intractability
DU
Intractability
Comments
Operation
Time to Obstruction
Treatment
Billroth I Billroth II, antecolic vagotomy Billroth I
1 year Postop, poor emptying
Billroth II, antecolic Nasogastric tube
Recovered Recovered
7 months
Billroth II, antecolic
Billroth I, vagotomy Billroth I, vagotomy Billroth I Billroth I, vagotomy Billroth I Billroth II, retrocolic vagotomy Billroth II, retrocolic vagotomy
Postop, poor emptying
Nasogastric tube
Recovered, two-layer gastroduodenostomy Recovered
6 years
Billroth I
Fibrosis
7 months Postop, poor empyting
Billroth II, antecolic Nasogastric tube
Recovered Recovered
8 months Postop, obstruction
Billroth II Reoperation
Postop, obstruction
Reoperation
Billroth I, vagotomy Billroth II, retrocolic vagotomy
Postop, poor emptying
Nasogastric tube
Recovered Gastrojejunostomy pulled up Gastrojejunostomy pulled up and twisted, regastrojejunostomy Recovered
Postop, obstruction
Reoperation
Gastrojejunostomy pulled up
DU = duodenal ulcer; GU = gastric ulcer.
pear to have contributed to a further decrease in its use. Vagotomy and pyloroplasty have long been in competition with gastric resection as the operative treatments of choice in patients with duodenal ulcer [9]. In some centers, supraselective vagotomy is offered as an alternative [2,3]. These trends have decreased the frequency of the use of gastric resection. In the presence of advanced duodenal ulcer, however, vagotomy and antrectomy remain the most effective operations short of total gastrectomy. In
Volume 152,StqHember
1996
the presence of gastric ulcer or cancer, some form of resection is necessary. Although the overall incidence of complications after gastrectomy is less [6-14, it becomes necessary to ensure that the relative incidence does not increase due to inattention to its problems. Patients with gastric cancer are in a somewhat different category than those with benign peptic ulcers. Vagotomy was added to partial gastrectomy in only three such patients in our series. Duodenal
305
Ahmad et al
leaks developed in two of those patients after Billroth II anastomoses, and leaks developed in two of the three patients with cancer who received total gastrectomies. None of the cancer patients had postoperative obstruction. The selection of operation for benign diseases reflected the opinions of the attending staff; however, duodenal and prepyloric ulcers were considered directly related to acid output, and vagotomy was added to the gastric resection by most surgeons. Gastric ulcer, on the other hand, was usually treated with resection without vagotomy. Postoperative leaks accounted for approximately one fourth of the postoperative deaths and usually required one or more operations. Leaks were more common after emergency operations and occurred predominantly after difficult stump closures in operations for duodenal ulcer. Instances of afferent loop obstruction were not identified [IO]. The increased incidence of postoperative leaks after antecolic anastomoses may be at least partially due to a preference of the staff for that type of anastomosis in difficult operations. When a high risk situation was recognized, no preventive measure was totally reliable, but duodenostomy achieved better results in 12 of 14 patients than drainage or intraluminal decompression [12,13]. No patient died from impairment of gastric emptying, but three patients with Billroth II procedures required early revision and five patients with Billroth I procedures required later revision. Obstruction also occurred predominantly after resection for duodenal ulcer. Vagotomy in four patients, three of whom had Billroth I procedures, was associated with early retention that subsided with conservative treatment. However, vagotomy appeared to have no relationship to the need for reoperation in eight patients. The use of vagotomy in patients with preoperative obstruction did not appear to adversely affect the results, although some staff members thought that vagotomy was contraindicated in such patients. Complications in 103 patients with peptic ulcer disease who had Billroth I procedures included eight patients with obstruction, three patients with leaks, and one patient each with pneumonia, bile gastritis, dumping, and diarrhea. Three of these patients died. Complications in 178 patients with peptic ulcer disease who had Billroth II procedures included 12 patients with leaks, 6 patients with bile gastritis, 4 patients with obstruction, 2 patients each with pneumonia, splenic injury, and gallstones, and 1 patient each with recurrent ulcer and postoperative hemorrhage. Twelve patients with this reconstruction died. A comparison of these complications suggests that leaks tend to occur in Billroth II procedures and obstruction tends to occur in Billroth I procedures [14,15]. The low incidence of suture line bleeding and clinically significant dumping
306
is noteworthy. Billroth I reconstruction was usually selected for patients with normal duodenums, and obstructions occurred only in the few patients with retained ulcers of the duodenum. A Billroth II procedure was the usual choice in emergency situations and in patients with badly diseased duodenums, and these accounted for most of the mortality in this series. The role of afferent loop obstruction in stump blowouts was recognized by the staff, and this recognition may have minimized the incidence of this complication. Difficult stump closure was avoided in some cases by pyloroplasty or gastrojejunostomy. When a difficult stump closure is unavoidable, the use of a tube duodenostomy through the side of the duodenum-not the closure line-is probably the best, if not an infallible, preventive measure 1131. External drainage permits earlier diagnosis but has no proved preventive value. Postoperatively, the less dramatic signs of leakage should be searched out. When a leak does occur, prompt and adequate drainage and augmentation of drainage are usually necessary, despite any previous operative precautions. Summary Postoperative gastric retention may be minimized by avoiding the use of the Billroth I reconstruction when a large duodenal ulcer must be retained. Postoperative gastric retention is more likely to remit with conservative therapy if the procedure was a Billroth I reconstruction with a vagotomy. In other instances where there is difficulty in gastric emptying, a mechanical cause should be strongly suspected. The optimum duration of a conservative trial with suction for postoperative gastric retention may be debatable, and contrast radiography or endoscopy may be helpful; however, patience and suction are not long-term substitutes for a needed operation. References 1. Gibson R, Hirschowitz Bi, Hutchinson G. Actions of metiamide, an HP-histamine receptor antagonist, on gastric H+ and pepsin secretion in dogs. Gastroenterology 1974;67: 93-9. 2. Johnston D, Wilkinson AR. Highly selective vagotomy without a drainage procedure in the treatment of duodenal ulcer. Br J Surg 1970;57:289-96. 3. Sawyer JL, Scott HW Jr. Selective gastric vagotomy with antrectomy or pyioropiasty. Ann Surg 1971;174:541-7. 4. Pearce CW, Jordan GJ Jr, DeBakey ME. Intra-abdominal complications following distal subtotal gastrectomy for benign gastroduodenai ulceration. Surgery 1956;42:447-61. 5. Hardy JD. Problems associated with gastric surgery. A review of 604 consecutive patients with annotation. Am J Surg 1964;108:699-716. 6. Jordan GL Jr, Walker LL. Severe problems with gastric emptying after gastric surgery. Ann Surg 1973;177:660-6. 7. Cohen AM, Dttinger LW. Delayed gastric emptying following
The American Journal01 Surgery
Leaks and Obstruction After Gastric Resection
gastrectomy. Ann Surg 1976; 184:689-96. 8. Donovan I, Alexander-Williams J. Postoperative gastric retention and delayed gastric emptying. Surg Clin North Am 1976;56:1413-9. 9. Farmer DA, Harrower HW, Smithwick RH. The choice of surgery in peptic ulcer disease. Am J Surg 1970;120: 295-305. 10. Buckberg GD. Acute obstruction of the afferent loop after gastrectomy. Am J Surg 1967;113:682-7. 11. Cooperman AM. Postgastrectomy syndromes. Surg Annu
volume 152, -ember
1988
1981;13:139-61. 12. Lamphier TA, Crooker C. Catheter duodenostomy for the difficult duodenal stump. South Med J 1968;61:751-7. 13. Dardik I, Dardik H, Shumofsky E, Gliedman ML. Lateral T-tube duodenostomy. Duodenal stump management and manometrics. Arch Surg 1973;107:89-90. 14. Jesseph JE. The trouble with Billroth II is Am J Surg 1974; 128:654-6. 15. Griffen WO Jr. Whither goest the duodenal stump blowout? Arch Surg 1973;107:11.
307
Wahwd Ahmad, MD, Louisville, Kentucky Phil J. Ha&m&t,
MD, Louisville, Kentucky
Hiram C. Polk, Jr., MD, Louisville, Kentucky
There has been a decrease in the use of gastric resection for the treatment of peptic ulcer disease. Less frequent occurrence of the disease and the widespread use of HZ receptor antagonists [I] may be responsible in part, but the type of primary operation has also changed since the introduction of various kinds of vagotomies [2,3]. Despite these changes, gastric resection is still a proved modality for the treatment of recalcitrant peptic ulcer disease and of neoplasms of the stomach. Leaks and obstructions are dreaded complications of gastric resection [4,5] but are seldom described in the current literature. In addition, what is found in the older literature is often controversial. Herein, we present a review of these complications of gastric resection to update the literature and to clarify some of the controversial issues. Material and Methods A retrospective review was undertaken at the Veterans Administration Medical Center in Louisville, Kentucky, to study 312 gastric resections (307 partial and 5 total) performed between 1968 and 1978. All patients were men, and their ages ranged from 30 to 70 years. Operative data are summarized in Table I.
Of these 312 gastric resections, the most frequent indications (listed in order) were duodenal ulcer, gastric ulcer, prepyloric ulcer, and gastric cancer. Vagotomy was performed in 181 patients, and continuity was restored with a Billroth II anastomosis in 193 patients, a Billroth I anastomosis in 114 paFrom the Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky. Requests for reprints should be addressed to Waheed Ahmad, MD, Department of Surgery, Ambulatory Care Building, University of Louisville, Louisville. Kentucky 40292.
Volume 152, September 1986
and esophagojejunostomy in 5 patients. Billroth II reconstructions were associated with vagotomy in 64 percent of the patients. The Hoffmeister modification was often used and was placed in the antecolic position in 82 percent of the patients. Billroth I reconstructions were divided equally into those with and without vagotomy. In most instances, the Shoemaker modification was used. Indications for gastric resection in patients with duodenal ulcers were perforation (11 patients), obstruction (23 patients), bleeding (26 patients), and intractability (124 patients); for patients with gastric ulcers, obstruction (1 patient), perforation (2 patients), bleeding (15 patients), and intractability (16 patients); and for patients with prepyloric ulcers, perforation (1 patient), obstruction (3 patients), bleeding (10 patients), and intractability (16 patients). Mortality rates were highest when resection was necessitated by cancer (10 percent), bleeding (15 percent), and perforation (28 percent) (Table II). The mortality rate for elective operations in patients with benign duodenal ulcers was 3.2 percent, and it was exactly half that for elective operations on benign gastric and prepyloric ulcers when the duodenum appeared normal. The mortality rate for emergency resections for benign disease was 12 percent. Early complications after gastric resection included leaks in 19 patients; obstruction in 12 patients; pneumonia, myocardial infarction, peritonitis, and intraperitoneal bleeding in 3 patients each; splenic injury in 2 patients; and gastrointestinal bleeding and gastrocolic fistula in 1 patient each. Late postoperative complications and treatments required are listed in Table III. Leaks: Nineteen leaks (6 percent) were observed after gastric resection, 14 of which occurred after Billroth II anastomosis and were from the duodenal
tients,
301
Ahmadet al
TABLE I
Management of 312 Patients With Gastric Resections
n
Billroth II With Vagotomy
Lesion
184 65 30 2 1 1 29
Duodenal ulcer Gastric ulcer Prepyloric ulcer Combined ulcer Gastrinoma Gastritis (portal hypertension) Cancer
Total
. .
TABLE II
37 13 5 1 0 0
99 7 15 1 0 0
n
Elective Intractable ulcer Gastric cancer Emergency Perforation Bleeding Obstruction
39 8 9 0 0 0
Billroth I Without Vagotomy
Total Gastrectomy
9 37 1 0 0 0
0 0 0 0 1 1
2
13
1
10
3
124
69
57
57
5
187 29 14 52 27
Cancer (n = 29)
n
Medical
Bile gastritis
7
3
Dumping
5
3
Diarrhea Bezoar Gallstones Recurrent peptic ulcer Pancreatic pseudocysts Adhesions with bowel
-
Duodenal Ulcer (n = 184)
Deaths Gastric Ulcer (n = 65)
Preplyoric Ulcer (n = 30)
Gastritis (n= 1)
...
4
...
1
3
...
...
. .
..
...
4 4
..
...
...
... ... ...
...
2
. . ..
Complications and Treatments ol Late Postgastric Resection
Complications
Treatment Surgical 2, Tanner Roux-Y 2, Roux-Y 2, 10 cm antiperistaltic loop
1 1 2, cholecystectomy 1, transthoracic vagotomy 1, cyst gastrostomy 2, laparotomy
obstruction
stump (Table IV). Eleven leaks occurred in patients with duodenal ulcers. Thus, 73 percent of the leaks occurred after Billroth II reconstructions, which were selected for 63 percent of the patients with duodenal ulcer. There were also three leaks after Billroth I anastomosis, and two leaks in the five patients who had esophagogastrectomy. Four of the patients with cancer (14 percent) had leaks, two after total gastrectomy (one did not require reoperation) and two after Billroth II reconstruction. In the patients with benign disease, 13
302
Operative Procedure Billroth I With Vagotomy
Relatlonshlp ot Mortality to Presentation
Operative Indications
TABLE Ill
Billroth II Without Vagotomy
...
1
...
patients with duodenal ulcer (7 percent) had leaks compared with only 2 patients (1.6 percent) in whom the duodenum was normal. In patients with benign disease who had a gastrectomy, there were six leaks (3 percent) among patients operated on for intractability, compared with nine leaks (10 percent) in patients who underwent emergency gastrectomy. After Billroth II anastomosis, 1 of 35 retrocolic anastomoses (3 percent) was associated with a duodenal stump leak, compared with 13 of 158 antecolic anastomoses (8 percent). Two of the 13 patients with duodenal ulcers and stump leaks had undergone previous operations for duodenal ulcer. Twenty-six patients (8 percent) were considered to be at high risk for leaks at gastrectomy and were treated with preventive or protective measures such as duodenostomy with drainage (14 patients), drainage alone (8 patients), or placement of a nasogastric tube secured in the afferent limb (2 patients). Leaks developed in eight of these patients, two with duodenostomies, four with drainage alone, and both patients who had drainage of a nasogastric tube in the afferent limb. Ten patients with leaks had documentation of a difficult stump closure due to posterior or penetrating duodenal ulcer disease. Two patients had undergone duodenal invagination to close the duodenal stump. In one patient, a staple line had been invaginated and oversutured. In no
The American Journal of Surgery
Leaks and Obstruction After Gastric Resection
TABLE IV
Relationshlp of Leaks to Operatlve Procedure and Inltlal Disease’
Operative Indications Duodenal ulcer Elective Emergency Gastric ulcer Elective Emergency Prepyloric ulcer Elective Emergency Cancer Elective l
Bilkoth II
Procedure Performed Billroth I Procedures Leaks
Total Gastrectomies Procedures Leaks
Pts (n)
Leaks
Procedures
124 60
5 6
84 52
0 2
40
..~ ...
. ...
47
18
0 0
16 4
1 0
31 14
.., ...
.. ...
16 14
0 1
11 9
0 0
5 5
.., ...
.
29
2
26
*. .
...
2
a
3
No leaks were found after operations for combined ulcers in two patients, gastrinoma in one patient, and gastritis in one patient.
was a mechanical defect identified at the termination of the afferent limb. Evidence of the leak occurred within 5 to 21 days in 18 patients (average 10 days). Curiously, one patient presented 1 year later with a subphrenic abscess at the duodenal stump which represented chronic leakage. In 14 patients, the presenting symptoms were high fever, leukocytosis, and abdominal pain. Pleural effusion was the initial sign in three patients, and jaundice was the initial sign in one patient. One patient with an esophagojejunostomy had a controlled leak that was treated conservatively, and the patient recovered. The other 18 patients all needed drainage or improvement of drainage, and 6 needed more than one reoperation. Two patients had a duodenostomy in addition to external drainage. The total duration of hospital stay for surviving patients was 1 to 2 months for 12 patients and more than 2 months for 2 patients. Five of the patients with leaks (26 percent) died as a result of uncontrolled sepsis, and these accounted for one fourth of the postoperative deaths after gastrectomy. Two of the surviving patients had persistent duodenal fistulas which needed excision at later elective operation. Data regarding the 19 patients with leaks are listed in Table V. Gastric retention and obstruction: Twelve cases of postoperative gastric outlet obstruction [6-8] were observed for an overall incidence of 4 percent (Table VI). Four obstructions occurred after Billroth I reconstruction without vagotomy, four after Billroth I reconstruction with vagotomy, and four after Billroth II reconstruction with vagotomy. There was no incidence of obstruction after Billroth II reconstruction without vagotomy or after total gastrectomy. All but one of the obstructions followed operation for duodenal ulcer. Four patients had emergency operations. Three of four patients with obstruction after Billroth II reconstruction with vagotomy and all of the patient
Volume 152, September 1986
patients with retrocolic anastomoses had a mechanical cause for their complications and required early reoperation. In two of the three patients, sutures from the mesocolon to the stomach had disintegrated and the gastrojejunostomy was pulled up and twisted. Another patient was found to have a twisted gastrojejunostomy caused by a different mechanism. The fourth patient of this group with a vagotomy and an antecolic anastomosis was conservatively treated, which resulted in remission. Three of eight patients had early obstruction after Billroth I anastomosis with vagotomy and responded to prolonged nasogastric suction. Five other patients presented at 7 months postoperatively or longer and required reoperation. Two-layer anastomoses had previously been performed for duodenal ulcers that were not resected; in three, the anastomoses included the edge of the ulcer and in another, the duodenum was noted as narrow. Four of these patients had conversion to a Billroth II anastomosis, and one had revision of a gastroduodenostomy. Twenty-seven patients who previously had undergone operation for duodenal ulcer with preoperative obstruction underwent gastric resection as follows: 1 Billroth I procedure, 2 Billroth I procedures with vagotomy, 7 Billroth II procedures, and 17 Billroth II procedures with vagotomy. Postoperative obstruction occurred in none of these patients, although vagotomy had been included in 19 of the operations. Gastric retention and obstruction did not contribute to mortality in this series. All patients survived and eventually improved after appropriate corrective treatment. Data regarding the 12 patients with impaired gastric emptying are summarized in Table VII. Comments
The use of surgery for the treatment of peptic ulcer disease was decreasing before the advent of the Hz receptor antagonists, although the latter ap-
303
Obstruction
Intractability
Bleeding
Intractability
Obstruction
Perforation
Intractability
Intractability Intractability
Intractability
Intractability
Intractability
DU
DU
RDU
DU
DU
DU
GU
CA CA
CA
DU
DU
Intractability
Obstruction
Intractability
Perforation
CA
PU
DU
RDU
Billroth II, antecolic Billroth II, antecolic Billroth II, antecolic Billroth II, antecolic vagotomy
vagotomy
vagotomy
vagotomy
Billroth II, antecolic Billroth II, antecolic vagotomy
Billroth II Total gastrectomy Total gastrectomy Billroth II, antecolic vagotomy Billroth II, antecolic retrocolic vagatomy Billroth II, antecolic vagotomy
Billroth II, antecolic vagotomy Billroth I leak; Billroth II, antecolic Billroth I
10 7
21
7 9 12 10
No Yes
No
No No No Yes
Penrose Sump
. .
.. Difficult closure
Difficult closure
.
Omental cover, difficult closure Difficult closure
Difficult closure, omental cover
..
Posterior ulcer, needed Nissen maneuver, omental pouch
. .
... ..
.
Penrose
...
...
Nasogastric limb
. . ... Sump
.. Nasogastric tube, efferent limb Yes
Penrose
.
. . .
Management
21
1 yr
Drainage, twice Drainage
Drainage
Drainage
8 7
Drainage Drainage
Drainage, twice Drainage twice
Drainage
Expectant
Drainage, colostomy for colon fistula, gastrojejunostomy for obstruction Drainage Drainage
End DD 8 drainage
Billroth II, drainage. DD for leak Drainage, 12th rib
Drainage
Drainage
Drainage
7 7
9
10
5
No
... Mass around duodenum Difficult closure
6
No
... ..
7
No
Penrose
Time to Leak (d) 10
DD No
Posterior ulcer, required Nissen maneuver Scarring, difficult closure
Billroth II, antecolic Billroth II, antecolic vagotomy Billroth II, antecolic Billroth I
Drain No
Comments
Operation
CA = cancer; DD = duodenostomy; DU = duodenal ulcer; GU = gastric ulcer; PU = prepyloric ulcer; RDU = recurrent duodenal ulcer.
Intractability Obstruction
DU DU
DU
Indication
Details of 10 Leaks in 19 Patients
Diagnosis
TABLE V
Fistula,
Recovered
Recovered
Recovered Recovered
Recovered
Died
Died
Recovered
Recovered Died
Recovered
Recovered
Fistula, excised Fistula, excised Died from sepsis Recovered
Recovered
Outcome
Leaks and Obstruction
TABLE VI
After Gastric
Resection
Relationship ol Gastric Retention to Operative Procedure and lnltlal Disease* Billroth II With Vagotomy Patients With GR Procedures
Condition Duodenal ulcer Elective (n = 124) Emergency (n = 60) Gastric ulcer Elective (n = 47) Emergency (n = 16) Prepyloric ulcer Elective (n = 16) Emergency (n = 14)
Billroth II Without Vagotomy Patients Procedures With GR
Billroth I With Vagotomy Patients With GR Procedures
Billroth I Without Vagotomy Patients With GR Procedures
1
64
0
20
3
33
3
7
2
35
0
17
1
6
1
2
1
5
0
11
0
6
0
25
0
2
0
2
0
2
0
12
0
8
0
3
0
4
0
1
0
7
0
2
0
5
0
0
There was no retention after operation for cancer in 29 patients, combined ulcer in 2 patients, gastrinoma in 1 patient, or gastritis in 1 patient. GR = gastric retention. l
TABLE VII Diagnosis
Details of Postoperatlve Obstructions In 12 Patients Presentation
DU DU
Bleeding
DU
Intractability
DU
Intractability
DU
Intractability
DU DU
intractability Bleeding
DU DU
Intractability Bleeding
GU
Intractability
DU
Intractability
DU
Intractability
Comments
Operation
Time to Obstruction
Treatment
Billroth I Billroth II, antecolic vagotomy Billroth I
1 year Postop, poor emptying
Billroth II, antecolic Nasogastric tube
Recovered Recovered
7 months
Billroth II, antecolic
Billroth I, vagotomy Billroth I, vagotomy Billroth I Billroth I, vagotomy Billroth I Billroth II, retrocolic vagotomy Billroth II, retrocolic vagotomy
Postop, poor emptying
Nasogastric tube
Recovered, two-layer gastroduodenostomy Recovered
6 years
Billroth I
Fibrosis
7 months Postop, poor empyting
Billroth II, antecolic Nasogastric tube
Recovered Recovered
8 months Postop, obstruction
Billroth II Reoperation
Postop, obstruction
Reoperation
Billroth I, vagotomy Billroth II, retrocolic vagotomy
Postop, poor emptying
Nasogastric tube
Recovered Gastrojejunostomy pulled up Gastrojejunostomy pulled up and twisted, regastrojejunostomy Recovered
Postop, obstruction
Reoperation
Gastrojejunostomy pulled up
DU = duodenal ulcer; GU = gastric ulcer.
pear to have contributed to a further decrease in its use. Vagotomy and pyloroplasty have long been in competition with gastric resection as the operative treatments of choice in patients with duodenal ulcer [9]. In some centers, supraselective vagotomy is offered as an alternative [2,3]. These trends have decreased the frequency of the use of gastric resection. In the presence of advanced duodenal ulcer, however, vagotomy and antrectomy remain the most effective operations short of total gastrectomy. In
Volume 152,StqHember
1996
the presence of gastric ulcer or cancer, some form of resection is necessary. Although the overall incidence of complications after gastrectomy is less [6-14, it becomes necessary to ensure that the relative incidence does not increase due to inattention to its problems. Patients with gastric cancer are in a somewhat different category than those with benign peptic ulcers. Vagotomy was added to partial gastrectomy in only three such patients in our series. Duodenal
305
Ahmad et al
leaks developed in two of those patients after Billroth II anastomoses, and leaks developed in two of the three patients with cancer who received total gastrectomies. None of the cancer patients had postoperative obstruction. The selection of operation for benign diseases reflected the opinions of the attending staff; however, duodenal and prepyloric ulcers were considered directly related to acid output, and vagotomy was added to the gastric resection by most surgeons. Gastric ulcer, on the other hand, was usually treated with resection without vagotomy. Postoperative leaks accounted for approximately one fourth of the postoperative deaths and usually required one or more operations. Leaks were more common after emergency operations and occurred predominantly after difficult stump closures in operations for duodenal ulcer. Instances of afferent loop obstruction were not identified [IO]. The increased incidence of postoperative leaks after antecolic anastomoses may be at least partially due to a preference of the staff for that type of anastomosis in difficult operations. When a high risk situation was recognized, no preventive measure was totally reliable, but duodenostomy achieved better results in 12 of 14 patients than drainage or intraluminal decompression [12,13]. No patient died from impairment of gastric emptying, but three patients with Billroth II procedures required early revision and five patients with Billroth I procedures required later revision. Obstruction also occurred predominantly after resection for duodenal ulcer. Vagotomy in four patients, three of whom had Billroth I procedures, was associated with early retention that subsided with conservative treatment. However, vagotomy appeared to have no relationship to the need for reoperation in eight patients. The use of vagotomy in patients with preoperative obstruction did not appear to adversely affect the results, although some staff members thought that vagotomy was contraindicated in such patients. Complications in 103 patients with peptic ulcer disease who had Billroth I procedures included eight patients with obstruction, three patients with leaks, and one patient each with pneumonia, bile gastritis, dumping, and diarrhea. Three of these patients died. Complications in 178 patients with peptic ulcer disease who had Billroth II procedures included 12 patients with leaks, 6 patients with bile gastritis, 4 patients with obstruction, 2 patients each with pneumonia, splenic injury, and gallstones, and 1 patient each with recurrent ulcer and postoperative hemorrhage. Twelve patients with this reconstruction died. A comparison of these complications suggests that leaks tend to occur in Billroth II procedures and obstruction tends to occur in Billroth I procedures [14,15]. The low incidence of suture line bleeding and clinically significant dumping
306
is noteworthy. Billroth I reconstruction was usually selected for patients with normal duodenums, and obstructions occurred only in the few patients with retained ulcers of the duodenum. A Billroth II procedure was the usual choice in emergency situations and in patients with badly diseased duodenums, and these accounted for most of the mortality in this series. The role of afferent loop obstruction in stump blowouts was recognized by the staff, and this recognition may have minimized the incidence of this complication. Difficult stump closure was avoided in some cases by pyloroplasty or gastrojejunostomy. When a difficult stump closure is unavoidable, the use of a tube duodenostomy through the side of the duodenum-not the closure line-is probably the best, if not an infallible, preventive measure 1131. External drainage permits earlier diagnosis but has no proved preventive value. Postoperatively, the less dramatic signs of leakage should be searched out. When a leak does occur, prompt and adequate drainage and augmentation of drainage are usually necessary, despite any previous operative precautions. Summary Postoperative gastric retention may be minimized by avoiding the use of the Billroth I reconstruction when a large duodenal ulcer must be retained. Postoperative gastric retention is more likely to remit with conservative therapy if the procedure was a Billroth I reconstruction with a vagotomy. In other instances where there is difficulty in gastric emptying, a mechanical cause should be strongly suspected. The optimum duration of a conservative trial with suction for postoperative gastric retention may be debatable, and contrast radiography or endoscopy may be helpful; however, patience and suction are not long-term substitutes for a needed operation. References 1. Gibson R, Hirschowitz Bi, Hutchinson G. Actions of metiamide, an HP-histamine receptor antagonist, on gastric H+ and pepsin secretion in dogs. Gastroenterology 1974;67: 93-9. 2. Johnston D, Wilkinson AR. Highly selective vagotomy without a drainage procedure in the treatment of duodenal ulcer. Br J Surg 1970;57:289-96. 3. Sawyer JL, Scott HW Jr. Selective gastric vagotomy with antrectomy or pyioropiasty. Ann Surg 1971;174:541-7. 4. Pearce CW, Jordan GJ Jr, DeBakey ME. Intra-abdominal complications following distal subtotal gastrectomy for benign gastroduodenai ulceration. Surgery 1956;42:447-61. 5. Hardy JD. Problems associated with gastric surgery. A review of 604 consecutive patients with annotation. Am J Surg 1964;108:699-716. 6. Jordan GL Jr, Walker LL. Severe problems with gastric emptying after gastric surgery. Ann Surg 1973;177:660-6. 7. Cohen AM, Dttinger LW. Delayed gastric emptying following
The American Journal01 Surgery
Leaks and Obstruction After Gastric Resection
gastrectomy. Ann Surg 1976; 184:689-96. 8. Donovan I, Alexander-Williams J. Postoperative gastric retention and delayed gastric emptying. Surg Clin North Am 1976;56:1413-9. 9. Farmer DA, Harrower HW, Smithwick RH. The choice of surgery in peptic ulcer disease. Am J Surg 1970;120: 295-305. 10. Buckberg GD. Acute obstruction of the afferent loop after gastrectomy. Am J Surg 1967;113:682-7. 11. Cooperman AM. Postgastrectomy syndromes. Surg Annu
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1988
1981;13:139-61. 12. Lamphier TA, Crooker C. Catheter duodenostomy for the difficult duodenal stump. South Med J 1968;61:751-7. 13. Dardik I, Dardik H, Shumofsky E, Gliedman ML. Lateral T-tube duodenostomy. Duodenal stump management and manometrics. Arch Surg 1973;107:89-90. 14. Jesseph JE. The trouble with Billroth II is Am J Surg 1974; 128:654-6. 15. Griffen WO Jr. Whither goest the duodenal stump blowout? Arch Surg 1973;107:11.
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