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15 Case on Stenosis of a Side-to-Side Gastrojejunostomy
https://t.me/med1917
Fig. 15.3 Gastroscopy
showing the bezoar
Fig. 15.4 First balloon
dilatation up to 13 mm
85
Patient was treated with total parenteral nutrition (TPN) and nasogastric tube for
gastric decompression.
It was proposed to dilate the stenosed anastomosis. However, at the fi rst attempt
a large bezoar was found at the gastrojejunostomy (Fig. 15.3 ).
Conservative medical treatment was established with pancreatic enzymes in
order to dissolve the bezoar. During the second gastroscopy, the anastomosis could
be visualized and dilated by means of a balloon up to 1.3 cm (Fig. 15.4 ). An enteral
feeding tube could be introduced through the stenosis. TPN was replaced by enteral
feeding (Fig. 15.4 ).
During the 4th balloon dilatation, a 3, 5-cm dilatation could be achieved (Fig. 15.5a ).
Six months postoperatively, a new gastroscopy showed an adequate patency of
the gastrojejunostomy and a normal CT scan (Fig. 15.5b ).
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a
Fig. 15.5 ( a ) Dilatation up to 35 mm. ( b ) Patent gastrojejunostomy at 6 months postoperatively
b
A.A. Poza and F.N. Noboa
Illustration 15.1 ( a , b )
After partial gastrectomy,
stenosis can be found at the
gastrojejunostomy or at the
efferent loop of the anastomosis. Once stenosis is
diagnosed, patient should be
treated by nasogastric tube
and TPN. A dilatation
program should be scheduled
by progressive balloon
dilatation. If an enteral
feeding tube can be passed
through the stenosed
anastomosis, enteral feeding
can replace the TPN
a
15 Case on Stenosis of a Side-to-Side Gastrojejunostomy
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b
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Gastrojejunostomy stenosis
Efferent loop stenosis
Illustration 15.1 (continued)
Discussion
Dilatation of stenosis of gastrojejunostomy
Dilatation of stenosis of
efferent loop
Gastric-outlet obstruction and intestinal obstruction are relatively frequently occurring complications after gastrectomy. Five percent of all gastrectomies are complicated with stenosis/obstruction of any anastomoses.
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A.A. Poza and F.N. Noboa
The main cause of the obstruction is an area of infl ammatory adhesions adjacent to
the anastomosis, probably as consequence of small suture-line leakages and bleeding. Clearly, these complications are preventable. Moreover, functional paralysis of
the stomach, common in patients after long-standing gastric dilatation as resulting
from pyloric stenosis, may mimic gastric-outlet obstruction. Gastric peristalsis may
also be reduced by postoperative hypopotasemia.
There are many mechanical problems related to the gastro-jejunostomy, whether
ante or retrocolic. Gastric outlet occurs in about 5 % of all retrocolic anastomoses.
A retrocolic anastomosis can be stenosed by the transverse mesocolon. In order to
prevent this, the defect in the mesocolon should be sutured to the stomach at least
2-cm above the anastomosis. If this is not performed, the mesocolon may slide
down resulting in mechanical obstruction of one or both jejunal loops. In making
the anastomosis, it does not matter if it is isoperistaltic or antiperistaltic, but it is
important that the anastomosis is not twisted or obstructed [ 1 ].
Following a total gastrectomy, another cause of obstruction may become the torsion of the long loop of the jejunum used for the esophago-jejunostomy. Furthermore,
if antecolic anastomosis is performed, an internal hernia between the loop and colon
may be the cause of obstruction.
Benign stenosis after esophago-jejunostomy occurs in 26–42 % of patients,
which is of signifi cant infl uence on the nutritional status and quality of life. Despite
the technical and postoperative improvements, the incidence of benign stenosis has
not changed in the last 15 years.
Stenosis is associated with anastomotic leakages and cardiovascular disease.
Stenosis after anastomotic leakage may be due to (a) initial local ischemia manifested as a leakage and/or (b) local infl ammatory reaction.
Also, cardiovascular disease may have an important infl uence on the anastomosis healing process due to poor irrigation, as consequence of atherosclerosis or a low
cardiac output.
Diagnosis of this complication. If transit through the anastomosis is impaired for
longer than 5 days, involving the necessity of emptying the gastric remnant by
means of nasogastric tube, then diagnostic assessment is indicated by means of a
CT scan using oral contrast. It will help not only for diagnosing the level of the
obstruction but also for ruling out abscesses or leakages that should be treated fi rst.
Stenosis may be found at the level of the esophago-jejunostomy, the gastro-jejunostomy, or after a Billroth II anastomosis at the afferent or efferent loop. Gastroscopy
is the next step in order to assess the stenosis/obstruction and to evaluate the possibility for dilatation therapy. If possible, progressive balloon dilatation done in several sessions will be the treatment of choice [ 1 ].
Decompression of the stomach is the initial step, along with adequate feeding by
means of intestinal feeding tube introduced by the gastroscopist distal of the stenosis or by TPN.
Treatment depends on the diagnosis. If abscesses are present, these must fi rst be
drained percutaneously before the dilatation program can be started. If there is only
stenosis, a dilatation program will be scheduled. Dilatation by means of a balloon
will frequently lead to optimal results. Currently, most of literature is based on
15 Case on Stenosis of a Side-to-Side Gastrojejunostomy
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balloon dilatation for stenosis of anastomosis after gastric bypass for morbid obesity showing that dilatation is safe and effi cient to solve the problem [ 1 , 2 ].
If dilatation is not possible or obstruction is complete because of a technical
problem, such as internal hernia or torsion, then reoperation will need to be planned.
References
1. Garcia Sabrido JL, Vasquez JW. How to prevent, early diagnose, and treat major postoperative
complications after gastric surgery. In: Cuesta MA, Bonjer HJ, editors. Treatment of complica-
tions after digestive surgery, chapter 9. London: Springer; 2013.
2. Ukleja A, Afonso BB, Pimentel R, et al. Outcome of endoscopic balloon dilation of strictures
after laparoscopic gastric bypass. Surg Endosc. 2008;22:1746–50.
Chapter 16
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Case on Leakage After Closure
of a Duodenal Perforation
Jose L Garcia Sabrido and Wenceslao Vasquez Jimenez
Keywords Duodenal perforation • Arthrosis • Laparoscopy • Omentoplasty •
Duodenal ulcer • Perforation closure
Diagnosis and Indication for Surgery
We behold a 78-year-old male patient with a history of arthrosis and a chronic use of
oral NSAID’s and opiates. He had been evaluated at the emergency room because of
abdominal pain lasting 72 h. At examination, the patient was hypotensive with a good
reaction to fl uid therapy. Clinical examination showed signs of generalized peritonitis, being confi rmed by CT scan with abundant intra-abdominal fl uid collections,
submesocolic pneumoperitoneum, and air bubbles at the level of the hepatoduodenal
ligament. The history was compatible with a perforated duodenal ulcer secondary to
NSAID’s use, and subsequently a diagnostic laparoscopy was performed.
Operation
A generalized peritonitis with a perforation larger than 1 cm at the level of the duodenal bulb was found. After abdominal lavage, the perforation was closed with
sutures and an omentoplasty was added. Moreover, the subhepatic space was drained.
J. L. G. Sabrido , M.D. (*) • W. V. Jimenez , M.D., Ph.D.
Department of Surgery , Gregorio Marañon Hospital , Madrid , Spain
e-mail: jlgsabrido@gmail.com, jlgsabrido@ciriii.hggm.es
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_16,
© Springer International Publishing Switzerland 2014
91
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Fig. 16.1 Leakage of the
duodenum following closure
of a perforation
J.L.G. Sabrido and W.V. Jimenez
Postoperative Course: Identifi cation and Treatment
of the Complication
At the fi fth postoperative day, the patient had severe abdominal pain with a tachycardia and hypotension. The complete blood count showed 23,000 leucocytes, 98 %
of them segmented, a hemoglobin of 14 g/dL, and mild coagulation alterations. The
abdominal CT scan with oral contrast (gastrographin) showed leakage of contrast at
the duodenal level (Fig. 16.1 ).
A supra-umbilical laparotomy found a dehiscence of the primary suture with an
important generalized peritonitis. The antrum of the stomach and the duodenal bulb
were resected with use of a stapler, and both the gastric and duodenal stump staple
lines were reinforced with PDS continuous sutures. A reconstruction by means of a
Roux-Y gastrojejunostomy was performed. The patient recovered slowly on the
Intensive Care Unit and could start with oral feeding and medication progressively
after 3 weeks.
Discussion
Perforated duodenal ulcers (Illustration 16.1 ) that cover more than 1/3 of the cir-
cumference are not suitable to primary suture reparation due to the high risk of
leakage. Moreover the fi rst choice is the horizontal closure and omentum plasty
with adequate use of drains. Gastric resection will be used only exceptionally.
Perforations equal or shorter than 1/3 of the circumference are suitable for primary
suture and omentoplasty.
16 Case on Leakage After Closure of a Duodenal Perforation
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Illustration 16.1 Perforated duodenal ulcers that cover more than 1/3 of the circumference are
not suitable to primary suture reparation due to the high risk of leakage. Perforations equal or
shorter than 1/3 of the circumference are suitable for primary suture and omentoplasty. In the case
of leakage a partial gastrectomy should be done with a Roux-en-Y anastomosis and adequate
drainage
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Chapter 17
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Case on Leakage After Closure
of a Perforated Duodenal Diverticulum
Ramon Gorter and J. Wolter Oosterhuis
Keywords Perforation • Duodenal diverticulum • Peritonitis • Laparoscopy •
Papilla of Vater
Diagnosis and Indication for Surgery
In view is a 76-year-old female patient, who presented at our cardiac care unit
because of acute distress, dyspnoe, and chest pain. Her medical history included
arterial hypertension, hypercholesterolemia, a cholecystectomy, hysterectomy, and
a diaphragmatic hernia. On physical examination, she was acutely ill, her blood
pressure was 100/60 mm Hg, her pulse 80 beats/min, without fever. Her abdomen
was painful with signs of generalized peritonitis. Laboratory fi ndings were normal
except for a mild leukocytosis of 13.4 × 10 9 /L. The electrocardiogram did not show
any sign of acute ischemia. A CT scan with double contrast revealed free fl uid and
air in the retroperitoneal space as well as in the right upper quadrant. The diagnosis
of a perforation of a hollow organ—probably a duodenal ulcer—was made, and a
laparoscopic exploration was proposed.
Operation
Diagnostic laparoscopy revealed intra-abdominal and retroperitoneal biliary fl uid.
Due to the reduced visibility, conversion to a laparotomy was performed, showing a
R. Gorter , M.D. ()
Pediatric Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: rr.gorter@vumc.nl
J.W. Oosterhuis
Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_17,
© Springer International Publishing Switzerland 2014
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Fig. 17.1 ( a ) CT showing
duodenal perforation. ( b ) CT
scan showing duodenal
perforation
R. Gorter and J.W. Oosterhuis
a
b
perforated duodenal diverticulum of the descending part of the duodenum
(Fig. 17.1a, b ). The diverticulum was resected using a GIA ® stapler; the suture line
was inverted and closed by means of a purse string suture (Illustration 17.1a ). To
control the possible damage of the papilla of Vater, a T-drain was placed in the common bile duct and the retroperitoneal space was drained.
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