VCUDEATH AND COMPLICATIONS CONFERENCE

Brief Overview

Surgery: Open distal gastrectomy with BII

Attending: Dr. Kaplan Resident: Jeffrey Stromberg Complication: Efferent loop obstruction,

cardiac arrest

Clavien-Dindo Classification

HPI

67 year old F presented for treatment of gastric cancer. Initially presented at OSH 1 month prior for work up of N/V and abd pain. During EGD which revealed ulcerated antral mass consistent with mucinous adenocarcinoma, had a cardiac event which lead to type II 2nd degree heart block and pacemaker placement.

PMHx: breast cancer s/p segmental mastectomy 2001, HTN, hypercholesterolemia, diabetes, GERD

Medications: Albuterol, omeprazole, HCTZ, metoprolol, pravastatin, metformin, coumadin/Lovenox bridge

Exam: Unremarkable

Surgery

Supraumbilical midline incision No gross evidence of metastatic disease Palpable firm nodular mass in antrum Omentectomy and lesser omentum divided. 1st portion duodenum divided GIA stapler. Gastric body

divided with GIA stapler. Jejunum 40cm distal to ligament of Treitz used to make

antecolic retrogastric stapled gastrojejunostomy. Jejunum lined up and secured to retrogastric body with stay

sutures. Gastrotomy and eneterotomy made. Antimesenteric stapled anastomosis. TA stapler used to close defects.

TA staple line imbricated with silk

PostOp Course

POD1 NG pulled and advanced to sips Rapid return of bowel function but unable to

ever advance diet beyond clears due to persistent nausea and 1-2 episodes bilious emesis every other day.

On POD10 had 1L bilious emesis. Refused NG placement

POD11 PICC placed and GI consulted for EGD for suspected efferent limb syndrome

POD11 UGI performed after 3L emesis:

EGD

Great difficulty finding efferent limb but once identified was patent. Noted to be edematous and angulated.

Prior to dilation her abdomen was noted to be distended and she became tachycardic up to 150s. Was given nitropaste

Balloon dilation of efferent limb entry with 15mm balloon

At conclusion of procedure, became dyspneic and hypoxic. Rapid response called and then intubated. CXR as follows:

Subsequently went into PEA arrest. During ACLS her abdomen was needle decompressed.

Return of pulses Admitted to ICU for arctic protocol After conclusion of arctic protocol CT

head noted evidence of ischemic stroke in basal ganglia and occipital lobes.

CT abdomen at time of CT head as follows:

Retrospective analysis

Was the complication preventable Yes

Would avoiding the complication change the outcome? Would not have required EGD which lead to the

perforation and subsequent arrest. What factors contributed to the complication?

Failure to recognize pneumoperitoneum Failure to stop the procedure earlier Possible technical factors such as excessively large

bites with imbrication sutures, too large a bite with TA stapler

Methods of Gastric Reconstruction

Billroth I

Billroth II

Roux-en-Y gastrojejunostomy

Postgastrectomy Syndrome

Gastric outlet obstruction Alkaline reflux gastritis Gastroparesis Roux limb syndrome Afferent loop syndrome Efferent loop syndrome Dumping syndrome

Alkaline Reflux Gastritis

Caused by reflux of intestinal contents into stomach

Symptoms typically arise late (1 year postop). Burning epigastric pain, nausea, emesis, pain aggravated by meals, pain unrelieved by emesis

Most common in BII, occasionally in B1, rare in Roux-en-Y

Work up can include EGD, Bernstein test, scintigraphy

Treatment – Braun anastomosis (historical only), antiperistaltic interpositions, conversion to Roux-en-Y (board answer)

Gastroparesis

Occurs in early postop period N/V, early satiety, bloating, abdominal pain High risk in diabetics or those who had chronic

preop gastric outlet/duodenal obstruction Diagnose with nuclear emptying study. Other

useful studies include UGI Mechanical causes include hematoma,

kinking, anastomotic leak, anastomotic edema Treat with NG decompression, TPN/tube feeds,

prokinetics (Reglan, erythromycin)

Surgically need to resect atonic stomach

Dumping Syndrome

Caused by hyperosmolar load to intestines with subsequent hypoglycemia Postprandial weakness, dizziness,

palpitations, diaphoresis, cramping, explosive diarrhea

Surgical treatment involves delaying gastric emptying (vagotomy) and conversion to roux-en-y

Afferent limb syndrome

Only after BII Typically afferent limb too long (>40cm) Present with intermittent RUQ or epigastric

pain relieved by bilious emesis (no food particles). May have hyperamylasemia Acute setting requires prompt diagnosis to

prevent stump blowout UGI and EGD ideal tests

Treatment is surgical as causes include internal herniation, volvulus, kinking, anastomotic stenosis, adhesions.

Efferent Limb Syndrome

Similar symptoms of afferent limb syndrome – crampy pain associated with bilious emesis

Causes are the same

Tension Pneumoperitoneum

Creates hyperacute abdominal compartment syndrome Decreased preload, decreases splanchnic blood flow,

decreased ventilation, decreased cardiac output Causes

Colonoscopy, endoscopy, percutaneous endoscopic gastrostomy, CPR, mechanical ventilation in patients with pleural-peritoneal shunts

Signs Tachycardia, abdominal distension, diffuse tympany,

hypotension, obtundation, decreased minute ventilation, increased peak pressures

Treatment Emergent needle paracentesis and then +/- surgery