GASTRECTOMY

AFTERCARE
BY,
NIRANJANA A
3RD UNIT-B BATCH
FINAL YEAR
IMMEDIATE POSTOPERATIVE COMPLICATIONS

ON DAY 1

Fever
Tachycardia

 Cough
 Breathlessness
ON DAY 3

FEVER
IV cannula related
Urinary tract infection ( through catheter )
• On day 5, Ryles tube is removed and check bowel
sounds if adequate ,started oral feeding..

after which patient following gastrectomy presented

with fever, tachycardia (>120/min),worsening
abdominal pain, abdominal distension ,food particles
in drainage tube
ANASTOMOTIC LEAK
• Frequently at gastro-jejunal anastomosis
• Intraabdominal leak > peritonitis > sepsis > multiorgan
failure

TREATMENT
Surgical emergency
Immediately shift the patient to OT
Stabilize the patient
Identify the site of leak
Do revision anastomosis
A patient who had undergone Bilroth II operation, after
starting the feeds orally, presented with sudden severe
right upper quadrant pain, fever, tachycardia, jaundice,
bile stained discharge from the incision
BILIARY PERITONITIS DUE TO DUODENAL STUMP
BLOW OUT
Increased tension
Excessive
Causes dissection of
Ischemia and on duodenal
necrosis stump due to
duodenal stump distal obstruction

Sometimes forms duodenal fistula through the drain placed

TREATMENT
Conservative
 Nasogastric aspiration
 IV fluids
 TPN
 Antibiotics
SURGERY
Indications
 Peritonitis
 Distal obstruction
 If fistula not responding

 For biliary peritonitis – laparotomy and peritoneal toilet done

Leave a Foley catheter in duodenum to establish a controlled fistula –
tube duodenostomy
If patient presents with fever after day 5
LOCAL WOUND INFECTION

TREATMENT
Antibiotics

Surgically
Removing sutures alternatively
Let the pus to drain
Allow the wound to heal by secondary intention
INTERNAL HERNIAS

bowel loops herniates through the mesenteric window

Retrocolic – Stemmers hernia

Antecolic – Petersons hernia
• Patient presented with bloody fluid from drain , tachycardia,
fall in Hb levels
POSTOPERATIVE ANASTOMOTIC HEMORRHAGE
• Open/ laparoscopic re exploration done

SMALL BOWEL SYNDROME

Early satiety following ulcer operations
In high selective vagotomy – due to loss of receptive
relaxation
Drainage tube is removed by day 6/7

Sutures removed by day 10

Patient is discharged by day 12-14

Advice to wear abdominal binder

Follow up after 1 month – for neoadjuvant

chemotherapy
Patient who had undergone gastrectomy, was following with
small meal plan , one day went for a party and had drinks
containing large amount of sugar, immediately after having
drinks, he had symptoms of sweating, tachycardia ,light
headedness, colicky abdominal pain and diarrhea, symptoms
relieved on lying down.
EARLY DUMPING SYNDROME

Sequestration of
Hyperosmolar food Abdominal and
fluid from
directly into small vasomotor
circulation into GI
bowel symptoms
tract
LATE DUMPING SYNDROME

Carbohydrate
Rise in plasma
load in small
glucose
bowel

Secondary Rise in insulin

hypoglycemia levels
 EARLY DUMPING LATE DUMPING
SYNDROME SYNDROME
Incidence 5-10% 5%
Relation to meals Almost immediate 2 hours after meal
Duration of attack 30-40 min 30-40 min
Relief Lying down Food
Aggravated by More food Exercise
Precipitating factor Food, especially Same as early
carbohydrate rich dumping
and wet
Major symptoms Epigastric fullness , Tremor, faintness,
sweating, prostration
lightheadedness,
tachycardia ,colic,
sometimes
diarrhoea
 TREATMENT
Dietary manipulation
Small regular meals ( protein and
fat based )
Avoid fluids with high
carbohydrate content
Octreotides
Revision surgery – Roux
en Y anastomosis
OTHER COMMON COMPLICATIONS
Deep vein thrombosis
Pneumatic compressive stocking
Early ambulation

Pulmonary embolism
Therapeutic dose of heparin

Bed sores
Advice to change posture
LATE COMPLICATIONS

Nutritional consequences
Bile reflux gastritis
Gall stones
Malignant transformation
Roux syndrome
NUTRITIONAL CONSEQUENCES

Weight loss Anemia Bone disease

• Altered diet • Iron deficiency anemia • Osteoporosis
• Malabsorption Reduced absorption
Gastric mucosal blood
loss
• Vit B12 deficiency
anemia
 After gastrectomy ,patient presented with bilious vomiting with
epigastric pain after meals – BILE REFLUX GASTRITIS
• Due to resection of pylorus
• Treated with –
Conservative measures
Proton pump inhibitors
Roux en Y anastomosis

GALL STONES

Truncal vagotomy Motor branch to GB is cut GB stasis and stones

If symptomatic cholecystectomy done

After gastrectomy , patient suffers from
severe diarrhoea following every meal ,
having foul breath (fecal smelling ),
severe weight loss and dehydration which is rapid in
onset
GASTROJEJUNAL COLIC FISTULA

• Complication of RECCURENT ULCERATION

• Symptom triad : Marshall and Knud – Hansen triad
• Detected by CT with oral contrast / barium enema
• Treatment
IV fluids
Total parenteral nutrition
Triple resection – single stage resection of involved
stomach,jejunum and colon maintaining corresponding
anastomotic continuity
ROUX SYNDROME
• Occurs after Roux en Y gastrojejunostomy
• Presents with – fullness, vomiting, early satiety ,abdominal pain, bloating
sensation after eating
Retrograde
Abnormal motility in Delayed gastric
contractions
Roux limb emptying
proximally

• Completion gastrectomy is the choice of treatment

MALIGNANT TRANSFORMATION
• Gastrectomy, drainage , vagotomy are independent risk factors
• Bile reflux gastritis, intestinal metaplasia and gastric cancer are linked

 POST VAGOTOMY DIARRHOEA

Most devastating symptom
Feeling like passing boiling water (severe, explosive ,urgency)
Due to rapid gastric emptying after peptic ulcer surgery
Difficult to treat

Anastomotic stricture
Marginal ulcer bleeding
Jejunogastric intussusception