Complications and management of peptic ulcer surgery Early Complications

The generic complications seen with gastric surgery are hemorrhage and infection. The most feared complication is suture line leakage, especially at the duodenal stump. Mechanical complications include anastomotic obstruction, jejunal volvulus, and afferent loop and efferent loop syndrome. Postoperative ileus can result in acute gastric dilatation. Gastric necrosis is unusual, but is occasionally seen (1 in 400 cases) with proximal gastric vagotomy owing to the extensive devascularization of the lesser curvature.

Significant postoperative hemorrhage should be managed with reoperation and control of bleeding. If the bleeding is intraluminal, endoscopy and coagulation or clipping may obviate reoperation. Care must be taken to minimize pressure on the suture line to prevent a suture line dehiscence. Delayed gastric emptying is a common annoying complication. This is generally a functional problem and resolves over time in most patients. Delayed gastric emptying can also be caused by stomal obstruction, usually from swelling or hematoma, and resolves within 2 wk. Early obstructive problems, not due to the anastomotic site, are best approached with early reoperation. Acute gastric dilatation is treated with gastric decompression until gastric ileus is resolved. Gastric necrosis requires reoperation and repair. Suture line leaks are generally treated with percutaneous drainage, antibiotics, and parenteral nutrition, in certain situations reoperation is necessary. Any significant abscesses as a result of the operation or to complications must be drained, preferably percutaneously.

Late Complications

The late complications of gastric surgery are referred to as postgastrectomy syndromes. The most clinically significant of these are dumping, alkaline reflux gastritis, and gastric stasis. Less clinically significant are small stomach syndrome, postvagotomy diarrhea, and the afferent and efferent loop obstruction. Nutritional side effects include anemia (primary iron deficiency and B12 deficiency), malabsorption, and vitamin deficiencies.

Dumping can generally be managed with dietary intervention. Occasional patients will require reoperation where Roux-en-Y gastrojejunostomy is the treatment of choice. Alkaline reflux gastritis responds poorly to medical management. Patients with significant symptoms require revisional gastric surgery. Because gastric stasis is often a component of the etiology of alkaline reflux gastritis, subtotal or near total gastrectomy in addition to the Roux-en-Y gastrojejunostomy should be done. Gastric stasis is best managed with near total gastrectomy. A more extensive discussion of postgastrectomy syndromes can be found in the chapter on reconstruction after distal gastrectomy.

Recurrent Ulcers Following Definitive Ulcer Surgery

Except for total gastrectomy, all ulcer operations carry some risk of ulcer recurrence. This varied from a 1% risk with vagotomy and antrectomy (Fig. 4) to greater than 50% risk for gastroenterostomy (Fig. 1) over 10 yr. Surgical treatment for recurrent ulcers in the past consisted of vagotomy or revagotomy, generally combined with further gastric resection. Results were unpredictable, reflecting the lack of understanding of H. pylori. Enigmas such as the higher incidence of recurrent ulceration with Billroth I vs Billroth II reconstruction could not be explained.

The understanding of the role of H. pylori in ulcer disease has resolved much of the confusion. The presence of bile in the stomach decreases the incidence of H. pylori. Thus, the greater presence of bile in the stomach after Billroth II likely resulted in less H. pylori and a lowered ulcer recurrence rate compared to a Billroth I or vagotomy and pyloroplasty. H. pylori is present in more than 90% of patients following proximal gastric vagotomy, which helps explain the high recurrence rate with this procedure. The Roux-en-Y gastrojejunostomy diverts bile from the stomach and is often used in revisional gastric surgery. The high ulcer recurrence rate after Roux-en-Y gastrojejunostomy may also be partly because of H. pylori, as the H. pylori infection rate increases following diversion of bile away from the stomach.

This new knowledge gives new approaches to treatment in patients with recurrent ulcer disease after gastric surgery. Patients with recurrent ulcers after proximal gastric vagotomy, vagotomy and pyloroplasty, or Billroth I reconstructions, are likely because of H. pylori. The eradication of the H. pylori will be curative. Ulcer recurrence after Billroth II reconstruction is not likely a result of H. pylori (7). The problem in this situation likely results from poor gastric emptying either from a mechanical or functional defect (8). In this case, medications will not be effective. Revision of the anastomosis is needed for mechanical obstruction. However, most gastric stasis following gastric surgery is on a functional basis. Thus, gastric stasis, not clearly because of mechanical causes, is best treated with near total gastrectomy.

special considerations in ulcer surgery Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Symptomatic ulcers will develop in 2% of patients on NSAIDs for 1 yr, at least a fourfold increase over the risk in the general population. The relationship of NSAIDs to H. pylori is not well defined, but NSAIDs are clearly an independent risk factor. NSAID ulcers appear to be more likely to perforate and up to 50% of perforated ulcers are associated with NSAIDs. Cost-effective ulcer prophylaxis exists for NSAIDs (9). In addition, specific COX2 inhibitors appear to greatly decrease the risk of ulcers (10). Because of these factors, there is currently no role for elective ulcer surgery for patients on NSAIDs. Furthermore, ulcer complications should not have more aggressive surgery because patients are on NSAIDs.

Low-dose aspirin is commonly used to prevent vascular diseases. It slightly increases the risk of ulcer disease (1.3 x the baseline). Surgical intervention to prevent ulcer complications of low dose aspirin is not indicated.

Smoking

Cigarette smoking is detrimental to mucosal protective mechanisms and increases the likelihood that gastric ulcers will develop. Although these ulcers are generally amenable to ulcer treatment, they can occasionally be refractory to healing. This can be a difficult clinical problem in a patient with symptoms. If multiple biopsies have been negative for cancer, it is highly unlikely to be a malignant ulcer. As the ulcers will heal with cessation of smoking, this is the treatment of choice. The surgeon should be careful about offering a definitive ulcer operation in this patient group. Symptoms are often times not eliminated, and postgastrectomy complications are high.

Zollinger Ellison Syndrome (ZE)

When ZE syndrome was first described, the treatment of choice was a total gastrec-tomy. As surgical treatment evolved, it became apparent that it was more effective to remove the gastrinoma than the stomach. In patients where the gastrinoma cannot be cured surgically, antacid medications (proton pump inhibitors) are adequate to prevent ulceration. In the rare patients where proton pump inhibitors are not acceptable, proximal gastric vagotomy is the surgical treatment of choice (Fig. 5). Proximal gastric vagotomy decreases the need for antacid therapy and may be cost effective for patients with unresectable ZE (11). Total gastrectomy for ZE is of historic interest only.

Giant Peptic Ulcer

Giant peptic ulcers have traditionally been associated with a high complication rate and have been treated surgically. This is yet another area where surgical principles have changed. With treatment of H. pylori, and modern acid suppression, most giant ulcers can be healed medically (12). Surgery is only indicated for complications of the ulcer disease.

Stress Gastritis

The incidence of stress related erosive gastritis has decreased dramatically in the past 20 yr because of antacid prophylaxis. For the occasional patient that has uncontrolled bleeding from stress gastritis, endoscopy is ineffective. The treatment of choice is highdose proton pump inhibitors. Only rarely is surgery required, and then a near total gastrectomy is necessary.

0 0

Post a comment