Complications after gastrojejunostomy, gastrectomy, vagotomy and gastrectomy

One of the frequent complications of gastrojejunostomy is the development of peptic ulcers in the field of fistula or in the jejunum. Peptic ulcers develop due to digestion mucosa jejunum gastric juice. This complication occurs mainly in patients with superimposed gastrojejunostomy about ulcers duodenal ulcer.
Leading symptom of ulcers anastomosis and jejunum are constant pain under the spoon, worse after eating. X-ray examination of the stomach of patients with peptic ulcers can be found a niche on the ground ulcer (30%). Auxiliary diagnostic value has a positive reaction of yens Gregersen collection. Peptic ulcer jejunum can lead to several complications, which are similar to those of gastric ulcer: bleeding, perforation, penetration, malignancy. Kind of complication is a fistula between the stomach and the transverse colon rectum (fistula gastro-jejunocolica). The patient's condition in this case is particularly severe: the pain intensifies, diarrhea occur in connection with the hit pieces of food from the stomach right into the large intestine, belching and often vomiting feces. All this leads to a marked depletion of patients. Recognition of the specified complications meets with difficulties, because x-ray shows the flow of barium from the stomach not only in skinny, but directly into the colon through the fistula. Symptomatic therapy is appropriate diet and regular washing stomach - may temporarily make the patient, but radical treatment must only be operated on. The surgery consists in gastrectomy, including the location of the anastomosis and the portion of the jejunum, where he developed a peptic ulcer.
Resection of the stomachthat is used for removing almost all small curvature and curvature the intersection of the stomach is made at the level of the upper or lower pole of the spleen, accompanied resistant ahilia. Bypass gastric stump is made or the duodenum (the way of Billroth I), or with a loop jejunum (the way of Billroth II), in this case, the stump of the duodenum is stitched closed. When creating anastomosis between the stump of the stomach and loop jejunum the latter can be "short" (20 cm from raceway folds) or "long" (50 cm from raceway folds). In short loop contents of the duodenum inevitably passes through the stump of the stomach and outlet loop of intestine, and in the long loop creates an incremental communication between leading and lateral knee loop jejunum, and thus the content of the duodenum will not fall into the stump of the stomach. Creation of bypass gastric stump with duodenum pursued save the passage of food through the duodenum and the approximation to the physiological conditions of digestion.
What long-term results of surgical resection of stomach ulcers? Most surgeons they are good, but not as already rare and failures after successfully passed operation resection of the stomach: in 6-10% of cases occur the so-called "diseases of operated stomach." These include: inflammation of the mucous membrane of the stump of a stomach, a peptic ulcer of a loop jejunum and anastomosis, a fistula between the stump of the stomach, loop jejunum and transverse colon rectum, Australia asthenia, dumping syndrome.
Chronic inflammation of the mucous membrane of stomach stump accompanied by the following symptoms: loss of appetite, feeling of heaviness in the stomach, intermittent diarrhea, weight loss, decreasing disability (Zuckschwerdt, Lindenschmidt, 1960). Inflammation of the mucous membrane of stomach stump is defined or gastritis associated ulcer before surgery, or newly-emerged after a long time afterwards. In the origin of inflammatory complications is throwing duodenal contents in the stomach as if anastomosis by Billroth I, and Billroth II on a short loop in the absence of inter-intestinal anastomosis. Palpation podlojecna area does not give any instructions on local tenderness. Aspiration biopsy of stomach stump can detect various stages of gastritis, more common atrophic gastritis (VP-Salupere, 1963).
The study of fermentative function of a pancreas shows oppression secreting trypsin and amylase. In the treatment of inflammation of the mucous membrane of stomach stump, thus, in addition to diet and gastric lavage, it is required to Pancreatin, b vitamins Century Of physiotherapeutic procedures in the area of the pancreas should use diathermy, UHF, iontophoresis (L. P. Volkov, 1960). However, physiotherapy on a stump after stomach resection of the tumor of the stomach is contraindicated.
Appearance after resection of the stomach in remote periods of persistent pain under the spoon, worse after eating should be a symptom of a peptic ulcer of the jejunum. This complication after resection of the stomach is very rare. About the diagnosis of peptic ulcer has already been mentioned above. Effective method of treatment should be considered the operation resection and anastomosis part of the gastric stump.
Australia asthenia (A. A. busalov, 1961), occurring after Subtotal resection of the stomach, is common symptoms of chronic inflammation of the gastric stump. When gastrolnoj asthenia, in addition to weakness, rapid onset of fatigue during operation, there are dyspeptic symptoms: loss of appetite, belching bitterly, feeling of heaviness in the stomach after eating, sometimes vomiting, often diarrhea without pain and fever. In the study of blood is installed hypochromic anemia (II. Century Demidov, 1963). The large majority of patients with resected stomach regardless of the fact whether resection made about ulcers or stomach cancer, has expressed hypoalbuminemia, regardless of the presence or absence gipoproteinemii. The total protein content of the blood in most patients with resected stomach usually remains within the normal range.
Much attention in the domestic and foreign literature is given dumping syndrome after resection of the stomach. This concept is connected with the name Mix (1922) and included a picture of the failure of food from the stomach into the intestine after gastroenterostomy. However, the study of this phenomenon led to the emergence of two new concepts: "early afternoon syndrome" and "late afternoon syndrome". Both of these syndrome unites collapsetable condition, they differ by the time of the occurrence after a meal.
"Early afternoon syndrome" in some patients occurs immediately after a meal, while others - in 10-15 minutes: there is a feeling of pressure or fullness in the stomach during a meal or soon after, nausea, weakness, feeling dizziness, palpitations, sweating. These phenomena are caused by the rapid filling of the gastric stump or the initial part of the jejunum with abundant food. Especially characterized by the emergence of such status after admission sweet tea, cakes, chocolates, and sometimes milk and fat. Objective evidence "early afternoon syndrome" few: redness, and sometimes blanching face, narrowing pupils, increased heart rate and breathing, increased blood pressure on 10-15 mm RT. Art. All these phenomena continue 1-2 hours. The described symptoms in some patients are so heavy that they can't get up from the table after a meal. In most cases, the clinical manifestations of early afternoon syndrome" smoothed out over time.
When "late afternoon syndrome"that occur 2-3 hours after eating, a feeling of weakness, pallor, tremor, sweating, feelings of dizziness. All these phenomena are not associated with rapid emptying of the stomach stump. When "late afternoon syndrome" in contrast to "early" decrease AD aetiology, weakness, and dizziness, accompanied by a feeling of acute hunger.
What pathogenetic entity early afternoon syndrome"? The rapid emergence of it after the meal has put forward a hypothesis reflex origin, but some connection clinical manifestations with the nature of food has allowed to make the following assumption: rapid transition hypertonic solutions of the resected stomach deprived gatekeeper, in the initial division of the jejunum (and this solution is also ordinary food) calls by osmosis rapid resorption of liquids in the bowel lumen and thus directly reducing the amount of blood plasma, as in shock. In the developed hypovolemia begins the next phase: the smaller volume of circulating blood by means of pressure receptors in large vessels excites the end of sympathetic nerves. Emerging simpatikotonia causes changes in pulse, AD ECG, an increase of plasmatica in the kidneys (polyuria with low specific gravity of the urine), the occurrence of migraine headaches (, Docks, 1963). Receptions of pipolfen or novocaine reduced or weakened these symptoms. "Early afternoon syndrome" may be combined with "late afternoon". The latter are usually coincided with hypoglycemic phase sugar curve (B. M. Meerovich, 1961).
In the literature there are often remarks that dampig syndrome rarely occurs after resection of the stomach by way of Billroth I.
Everson (1952) made a number of observations over two groups of patients after resection of the stomach by Billroth I and by Billroth II later in average 8-18 months after surgery. He caused them artificial dumping syndrome as follows: patients drank on an empty stomach 150 ml of 50% glucose solution, and then we all had a dumping syndrome in a much more dramatic way than usual after the meal. Not noted any difference between the results of observations on patients undergoing surgery on Billroth I or by Billroth II.
In the complex of therapeutic and preventive measures against dumping syndrome after resection of the stomach is the most essential purpose of rational diet and proper organization of operation. It should be considered justifiable compliance with strict sparing diet in the first 3-4 months after the surgery. In the future it is necessary to gradually expand, including more varied (see "peptic Ulcer disease"). Therapy dumping syndrome following: frequent methods of small amounts of food, avoiding excess carbohydrates, horizontal position after the main meal - all this over time leads to improvement (B. L. Meerovich, 1961).
Holler (1956) recommends the following power mode when dumping syndrome: eating 5 times a day in small, gradually increasing doses. The morning Breakfast first consists of dry rations with not a very sweet drink. The diet should be rich in protein, and contain sufficient amount of fat (30-40 g of butter per day). It should limit consumption of bread and farinaceous dishes (especially sweet). It is advisable to include in the food mode sufficient amount of vegetables and fruits. Strictly no Smoking and alcohol use.
However, in recent years in cases resistant not resistant to conservative treatment, dumping syndrome surgeons in the USSR and abroad are various reconstructive operations, the purpose of which is the direction of the passage of food from the stump of the stomach into the duodenum (I. E. Zakharov, 1961; M. I. Petrushansky, 1962). Reconstructive surgery is offered to eliminate dumping syndrome, has not been sufficiently studied in the clinic, and the complexity and trauma while not give grounds to publicize them.

Vagotomy, i.e. transection both wandering nerves, aims break serverelement arc. One time (1943-1948 biennium). it was expected that this operation is beneficial, and performing it's so simple that it is possible to assert its superiority over all other operations, proposed for the treatment of peptic ulcer. After crossing stray nerves at the level of the abdominal esophagus ulcer, usually roboeda and pain disappear but vagotomy creates significant disorders of the gastrointestinal digestion. Due to paralysis of the muscles of the stomach upsets the emptying of the stomach, food is delayed in it for the long term. When dramatically weakened bactericides gastric juice associated with lower acidity and peptic actions in the stomach creates conditions favorable for development of active bacterial flora. Stagnating food is subjected to fermentation, which causes bloating, belching rotten, the symptoms of intoxication. As vomiting in patients after vagotomy is rare, is to facilitate the condition of the patient have to resort to gastric lavage. The phenomenon of gastric paralysis and persistent diarrhea identified as the most serious complications after vagotomy. The result is that the disorder after transection stray nerves sometimes more painful than those who were before surgery. Treatment of complications after vagotomy is symptomatic. Usually within 1/2-1 year these unpleasant disorders may decrease or even cease. However, as the restoration of severed nerves that there is often a relapse of peptic ulcer disease.
Consequences gastrectomy (used in cancer of the stomach) is (besides dumping syndrome) weight loss in 1/3 of the patients, which is explained by several factors. According to Everson (1952), weight in patients after gastrectomy from 40 operated tracked in the remote periods after operation, only 3 returned to the original level before the operation. The reason of falling weight are: the lack of digestive and reservoir function of the stomach, lack of mechanical processing of food in the stomach, reducing stimulate the secretion of bile and pancreatic juice, incomplete mixing food with pancreatic juice and bile, increased intestinal peristalsis. All these functional disorders lead to a decrease absorption of fats and proteins for food.
The basis of conservative treatment is diet. Food should be enough calories (not less than 50 calories per 1 kg of patient's weight), contain 100-150 g of protein, 100 g of digestible fat.
Patients after gastrectomy should appoint Pancreatin, atropine sulfate to relieve bowel spasms, geksony and other holinolitiki.
Undoubtedly of great practical importance pancreatitisarising after gastrectomy about ulcer or cancer. The occurrence of postoperative pancreatitis may be a direct result of injury of the pancreas caused by the pressure of surgical instruments used in gastrectomy, Department section of the stomach or duodenum from the pancreas. The congestion in the cult of the duodenum after resection of the stomach may in turn cause congestion in the ducts of the pancreas that may also be a cause for the occurrence of acute postoperative pancreatitis.
There is a fairly extensive literature on the occurrence of pancreatitis after resection of the stomach (L. P. Volkov, 1966). These pancreatitis often was the direct cause of death. Recognition of this complication is quite difficult, as it develops in the postoperative period and often is diagnosed on the section.
The patient after resection of the stomach, complicated acute pancreatitis, appears tachycardia may occur kollaptoidnye condition. In the urine increases the amount of amylase.
C. Century Lobachev (1958) presented data on 166 patients during gastrectomy had the injury of the pancreas in the separation from it of the tumor or penetrating ulcers of the stomach. From 166 in 38 patients developed postoperative pancreatitis ended lethal in 19 patients. I. B. their Teitelbaum (1966) observed 7 patients with acute pancreatitis after resection of the stomach.
According to the statistics Pendower and Tanner (1959), in 1689 operations on the stomach, it was noted 12 deaths (of 0.7%) from pancreatitis. The authors indicate that this complication arose in different terms after the operation is over weeks and even years. Cause pancreatitis they believe the trauma of cancer and obstruction afferent loop anastomosis. According to the clinical symptoms of postoperative pancreatitis depending on the degree of morphological changes in the pancreas can be divided into 3 groups: group I - a mild form without clinical manifestations, but with dictatorial; group II - moderate with fever, bowel paresis, tachycardia, dictatorial; group III - severe destructive postoperative pancreatitis with the phenomena of acute abdomen, severe cardiovascular disorders, nerezko expressed by amylasemia. Juwara and Radulescu (1963) there are two groups of postoperative pancreatitis after gastrectomy: 1) chronic pancreatitis flow of origin, when it is assumed functional or organic obstacle in the field of the main duct; 2) chronic interstitial pancreatitis - inflammation of the pancreas. The first type occurs in the first 9 days after the operation. The second syndrome late chronic pancreatitis. Mention should be made about the outcome of acute pancreatitis in pseudohistory pancreatitis.
Treatment of acute pancreatitis in the stage of edema cancer - conservative: hunger in 3-5 days, parenteral and pryamokishechnye introduction a day to 5 liters saline solution and intravenous 150-200 ml of 0.25% solution novokaina, Long pumping gastric content using a thin probe to prevent the expansion of the stomach, receipt of gastric juice in the duodenum and thereby to contribute to the reduction of pancreatic secretion. Bilateral perirenal novocaine blockade. When endless pain - promedol, pantopon. Shows the use of trasilol in a 5% glucose solution (500 ml) in the first 3 days, 10 000 IU, within the next 4-6 days 6000 IU, in the next 3 days - 400 UNITS.
Surgical treatment of the subject necrotic form of acute pancreatitis, as well as forms, where conducted the conservative treatment is indicated complications and consequences of acute pancreatitis (abscess gland abscess stuffing bags, cyst gland).
Treatment of chronic pancreatitis with obstructive jaundice - surgical and involves application of fistula between the gall bladder and digestive tract, the duodenostasis - the elimination of the last surgically (A. M. Mirzaev, 1969).
In pain pancreatitis shown operation - postganglionarnyh neurotomy. Along with surgical treatment of certain forms of chronic pancreatitis, is conservative treatment: the ingestion lipokaina, hexane; radiotherapy; dietotherapy, aimed at improvement of the liver and biliary excretion. Prohibits the consumption of fatty foods, pastry and cookies, pies, cakes, jam, strong spices, meat and fish canned food, alcoholic beverages. Vitamins C, B1, B2, B6, B12.