Powerpoint: Sequelae Of Gastric Surgery

SEQUELAE OF GASTRIC SURGERY

SEQUELAE OF GASTRIC SURGERYA (sequela, plural sequelæ) is a pathological condition resulting from a disease, injury, or other trauma

Minor postprandial complaints are commonly after gastric operations These usually improve with time- dietary adjustments 5-20% of gastric surgery patients- severe symptoms- altered anatomy and physiology of the upper GI tract

SEQUELAE OF GASTRIC SURGERY 1. Recurrent ulcer 2. Dumping symptoms 3. Reactive hypoglycemia 4. Bile vomiting 5. Diarrhea 6. Small stomach syndrome 7. Mechanical complications 8. Other: cholelithiasis, bezoar formation, gastric stump carcinoma

DUMPING Systemic symptoms: – Weakness, tiredness, dizziness – Headache, fainting, warmth, palpitations – Dyspnea, sweating

Gastrointestinal symptoms: – Fullness, epigastric discomfort, heaviness – Nausea, vomiting – Excessive distension, diarrhea

DUMPING Dumping syndrome is associated with rapid gastric emptying The systemic symptoms occur within minutes of eating- hypovolemia- massive outpouring of fluid from vessels into the bowel lumen Hyperosmolar nature of the intestinal contents secondary to rapid gastric emptying

Dumping Kinines, enteroglucagon- vasoactive peptides responsible for systemic and digestive symptoms Gastrointestinal symptoms occur later during the course of a dumping attack

DUMPING- TREATMENT Small dry meals rich in protein and fat but low in carbohydrate Additive which slow gastric emptying such as pectin or bran Remedial gastric surgery for patients with severe dumping syndrome

REACTIVE HYPOGLYCEMIA Rare complication, incidence of 1-6% Occur 2-3 hours after meal Sweating, tremor, difficult concentration Reactive hypoglycemia may coexist with vasomotor dumping and diarrhea

REACTIVE HYPOGLYCEMIA Diagnosis – oral glucose tolerance test Initial hyperglycemia- exagerated insulin release- elevated plasma insulin and enteroglucagon- hypoglycemia It responds to dietary measures, including low-carbohydrate and high protein meals

BILE VOMITING

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Vomiting of bile or bile-stained fluid before or after meals- common after gastric op. It may be due to: recurrent ulcer enterogastric reflux, intermittent obstruction of the afferent or efferent loop of gastroenterostomy, cardioesophageal incompetence

ENTEROGASTRIC REFLUX Causes a reflux erosive Gastritis and bile vomiting Symptoms: epigastric pain, nausea, bile vomiting in the early postprandial period The pain- burning in nature, aggravated by food and not relieved by antacids The attack culminates in the vomiting of bilestained fluid 1-2 hours after a meal The erosive gastritis leads to chronic blood loss with iron-deficiency anemia

ENTEROGASTRIC REFLUX Treatment: – bile salt-binding agents- cholestiramine, – remedial surgical intervention

Prolonged enterogastric reflux can result in atrophic gastritis and intestinal metaplasia This is a risk factor for gastric stump carcinoma

EXTRINSIC LOOP OBSTRUCTION -

The causes are: internal herniation, kinking of the anastomosis, adhesions, volvulus, stenosis, intussusception

Disorders that can develop after resection of the stomach, as a result of the technique used to re-establish gastrointestinal continuity

EXTRINSIC LOOP OBSTRUCTION Symptoms- upper GI obstruction Diagnosis- rx. contrast study of the GI tract Treatment- surgical correction

Complications after Billroth II First successful gastfrectomy-Theodor Billroth- 1881

DIARRHEA Severe intractable diarrhea- 2% of pts. after truncal vagotomy Characterized by extreme urgency and often causes incontinence during an acute attack Malabsorbtion of bile salts and fatty acids secondary to intestinal denervation is implicated The sma;ll bowel transit is accelerated Treatment: low fat diet, codeine phosphate, imodium, cholestyramine

SMALL STOMACH SYNDROME It appears after extensive gastrectomy and GI disfunction after truncal vagotomy The condition leads to gross malnutrition Surgical treatment- reconstruct a gastric reservoir and restore duodenal continuity

OTHER COMPLICATIONS Formation of gall stones and bezoars due to: – Hypoacidity – Impaired proteolytic activity – Loss of antral pump

Development of gastric stump carcinoma after 15-20 years postoperatively

BENIGN GASTRIC TUMORS Gastric polyps- benign adenomas – Solitary or multiple – Sessile or pedunculated – Usually asymptomatic – Found incidentally on rx.or endoscopic exam. – 20% show histological features of dysplasia – Treatment- endoscopic excision biopsy, follow-up

BENIGN GASTRIC TUMORS Leyomyomas- smooth muscle tumors – May arise anywhere in the muscle wall of GI – Common in the stomach and small bowel – Discovered incidentally- rx, endoscopy – Large lesions may cause chronic blood loss or intermittent gastric outlet obstruction – Sessile or pedunculated, covered by normal mucosa

MALIGNANT GASTRIC TUMORS Lymphomas- 10% of gastric malignancies – May present as a bulky ulcerated mass or diffusely infiltrating the gastric wall – Diagnosis- barium meal, endoscopy with bx. – Treatment- total gastrectomy, radio/chemotherapy – Better prognosis than gastric adenocarcinoma

ENDOSCOPIC VIEW OF GASTRIC LYMPHOMA

GASTRIC LYMPHOMA OF THE GASTRIC FUNDUS

GASTRIC ADENOCARCINOMA 90% of gastric malignant tumors Better outcome when diagnosed early Risk factors: – – – –

atrophic gastritis, pernicious anemia, previous partial gastrectomy, polyps

ATROPHIC GASTRITIS

GASTRIC CARCINOMA Three morphological forms – Fungating tumor – Ulcerated tumor- necrosis at the centre of the tumor, large, heaped-up indurated margin with no surrounding mucosal puckering – Infiltrating tumor- diffusely invades the muscular wall of the stomach- wall thickening and rigidity- linita plastica “lether bottle”

LINITA PLASTICA

EARLY GASTRIC CANCER Cancer limited to the mucosa and submucosa Prognosis with adequte resection excellent with 5-year survival rates of more than 80% 10-15% of early gastric cancers have positive regional lymph nodes- this subgroup is referred to as early-simulating advanced gastric cancer

EARLY GASTRIC CANCER

ADVANCED GASTRIC CANCER Tumor which has involved the muscular layer of the stomach Positive lymph nodes, peritoneal and hepatic deposits (secondaries)

TNM STAGING SYSTEM T1- tu.limited to the mucosa, submucosa T2- tu. involves the muscular layer T3- tu. penetrates the serosa T4- tu.invades the adjacent structures N0- no positive lymph nodes N1- positive perigastric lymph nodes within 3 cm. of the primary tu. N2- positive lymph nodes more than 3 cm. M0- no distant metastases M1- evidence of distant metastases

SPREAD OF GASTRIC CANCER Direct spread through the gastric wall Extragastric lymphatic spread- perigastric and regional Vascular spread-distant metastases Serosal peritoneal spreadcarcinomatosis, Blummer tu., Krukenberg tu.

GASRIC CANCER CLINICAL FEATURES Early gastric cancer- asymptomatic or dyspepsia simulating an gastric ulcer Malaise, postprandial fullness, loss of appetite Cardia cancer-dysphagia Antral cancer- obstructive symptoms Hematemesis/melena The most frequent reason for the delayed dg. Is a period of symptomatic therapy with antacids before referral for endoscopy

GASTRIC CANCER CLINICAL FEATURES Anemia- chronic blood loss Weight loss- persistent skin fold, low serum albumin Enlarged left supraclavicular lymph node Palpable epigastric mass Jaundice- liver metastases or biliary compressive lymphadenopathy in the porta hepatis

GASTRIC CANCER DIAGNOSIS GI endoscopy with biopsy and brush cytology

Radiological contrast study- barium meal

Abdo CT

CXR USS of the abdomen Laparoscopy

GASTRIC CANCER TREATMENT Only effective treatment which offer a chance for cure- adequate surgical resection A palliative resection whenever feasible is more effective in relieving sy.than by-pass procedures. Radio/chemotherapy useless

GASTRIC CANCER TREATMENT Principles of potentially curative resection: – Resection with tumor-free margins – Lymph node clearance according to the location of the primary tu. in the stomach – Safe and well functioning reconstruction

GASTRIC CANCER TREATMENT Classification of gastric resection – R0- complete resection, no microscopic tu.left – R1- residual microscopic tu. – R2- residual macroscopic tu.

GASTRIC CANCER TREATMENT Total gastrectomy is necessary: – To achieve a safe tumor free margin – When the neoplasm involves 2 or 3 regions of

the stomach – Diffuse carcinoma

GASTRIC CANCER TREATMENT Omentectomy- the lesser and greater omentum removed for a better lymphadenectomy Lymph node clearance: – D1 resection- perigastric lymphadenectomy – D2 resection- along left gastric, hepatic, celiac, splenic arteries nodes – D3 resection- hepatoduodenal, retropancreatoduodenal, root of the mesentery, middle colic, paraaortic nodes

CURATIVE RESECTION There is no peritoneal or hepatic metastases The serosa is not involved by the tumor The resection level exceeds the level of nodal involvement

RECONSTRUCTION Subtotal gastrectomy with Roux-en Y procedure Total gastrectomy with eso-jejunal anastomosis

PALLIATIVE SURGICAL TREATMENT Gastroenterostomy- by-pass op. for obstructing antral carcinoma Intubation for the cardia carcinoma Feeding jejunostomy

Gastric stump adenocarcinoma Case report

Gastric stump adenocarcinoma Male, MV, 56-year of age, retired brick mason 2002- 3 months history of epigastric pain, vomiting after meals, asthenia, weight loss Habits: smoking, heavy alcohol drinking PMH- partial gastric resection for gastric ulcer-20 years ago

Physical signs General: underweight, palor, inelastic skin fold Abdominal examination Flat abdomen moving with respirations Post. Op.scar- median xypho- ombilical Moderate tenderness in epigastrium Succusion splash NG aspiration- 100o ml. Gastric fluid non-bile

stained with undigested food

What is the clinical suspicion? Previous partial gastric resection- stump problem Frequent vomiting- undigested food- stenosis Anemia- chronic blood loss Weight loss- bad nutrition Succusion splash- stenosis

Clinical diagnosis Cancer of the gastric stump ?

Investigations Lab. Tests- NAD except a moderate anemia Barium meal- partial gastric resection Billroth I, gastric stump dilated, desorganized mucosal folds Endoscopy- stenotic gastro-duodenal anastomosis , multiple gastro-duodenal polyps Biopsy- adenocarcinoma of the gastric stump of papillary type Abdominal USS- absent liver MTS CXR- NAD

Operative findings Gastric stump tumour staring from the

gastro-duodenal anastomosis

Invasion of the D1 and D2 Perigastric lymphadenopathy Liver and peritoneum intact

What to do? Frozen section from the a perigastric lymph node negative for tumour cells Mobile tumour on adjacent planes Age Absent comorbidities

Operative decision Completion gastrectomy D2 lymphadenectomy: loco-regional Tactic splenectomy Cephalic duodenopancreatectomy Digestive continuity: – Eso-jejunal anastomosis – 60 cm distal to it- Wirsungo-jejunal anastomosis – 20 cm distal to it- biliary-jejunal anastomosis

Case report Operative time- 6 hours Postoperative course- uneventful Contrast medium eso-jejunal radiological check-up- intact anastomosis without any leak Hospital stay- 26 days

Case report Operative time- 6 hours Postoperative course- uneventful Contrast medium eso-jejunal radiological check-up- intact anastomosis without any leak Hospital stay- 26 days

Pathological report of the surgical specimen Polipoyd adenocarcinoma Lymph nodes: perigastric, retroduodenal, celiac trunk, hilum of the spleen were negative for tumour cells pTNM- T2 N0 M0

2003-1 year post-operatively 10 Kg weight gain Good digestive tolerance Symptoms-free Normal hematological and biochemistry tests

Next post-operative course 2005- acute appendicitis- appendectomy

2007-routine endoscopic check-up eso-jejunal anastomotic recurrence

2007- further investigations Endoscopic biopsy- adenocarcinoma CXR- NAD Abdominal USS-slightly enlarged liver, pneumobilia, normal remnant pancreas, no ascites, no lombo-aortic lymph nodes Respiratory tests- WNL

2007- further investigations Barium meal: eso-jejunal anastomosis TL, anastomotic lacunar image- 2cm in size Abdominal CT- thickening at the level of the anastomosis with esophageal extent

What to do? Surgical options: – Partial esophagectomy with intrathoracic graft interposition – Esophageal stripping with colic graft Small eso-jejunal tumour Absence of mediastinal lymph nodesCT Avoidance of left thoracotomy

Decisions Surgical resection – Esophageal stripping – Proximal jejunostomy

Digestive reconstruction – Left colon graft – Colo-jejunal anastomosis – Colo-colic anastomosis – Cervical eso-colic anastomosis

Nutrition – TPN – Jejunostomy tube

Pathology report Colloid adenocarcinoma invading the digestive wall thickness till subserosa 3 out of 4 jejunal mesentry limph nodes positive Periesophageal lymph nodes negative

Early morbidity Cervical eso-colic fistula – Small output – Conservative treatment – Oral hygene – Spontaneous closure in 2 weeks – Radiological check-up before oral intake

Eso-colic fistula-jan.2008

Late morbidity Colic fistula due to forcibly coughing episodes after quit smoking Relaparotomy-transverse colon fistula – Colo-jejunal and colo-colic anastomoses intact – Coloraphy and abdominal drainage – Good recovery – Discharged after 9 days

Patent eso-colic anastomosis, may 2008

Intact colo-jejunal anastomoses, may 2008

2009

Multiple pulmonary metastases