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2. Gastric Surgeries

3. Gastric Surgeries
• Gastrectomies.
• Gastrostomy
• Vagotomy
• Drainage procedures
– Pyloroplasty
– Gastrojujunostomy.
– Pyloromyotomy

4. Indications for Gastric surgery

5. Indications for Gastric surgery
• Complicated Peptic Ulcer Disease
• Surgical management of Duodenal ulcers
• Ca. Stomach
• Obesity.
• GIST
• Zollinger- Ellison Syndrome
• Corrosive stricture of the stomach

6. Complicated Peptic Ulcer Disease

7. Complicated Peptic Ulcer Disease
• Refractory to treatment
• Haemorrhage
• Perforation
• Obstructive symptoms

8. Complicated Peptic Ulcer Disease
Procedures
• Vagotomy with drainage.
• Billroth II Gastrectomy
• Gastrotomy with hemostasis.

9. Ca. Stomach

10. Ca. Stomach
• Radical Total Gastrectomy.
• Radical Partial Gastrectomy.
• Palliative resection.
• Bypass

11. Surgical management of
Duodenal ulcers

12. Surgical management of
Duodenal ulcers
• Principles
– Reduce acid secretion by dividing the vagus nerve
– called a vagotomy.
• Vagotomy denervates the stomach and therefore
the pylorus which will lead to gastric outlet
obstruction.
• Therefore a drainage procedure is performed
called a pyloroplasty.
• 2 surgical operations
– Truncal vagotomy and pyloroplasty
– Selective vagotomy and pyloroplasty

13. Obesity

14. Obesity
Procedures
• Malabsortives
• Restrictive
– Gastroplasties
– Gastric banding
– Sleeve gastrectomy
• Mixed
– Gastric bypass
– Biliopancreatic diversion withDuodenal switch
• Endoscopic Sleeve Gastroplasty

15. Gastric Surgery
• Billroth 1-remove
distal third
of stomach and
anastomose
remainder to
duodenum

16. Gastric surgery
• Billroth 2- remove
distal 2/3rds of
stomach and perform
gastro-jejunostomy

17. Roux en Y anastomosis

18. Complications Gastric Surgery

19. Complications Gastric Surgery
• Early
• Late

20. Early Complications

21. Early Complications
• Anastomotic leak (1-3%)
• Pulmonary embolism, DVT (<1%)
• Wound infection (more common with open
approach)
• Gastrointestinal hemorrhage, bleeding (0.5-
2%)
• Respiratory insufficiency, pneumonia
• Acute gastroparesis.
• Ischemic necrosis of gastric ramnant or
conduit.

22. Early Complications
• Duodenal stump blowout.

23. Late Complications

24. Late Complications
• Stomal stenosis
• Bowel obstruction, small bowel obstruction
• Internal hernia
• Cholelithiasis
• Micronutrient deficiencies
• Marginal ulcer
• Staple line disruption
• Ventral hernia formation
• Postvagotomy Diarrhea

25. Late Complications
• Malabsorption of fat soluble vitamins
(vitamins A, D, E, and K)
• Vitamin A deficiency, which causes night
blindness
• Vitamin D deficiency, which causes
osteoporosis
• Iron deficiency
• Protein-energy malnutrition
• Afferent loop Obstruction
• Blind Loop Syndrome

26. Late Complications
• Alkaline gastritis.
• Stomal ulcers
• Gastrojejunocolic fistula
• Small stomach syndrome (Early Satiety)
• Bile vomiting
• Gastric Cancer.

27. Vagotomy complications

28. Vagotomy complications
• Decreased acid secretion (aim of the game)
• Faster gastric emptying (loss of vagally
mediated)
– Diarrhoea
– Dumping syndrome
• Gastric outlet obstruction(unless
pyloroplasty performed)

29. Vagotomy complications
• Vagotomy denervates from the
stomach to the distal transverse colon
including the pancreas and gallbladder
• Gallbladder denervation leads to stasis
and which increases the chance of
gallstones.
• Decrease in pancreatic and gallbladder
secreations leading to undigested fats-
steatorrhoea

30. Complications of gastrectomy

31. Complications of gastrectomy
• Dumping syndrome
–Early v’s late
–Cardiovascular and GI symptoms
due to vagotomy and
pyloroplasty or gastrectomy
–Early DS due to hypovolaemia
–Late DS due to hypoglycaemia

32. Complications of gastrectomy
continued
• Anaemia( Intrinsic factor essential for
binding of Vit B12 for absorption in the
terminal ileum)
• Early satiety
• Hypocalcaemia- reduced HCl prod
interferes with absorption of calcium and Fe
in the duodenum
• Gastric Stump carcinoma? Due to chronic
irritation of stump by duodenal secretions

33. Early Dumping Syndrome

34. Early Dumping Syndrome
• No intact pylorus leads to dumping of large
amounts of chyme,biliary and pancreatic
secretions into duodenum at once
• Results in large fluid shift
• Occurs within 40 minutes of ingestion
• Symptoms include
– Tachycardia
– Diaphoresis
– Palpitations
– Diarrhoea
– Abdominal pain

35. Late Dumping Syndrome

36. Late Dumping Syndrome
• Due to rebound hypoglycaemia
• Occurs 2-4 hours post op
• Symptoms include
–Tachycardia
–Palpitations
–Diaphoresis
–Dizziness

37. Afferent loop Obstruction

38. Afferent loop Obstruction
• Symptoms show immediately after a meal
• Occurs only with Billroth II reconstruction
• Obstruction of the afferent limb adjacent to
the anastomosis.
• cramping pain defined as crushing
• vomit of a dark brown bitter tasting
material with consistency of motor oil.
• Symptoms resolve with vomiting,
• profound weight loss to prevent pain

39. Blind Loop Syndrome

40. Blind Loop Syndrome
• after Billroth II than roux en y gastrojejunostomy.
Also seen after irradiation or morbid obesity
• Associated to bacteria overgrowth in the limb of
the intestine excluded from the flow of chyme.
This limb has bacteria that proliferate and
interfere with folate and Vit B12 metabolism, also
bacterial overgrowth cause deconjugation of bile
salts ---steatorrhea
• B12 deficiency leads to megaloblastic anemia
• Diarrhea
• Weight loss
• Weakness

41. T/t
Blind Loop Syndrome
• Antibiotics (Tetracyclins)
• Conversion to Billroth I may be required for
some pts.

42. Recurrent Ulcer Disease

43. Recurrent Ulcer Disease
• Incomplete vagotomy, posterior vagal trunk or a
branch of this trunk (criminal nerve of Grassi) is
left intact.
• Truncal vagotomy + antrectomy lowest rate 2%
• Proximal gastric vagotomy highest rate of 12%
• Endoscopy + Congo red (to demostrate areas of
pH drop in gastric mucosa after a secretagogue is
administered, pentagastrin )
• PPI’S Long term
• Reoperative vagotomy:
• Recurrent ulceration and verified complete
vagotomy look for endocrine etiology like family
Hx of MEN-1. Also look for hyperparathyroidism
and Gastrinoma as possible causes.

44. Gastric Atony

45. Gastric Atony
• Atony of stomach may result from gastric
reconstruction and denervation (vagotomy) and
ablation of pylorus.
• Motility of stomach is altered.
• Rapid emptying of liquids can result in early or
late dumping, yet delayed of emptying solids
due to gastric atony
• Only 50% of pts have symptoms.
• Promotility agents like
metoclopramide,erythromycin.

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