VCU Death and Complications Conference

Brief Overview Surgery: Open distal gastrectomy with BII Attending: Dr. Kaplan Resident: Jeffrey Stromberg Complication: Efferent loop obstruction, cardiac arrest

Clavien-Dindo Classification

HPI 67 year old F presented for treatment of gastric cancer. Initially presented at OSH 1 month prior for work up of N/V and abd pain. During EGD which revealed ulcerated antral mass consistent with mucinous adenocarcinoma, had a cardiac event which lead to type II 2nd degree heart block and pacemaker placement. PMHx: breast cancer s/p segmental mastectomy 2001, HTN, hypercholesterolemia, diabetes, GERD Medications: Albuterol, omeprazole, HCTZ, metoprolol, pravastatin, metformin, coumadin/Lovenox bridge Exam: Unremarkable

Surgery Supraumbilical midline incision No gross evidence of metastatic disease Palpable firm nodular mass in antrum Omentectomy and lesser omentum divided. 1st portion duodenum divided GIA stapler. Gastric body divided with GIA stapler. Jejunum 40cm distal to ligament of Treitz used to make antecolic retrogastric stapled gastrojejunostomy. Jejunum lined up and secured to retrogastric body with stay sutures. Gastrotomy and eneterotomy made. Antimesenteric stapled anastomosis. TA stapler used to close defects. TA staple line imbricated with silk

PostOp Course POD1 NG pulled and advanced to sips Rapid return of bowel function but unable to ever advance diet beyond clears due to persistent nausea and 1-2 episodes bilious emesis every other day. On POD10 had 1L bilious emesis. Refused NG placement POD11 PICC placed and GI consulted for EGD for suspected efferent limb syndrome POD11 UGI performed after 3L emesis:

EGD Great difficulty finding efferent limb but once identified was patent. Noted to be edematous and angulated. Prior to dilation her abdomen was noted to be distended and she became tachycardic up to 150s. Was given nitropaste Balloon dilation of efferent limb entry with 15mm balloon At conclusion of procedure, became dyspneic and hypoxic. Rapid response called and then intubated. CXR as follows:

Subsequently went into PEA arrest Subsequently went into PEA arrest. During ACLS her abdomen was needle decompressed. Return of pulses Admitted to ICU for arctic protocol After conclusion of arctic protocol CT head noted evidence of ischemic stroke in basal ganglia and occipital lobes. CT abdomen at time of CT head as follows:

Retrospective analysis Was the complication preventable Yes Would avoiding the complication change the outcome? Would not have required EGD which lead to the perforation and subsequent arrest. What factors contributed to the complication? Failure to recognize pneumoperitoneum Failure to stop the procedure earlier Possible technical factors such as excessively large bites with imbrication sutures, too large a bite with TA stapler

Methods of Gastric Reconstruction

Billroth I

Billroth II

Roux-en-Y gastrojejunostomy

Postgastrectomy Syndrome Gastric outlet obstruction Alkaline reflux gastritis Gastroparesis Roux limb syndrome Afferent loop syndrome Efferent loop syndrome Dumping syndrome

Alkaline Reflux Gastritis Caused by reflux of intestinal contents into stomach Symptoms typically arise late (1 year postop). Burning epigastric pain, nausea, emesis, pain aggravated by meals, pain unrelieved by emesis Most common in BII, occasionally in B1, rare in Roux-en- Y Work up can include EGD, Bernstein test, scintigraphy Treatment – Braun anastomosis (historical only), antiperistaltic interpositions, conversion to Roux-en-Y (board answer)

Gastroparesis Occurs in early postop period N/V, early satiety, bloating, abdominal pain High risk in diabetics or those who had chronic preop gastric outlet/duodenal obstruction Diagnose with nuclear emptying study. Other useful studies include UGI Mechanical causes include hematoma, kinking, anastomotic leak, anastomotic edema Treat with NG decompression, TPN/tube feeds, prokinetics (Reglan, erythromycin)

Surgically need to resect atonic stomach

Dumping Syndrome Caused by hyperosmolar load to intestines with subsequent hypoglycemia Postprandial weakness, dizziness, palpitations, diaphoresis, cramping, explosive diarrhea Surgical treatment involves delaying gastric emptying (vagotomy) and conversion to roux-en-y

Afferent limb syndrome Only after BII Typically afferent limb too long (>40cm) Present with intermittent RUQ or epigastric pain relieved by bilious emesis (no food particles). May have hyperamylasemia Acute setting requires prompt diagnosis to prevent stump blowout UGI and EGD ideal tests Treatment is surgical as causes include internal herniation, volvulus, kinking, anastomotic stenosis, adhesions.

Efferent Limb Syndrome Similar symptoms of afferent limb syndrome – crampy pain associated with bilious emesis Causes are the same

Tension Pneumoperitoneum Creates hyperacute abdominal compartment syndrome Decreased preload, decreases splanchnic blood flow, decreased ventilation, decreased cardiac output Causes Colonoscopy, endoscopy, percutaneous endoscopic gastrostomy, CPR, mechanical ventilation in patients with pleural-peritoneal shunts Signs Tachycardia, abdominal distension, diffuse tympany, hypotension, obtundation, decreased minute ventilation, increased peak pressures Treatment Emergent needle paracentesis and then +/- surgery