1. VCU Death and Complications Conference

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

3. Clavien-Dindo Classification

4. 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

6. 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

7. 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:

9. 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:

11. 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:

14. 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

15. Methods of Gastric Reconstruction

16. Billroth I

17. Billroth II

21. Roux-en-Y gastrojejunostomy

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

23. 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)

24. 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)

25. Surgically need to resect atonic stomach

26. 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

27. 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.

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

29. 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