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Complications - Gastrectomy

general and visceral surgery
Anatomy Perioperative management Technique Complications Evidence Total Video Medical Equipment

  1. Intraoperative complications

    Vascular injuries
    Treatment: Oversew; vascular reconstruction

    Bile duct injuries
    Treatment: Oversew; possibly T-drain; bilioenteric anastomosis

    Pancreatic injuries
    Treatment: Oversew and extensive drainage

    Splenic injury
    Treatment: Coagulation with argon beamer, fibrin sealant patch, e.g., TachoSil®
    Last resort: Splenectomy 

    Injury to pleura/ diaphragm
    Treatment: Oversew; chest tube

  2. Postoperative complications

    Esophagojejunostomy suture line failure 3%–10%

    • Confirmation by endoscopy; sensitivity of radiological detection with water-soluble contrast agent is only 50%!
    • Nothing by mouth; placement of a nasoenteric tube, broad antibiotic and possibly antifungal regimen.
    • With early intervention and favorable tissue conditions, direct suture closure may still possible in rare cases.
    • Fully covered self-expanding metal/plastic stent with adequate drainage of leakage cavity for defects up to 60% of circumference. Benefit: With good defect coverage the patient can eat.
    • For larger defects: Endoscopic vacuum therapy (EsoSponge®)
    • In large, otherwise not controllable defects with mediastinitis -> discontinuity resection with cervical diversion

    Suture line failure of duodenal remnant <3% 

    Treatment: Adequate drainage; revision surgery usually indicated (oversew; duodenojejunostomy, partial pancreaticoduodenectomy). 

    Jejunojejunostomy suture line failure rare (<1%)

    Treatment: Usually revision surgery.

    Intraluminal secondary bleeding

    • Primarily endoscopic coagulation, if unsuccessful, revision surgery indicated.

    Extraluminal secondary bleeding

    • Surgical revision, depending on bleeding intensity
    • Bleeding source spleen: Local hemostasis sparing the spleen, if possible; splenectomy as last resort
    • Note: Infection-induced erosive bleeding in duodenal stump suture line failure!

    Intra-abdominal hematoma/abscess

    • Ultrasound/CT-guided paracentesis and drainage
    • Often concomitant with suture line failure

    Lymphatic fistulas

    • Possible following systematic (D2-) or extended (D3-) lymphadenectomy, rarely also chylous ascites.
    • After removal of inserted drains, lymphatic fistulas usually cease spontaneously.
    • Rare cases may require temporary parenteral nutrition.

    Pancreatitis

    • Most often edematous pancreatitis with good prognosis; nothing by mouth; nonsurgical treatment with medication.
    • Hemorrhagic necrotizing pancreatitis, often resulting from iatrogenic pancreatic injury; interdisciplinary ICU treatment; also, surgical necrosectomy/lavage; Caution: High mortality!

    Esophagojejunostomy transit disorders

    • Origins: Edematous anastomosis, hematoma
    • Remission expected within 10–14 days
    • Revision surgery indicated only in exceptional cases

    Secondary healing

    • Treatment: Reopening wound; wound debridement, secondary wound healing; negative pressure wound therapy