Complications - Partial gastrectomy with Roux-en-Y gastrojejunostomy

Intraoperative complications are rare with standardized surgical techniques.

Vascular injuries
Treatment: Suture

Bile duct injury
Management: Suture, T-drain if necessary

Pancreatic injury
Treatment: Suture and extensive drainage

Splenic injury
Management: Hemostasis with argon beamer, tissue sealing, e.g., with TachoSil® sealant matrix
As last resort: Splenectomy

Caution: If splenectomy must be performed in partial gastric resection, the blood supply of the gastric remnant is endangered because the short gastric arteries will have been transected. Gastrectomy then becomes mandatory!

Early failure of the gastroenterostomy

• Most often on postoperative day 3–4
• Confirmed by endoscopy; radiological studies by water-soluble contrast agent have a sensitivity of only 50%
• Mandatory revision surgery: With early intervention and favorable tissue conditions, direct closure by suturing may still be possible, otherwise a new anastomosis must be fashioned.

Early failure of the duodenal stump

• Revision surgery with direct suturing
• If suturing is not possible technically: Drain the duodenal stump to the outside with a large-bore Foley catheter

Late failure of the duodenal stump

• With good external drainage (e.g., CT-guided insertion) non-surgical management may be possible; the resulting duodenal fistula may be anastomosed later with a diverted jejunal loop

Failure of the jejunojejunostomy

• Usually requires revision surgery

Intragastric secondary bleeding

• Primarily endoscopic hemostasis, if unsuccessful revision surgery is indicated
• Reopen the stomach by transverse incision approx. 4-5 cm proximal to the anastomosis and manage the source of bleeding under direct view by suture ligature; close the gastric incision also in transverse direction.

Extraluminal secondary bleeding

• May require revision surgery, depending on the intensity of the bleeding
• Primarily caused by the lymphadenectomy or inadequate ligation of larger vessels
• Bleeding spleen: Local hemostasis with preservation of spleen, if possible; should splenectomy be required, gastrectomy becomes mandatory.

Intraabdominal hematoma/abscess

• Centesis and drainage under ultrasound or CT guidance
• Often together with suture line failure

Lymph fistulas

• Possible after systematic (D2) or extended (D3) lymphadenectomy, rarely chyliform ascites
• Once the inserted drains have been removed, lymph fistulas usually stop spontaneously.
• In special cases, temporary parenteral nutrition may become necessary.

Pancreatitis

• Mostly edematous pancreatitis with good prognosis; nothing solid by mouth, non-surgical/medicinal management
• Hemorrhagic necrotizing pancreatitis, often due to intraoperative pancreatic lesion; interdisciplinary intensive-care management, also surgical necrosectomy/lavage; high mortality!

Temporary gastrojejunostomy disorders

• Origins: Anastomotic edema, hematoma or atonic gastric remnant
• Remission expected within 10-14 days
• Extremely rare indication for revision surgery

Secondary healing

• Treatment: Reopening the wound, wound toilet, secondary wound healing, NPWT of the abdominal wall