Delayed Gastric Emptying Following Gastrectomy ALFRED M. COHEN, M.D., LESLIE W. OTTINGER, M.D.
The characteristics of 46 patients unable to take a solid diet within two weeks of gastric resection and had no other postoperative complications are reviewed. The incidence of delayed gastric emptying was found to be 2½/2 times greater in patients with vagotomy and heniigastrectomy than in those with subtotal gastrectomy. In addition, postoperative delay was often prolonged in the hemigastrectomy and vagotomy group. Mechanical factors were responsible for delay in only 10% of these patients. Possible explanations for these delays are made and it is suggested that localized starch peritonitis may explain many cases of "functional efferent limb ileus." Measures to evaluate the source of delay are recommended and suggest conservative management for the majority of patients. Reoperation is reserved for those who require feeding or draining enterostomy tubes and those whose clinical course and evaluation suggest obstruction. F OLLOWING gastric resection, return of bowel func-
tion will be delayed in a small proportion of cases. However, most patients are able to eat a solid diet within 10 days following an uncomplicated gastric resection. A mechanical problem is usually considered responsible for persistent elevations of gastric residuals past this point and exploratory surgery is often recommended.2 3'6'0'16 In addition to mechanical problems, inflammatory and functional abnormalities of the stomach, gastroenterostomy, duodenum, or efferent limb of a gastrojejunostomy may be the source of the delay. Occasionally, delay is secondary to a major postoperative complication, such as pneumonia or pancreatitis. Hypokalemia or marked nutritional wasting with hypoalbuminemia may also be responsible. Some patients without any other apparent postoperative problems or signs of generalized bowel ileus have delay in gastric emptying after a gastrectomy. It is the purpose of this paper to describe and analyze the exSubmitted for publication February 23, 1976. Reprint requests: Dr. Alfred M. Cohen, Cox Building, Floor 1, Massachusetts General Hospital, Boston, Massachusetts 02114.
From the Department of Surgery, Harvard Medical School and The Massachusetts General Hospital, Boston, Massachusetts
perience of 46 such patients at the Massachusetts General Hospital who could not tolerate a solid diet for at least two weeks following gastrectomy. Material From 1962 until the end of 1974, 1,774 patients at the Massachusetts General Hospital underwent partial gastrectomy. This, number excludes patients with proximal gastrectomy as part of an esophagogastrectomy and those who had a gastrectomy at the time of pancreaticoduodenectomy. Records of patients who had been hospitalized for at least 21 days were selected for evaluation, and patients who had major postoperative complications or a serious systemic illness unrelated to their surgery were excluded from the sample. Forty-six patients were found suitable for analysis, the major criterion for their selection being inability to tolerate a solid diet until 14 or more days following surgery. A solid diet was defined as a soft solid diet, a house diet, or a 6-meal bland diet. Of the 46 patients, 14 underwent emergency gastrectomy and 32 underwent elective or semielective gastrectomy. The procedures were partial distal gastrectomy, subtotal gastrectomy, or hemigastrectomy and vagotomy. Results Diagnosis. The results according to pathological diagnosis are presented in Fig. 1. Ten patients underwent surgery for intractable duodenal ulcer disease, 11 for bleeding duodenal ulcer, 8 for obstructing duodenal ulcer, 11 for gastric ulcer, 3 for gastric tumors, and
689
COHEN AND OT'TINGER
690 * o
o
Ann.
cedure. Specifically, 17 of these 30 patients had
HG+V STG
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the
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in good to excellent nutritional balance at the time of surgery. In the past 5 years, malnourished patients, particularly those with chronically obstructing duodenal ulcers, have received intravenous alimentation prior to surgery. There was no correlation of preoperative nutritional deficiency with postoperative delay in gastric emptying. o~~~~ Billroth I Reconstruction. Of the 46 patients in this
*
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being
when compared
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Surg. o December 1976
underwent
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The range of delay in gastric median not in these patients was 18 to 31 days, with a emptying significantly different from those who underwent gastrojejunostomy. Fig. 3 describes the results of
upper
gastrointestinal
delay in gastric emptying after
gastrectomy.
3 for hemorrhagic gastritis. Although the sample is too small for definitive analysis, there seemed to be no difference in median delay or range of delay within 70 these groups. Specifically, patients -with obstructing duodenal ulcers were no more prone to lengthy delays in gastric emptying than those with other diagnoses. 60 Type of Operative Procedure. Fig. 2 presents the 46 patients grouped according to the type of operative procedure performed. There were 5 patients who under50 went a partial distal gastrectomy, 11 who underwent subtotal gastrectomy and the remaining 30 had a hemigastrectomy and truncal vagotomy. The degree of gastric 40 Fresection in the hemigastrectomy group varied from 40W to 50%. Patients who underwent subtotal gas- (f) trectomy had from 2/3 to 3/4 of the stomach removed. Ilk Those patients undergoing a distal gastrectomy had K2 30 F50% or less resected. During the 12 years evaluated in this study, approximately 701 patients underwent subtotal gastrectomy, and 20 e842 hemigastrectomy and vagotomy. This indicates that delayed gastric emptying occurs 2½2 times as often in the vagotomy and hemigastrectomy group as compared 10 to subtotal gastrectomy. Of particular interest is that all 11 patients with subtotal gastrectomy were able to resume a solid diet 0 by the 27th postoperative day. The same was true for 4 of the 5 patients who underwent partial distal gastrectomy. However, patients undergoing hemigastrectomy and truncal vagotomy had a median resumption FIG. 2. Effect of of solid diet of 31 days after the operative pro- emptying.
@126
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type of operative procedure on delayed gastric
Vol. 184 . No. 6
DELAYED GASTRIC EMPTYING
691 The large majority of these patients had an antecolic 40gastrojejunostomy so it is impossible to compare the functional results of antecolic with retrocolic reconstructions. 0 The findings on upper gastrointestinal series obtained 30 10 to 14 days postoperatively are presented in Fig. 4. 0 Of the 33 patients undergoing upper gastrointestinal *0 series, 18 showed no emptying of the gastric remnant 20 after one to 4 hours of observation. One of these pa(I) tients was subsequently operated upon and a mechanical KZ obstruction in the efferent limb was corrected. Six patients demonstrated some emptying through what ap10 peared to be a narrow stoma on upper gastrointestinal series. The afferent limb was visualized in only three patients and one of these was found to have a mechanical efferent limb obstruction at the time of exploration. 0 Three patients had delayed gastric emptying, and two NO SMALL NORMAL patients had a normal study. In only one case did the EMPTYING STOMA positioning of the patient in the upright or prone position have any effect on the rapidity with which the FINDINGS ON UGIS dye left the gastric remnant. Of the 41 patients undergoing Billroth II reconstrucFIG. 3. Upper gastrointestinal series findings in Billroth I patients. tion, only 4 had mechanical problems requiring surgical intervention. Of these, one had stomal narrowing series in these patients plotted against the number of days or obstruction and the remaining three had mechanical until return of normal function. The length of delay could obstruction of the efferent limb. Late followup of these patients revealed that one panot be correlated with the apparent degree of patency of the stoma. All of these tests were done with barium sulfate as the contrast medium. *026 In only one of these patients did a mechanical problem cause the delay in postoperative gastric emptyI7 ing. An upper gastrointestinal series performed on that 701fpatient on the 13th postoperative day showed no obstruction to passage of barium. An intra-abdominal abscess 60 _subsequently drained and soon after the patient was able to tolerate a solid diet. In the remaining 4 patients, the gastric outlet obstruction resolved spon50 _taneously. Biliroth II Reconstruction. Forty-one of the 46 pa- 4i) 40 _tients had a gastrojejunostomy. Approximately 13 of the a patients who underwent Billroth II gastrojejunostomy had an omentectomy also. This additional procedure had 30 no bearing on the length of delay. There seemed to be no significant difference in the 20 _postoperative courses of those patients who underwent Polya as opposed to Hofmeister gastrojejunostomy. Of 4, 12 patients in this group who had delays of at least 30 1o _days, 6 patients had a Polya reconstruction and 6 patients had a Hofmeister. In the group with a Polya reconstruction, 4 patients had the efferent limb of the NO SMALL AFFERENT DELAYED POSITIONAL NORMAL EMPTYING STOMA LIMB FILLS EMPTYING EMPTYING gastrojejunostomy brought off the lesser curvature of the stomach and two had it brought off the greater curvaFINDINGS ON /JGIS ture. In the Hofmeister group, 4 had the efferent limb FIG. 4. Upper gastrointestinal series findings after Billroth rebrought off the greater curvature and two off the lesser. construction. K
0
0
K
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0
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0 0
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II
COHEN AND OTTINGER
692
Ann. Surg. m December 1976
TABLE 1. Summary of Reoperations
Total Days Solid Diet! Days after Reoperation
to
Day of Reop.
Initial Operation
Hemigastrectomy & vagotomy, Billroth II, antecolic-Hofmeister, greater omentum resected Hemigastrectomy & vagotomy, Billroth II, antecolic-Hofmeister, greater omentum not resected
23
22
Operative Findings
Reoperation
Stoma patent, adhesions and inflammation in upper abdomen. Talc on pathology
Lysis of adhesions, placement of gastrostomy & feeding jejun-
72/49
ostomy Omentectomy & resection of gastrojejunostomy, gastrostomy & feeding
37/15
Stoma patent, Omentum wrapped around anastomosis
jejunostomy Hemigastrectomy & vagotomy, Billroth 11, antecolic-Polya, greater omentum not resected
14
Stoma patent. Adhesions around efferent limb
Lysis of adhesions, gastrostomy & feeding jejunostomy
32/18
Hemigastrectomy & vagotomy, Billroth 11, antecolic-Polya, greater omentum resected
9
Stoma patent with kinking of the efferent limb. Adhesions around efferent limb
Lysis of adhesions, gastrostomy & feeding jejunostomy
29/20
Hemigastrectomy & vagotomy, Billroth 11, antecolic-Hofmeister, greater omentum not resected Hemigastrectomy & vagotomy, Billroth 11, antecolic-Polya, greater omentum resected. gastrostomy Hemigastrectomy & vagotomy, Billroth 11, antecolic-Hofmeister Hemigastrectomy & vagotomy, Billroth II, antecolic-Hofmeister, greater omentum not resected, gastrostomy & jejunostomy Hemigastrectomy & vagotomy, Billroth 11, antecolic-Polya. greater omentum not resected, gastrostomy & jejunostomy Hemigastrectomy & vagotomy, Billroth 11, antecolic-Hofmeister Hemigastrectomy & vagotomy, Billroth 11, antecolic-Hofmeister, greater omentum not resected
22
Omentum wrapped around the anastomosis with question of some mechanical obstruction
Omentectomy & resection of gastrojejunostomy
35/13
19
Stoma patent
Feeding jejunostomy
35/16
36
Kinked efferent limb
Lysis of adhesions, gastrostomy, feeding jejunostomy
48/12
44
Stoma patent. Some adhesions
Lysis of adhesions, new gastrostomy & feeding jejunostomy
51/7
18
Stoma patent with some kinking at the jejunostomies
Lysis of adhesions, removal of gastrostomy & jejunostomy
56/38
14 wks.
Stoma patient with minimal reaction Stomal stenosis
Exploration
18 mos.
126/25
Revision of gastrojejunostomy
tient who had a narrow stoma on upper gastrointestinal jejunostomy tube feedings and 72 days from his initial surgery he series required re-resection of his gastrojejunostomy for was able to take a soft solid diet. A 32-year-old man with duodenal ulcer disease underwent elective stomal stenosis 18 months after the original procedure. Case
Reports
Patients Undergoing Reoperation. Patients requiring reoperation either for placement of a feeding jejunostomy or gastrostomy tube or for definitive repair are presented in Table 1. A 48-year-old man underwent a hemigastrectomy and vagotomy, resection of the greater omentum and antecolic Hofrneister gastrojejunostomy for hemorrhagic gastritis. On his ninth postoperative day, an upper G6 series revealed that no barium left the stomach over a two hour period. At reoperation on his 23rd postoperative day, extensive adhesions and inflammation in the upper abdomen were found. The stoma was widely patent. He underwent lysis of adhesions and placement of feeding and draining jejunostomy catheters. His pathology revealed talc granules and a granulomatous reaction. Large amounts of bilious gastric drainage persisted and an upper GI series obtained 6 weeks after the second operation showed persistent slow passage of barium out of the stomach. He was maintained on
hemigastrectomy and vagotomy. The greater omentum was not removed and an antecolic Hofmeister gastrojejunostomy with the afferent limb to the lesser curve was performed. A draining jejunostomy tube was placed. Large gastric residuals persisted postoperatively and an upper GI series revealed no drainage of barium from the stomach. Because the patient had inadvertently removed the draining jejunostomy, he underwent reoperation on his 22nd postoperative day. Operative findings included some omentum wrapped around the anastomosis, but were generally unremarkable. He underwent revision of the gastrojejunostomy and resection of the omentum, Feeding and draining jejunostomy catheters were placed. Following this operation, large gastric drainage persisted and he was maintained on jejunostomy tube feedings. Thirty-seven days after the original operation and fifteen days after the second procedure, he was able to take a soft solid'diet. A 67-year-old man underwent elective surgery for duodenal ulcer. A hemigastrectomy and vagotomy with an antecolic Polya gastrojejunostomy was performed. The greater omentum was not resected. An upper GI series on postop day 9 revealed high grade stomal
obstruction. On the 14th postop day, laparotomy revealed dense adhesions around the efferent limb and a patent stoma. He underwent lysis of adhesions and placement of feeding and draining jejunostomies. Large bilious gastric residuals persisted after the second operation. He was maintained on jejunostomy tube feedings with resolution of the obstruction and, on the 32nd day after the first operation and 18th day after the second operation, he was able to take a soft solid diet. A 57-year-old man underwent elective surgery for duodenal ulcer. He was well nourished but had a history of an 80 pound weight loss over a two-year period. He underwent hemigastrectomy, vagotomy, resection of greater omentum, and antecolic Polya gastrojejunostomy with the afferent limb to the greater curve. An upper GI series on the 7th postoperative day revealed barium passing into a dilated efferent limb and complete obstruction at the efferent limb. He underwent reoperation on the 9th postoperative day with the findings suggestive of a kinked efferent limb. The stoma was otherwise patent. The surgery involved placement of feeding and draining jejunostomies and lysis of adhesions. He had persistent large gastric residuals and an upper GI series obtained on the 12th day after the second operation revealed emptying of the gastric remnant into the efferent limb only when the patient was supine. He was able to take a soft solid diet on the 29th day after the first operation and the 20th day after the reoperation. A 32-year-old man underwent elective surgery for duodenal ulcer. He underwent hemigastrectomy and vagotomy without resection of the greater omentum. An antecolic Hofmeister gastrojejunostomy with afferent limb to lesser curve was performed. An upper GI series on the 14th postoperative day revealed complete absence of drainage of barium from the gastric remnant. He underwent surgery 22 days after the initial procedure with the findings of omentum wrapping around the anastomosis with perhaps partial mechanical obstruction. The greater omentum and gastrojejunostomy were resected. Gastric drainage remained poor after the reoperation. He was able to take a soft solid diet 35 days after the initial procedure and 13 days after the second procedure. A 71-year-old man had surgery for an obstructing duodenal ulcer. He was well nourished and had four days of nasogastric tube suction prior to the procedure. He underwent hemigastrectomy, vagotomy, and resection of the greater omentum. An antecolic Polya gastrojejunostomy with afferent limb to the greater curve was performed. A draining jejunostomy was placed. On several subsequent upper GI series, no barium left the gastric remnant. On the 19th postoperative day he underwent reoperation. There were no significant findings at surgery and the stoma was widely patent. A feeding jejunostomy was
placed. He
a
was
maintained
on
jejunostomy tube feedings and
the 35th day following the initial procedure he soft solid diet.
on
693
DELAYED GASTRIC EMPTYING
Vol. 184 * No. 6
was
able
to
take
A 52-year-old man had elective surgery for duodenal ulcer. He was well nourished but had lost 13 pounds the previous year. His chemistries were within normal limits. He underwent hemigastrectomy and vagotomy without resection of the greater omentum. An antecolic Hofmeister gastrojejunostomy with the efferent limb to the lesser curve was performed. He had persistent hiccoughs after surgery and gastric dilatation required prolonged nasogastric tube suction. Nutrition was maintained on intravenous hyperalimentation, although his serum albumin fell as low as 2.6. On the 26th postoperative day he was able to take a soft solid diet. Eighteen months after the initial procedure, he underwent revision of the gastrojejunostomy for stomal
stenosis. A 66-year-old man underwent elective surgery for duodenal ulcer. A hemigastrectomy and vagotomy with an antecolic Hofmeister gastrojejunostomy with afferent limb to lesser curve was performed. Barium upper GI series on postoperative days 18, 27, and 35 revealed no drainage from the gastric remnant. At surgery on postop day 36, twisting and kinking of the efferent limb was present. He underwent lysis
of adhesions and placement of feeding and draining catheter jejunostomies. He was on a soft solid diet 48 days after the original procedure and 12 days after the reoperation. A 62-year-old man underwent surgery for an obstructing duodenal ulcer. He had not lost weight and appeared well nourished prior to his surgery. Nasogastric suction was used for 5 days prior to a hemigastrectomy and vagotomy. Greater omentum was not resected and an antecolic Hofmeister gastrojejunostomy with the afferent limb to the lesser curve was performed. Feeding and draining catheter jejunostomies were placed. Barium upper GI series on days 13, 24, 29. and 37 demonstrated no drainage of barium from the gastric remnant; however, large amounts of bile drained out of the gastric remnant and on day 44 he underwent reoperation. At the time of surgery, there were some adhesions but the stoma was widely patent and the efferent limb was slightly dilated. 32nd day after the second procedure showed much improved drainage with the patient in the prone position. He was maintained on jejunostomy tube feedings and was able to take a soft solid diet 56 days after the original procedure and 38 days after the reoperation. A 59-year-old woman underwent elective surgery for a gastric ulcer. A hemigastrectomy and vagotomy with antecolic Hofmeister gastrojejunostomy with afferent limb to greater curve was performed. She was on liquids early postoperatively, but developed nausea and vomiting. An upper GI series on the 9th postoperative day revealed complete stomal obstruction. On her 28th postoperative day, narrow stoma was apparent on repeat upper GI series. She had persistent postprandial emesis with upper GI series at 6. 8, and 10 weeks showing a very narrowed stoma. Fourteen weeks after the initial procedure, she underwent exploration with the finding of a gastrojejunostomy stoma that would admit two fingers with minimal reaction. On the 11th day following this second operation, upper GI series rea
vealed complete obstruction. However, she
was able to take a soft diet 126 days after the initial procedure and 25 days after the second procedure at which time the upper GI series was normal.
Discussion The incidence of delayed gastric emptying after gastric resection as reported in the literature can be as high as 20%.7.9.12.1 ,6.18 In a series of 1,261 patients undergoing gastric resection reported by Jordan and Walker, only 1.6% required nasogastric suction for greater than 10 days.7 These authors found no difference in length of delay between patients who had a subtotal gastrectomy and those who had a hemigastrectomy and vagotomy. In a series of 500 patients undergoing subtotal gastrectomy at St. Vincent's Hospital, 4% had gastric outlet obstruction postoperatively.18 In the Vanderbilt series of 371 patients undergoing gastrectomy and Billroth I reconstruction, 5% had delayed emptying. 14 In a report of 325 patients undergoing elective subtotal
Clinic, 3% of these patients had delayed emptying.9 Most of these patients had Billroth II, retrocolic Hofmeister reconstructions. Patterson reported his postoperative complications following gastrectomy and in this series of over 200 patients the incidence of delayed gastric emptying postoperatively was 16-20.12 He found no difference between patients who had a gastrectomy with vagotomy and those who had a gastrectomy without vagotomy, but twice as many patients with hemigastrectomy and vagotomy with Billgastrectomy at the Mayo
COHEN AND OTTINGER
694 TABLE 2.
A. Mechanical 1. Stomal stenosis 2. Stomal edema 3. Efferent limb kinking 4. Efferent limb hernia 5. Efferent limb obstructed by enterostomy tube 6. Efferent limb obstructed by mesocolon 7. Jejunostomy intussusception B. Functional 1. Efferent limb 2. Stomal
3. Gastric C. Inflammatory 1. Adhesions (omentum, talc or starch) 2. Intra-abdominal abscess
roth II reconstructions had delayed emptying for at least 3 weeks compared to those with a Billroth I reconstruction. There are few reports in the literature describing the time course of resolution of delayed gastric emptying following gastrectomy. In patients in the Mayo Clinic series, normal gastric function resumed in 17 days or less.9 In Patterson's report, almost one-half of the patients had at least three weeks delay in eating.'2 Kraft reported that patients with delay resolved their problems in an average of 25-37 days.10 In our group of 46 patients, recovery from delayed gastric emptying occurred over a wide time range. Significantly, the median delay in the group undergoing hemigastrectomy with vagotomy was 30 days while all but one patient had resolution within 27 days in the group undergoing gastric resection without vagotomy. This suggests that not only does vagotomy with gastric resection increase the incidence of delayed remnant emptying, but when delay does occur, it is often prolonged. Delay in gastric emptying following gastrectomy can be attributed to three major sources: mechanical abnormalities, functional problems and inflammatory processes. Table 2 outlines the possibilities, excluding those causes that lead to generalized bowel ileus, such as pancreatitis. In cases of mechanical stomal obstruction at a gastrojejunostomy, it is rarely the size of the stoma that limits gastric drainage since in almost all cases the circumference of the gastrojejunostomy exceeds the circumference of the efferent limb. In fact, it is the size of the jejunum which limits the rate of gastric emptying. Edema of the gastroenterostomy is probably not responsible for obstruction in patients whose eating is delayed for at least two weeks, since experience with wound healing suggests that wound edema has resolved by this time. Mechanical problems involving the efferent limb have been reported, particularly internal herniation and intussusception.15"19 It is possible that in a number of cases
Ann. Surg. * December 1976
in our group, a mechanical efferent limb obstruction spontaneously resolved, as is often the case with early postoperative small bowel obstruction. A number of surgeons are adamant about placement of the efferent limb with regard to the greater or lesser curvature of the stomach to prevent such mechanical obstructions.3'11'13 There appeared to be no difference in results between the two techniques in our study. Golden first suggested in 1952 that delayed gastric emptying could be attributed to functional obstruction of the efferent limb of the gastrojejunostomy as evidenced by spasm of the limb on barium study.4 More recently, Bodon and Ramanath reported 5 patients with this so-called "efferent limb obstruction" in whom, at the time of surgery, the efferent limb was flaccid and peristalsis could not be elicited by pinching or touching the bowel.2 It is quite possible that a functional efferent limb ileus is a result of low grade inflammatory processes. Many of our patients who underwent reoperation had inflammation in the upper abdomen. In one patient, talc granules were identified on pathology, suggesting that "efferent loop syndrome" could be due to a localized starch reaction that resolves spontaneously. This could account for the appearance of signs of obstruction late in the postoperative course, which is consistent with the experience with starch peritonitis elsewhere.21 Among our patients with "obstruction" of the efferent limb, lysis of adhesions and resection of the gastrojejunostomy usually did not provide an immediate cure, which suggests either a functional or inflammatory abnormality involving the bowel. If a localized starch reaction is at fault, surgery could worsen the situation by introducing additional contamination by starch granules. Measurements of serum lysozyme levels may be helpful in making this diagnosis.20 It has been suggested that gastric atony aggravated by vagotomy contributes to delayed gastric emptying. However, Nyhus points out that studies of the motility of the stomach by barium and manometric techniques have demonstrated that gastric atony is not a factor in postoperative retention.'0 His findings, among others, have demonstrated that there is normally no peristalsis in the gastric remnant following subtotal gastrectomy or hemigastrectomy with or without vagotomy. Even in the normal stomach, peristaltic waves are limited almost exclusively to the antrum. Some surgeons consider it inadvisable to perform a vagotomy in patients with obstructing duodenal ulcer.1"5'8 In a detailed paper on the problems of vagotomy in patients with duodenal ulcer disease, Kraft reported on 145 patients undergoing gastric resection for obstructing duodenal ulcer.8 Half of the patients underwent vagotomy and hemigastrectomy and the other half subtotal gastrectomy. The incidence of delayed gastric emptying
Vol. 184 . No. 6
DELAYED GASTRIC EMPTYING
in the subtotal gastrectomy group was 3% compared to 9% in the group with vagotomy and hemigastrectomy. However, his data reveal that the incidence of delay after vagotomy and hemigastrectomy in another 79 patients without preoperative obstruction was also 9o, suggesting that it was the operative procedure and not antecedent gastric distention that produced delayed gastric emptying. In our series, the incidence of delayed gastric emptying was 2½2 times greater in patients with vagotomy and hemigastrectomy than in those with subtotal resection alone. The data were insufficient to comment on the relative incidence in the group with obstructed duodenal ulcers. A number of authors have suggested that if patients are unable to tolerate eating 10 to 14 days after gastric resection, they should undergo a "corrective" operation.2'3.6"0 Thompson and Rodgers stated that kinking and adhesions involving the efferent limb with mechanical obstruction are almost always the cause of delayed emptying after gastrectomy.16 Herrington recommended that patients without return of function in two weeks should have a reoperation, that a new gastroenterostomy be fashioned and a nasogastric tube placed into the efferent limb.6 Bodon and Ramanath usually reoperated after two weeks, performing a jejunostomy between the afferent and efferent limbs. In Kraft's series, gastrostomy and feeding jejunostomy tubes were placed in patients requiring reoperation and all but one did well.8 Of 14 patients with reoperations in Jordan and Walker's series, one patient required an addition gastrectomy; 2, revision of the gastroenterostomy; 5, lysis of adhesions; 4, feeding and draining enterostomy tubes; and 2, gastrojejunostomy.5 In an older paper Prohaska et al. discussed 5 patients with delayed gastric emptying following subtotal gastrectomy; upon reoperation all five had patent stomas and underwent jejunojejunostomy between the efferent and afferent limbs with satisfactory results.13 In our series of 46 patients, 10 required reoperation in the immediate postoperative period. An additional patient underwent reoperation 18 months after the initial procedure because of persistent stomal stenosis. In this latter patient, an organically small stoma aggravated by stomal edema was probably responsible for the initial delay in gastric emptying. In 9 of the 11 patients, the stoma was patent at reoperation. In 6 patients, adhesions and/or inflammation involving the stoma or the efferent limb was present. A mechanical problem was definitely present in two patients and suspected in an additional two, representing less than 10o of our total sample. As indicated in Table 1, gastric function was not often improved by reoperation such as lysis of adhesions and omentectomy or even re-resection of the
gastrojejunostomy.
695 Upper gastrointestinal series did not provide a clear guide in the management of our group of patients. It is difficult to interpret the reasons for barium retention in the gastric remnant even after a prolonged waiting period. Although no barium entered the efferent or afferent limbs in many of these patients, we know from their charts that bile was present in the stomach, indicating that the afferent limb was open. Presumably, the continuous drainage of pancreatic and biliary fluid from the afferent limb prevented filling by the barium. On occasion, however, the upper gastrointestinal series is beneficial, particularly in diagnosing factitious obstruction. In one case, a gastrostomy tube which had been placed by the retrograde jejunostomy technique had slipped into the afferent limb. Once this type of obstruction is noted on x-ray, it can be confirmed by intermittent clamping of the catheter and advancement of the patient's diet. The gastrointestinal series can also be useful in determining whether the gastric remnant empties only when the patient is in a certain position. Very few patients in our series underwent gastroscopy and none underwent selective efferent limb barium x-rays. Both of these studies might have provided information helpful in the management of the patient. It has been suggested that meglamine diatrizoate (Gastrografing) be employed therapeutically as well as diagnostically during the gastrointestinal series.22 The hypertonic aspects of Gastrografin reduces edema of surrounding tissues and, in addition, produces hyperperistalsis of the small bowel. In the few patients in our series in whom Gastrografin was employed in upper gastrointestinal series, gastric emptying did not resume any more quickly than when other contrast media were used. Vasconez et al. have reported the use of urecholine chloride in 6 patients following hemigastrectomy and vagotomy with persistent gastric retention.17 Five of the 6 patients responded to the treatment including 3 patients who had already undergone reoperation without improvement. The patients were given intermittent subcutaneous urecholine chloride following a barium meal until gastric emptying began; subsequently, the patient was allowed to eat with a tapering course of urecholine chloride for one month.
Conclusions In only a small number of cases will delay in gastric emptying after gastrectomy be due to mechanical problems. Following hemigastrectomy and vagotomy, large gastric residuals may persist for months. If the patient has persistent copious gastric drainage after 10 to 14 days, it should be noted whether there is bile in the nasogastric or gastrostomy tube. An upper gastrointestinal
696
COHEN AND OTTINGER
series using barium for better delineation of the stoma and the efferent limb should then be obtained. Careful attention to location of any enterostomy tubes should be made. Delayed films should be taken for at least 4 hours in an attempt to assess either the gastroduodenostomy or the status of the gastrojejunostomy and efferent limb. In the case of a retrocolic anastomosis, obstruction by the mesocolon should be ruled out. Fluoroscopic placement of a nasogastric tube in the efferent limb with subsequent barium injections would be helpful if this can be done safely. If there is no other way to rule out the presence of a mechanical abnormality within the efferent limb, flexible gastroscopy with minimal air distention may be helpful. If the problem appears to be "'functional," an extended period of nutritional support with intravenous hyperalimentation is indicated. Measurement of serum lysozyme levels may suggest starch peritonitis, and a trial course of corticosteroids administered parenterally or aspirin administered rectally should be undertaken. Reoperation is indicated in two situations. The most common circumstance is the requirement for a feeding jejunostomy. This is often combined with placement of a gastric drainage tube via the retrograde jejunostomy approach. The second indication is the suggestion of mechanical stomal or efferent limb obstruction. Impatience on the part of the patient or surgeon should not dictate reoperation. If no significant pathology is found upon reoperation, the surgeon should not feel obligated to resect the patent gastroenterostomy, but should be content to place feeding and draining enterostomy tubes.
Acknowledgment
3. 4. 5. 6.
7. 8. 9. 10. 11.
12. 13. 14. 15.
16. 17. 18.
The assistance of Ms. Susanna Nitzsche in collecting the above data and writing this paper is gratefully acknowledged.
19.
References
20. 21.
1. Bergin, W. F. and Jordan, P. H., Jr.: Gastric Atonia and Delayed Gastric Emptying After Vagotomy for Obstructing ulcer. Am. J. Surg., 98:612, 1959. 2. Bodon, G. R. and Ramanath. H. K.: The Gastrojejunostomy
22.
Ann.
Surg. * December 1976
Efferent Loop Syndrome. Surg. Gynecol. Obstet., 134:777, 1972. Colp, R. and Weinstein, V.: Postoperative Complications Following Subtotal Gastrectomy for Peptic Ulcer. Surg. Clin. North Am., 35:383, 1955. Golden, R.: Functional Obstruction of Efferent Loop of Jejunum Following Partial Gastrectomy JAMA, 148:721, 1952. Harper, F. B.: Gastric Dysfunction After Vagectomy. Am. J. Surg., 112:94, 1966. Herrington, J. L.: Remedial Operations for Postgastrectomy Syndromes. Curr. Prob. Surg., April, pp. 14- 17, 1970. Jordan, G. L., Jr. and Walker, L. L.: Severe Problems with Gastric Emptying After Gastric Surgery. Ann. Surg., 177: 660, 1973. Kraft, R. O., Fry, W. J. and DeWeese, M. S.: Postvagotomy Gastric Atony. Arch. Surg., 88:865, 1964. Magnuson, F. K., Juddes, E. S. and Dearing, W. H.: Comparison of Postgastrectomy Complications in Gastric and Duodenal Ulcer Patients. Am. Surg., 32:375, 1966. Nyhus, L. M. and Harkins, H. N., eds.: Surgery of the Stomach and Duodenum. Boston, Little, Brown & Co., 1969; pp. 670-678. Olovson, T.: Postgastrectomy Retention and Its Relation to the Technique of Anastomosis. Int. Surg., 52:458, 1969. Patterson, H. C.: Morbidity Following Gastric Resection for Duodenal Ulcer With and Without Vagotomy. Am. Surg., 31: 175, 1965. Prohaska, J. V., Govostis, M. C. and Kirsteins, A.: Mechanism of Efferent Stomal Dysfunction Following Subtotal Gastrectomy. Arch. Surg., 68:491, 1954. Sawyers, J. L., Scott, H. W., Winberly, J. E., et al.: Is it Necessary to Excise the Duodenal Ulcer With a Billroth I Anastomosis? Am. Surg., 37:150, 1971. Stammers, F. A. R.: Remarks on 15 Cases of Small Bowel Obstruction Following Antecolic Partial Gastrectomy and One Case Following Retrocolic Partial Gastrectomy. Br. J. Surg., 42:34-38, 1954. Thompson, J. E. and Rodgers, J. B.: The Management and Prevention of Abdominal Complications Associated With Gastric and Duodenal Surgery. Am. Surg., 30:553, 1964. Vasconez, L. O., Adams, J. T. and Woodward, E. R.: Treatment of Reluctant Postvagotomy Stoma With Bethanechol. Arch. Surg., 100:693, 1970. Wallace, R., deChantal, J. and Mitty, W. F., Jr.: Morbidity and Mortality of Subtotal Gastrectomy. Am. J. Dig. Dis., 9:745, 1964. Warren, R. P.: Acute Obstruction of Efferent Loop Following Antecolic Partial Gastrectomy with Report of Three Cases. Ann. Surg., 139:202, 1954. Warshaw, A. L.: Personal communication. Warshaw, A. L.: Management of Starch Peritonitis Without the Unnecessary Second Operation. Surgery, 73:681, 1973. Zer, N., Dintsman, M. and Chaimoff, C.: Gastrografin as a Therapeutic Agent in Stomal Malfunction After Gastric Resection. Am. J. Surg., 124:591, 1972.
The characteristics of 46 patients unable to take a solid diet within two weeks of gastric resection and had no other postoperative complications are reviewed. The incidence of delayed gastric emptying was found to be 2½/2 times greater in patients with vagotomy and heniigastrectomy than in those with subtotal gastrectomy. In addition, postoperative delay was often prolonged in the hemigastrectomy and vagotomy group. Mechanical factors were responsible for delay in only 10% of these patients. Possible explanations for these delays are made and it is suggested that localized starch peritonitis may explain many cases of "functional efferent limb ileus." Measures to evaluate the source of delay are recommended and suggest conservative management for the majority of patients. Reoperation is reserved for those who require feeding or draining enterostomy tubes and those whose clinical course and evaluation suggest obstruction. F OLLOWING gastric resection, return of bowel func-
tion will be delayed in a small proportion of cases. However, most patients are able to eat a solid diet within 10 days following an uncomplicated gastric resection. A mechanical problem is usually considered responsible for persistent elevations of gastric residuals past this point and exploratory surgery is often recommended.2 3'6'0'16 In addition to mechanical problems, inflammatory and functional abnormalities of the stomach, gastroenterostomy, duodenum, or efferent limb of a gastrojejunostomy may be the source of the delay. Occasionally, delay is secondary to a major postoperative complication, such as pneumonia or pancreatitis. Hypokalemia or marked nutritional wasting with hypoalbuminemia may also be responsible. Some patients without any other apparent postoperative problems or signs of generalized bowel ileus have delay in gastric emptying after a gastrectomy. It is the purpose of this paper to describe and analyze the exSubmitted for publication February 23, 1976. Reprint requests: Dr. Alfred M. Cohen, Cox Building, Floor 1, Massachusetts General Hospital, Boston, Massachusetts 02114.
From the Department of Surgery, Harvard Medical School and The Massachusetts General Hospital, Boston, Massachusetts
perience of 46 such patients at the Massachusetts General Hospital who could not tolerate a solid diet for at least two weeks following gastrectomy. Material From 1962 until the end of 1974, 1,774 patients at the Massachusetts General Hospital underwent partial gastrectomy. This, number excludes patients with proximal gastrectomy as part of an esophagogastrectomy and those who had a gastrectomy at the time of pancreaticoduodenectomy. Records of patients who had been hospitalized for at least 21 days were selected for evaluation, and patients who had major postoperative complications or a serious systemic illness unrelated to their surgery were excluded from the sample. Forty-six patients were found suitable for analysis, the major criterion for their selection being inability to tolerate a solid diet until 14 or more days following surgery. A solid diet was defined as a soft solid diet, a house diet, or a 6-meal bland diet. Of the 46 patients, 14 underwent emergency gastrectomy and 32 underwent elective or semielective gastrectomy. The procedures were partial distal gastrectomy, subtotal gastrectomy, or hemigastrectomy and vagotomy. Results Diagnosis. The results according to pathological diagnosis are presented in Fig. 1. Ten patients underwent surgery for intractable duodenal ulcer disease, 11 for bleeding duodenal ulcer, 8 for obstructing duodenal ulcer, 11 for gastric ulcer, 3 for gastric tumors, and
689
COHEN AND OT'TINGER
690 * o
o
Ann.
cedure. Specifically, 17 of these 30 patients had
HG+V STG
delays
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.
least 4 weeks before marked
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age range
correlation
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groups.
postoperative
with
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Almost
all
of
patients
the
were
in good to excellent nutritional balance at the time of surgery. In the past 5 years, malnourished patients, particularly those with chronically obstructing duodenal ulcers, have received intravenous alimentation prior to surgery. There was no correlation of preoperative nutritional deficiency with postoperative delay in gastric emptying. o~~~~ Billroth I Reconstruction. Of the 46 patients in this
*
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was a
no
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being
when compared
resumption of gastric function.
50
40
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Age. There There
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70;
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Surg. o December 1976
underwent
Billroth
I
gastroduodenostomy.
The range of delay in gastric median not in these patients was 18 to 31 days, with a emptying significantly different from those who underwent gastrojejunostomy. Fig. 3 describes the results of
upper
gastrointestinal
delay in gastric emptying after
gastrectomy.
3 for hemorrhagic gastritis. Although the sample is too small for definitive analysis, there seemed to be no difference in median delay or range of delay within 70 these groups. Specifically, patients -with obstructing duodenal ulcers were no more prone to lengthy delays in gastric emptying than those with other diagnoses. 60 Type of Operative Procedure. Fig. 2 presents the 46 patients grouped according to the type of operative procedure performed. There were 5 patients who under50 went a partial distal gastrectomy, 11 who underwent subtotal gastrectomy and the remaining 30 had a hemigastrectomy and truncal vagotomy. The degree of gastric 40 Fresection in the hemigastrectomy group varied from 40W to 50%. Patients who underwent subtotal gas- (f) trectomy had from 2/3 to 3/4 of the stomach removed. Ilk Those patients undergoing a distal gastrectomy had K2 30 F50% or less resected. During the 12 years evaluated in this study, approximately 701 patients underwent subtotal gastrectomy, and 20 e842 hemigastrectomy and vagotomy. This indicates that delayed gastric emptying occurs 2½2 times as often in the vagotomy and hemigastrectomy group as compared 10 to subtotal gastrectomy. Of particular interest is that all 11 patients with subtotal gastrectomy were able to resume a solid diet 0 by the 27th postoperative day. The same was true for 4 of the 5 patients who underwent partial distal gastrectomy. However, patients undergoing hemigastrectomy and truncal vagotomy had a median resumption FIG. 2. Effect of of solid diet of 31 days after the operative pro- emptying.
@126
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type of operative procedure on delayed gastric
Vol. 184 . No. 6
DELAYED GASTRIC EMPTYING
691 The large majority of these patients had an antecolic 40gastrojejunostomy so it is impossible to compare the functional results of antecolic with retrocolic reconstructions. 0 The findings on upper gastrointestinal series obtained 30 10 to 14 days postoperatively are presented in Fig. 4. 0 Of the 33 patients undergoing upper gastrointestinal *0 series, 18 showed no emptying of the gastric remnant 20 after one to 4 hours of observation. One of these pa(I) tients was subsequently operated upon and a mechanical KZ obstruction in the efferent limb was corrected. Six patients demonstrated some emptying through what ap10 peared to be a narrow stoma on upper gastrointestinal series. The afferent limb was visualized in only three patients and one of these was found to have a mechanical efferent limb obstruction at the time of exploration. 0 Three patients had delayed gastric emptying, and two NO SMALL NORMAL patients had a normal study. In only one case did the EMPTYING STOMA positioning of the patient in the upright or prone position have any effect on the rapidity with which the FINDINGS ON UGIS dye left the gastric remnant. Of the 41 patients undergoing Billroth II reconstrucFIG. 3. Upper gastrointestinal series findings in Billroth I patients. tion, only 4 had mechanical problems requiring surgical intervention. Of these, one had stomal narrowing series in these patients plotted against the number of days or obstruction and the remaining three had mechanical until return of normal function. The length of delay could obstruction of the efferent limb. Late followup of these patients revealed that one panot be correlated with the apparent degree of patency of the stoma. All of these tests were done with barium sulfate as the contrast medium. *026 In only one of these patients did a mechanical problem cause the delay in postoperative gastric emptyI7 ing. An upper gastrointestinal series performed on that 701fpatient on the 13th postoperative day showed no obstruction to passage of barium. An intra-abdominal abscess 60 _subsequently drained and soon after the patient was able to tolerate a solid diet. In the remaining 4 patients, the gastric outlet obstruction resolved spon50 _taneously. Biliroth II Reconstruction. Forty-one of the 46 pa- 4i) 40 _tients had a gastrojejunostomy. Approximately 13 of the a patients who underwent Billroth II gastrojejunostomy had an omentectomy also. This additional procedure had 30 no bearing on the length of delay. There seemed to be no significant difference in the 20 _postoperative courses of those patients who underwent Polya as opposed to Hofmeister gastrojejunostomy. Of 4, 12 patients in this group who had delays of at least 30 1o _days, 6 patients had a Polya reconstruction and 6 patients had a Hofmeister. In the group with a Polya reconstruction, 4 patients had the efferent limb of the NO SMALL AFFERENT DELAYED POSITIONAL NORMAL EMPTYING STOMA LIMB FILLS EMPTYING EMPTYING gastrojejunostomy brought off the lesser curvature of the stomach and two had it brought off the greater curvaFINDINGS ON /JGIS ture. In the Hofmeister group, 4 had the efferent limb FIG. 4. Upper gastrointestinal series findings after Billroth rebrought off the greater curvature and two off the lesser. construction. K
0
0
K
0
K1
0
0
0
0
S.
0 0
0
II
COHEN AND OTTINGER
692
Ann. Surg. m December 1976
TABLE 1. Summary of Reoperations
Total Days Solid Diet! Days after Reoperation
to
Day of Reop.
Initial Operation
Hemigastrectomy & vagotomy, Billroth II, antecolic-Hofmeister, greater omentum resected Hemigastrectomy & vagotomy, Billroth II, antecolic-Hofmeister, greater omentum not resected
23
22
Operative Findings
Reoperation
Stoma patent, adhesions and inflammation in upper abdomen. Talc on pathology
Lysis of adhesions, placement of gastrostomy & feeding jejun-
72/49
ostomy Omentectomy & resection of gastrojejunostomy, gastrostomy & feeding
37/15
Stoma patent, Omentum wrapped around anastomosis
jejunostomy Hemigastrectomy & vagotomy, Billroth 11, antecolic-Polya, greater omentum not resected
14
Stoma patent. Adhesions around efferent limb
Lysis of adhesions, gastrostomy & feeding jejunostomy
32/18
Hemigastrectomy & vagotomy, Billroth 11, antecolic-Polya, greater omentum resected
9
Stoma patent with kinking of the efferent limb. Adhesions around efferent limb
Lysis of adhesions, gastrostomy & feeding jejunostomy
29/20
Hemigastrectomy & vagotomy, Billroth 11, antecolic-Hofmeister, greater omentum not resected Hemigastrectomy & vagotomy, Billroth 11, antecolic-Polya, greater omentum resected. gastrostomy Hemigastrectomy & vagotomy, Billroth 11, antecolic-Hofmeister Hemigastrectomy & vagotomy, Billroth II, antecolic-Hofmeister, greater omentum not resected, gastrostomy & jejunostomy Hemigastrectomy & vagotomy, Billroth 11, antecolic-Polya. greater omentum not resected, gastrostomy & jejunostomy Hemigastrectomy & vagotomy, Billroth 11, antecolic-Hofmeister Hemigastrectomy & vagotomy, Billroth 11, antecolic-Hofmeister, greater omentum not resected
22
Omentum wrapped around the anastomosis with question of some mechanical obstruction
Omentectomy & resection of gastrojejunostomy
35/13
19
Stoma patent
Feeding jejunostomy
35/16
36
Kinked efferent limb
Lysis of adhesions, gastrostomy, feeding jejunostomy
48/12
44
Stoma patent. Some adhesions
Lysis of adhesions, new gastrostomy & feeding jejunostomy
51/7
18
Stoma patent with some kinking at the jejunostomies
Lysis of adhesions, removal of gastrostomy & jejunostomy
56/38
14 wks.
Stoma patient with minimal reaction Stomal stenosis
Exploration
18 mos.
126/25
Revision of gastrojejunostomy
tient who had a narrow stoma on upper gastrointestinal jejunostomy tube feedings and 72 days from his initial surgery he series required re-resection of his gastrojejunostomy for was able to take a soft solid diet. A 32-year-old man with duodenal ulcer disease underwent elective stomal stenosis 18 months after the original procedure. Case
Reports
Patients Undergoing Reoperation. Patients requiring reoperation either for placement of a feeding jejunostomy or gastrostomy tube or for definitive repair are presented in Table 1. A 48-year-old man underwent a hemigastrectomy and vagotomy, resection of the greater omentum and antecolic Hofrneister gastrojejunostomy for hemorrhagic gastritis. On his ninth postoperative day, an upper G6 series revealed that no barium left the stomach over a two hour period. At reoperation on his 23rd postoperative day, extensive adhesions and inflammation in the upper abdomen were found. The stoma was widely patent. He underwent lysis of adhesions and placement of feeding and draining jejunostomy catheters. His pathology revealed talc granules and a granulomatous reaction. Large amounts of bilious gastric drainage persisted and an upper GI series obtained 6 weeks after the second operation showed persistent slow passage of barium out of the stomach. He was maintained on
hemigastrectomy and vagotomy. The greater omentum was not removed and an antecolic Hofmeister gastrojejunostomy with the afferent limb to the lesser curve was performed. A draining jejunostomy tube was placed. Large gastric residuals persisted postoperatively and an upper GI series revealed no drainage of barium from the stomach. Because the patient had inadvertently removed the draining jejunostomy, he underwent reoperation on his 22nd postoperative day. Operative findings included some omentum wrapped around the anastomosis, but were generally unremarkable. He underwent revision of the gastrojejunostomy and resection of the omentum, Feeding and draining jejunostomy catheters were placed. Following this operation, large gastric drainage persisted and he was maintained on jejunostomy tube feedings. Thirty-seven days after the original operation and fifteen days after the second procedure, he was able to take a soft solid'diet. A 67-year-old man underwent elective surgery for duodenal ulcer. A hemigastrectomy and vagotomy with an antecolic Polya gastrojejunostomy was performed. The greater omentum was not resected. An upper GI series on postop day 9 revealed high grade stomal
obstruction. On the 14th postop day, laparotomy revealed dense adhesions around the efferent limb and a patent stoma. He underwent lysis of adhesions and placement of feeding and draining jejunostomies. Large bilious gastric residuals persisted after the second operation. He was maintained on jejunostomy tube feedings with resolution of the obstruction and, on the 32nd day after the first operation and 18th day after the second operation, he was able to take a soft solid diet. A 57-year-old man underwent elective surgery for duodenal ulcer. He was well nourished but had a history of an 80 pound weight loss over a two-year period. He underwent hemigastrectomy, vagotomy, resection of greater omentum, and antecolic Polya gastrojejunostomy with the afferent limb to the greater curve. An upper GI series on the 7th postoperative day revealed barium passing into a dilated efferent limb and complete obstruction at the efferent limb. He underwent reoperation on the 9th postoperative day with the findings suggestive of a kinked efferent limb. The stoma was otherwise patent. The surgery involved placement of feeding and draining jejunostomies and lysis of adhesions. He had persistent large gastric residuals and an upper GI series obtained on the 12th day after the second operation revealed emptying of the gastric remnant into the efferent limb only when the patient was supine. He was able to take a soft solid diet on the 29th day after the first operation and the 20th day after the reoperation. A 32-year-old man underwent elective surgery for duodenal ulcer. He underwent hemigastrectomy and vagotomy without resection of the greater omentum. An antecolic Hofmeister gastrojejunostomy with afferent limb to lesser curve was performed. An upper GI series on the 14th postoperative day revealed complete absence of drainage of barium from the gastric remnant. He underwent surgery 22 days after the initial procedure with the findings of omentum wrapping around the anastomosis with perhaps partial mechanical obstruction. The greater omentum and gastrojejunostomy were resected. Gastric drainage remained poor after the reoperation. He was able to take a soft solid diet 35 days after the initial procedure and 13 days after the second procedure. A 71-year-old man had surgery for an obstructing duodenal ulcer. He was well nourished and had four days of nasogastric tube suction prior to the procedure. He underwent hemigastrectomy, vagotomy, and resection of the greater omentum. An antecolic Polya gastrojejunostomy with afferent limb to the greater curve was performed. A draining jejunostomy was placed. On several subsequent upper GI series, no barium left the gastric remnant. On the 19th postoperative day he underwent reoperation. There were no significant findings at surgery and the stoma was widely patent. A feeding jejunostomy was
placed. He
a
was
maintained
on
jejunostomy tube feedings and
the 35th day following the initial procedure he soft solid diet.
on
693
DELAYED GASTRIC EMPTYING
Vol. 184 * No. 6
was
able
to
take
A 52-year-old man had elective surgery for duodenal ulcer. He was well nourished but had lost 13 pounds the previous year. His chemistries were within normal limits. He underwent hemigastrectomy and vagotomy without resection of the greater omentum. An antecolic Hofmeister gastrojejunostomy with the efferent limb to the lesser curve was performed. He had persistent hiccoughs after surgery and gastric dilatation required prolonged nasogastric tube suction. Nutrition was maintained on intravenous hyperalimentation, although his serum albumin fell as low as 2.6. On the 26th postoperative day he was able to take a soft solid diet. Eighteen months after the initial procedure, he underwent revision of the gastrojejunostomy for stomal
stenosis. A 66-year-old man underwent elective surgery for duodenal ulcer. A hemigastrectomy and vagotomy with an antecolic Hofmeister gastrojejunostomy with afferent limb to lesser curve was performed. Barium upper GI series on postoperative days 18, 27, and 35 revealed no drainage from the gastric remnant. At surgery on postop day 36, twisting and kinking of the efferent limb was present. He underwent lysis
of adhesions and placement of feeding and draining catheter jejunostomies. He was on a soft solid diet 48 days after the original procedure and 12 days after the reoperation. A 62-year-old man underwent surgery for an obstructing duodenal ulcer. He had not lost weight and appeared well nourished prior to his surgery. Nasogastric suction was used for 5 days prior to a hemigastrectomy and vagotomy. Greater omentum was not resected and an antecolic Hofmeister gastrojejunostomy with the afferent limb to the lesser curve was performed. Feeding and draining catheter jejunostomies were placed. Barium upper GI series on days 13, 24, 29. and 37 demonstrated no drainage of barium from the gastric remnant; however, large amounts of bile drained out of the gastric remnant and on day 44 he underwent reoperation. At the time of surgery, there were some adhesions but the stoma was widely patent and the efferent limb was slightly dilated. 32nd day after the second procedure showed much improved drainage with the patient in the prone position. He was maintained on jejunostomy tube feedings and was able to take a soft solid diet 56 days after the original procedure and 38 days after the reoperation. A 59-year-old woman underwent elective surgery for a gastric ulcer. A hemigastrectomy and vagotomy with antecolic Hofmeister gastrojejunostomy with afferent limb to greater curve was performed. She was on liquids early postoperatively, but developed nausea and vomiting. An upper GI series on the 9th postoperative day revealed complete stomal obstruction. On her 28th postoperative day, narrow stoma was apparent on repeat upper GI series. She had persistent postprandial emesis with upper GI series at 6. 8, and 10 weeks showing a very narrowed stoma. Fourteen weeks after the initial procedure, she underwent exploration with the finding of a gastrojejunostomy stoma that would admit two fingers with minimal reaction. On the 11th day following this second operation, upper GI series rea
vealed complete obstruction. However, she
was able to take a soft diet 126 days after the initial procedure and 25 days after the second procedure at which time the upper GI series was normal.
Discussion The incidence of delayed gastric emptying after gastric resection as reported in the literature can be as high as 20%.7.9.12.1 ,6.18 In a series of 1,261 patients undergoing gastric resection reported by Jordan and Walker, only 1.6% required nasogastric suction for greater than 10 days.7 These authors found no difference in length of delay between patients who had a subtotal gastrectomy and those who had a hemigastrectomy and vagotomy. In a series of 500 patients undergoing subtotal gastrectomy at St. Vincent's Hospital, 4% had gastric outlet obstruction postoperatively.18 In the Vanderbilt series of 371 patients undergoing gastrectomy and Billroth I reconstruction, 5% had delayed emptying. 14 In a report of 325 patients undergoing elective subtotal
Clinic, 3% of these patients had delayed emptying.9 Most of these patients had Billroth II, retrocolic Hofmeister reconstructions. Patterson reported his postoperative complications following gastrectomy and in this series of over 200 patients the incidence of delayed gastric emptying postoperatively was 16-20.12 He found no difference between patients who had a gastrectomy with vagotomy and those who had a gastrectomy without vagotomy, but twice as many patients with hemigastrectomy and vagotomy with Billgastrectomy at the Mayo
COHEN AND OTTINGER
694 TABLE 2.
A. Mechanical 1. Stomal stenosis 2. Stomal edema 3. Efferent limb kinking 4. Efferent limb hernia 5. Efferent limb obstructed by enterostomy tube 6. Efferent limb obstructed by mesocolon 7. Jejunostomy intussusception B. Functional 1. Efferent limb 2. Stomal
3. Gastric C. Inflammatory 1. Adhesions (omentum, talc or starch) 2. Intra-abdominal abscess
roth II reconstructions had delayed emptying for at least 3 weeks compared to those with a Billroth I reconstruction. There are few reports in the literature describing the time course of resolution of delayed gastric emptying following gastrectomy. In patients in the Mayo Clinic series, normal gastric function resumed in 17 days or less.9 In Patterson's report, almost one-half of the patients had at least three weeks delay in eating.'2 Kraft reported that patients with delay resolved their problems in an average of 25-37 days.10 In our group of 46 patients, recovery from delayed gastric emptying occurred over a wide time range. Significantly, the median delay in the group undergoing hemigastrectomy with vagotomy was 30 days while all but one patient had resolution within 27 days in the group undergoing gastric resection without vagotomy. This suggests that not only does vagotomy with gastric resection increase the incidence of delayed remnant emptying, but when delay does occur, it is often prolonged. Delay in gastric emptying following gastrectomy can be attributed to three major sources: mechanical abnormalities, functional problems and inflammatory processes. Table 2 outlines the possibilities, excluding those causes that lead to generalized bowel ileus, such as pancreatitis. In cases of mechanical stomal obstruction at a gastrojejunostomy, it is rarely the size of the stoma that limits gastric drainage since in almost all cases the circumference of the gastrojejunostomy exceeds the circumference of the efferent limb. In fact, it is the size of the jejunum which limits the rate of gastric emptying. Edema of the gastroenterostomy is probably not responsible for obstruction in patients whose eating is delayed for at least two weeks, since experience with wound healing suggests that wound edema has resolved by this time. Mechanical problems involving the efferent limb have been reported, particularly internal herniation and intussusception.15"19 It is possible that in a number of cases
Ann. Surg. * December 1976
in our group, a mechanical efferent limb obstruction spontaneously resolved, as is often the case with early postoperative small bowel obstruction. A number of surgeons are adamant about placement of the efferent limb with regard to the greater or lesser curvature of the stomach to prevent such mechanical obstructions.3'11'13 There appeared to be no difference in results between the two techniques in our study. Golden first suggested in 1952 that delayed gastric emptying could be attributed to functional obstruction of the efferent limb of the gastrojejunostomy as evidenced by spasm of the limb on barium study.4 More recently, Bodon and Ramanath reported 5 patients with this so-called "efferent limb obstruction" in whom, at the time of surgery, the efferent limb was flaccid and peristalsis could not be elicited by pinching or touching the bowel.2 It is quite possible that a functional efferent limb ileus is a result of low grade inflammatory processes. Many of our patients who underwent reoperation had inflammation in the upper abdomen. In one patient, talc granules were identified on pathology, suggesting that "efferent loop syndrome" could be due to a localized starch reaction that resolves spontaneously. This could account for the appearance of signs of obstruction late in the postoperative course, which is consistent with the experience with starch peritonitis elsewhere.21 Among our patients with "obstruction" of the efferent limb, lysis of adhesions and resection of the gastrojejunostomy usually did not provide an immediate cure, which suggests either a functional or inflammatory abnormality involving the bowel. If a localized starch reaction is at fault, surgery could worsen the situation by introducing additional contamination by starch granules. Measurements of serum lysozyme levels may be helpful in making this diagnosis.20 It has been suggested that gastric atony aggravated by vagotomy contributes to delayed gastric emptying. However, Nyhus points out that studies of the motility of the stomach by barium and manometric techniques have demonstrated that gastric atony is not a factor in postoperative retention.'0 His findings, among others, have demonstrated that there is normally no peristalsis in the gastric remnant following subtotal gastrectomy or hemigastrectomy with or without vagotomy. Even in the normal stomach, peristaltic waves are limited almost exclusively to the antrum. Some surgeons consider it inadvisable to perform a vagotomy in patients with obstructing duodenal ulcer.1"5'8 In a detailed paper on the problems of vagotomy in patients with duodenal ulcer disease, Kraft reported on 145 patients undergoing gastric resection for obstructing duodenal ulcer.8 Half of the patients underwent vagotomy and hemigastrectomy and the other half subtotal gastrectomy. The incidence of delayed gastric emptying
Vol. 184 . No. 6
DELAYED GASTRIC EMPTYING
in the subtotal gastrectomy group was 3% compared to 9% in the group with vagotomy and hemigastrectomy. However, his data reveal that the incidence of delay after vagotomy and hemigastrectomy in another 79 patients without preoperative obstruction was also 9o, suggesting that it was the operative procedure and not antecedent gastric distention that produced delayed gastric emptying. In our series, the incidence of delayed gastric emptying was 2½2 times greater in patients with vagotomy and hemigastrectomy than in those with subtotal resection alone. The data were insufficient to comment on the relative incidence in the group with obstructed duodenal ulcers. A number of authors have suggested that if patients are unable to tolerate eating 10 to 14 days after gastric resection, they should undergo a "corrective" operation.2'3.6"0 Thompson and Rodgers stated that kinking and adhesions involving the efferent limb with mechanical obstruction are almost always the cause of delayed emptying after gastrectomy.16 Herrington recommended that patients without return of function in two weeks should have a reoperation, that a new gastroenterostomy be fashioned and a nasogastric tube placed into the efferent limb.6 Bodon and Ramanath usually reoperated after two weeks, performing a jejunostomy between the afferent and efferent limbs. In Kraft's series, gastrostomy and feeding jejunostomy tubes were placed in patients requiring reoperation and all but one did well.8 Of 14 patients with reoperations in Jordan and Walker's series, one patient required an addition gastrectomy; 2, revision of the gastroenterostomy; 5, lysis of adhesions; 4, feeding and draining enterostomy tubes; and 2, gastrojejunostomy.5 In an older paper Prohaska et al. discussed 5 patients with delayed gastric emptying following subtotal gastrectomy; upon reoperation all five had patent stomas and underwent jejunojejunostomy between the efferent and afferent limbs with satisfactory results.13 In our series of 46 patients, 10 required reoperation in the immediate postoperative period. An additional patient underwent reoperation 18 months after the initial procedure because of persistent stomal stenosis. In this latter patient, an organically small stoma aggravated by stomal edema was probably responsible for the initial delay in gastric emptying. In 9 of the 11 patients, the stoma was patent at reoperation. In 6 patients, adhesions and/or inflammation involving the stoma or the efferent limb was present. A mechanical problem was definitely present in two patients and suspected in an additional two, representing less than 10o of our total sample. As indicated in Table 1, gastric function was not often improved by reoperation such as lysis of adhesions and omentectomy or even re-resection of the
gastrojejunostomy.
695 Upper gastrointestinal series did not provide a clear guide in the management of our group of patients. It is difficult to interpret the reasons for barium retention in the gastric remnant even after a prolonged waiting period. Although no barium entered the efferent or afferent limbs in many of these patients, we know from their charts that bile was present in the stomach, indicating that the afferent limb was open. Presumably, the continuous drainage of pancreatic and biliary fluid from the afferent limb prevented filling by the barium. On occasion, however, the upper gastrointestinal series is beneficial, particularly in diagnosing factitious obstruction. In one case, a gastrostomy tube which had been placed by the retrograde jejunostomy technique had slipped into the afferent limb. Once this type of obstruction is noted on x-ray, it can be confirmed by intermittent clamping of the catheter and advancement of the patient's diet. The gastrointestinal series can also be useful in determining whether the gastric remnant empties only when the patient is in a certain position. Very few patients in our series underwent gastroscopy and none underwent selective efferent limb barium x-rays. Both of these studies might have provided information helpful in the management of the patient. It has been suggested that meglamine diatrizoate (Gastrografing) be employed therapeutically as well as diagnostically during the gastrointestinal series.22 The hypertonic aspects of Gastrografin reduces edema of surrounding tissues and, in addition, produces hyperperistalsis of the small bowel. In the few patients in our series in whom Gastrografin was employed in upper gastrointestinal series, gastric emptying did not resume any more quickly than when other contrast media were used. Vasconez et al. have reported the use of urecholine chloride in 6 patients following hemigastrectomy and vagotomy with persistent gastric retention.17 Five of the 6 patients responded to the treatment including 3 patients who had already undergone reoperation without improvement. The patients were given intermittent subcutaneous urecholine chloride following a barium meal until gastric emptying began; subsequently, the patient was allowed to eat with a tapering course of urecholine chloride for one month.
Conclusions In only a small number of cases will delay in gastric emptying after gastrectomy be due to mechanical problems. Following hemigastrectomy and vagotomy, large gastric residuals may persist for months. If the patient has persistent copious gastric drainage after 10 to 14 days, it should be noted whether there is bile in the nasogastric or gastrostomy tube. An upper gastrointestinal
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series using barium for better delineation of the stoma and the efferent limb should then be obtained. Careful attention to location of any enterostomy tubes should be made. Delayed films should be taken for at least 4 hours in an attempt to assess either the gastroduodenostomy or the status of the gastrojejunostomy and efferent limb. In the case of a retrocolic anastomosis, obstruction by the mesocolon should be ruled out. Fluoroscopic placement of a nasogastric tube in the efferent limb with subsequent barium injections would be helpful if this can be done safely. If there is no other way to rule out the presence of a mechanical abnormality within the efferent limb, flexible gastroscopy with minimal air distention may be helpful. If the problem appears to be "'functional," an extended period of nutritional support with intravenous hyperalimentation is indicated. Measurement of serum lysozyme levels may suggest starch peritonitis, and a trial course of corticosteroids administered parenterally or aspirin administered rectally should be undertaken. Reoperation is indicated in two situations. The most common circumstance is the requirement for a feeding jejunostomy. This is often combined with placement of a gastric drainage tube via the retrograde jejunostomy approach. The second indication is the suggestion of mechanical stomal or efferent limb obstruction. Impatience on the part of the patient or surgeon should not dictate reoperation. If no significant pathology is found upon reoperation, the surgeon should not feel obligated to resect the patent gastroenterostomy, but should be content to place feeding and draining enterostomy tubes.
Acknowledgment
3. 4. 5. 6.
7. 8. 9. 10. 11.
12. 13. 14. 15.
16. 17. 18.
The assistance of Ms. Susanna Nitzsche in collecting the above data and writing this paper is gratefully acknowledged.
19.
References
20. 21.
1. Bergin, W. F. and Jordan, P. H., Jr.: Gastric Atonia and Delayed Gastric Emptying After Vagotomy for Obstructing ulcer. Am. J. Surg., 98:612, 1959. 2. Bodon, G. R. and Ramanath. H. K.: The Gastrojejunostomy
22.
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Surg. * December 1976
Efferent Loop Syndrome. Surg. Gynecol. Obstet., 134:777, 1972. Colp, R. and Weinstein, V.: Postoperative Complications Following Subtotal Gastrectomy for Peptic Ulcer. Surg. Clin. North Am., 35:383, 1955. Golden, R.: Functional Obstruction of Efferent Loop of Jejunum Following Partial Gastrectomy JAMA, 148:721, 1952. Harper, F. B.: Gastric Dysfunction After Vagectomy. Am. J. Surg., 112:94, 1966. Herrington, J. L.: Remedial Operations for Postgastrectomy Syndromes. Curr. Prob. Surg., April, pp. 14- 17, 1970. Jordan, G. L., Jr. and Walker, L. L.: Severe Problems with Gastric Emptying After Gastric Surgery. Ann. Surg., 177: 660, 1973. Kraft, R. O., Fry, W. J. and DeWeese, M. S.: Postvagotomy Gastric Atony. Arch. Surg., 88:865, 1964. Magnuson, F. K., Juddes, E. S. and Dearing, W. H.: Comparison of Postgastrectomy Complications in Gastric and Duodenal Ulcer Patients. Am. Surg., 32:375, 1966. Nyhus, L. M. and Harkins, H. N., eds.: Surgery of the Stomach and Duodenum. Boston, Little, Brown & Co., 1969; pp. 670-678. Olovson, T.: Postgastrectomy Retention and Its Relation to the Technique of Anastomosis. Int. Surg., 52:458, 1969. Patterson, H. C.: Morbidity Following Gastric Resection for Duodenal Ulcer With and Without Vagotomy. Am. Surg., 31: 175, 1965. Prohaska, J. V., Govostis, M. C. and Kirsteins, A.: Mechanism of Efferent Stomal Dysfunction Following Subtotal Gastrectomy. Arch. Surg., 68:491, 1954. Sawyers, J. L., Scott, H. W., Winberly, J. E., et al.: Is it Necessary to Excise the Duodenal Ulcer With a Billroth I Anastomosis? Am. Surg., 37:150, 1971. Stammers, F. A. R.: Remarks on 15 Cases of Small Bowel Obstruction Following Antecolic Partial Gastrectomy and One Case Following Retrocolic Partial Gastrectomy. Br. J. Surg., 42:34-38, 1954. Thompson, J. E. and Rodgers, J. B.: The Management and Prevention of Abdominal Complications Associated With Gastric and Duodenal Surgery. Am. Surg., 30:553, 1964. Vasconez, L. O., Adams, J. T. and Woodward, E. R.: Treatment of Reluctant Postvagotomy Stoma With Bethanechol. Arch. Surg., 100:693, 1970. Wallace, R., deChantal, J. and Mitty, W. F., Jr.: Morbidity and Mortality of Subtotal Gastrectomy. Am. J. Dig. Dis., 9:745, 1964. Warren, R. P.: Acute Obstruction of Efferent Loop Following Antecolic Partial Gastrectomy with Report of Three Cases. Ann. Surg., 139:202, 1954. Warshaw, A. L.: Personal communication. Warshaw, A. L.: Management of Starch Peritonitis Without the Unnecessary Second Operation. Surgery, 73:681, 1973. Zer, N., Dintsman, M. and Chaimoff, C.: Gastrografin as a Therapeutic Agent in Stomal Malfunction After Gastric Resection. Am. J. Surg., 124:591, 1972.
