Symposium of Peptic Ulcer Disease
Postoperative Gastric Retention and Delayed Gastric Emptying Ian Donovan, MD., F R.C.B., * and J. Alexander-Williams, MD., Ch.M., F.R.C.B. t
Since the beginning of the era of gastric operations, surgeons have been aware of the complication of delay in emptying of the stomach. There is no absolute criterion of diagnosis of delayed gastric emptying but we suggest the arbitrary definition of failure to establish adequate emptying of fluids through the pylorus or stoma by the fifth postoperative day. Some surgeons routinely continue nasogastric suction and do not allow oral feeding until the fifth postoperative day.15 Others use no nasogastric suction and allow patients to eat and drink as soon as they are hungry and thirsty.7 However, all surgeons recognize the phenomenon of the patient who, after a gastric operation, either vomits or has gastric aspirate volume in excess of irltake at 7, 10, or more days after operation. The incidence of the complication varies in reported series. Some claim never to encounter it,7 others report incidences that vary with the operation and the type of patient operated upon. Bergin and Jordan4 found delaying gastric emptying in 28 per cent of their patients treated by truncal vagotomy and pyloroplasty for duodenal ulcer with stenosis. Roth and his coUeagues12 reported that 27.5 per cent of their patients had gastric stasis after vagotomy and hemigastrectomy. In the early years of our experience with vagotomy and pyloroplasty we had delayed gastric emptying in 17 per cent of our patients but, as the result of a modification of technique described later, within 4 years the incidence has fallen to 2 per cent.3
CAUSES The causes of delayed gastric emptying are (1) occlusion of the lumen at the stoma and (2) gastric atony as a result of vagal denervation From The General Hospital, Binningham, England • Senior Registrar tClinical Senior Lecturer, University of Birmingham; Consultant Surgeon, United Binningham Hospital, External Scientific Staff, Medical Research Council, England
Surgical Clinics of North America- Vol. 56, No.6, December 1976
1413
1414
IAN DONOVAN AND
J.
ALEXANDER-WILLIAMS
of the motor fibers of the stomach. In those patients who have had an intestinal suture line and vagal denervation, both factors can occur. Predisposing factors include long-standing obstruction, inanition, gastritis, and chronic electrolyte depletion. There is no evidence that early drinking or eating predisposes to delayed emptying. Luminal Obstruction Temporary mechanical obstruction may result from stomal edema when too generous a cuff is inverted in a two-layer anastomosis. However, we believe that the commonest cause of serious prolonged delay in gastric emptying is minor suture line leakage resulting in an abscess with surrounding edema and sometimes fibrosis. Rarely stomal obstruction may result from kinking of a gastrojejunal anastomosis or from the technical error of suturing the front to the back wall of the anastomosis. Obstruction of the stoma due to internal herniation or retrograde jejunogastric intussusception are well recognized but rare complications. A less well recognized but probably commoner cause is postischemic fibrosis of the duodenum following devascularization by a too thorough dissection before gastroduodenal anastomosis. Vagal Denervation Vagotomy divides both secretory and motor nerves to the stomach. It has long been known that truncal vagotomy alone, without a drainage
procedure, is associated with a high incidence of gastric retention. Tanner14 found that 49 per cent of patients had postoperative gastric stasis with vomiting and eructations after truncal vagotomy alone without drainage. However, even after this operation Dragstedt and his colleagues5 found that if the stomach was emptied frequently by nasogastric suction, its tone gradually returned and after some weeks or months the patient was able to empty the stomach satisfactorily via the pylorus despite continued complete vagal denervation. In the dog it has been shown that vagotomy temporarily disorganizes the electrical activity of the stomach and causes a permanent slowing of pacesetter potential in the corpus and antrum. Furthermore, there is permanent impairment of the electrical response to stimuli. to Studies of gastroduodenal motor co-ordination, also in the dog, have shown no long-term effect of vagal denervation either of the whole or of the proximal part of the stomach. t Operations that retain the vagal innervation of the antrum (proximal gastric vagotomy) cause little disturbance of normal motor function. Studies of myoelectrical and motor activity of the stomach in man have shown that in the early postoperative days there is a decrease to 75 per cent of preoperative activity following proximal gastric vagotomy compared with a decrease to 38 per cent after selective and 31 per cent after truncal vagotomyY In our experience it is possible, after proximal gastric vagotomy, to allow patients to eat and drink as soon as they wish without risk of complication. Johnston9 has reported a cumulative review of over 5000 patients after proximal gastric vagotomy with a very low incidence of gastric retention.
1415
POSTOPERATIVE COMPLICATIONS
DIAGNOSIS In the immediate postoperative period, delay in gastric emptying must be distinguished from a generalized paralytic ileus and from mechanical intestinal obstruction. Although this will often be possible on clinical evidence, specialized investigation may also be required. X-ray examination is helpful in that it gives a visual indication of the nature and site of any obstruction and an estimation of the volume of fluid passing from the stomach into the distal bowel. Although watersoluble contrast media such as Gastrografin are safer than barium if there is any question of leakage from the gut, they have the disadvantage of giving a less clear image and of being hyperosmolar. We recommend the use of a dilute barium suspension if the clinical findings exclude the possibility of leakage. Gastroscopy will indicate whether there is mechanical obstruction to the stoma but in a patient with an anastomosis it may not be safe to distend the stomach with air in the first 10 days after operation. Endoscopy is, however, helpful in assessing patients with persistent delay in gastric emptying and may help to avoid reoperating on patients who have a widely patent stoma. Reoperation is a poor means of determining the cause of postoperative gastric retention. There is a group of patients who have impaired gastric emptying which is not an obvious problem in the immediate postoperative period. They present at varying time intervals within the first year after surgery with symptoms of postcibal fullness, foul eructations, and vomiting of old food residues. There is usually a gastric outlet obstruction with or without the added effects of vagal denervation. The delay in clinical presentation is probably due to progressive fibrosis following the initial suture line leak and surrounding inflammation. Diagnosis in these patients is confirmed by barium meal examination. Where the clinical presentation is less florid and barium studies are equivocal, external scanning measurement of the gastric emptying of a radio-isotopically labelled solid meal is helpful.
PREVENTION Prevention of the complication of suture line obstruction demands a meticulous operative technique. A two-layer intestinal closure causes more suture line inversion than does a single layer. However, a single layer anastomosis may have a greater tendency to leak, particularly if an interrupted suture "cuts through" inflamed or edematous tissue. When we began to employ vagotomy and pyloroplasty in the treatment of duodenal ulcer we followed the Heineke-Mickulicz technique with a two-layer closure. However, the high incidence of postoperative gastric retention (17 per cent in the first year) led us to adopt the Weinberg onelayer closure with interrupted silk. The results rapidly improved until the incidence of retention was 2 per cent. Later, two patients had prolonged gastric retention due to a peristomal abscess complicating leakage. As a consequence of these experiences, we now perform a
1416
IAN DONOVAN AND
J.
ALEXANDER-WILLIAMS
pyloroplasty with an inner layer of continuous chromic catgut that approximates the gastric mucosa to the full thickness of the duodenal wall. This is covered by an interrupted layer of silk sutures that suture the stomach wall to the duodenal wall with minimal inversion. This technique gives so little trouble that we no longer use postoperative nasogastric intubation and allow patients to drink as soon as they wish after the operation. Preoperative cleansing of the stomach and removal of gastric residue is important in those patients with preoperative gastric outlet obstruction and those with gastric carcinoma. The normal stomach contains relatively few pathogenic organisms, but the obstructed stomach or a stomach with malignancy is heavily contaminated and is likely to be associated with a greater risk of local sepsis after operation. In these patients we employ preoperative gastric lavage and use preoperative parenteral antibiotic therapy, depending on the type of organism cultured from material obtained from the stomach at endoscopy or preoperative lavage. Electrolyte repletion is important in patients with long-standing gastric outlet obstruction and vomiting. Intravenous sodium and potassium are given, but we do not find it necessary to take more than 24 hours in preoperative correction of electrolyte depletion. We have investigated the value of prolonged preoperative parenteral feeding in patients with gastric outlet obstruction who were undernourished but we could demonstrate no advantage of this often troublesome regimen when compared with the policy of rapid electrolyte repletion, early operation and early return to normal alimentation. We have found no advantage in prolonged nasogastric decompression of a preoperatively obstructed stomach. Gastric tone appears to return to normal within 24 hours after gastric retention is relieved. There are no preventive measures that can be taken when performing total vagal denervation. However, when perfonning a proximal gastric vagotomy it is vital to ensure that the nerve of Latarjet is preserved. This is best achieved by dissecting the anterior and posterior leaves of the lesser omentum separately on the anterior and posterior aspects of the lesser curve, as far as possible away from the left gastric artery and vein. Hematomata must be avoided by gentle meticulous dissection with separate ligation of the many fine vessels. Some surgeons employ electrical nerve stimulation tests to demonstrate the integrity of antral innervation after proximal gastric vagotomy. We began by using this technique and can confirm that antral contraction can be checked visually and manometrically during operation. However, we find that with a careful technique the nerves were never damaged and in our practice routine nerve stimulation has been abandoned.
TREATMENT OF ESTABLISHED DELAY When the diagnosis of delayed gastric emptying in the early postoperative phase has been established by the methods described above,
POSTOPERATIVE COMPLICATIONS
1417
gastric decompression is advisable until normal gastric emptying is shown to have returned. When the obstruction is at the gastric outlet, the volume of fluid secreted into the stomach rarely exceeds 1 liter in 24 hours. If the delay is due to gastric atony, some emptying usually occurs and the volume of aspirate is less. Continuous gastric aspiration is therefore unnecessary, intermittently hourly aspiration is adequate, allowing the tube to drain freely into a drainage bag so that swallowed air may escape. Fluid and electrolyte replacement must continue and intravenous feeding with calories begun.
Drug Therapy Urecholine has been shown to improve the rate of gastric emptying in patients with atony immediately after vagotomy when there is no mechanical obstruction, but to be ineffective if there is an element of obstruction. 6 ,11 Similar claims have been made for the drug bethanecol chloride but so far the claims have not been fully substantiated. Metaclopramide (Maxolon) increases gastric emptying in the normal vagally innervated stomach. s There is no evidence of its efficacy in improving the rate of emptying of the stomach in the early phase of atony after vagal denervation. However, metaclorpromide may be of some value in patients with inadequate gastric emptying many weeks or months after operation. Anti-inflammatory drugs have been recommended in patients with stomal edema; Butazolodin and steroids have had their advocates but they are dangerous drugs whose efficacy is unproven. We do not recommend their use. If tissue infection is playing a part in inflammatory edema then an antibiotic capable of achieving a high tissue concentration may be helpful.
Diet When obstruction is complete due to inflammatory swelling there is no value in giving either liquid or solid food. However, fluids may be given by mouth and reaspirated to improve the patient's comfort and morale. It is important to remember that if clear water is given it returns as an isotonic aspirate and so electrolytes are dialyzed from the stomach. When there is no mechanical outlet obstruction but the delayed emptying is due to vagal denervation there is evidence and clinical experience suggesting that solid foods are emptied better than liquids. A patient who continues to have large gastric aspirates when given a liquid diet may therefore empty the stomach relatively normally if given light solid food.
Reoperation When a patient has established delayed postoperative gastric emptying, aspiration and parenteral feeding are continued in the expectation of return of normal emptying within 10 to 14 days. Fortunately, most patients fulfill this expectation. However, when complete gastric retention has persisted for 14 days after the operation the question of reoperation
1418
IAN DONOVAN AND
J.
ALEXANDER-WILLIAMS
has to be considered. It is important to attempt to diagnose the cause of the obstruction; by the 14th day endoscopy is safe and usually informative. If there is not complete stomal obstruction, we have continued a gastric aspiration regimen for up to 23 days in two patients who have subsequently recovered normal gastric emptying. 2 Follow-up studies 5 years later show that both patients have no symptoms related to any defect of gastric emptying. If, however, at 14 days there is still complete stomal obstruction, the fortitude of the patient and the medical attendants is usually weakening and reoperation has to be considered. In those patients presenting some time after operation, drug therapy, as mentioned previously, may be of benefit if the major problem is atony; if the delay is due to stomal obstruction, however, reoperation will probably be necessary.
Choice of Operation When the operation is at a gastroduodenostomy or pyloroplasty, it is usual to bypass the duodenum. We have experience of three patients treated in this manner, one of whom still failed to drain satisfactorily with a gastrojejunostomy and later required a Roux-en-y operation. As an alternative approach, the stoma can be explored by a finger through a gastrotomy. If there is patency of the stoma or it can be established by gentle dilatation, then a tube can be passed through the stoma into the duodenum via the gastrotomy; another tube is passed into the stomach. The patient can then be managed by gastric aspiration and replacement into the duodenum either of the gastric aspirate or a prepared diet. Our experience is limited to three patients treated by this method, two fared well and normal emptying returned, the third later required a gastrojejunostomy. As a consequence of this limited experience, we cannot give an authoritative statement. However, we advise that if there is gross peristomal edema and patency cannot be established easily, gastrojejunostomy is advocated but, where technically feasible, we prefer the double intubation techniqu't!. We consider it unwise in the early stage or weeks after the first operation to take down the entire anastomosis, as this is invariably technically difficult and hazardous. In the rare cases where technical disasters have made further dissection inevitable, we advocate completing the operation as a truncal vagotomy and antrectomy with a Roux-en-y anastomosis and a protecting gastrostomy and duodenostomy (see below).
Anticipation As previously stated we find that postoperative gastric retention is a rare complication in the patient with simple peptic ulceration requiring operative treatment. However, there are exceptional cases when the complication is expected, for example in patients with gross duodenal ulceration in whom there are special indications to perform a vagotomy and pyloroplasty or vagotomy, antrectomy, and gastroduodenal anastomosis. In such patients we feel that the discomfort and danger of prolonged nasogastric intubation is better avoided by performing a balloon catheter gastrostomy at the time of the first operation. Balloon
1419
POSTOPERATIVE COMPLICATIONS
catheters have been developed with a third long limb that can be passed through the stoma into the bowel beyond. This allows simultaneous gastric decompression and duodenal feeding. There is much to recommend the use of this tube, although the fine distal tube can be difficult to site and the tubes may not readily be available. In 25 patients having total gastrectomy or Roux-en-y anastomoses, we have employed balloon catheter gastrostomy combined with a small balloon catheter duodenostomy in the second part of the duodenum. There were no local complications, so we were encouraged to use this technique after vagotomy and antrectomy. This combination has been trouble-free in eight patients and gave us complete command of the situation. We were able to aspirate or introduce fluid on either side of the anastomosis. By this technique prolonged delays in postoperative gastric emptying could be managed with ease for the surgeon and comfort for the patient.
REFERENCES 1. Aeberhard, P. and Bedi, B. S. Effect of proximal gastric vagotomy and total vagotomy on the co-ordination of electrical activity of the stomach and duodenum. Br. J. Surg., 62:153,1975. 2. Alexander-Williams, J., and Barnes, A. D.: Post-operative gastric retention. In AlexanderWilliams, J., and Cox, A. G. (eds.): After Vagotomy. London, Butterworths, p. 175. 3. Barnes, A. D., and Williams, J. Alexander: Stomach drainage after vagotomy and pyloroplasty. Am. J. Surg., 113:494, 1967. 4. 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. 5. Dragstedt, L. R., Harper, P. V., Jr., Tovee, E. B., and Woodward, E. R.: Section of vagus nerves to the stomach in the treatment of peptic ulcer: Complications and end results after four years. Ann. Surg., 126:687, 1947. 6. Eisenberg, M. M., Woodward, E. R., Carson, T. J., and Dragstedt, L. R.: Vagotomy and drainage procedure for duodenal ulcer: The results of ten years experience. Ann. Surg., 170:317,1969. 7. Hendry, W. G.: Tubeless gastric surgery. Br. Med. J., 1:1736, 1962. 8. Johnson, A. G.: Postgrad. Med., 7(July suppL):29-34, 1973. 9. Johnston, D.: Operative mortality and postoperative morbidity of highly selective vagotomy. Br. Med. J., 4:545, 1975. 10. Kelly, K. A., and Code, C. F.: Effects of transthoracic vagotomy on canine gastric electrical activity. Gastroenterology, 57:51-58, 1969. 11. Machella, T. E., and Lorber, S. H.: Gastrointestinal motility following vagotomy and the use of urecholine for the control of certain undesirable phenomena. Gastroenterology, 11 :426, 1948. 12. Roth, J. L. A., Vilardell, F., and Affolter;H.: Postvagotomy gastric stasis. Ann. N.Y. Acad. Sci., 99:203, 1962. 13. Stoddard, C. J., Waterfall, W. E., Brown, B. H., and Duthie, H. L.: The effects of varying the extent of the vagotomy on the myoelectrical and motor activity of the stomach. Gut, 14:657, 1973. 14. Tanner, N. C.: Vagotomy and pyloroplasty. Post grad. Med. J., 26:575,1950. The General Hospital Steelhouse Lane Birmingham B4 6NH England
Postoperative Gastric Retention and Delayed Gastric Emptying Ian Donovan, MD., F R.C.B., * and J. Alexander-Williams, MD., Ch.M., F.R.C.B. t
Since the beginning of the era of gastric operations, surgeons have been aware of the complication of delay in emptying of the stomach. There is no absolute criterion of diagnosis of delayed gastric emptying but we suggest the arbitrary definition of failure to establish adequate emptying of fluids through the pylorus or stoma by the fifth postoperative day. Some surgeons routinely continue nasogastric suction and do not allow oral feeding until the fifth postoperative day.15 Others use no nasogastric suction and allow patients to eat and drink as soon as they are hungry and thirsty.7 However, all surgeons recognize the phenomenon of the patient who, after a gastric operation, either vomits or has gastric aspirate volume in excess of irltake at 7, 10, or more days after operation. The incidence of the complication varies in reported series. Some claim never to encounter it,7 others report incidences that vary with the operation and the type of patient operated upon. Bergin and Jordan4 found delaying gastric emptying in 28 per cent of their patients treated by truncal vagotomy and pyloroplasty for duodenal ulcer with stenosis. Roth and his coUeagues12 reported that 27.5 per cent of their patients had gastric stasis after vagotomy and hemigastrectomy. In the early years of our experience with vagotomy and pyloroplasty we had delayed gastric emptying in 17 per cent of our patients but, as the result of a modification of technique described later, within 4 years the incidence has fallen to 2 per cent.3
CAUSES The causes of delayed gastric emptying are (1) occlusion of the lumen at the stoma and (2) gastric atony as a result of vagal denervation From The General Hospital, Binningham, England • Senior Registrar tClinical Senior Lecturer, University of Birmingham; Consultant Surgeon, United Binningham Hospital, External Scientific Staff, Medical Research Council, England
Surgical Clinics of North America- Vol. 56, No.6, December 1976
1413
1414
IAN DONOVAN AND
J.
ALEXANDER-WILLIAMS
of the motor fibers of the stomach. In those patients who have had an intestinal suture line and vagal denervation, both factors can occur. Predisposing factors include long-standing obstruction, inanition, gastritis, and chronic electrolyte depletion. There is no evidence that early drinking or eating predisposes to delayed emptying. Luminal Obstruction Temporary mechanical obstruction may result from stomal edema when too generous a cuff is inverted in a two-layer anastomosis. However, we believe that the commonest cause of serious prolonged delay in gastric emptying is minor suture line leakage resulting in an abscess with surrounding edema and sometimes fibrosis. Rarely stomal obstruction may result from kinking of a gastrojejunal anastomosis or from the technical error of suturing the front to the back wall of the anastomosis. Obstruction of the stoma due to internal herniation or retrograde jejunogastric intussusception are well recognized but rare complications. A less well recognized but probably commoner cause is postischemic fibrosis of the duodenum following devascularization by a too thorough dissection before gastroduodenal anastomosis. Vagal Denervation Vagotomy divides both secretory and motor nerves to the stomach. It has long been known that truncal vagotomy alone, without a drainage
procedure, is associated with a high incidence of gastric retention. Tanner14 found that 49 per cent of patients had postoperative gastric stasis with vomiting and eructations after truncal vagotomy alone without drainage. However, even after this operation Dragstedt and his colleagues5 found that if the stomach was emptied frequently by nasogastric suction, its tone gradually returned and after some weeks or months the patient was able to empty the stomach satisfactorily via the pylorus despite continued complete vagal denervation. In the dog it has been shown that vagotomy temporarily disorganizes the electrical activity of the stomach and causes a permanent slowing of pacesetter potential in the corpus and antrum. Furthermore, there is permanent impairment of the electrical response to stimuli. to Studies of gastroduodenal motor co-ordination, also in the dog, have shown no long-term effect of vagal denervation either of the whole or of the proximal part of the stomach. t Operations that retain the vagal innervation of the antrum (proximal gastric vagotomy) cause little disturbance of normal motor function. Studies of myoelectrical and motor activity of the stomach in man have shown that in the early postoperative days there is a decrease to 75 per cent of preoperative activity following proximal gastric vagotomy compared with a decrease to 38 per cent after selective and 31 per cent after truncal vagotomyY In our experience it is possible, after proximal gastric vagotomy, to allow patients to eat and drink as soon as they wish without risk of complication. Johnston9 has reported a cumulative review of over 5000 patients after proximal gastric vagotomy with a very low incidence of gastric retention.
1415
POSTOPERATIVE COMPLICATIONS
DIAGNOSIS In the immediate postoperative period, delay in gastric emptying must be distinguished from a generalized paralytic ileus and from mechanical intestinal obstruction. Although this will often be possible on clinical evidence, specialized investigation may also be required. X-ray examination is helpful in that it gives a visual indication of the nature and site of any obstruction and an estimation of the volume of fluid passing from the stomach into the distal bowel. Although watersoluble contrast media such as Gastrografin are safer than barium if there is any question of leakage from the gut, they have the disadvantage of giving a less clear image and of being hyperosmolar. We recommend the use of a dilute barium suspension if the clinical findings exclude the possibility of leakage. Gastroscopy will indicate whether there is mechanical obstruction to the stoma but in a patient with an anastomosis it may not be safe to distend the stomach with air in the first 10 days after operation. Endoscopy is, however, helpful in assessing patients with persistent delay in gastric emptying and may help to avoid reoperating on patients who have a widely patent stoma. Reoperation is a poor means of determining the cause of postoperative gastric retention. There is a group of patients who have impaired gastric emptying which is not an obvious problem in the immediate postoperative period. They present at varying time intervals within the first year after surgery with symptoms of postcibal fullness, foul eructations, and vomiting of old food residues. There is usually a gastric outlet obstruction with or without the added effects of vagal denervation. The delay in clinical presentation is probably due to progressive fibrosis following the initial suture line leak and surrounding inflammation. Diagnosis in these patients is confirmed by barium meal examination. Where the clinical presentation is less florid and barium studies are equivocal, external scanning measurement of the gastric emptying of a radio-isotopically labelled solid meal is helpful.
PREVENTION Prevention of the complication of suture line obstruction demands a meticulous operative technique. A two-layer intestinal closure causes more suture line inversion than does a single layer. However, a single layer anastomosis may have a greater tendency to leak, particularly if an interrupted suture "cuts through" inflamed or edematous tissue. When we began to employ vagotomy and pyloroplasty in the treatment of duodenal ulcer we followed the Heineke-Mickulicz technique with a two-layer closure. However, the high incidence of postoperative gastric retention (17 per cent in the first year) led us to adopt the Weinberg onelayer closure with interrupted silk. The results rapidly improved until the incidence of retention was 2 per cent. Later, two patients had prolonged gastric retention due to a peristomal abscess complicating leakage. As a consequence of these experiences, we now perform a
1416
IAN DONOVAN AND
J.
ALEXANDER-WILLIAMS
pyloroplasty with an inner layer of continuous chromic catgut that approximates the gastric mucosa to the full thickness of the duodenal wall. This is covered by an interrupted layer of silk sutures that suture the stomach wall to the duodenal wall with minimal inversion. This technique gives so little trouble that we no longer use postoperative nasogastric intubation and allow patients to drink as soon as they wish after the operation. Preoperative cleansing of the stomach and removal of gastric residue is important in those patients with preoperative gastric outlet obstruction and those with gastric carcinoma. The normal stomach contains relatively few pathogenic organisms, but the obstructed stomach or a stomach with malignancy is heavily contaminated and is likely to be associated with a greater risk of local sepsis after operation. In these patients we employ preoperative gastric lavage and use preoperative parenteral antibiotic therapy, depending on the type of organism cultured from material obtained from the stomach at endoscopy or preoperative lavage. Electrolyte repletion is important in patients with long-standing gastric outlet obstruction and vomiting. Intravenous sodium and potassium are given, but we do not find it necessary to take more than 24 hours in preoperative correction of electrolyte depletion. We have investigated the value of prolonged preoperative parenteral feeding in patients with gastric outlet obstruction who were undernourished but we could demonstrate no advantage of this often troublesome regimen when compared with the policy of rapid electrolyte repletion, early operation and early return to normal alimentation. We have found no advantage in prolonged nasogastric decompression of a preoperatively obstructed stomach. Gastric tone appears to return to normal within 24 hours after gastric retention is relieved. There are no preventive measures that can be taken when performing total vagal denervation. However, when perfonning a proximal gastric vagotomy it is vital to ensure that the nerve of Latarjet is preserved. This is best achieved by dissecting the anterior and posterior leaves of the lesser omentum separately on the anterior and posterior aspects of the lesser curve, as far as possible away from the left gastric artery and vein. Hematomata must be avoided by gentle meticulous dissection with separate ligation of the many fine vessels. Some surgeons employ electrical nerve stimulation tests to demonstrate the integrity of antral innervation after proximal gastric vagotomy. We began by using this technique and can confirm that antral contraction can be checked visually and manometrically during operation. However, we find that with a careful technique the nerves were never damaged and in our practice routine nerve stimulation has been abandoned.
TREATMENT OF ESTABLISHED DELAY When the diagnosis of delayed gastric emptying in the early postoperative phase has been established by the methods described above,
POSTOPERATIVE COMPLICATIONS
1417
gastric decompression is advisable until normal gastric emptying is shown to have returned. When the obstruction is at the gastric outlet, the volume of fluid secreted into the stomach rarely exceeds 1 liter in 24 hours. If the delay is due to gastric atony, some emptying usually occurs and the volume of aspirate is less. Continuous gastric aspiration is therefore unnecessary, intermittently hourly aspiration is adequate, allowing the tube to drain freely into a drainage bag so that swallowed air may escape. Fluid and electrolyte replacement must continue and intravenous feeding with calories begun.
Drug Therapy Urecholine has been shown to improve the rate of gastric emptying in patients with atony immediately after vagotomy when there is no mechanical obstruction, but to be ineffective if there is an element of obstruction. 6 ,11 Similar claims have been made for the drug bethanecol chloride but so far the claims have not been fully substantiated. Metaclopramide (Maxolon) increases gastric emptying in the normal vagally innervated stomach. s There is no evidence of its efficacy in improving the rate of emptying of the stomach in the early phase of atony after vagal denervation. However, metaclorpromide may be of some value in patients with inadequate gastric emptying many weeks or months after operation. Anti-inflammatory drugs have been recommended in patients with stomal edema; Butazolodin and steroids have had their advocates but they are dangerous drugs whose efficacy is unproven. We do not recommend their use. If tissue infection is playing a part in inflammatory edema then an antibiotic capable of achieving a high tissue concentration may be helpful.
Diet When obstruction is complete due to inflammatory swelling there is no value in giving either liquid or solid food. However, fluids may be given by mouth and reaspirated to improve the patient's comfort and morale. It is important to remember that if clear water is given it returns as an isotonic aspirate and so electrolytes are dialyzed from the stomach. When there is no mechanical outlet obstruction but the delayed emptying is due to vagal denervation there is evidence and clinical experience suggesting that solid foods are emptied better than liquids. A patient who continues to have large gastric aspirates when given a liquid diet may therefore empty the stomach relatively normally if given light solid food.
Reoperation When a patient has established delayed postoperative gastric emptying, aspiration and parenteral feeding are continued in the expectation of return of normal emptying within 10 to 14 days. Fortunately, most patients fulfill this expectation. However, when complete gastric retention has persisted for 14 days after the operation the question of reoperation
1418
IAN DONOVAN AND
J.
ALEXANDER-WILLIAMS
has to be considered. It is important to attempt to diagnose the cause of the obstruction; by the 14th day endoscopy is safe and usually informative. If there is not complete stomal obstruction, we have continued a gastric aspiration regimen for up to 23 days in two patients who have subsequently recovered normal gastric emptying. 2 Follow-up studies 5 years later show that both patients have no symptoms related to any defect of gastric emptying. If, however, at 14 days there is still complete stomal obstruction, the fortitude of the patient and the medical attendants is usually weakening and reoperation has to be considered. In those patients presenting some time after operation, drug therapy, as mentioned previously, may be of benefit if the major problem is atony; if the delay is due to stomal obstruction, however, reoperation will probably be necessary.
Choice of Operation When the operation is at a gastroduodenostomy or pyloroplasty, it is usual to bypass the duodenum. We have experience of three patients treated in this manner, one of whom still failed to drain satisfactorily with a gastrojejunostomy and later required a Roux-en-y operation. As an alternative approach, the stoma can be explored by a finger through a gastrotomy. If there is patency of the stoma or it can be established by gentle dilatation, then a tube can be passed through the stoma into the duodenum via the gastrotomy; another tube is passed into the stomach. The patient can then be managed by gastric aspiration and replacement into the duodenum either of the gastric aspirate or a prepared diet. Our experience is limited to three patients treated by this method, two fared well and normal emptying returned, the third later required a gastrojejunostomy. As a consequence of this limited experience, we cannot give an authoritative statement. However, we advise that if there is gross peristomal edema and patency cannot be established easily, gastrojejunostomy is advocated but, where technically feasible, we prefer the double intubation techniqu't!. We consider it unwise in the early stage or weeks after the first operation to take down the entire anastomosis, as this is invariably technically difficult and hazardous. In the rare cases where technical disasters have made further dissection inevitable, we advocate completing the operation as a truncal vagotomy and antrectomy with a Roux-en-y anastomosis and a protecting gastrostomy and duodenostomy (see below).
Anticipation As previously stated we find that postoperative gastric retention is a rare complication in the patient with simple peptic ulceration requiring operative treatment. However, there are exceptional cases when the complication is expected, for example in patients with gross duodenal ulceration in whom there are special indications to perform a vagotomy and pyloroplasty or vagotomy, antrectomy, and gastroduodenal anastomosis. In such patients we feel that the discomfort and danger of prolonged nasogastric intubation is better avoided by performing a balloon catheter gastrostomy at the time of the first operation. Balloon
1419
POSTOPERATIVE COMPLICATIONS
catheters have been developed with a third long limb that can be passed through the stoma into the bowel beyond. This allows simultaneous gastric decompression and duodenal feeding. There is much to recommend the use of this tube, although the fine distal tube can be difficult to site and the tubes may not readily be available. In 25 patients having total gastrectomy or Roux-en-y anastomoses, we have employed balloon catheter gastrostomy combined with a small balloon catheter duodenostomy in the second part of the duodenum. There were no local complications, so we were encouraged to use this technique after vagotomy and antrectomy. This combination has been trouble-free in eight patients and gave us complete command of the situation. We were able to aspirate or introduce fluid on either side of the anastomosis. By this technique prolonged delays in postoperative gastric emptying could be managed with ease for the surgeon and comfort for the patient.
REFERENCES 1. Aeberhard, P. and Bedi, B. S. Effect of proximal gastric vagotomy and total vagotomy on the co-ordination of electrical activity of the stomach and duodenum. Br. J. Surg., 62:153,1975. 2. Alexander-Williams, J., and Barnes, A. D.: Post-operative gastric retention. In AlexanderWilliams, J., and Cox, A. G. (eds.): After Vagotomy. London, Butterworths, p. 175. 3. Barnes, A. D., and Williams, J. Alexander: Stomach drainage after vagotomy and pyloroplasty. Am. J. Surg., 113:494, 1967. 4. 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. 5. Dragstedt, L. R., Harper, P. V., Jr., Tovee, E. B., and Woodward, E. R.: Section of vagus nerves to the stomach in the treatment of peptic ulcer: Complications and end results after four years. Ann. Surg., 126:687, 1947. 6. Eisenberg, M. M., Woodward, E. R., Carson, T. J., and Dragstedt, L. R.: Vagotomy and drainage procedure for duodenal ulcer: The results of ten years experience. Ann. Surg., 170:317,1969. 7. Hendry, W. G.: Tubeless gastric surgery. Br. Med. J., 1:1736, 1962. 8. Johnson, A. G.: Postgrad. Med., 7(July suppL):29-34, 1973. 9. Johnston, D.: Operative mortality and postoperative morbidity of highly selective vagotomy. Br. Med. J., 4:545, 1975. 10. Kelly, K. A., and Code, C. F.: Effects of transthoracic vagotomy on canine gastric electrical activity. Gastroenterology, 57:51-58, 1969. 11. Machella, T. E., and Lorber, S. H.: Gastrointestinal motility following vagotomy and the use of urecholine for the control of certain undesirable phenomena. Gastroenterology, 11 :426, 1948. 12. Roth, J. L. A., Vilardell, F., and Affolter;H.: Postvagotomy gastric stasis. Ann. N.Y. Acad. Sci., 99:203, 1962. 13. Stoddard, C. J., Waterfall, W. E., Brown, B. H., and Duthie, H. L.: The effects of varying the extent of the vagotomy on the myoelectrical and motor activity of the stomach. Gut, 14:657, 1973. 14. Tanner, N. C.: Vagotomy and pyloroplasty. Post grad. Med. J., 26:575,1950. The General Hospital Steelhouse Lane Birmingham B4 6NH England
