48 Postgrad Med J: first published as 10.1136/pgmj.33.376.48 on 1 February 1957. Downloaded from

THE POST-OPERATIVE MANAGEMENT, INCLUDING THE MANAGEMENT OF SOME OF THE COMMON COMPLICATIONS, OF PARTIAL By 0. E. OWEN, M.B., F.R.C.S. Senior Surgical Registrar, St. James' Hospital, London, S. W. I

The care of the patient after partial gastrectomy is, as for ulcer; or radical (removing perigastric is a highly individualized problem which will be tissues), as for cancer. rendered less complicated by careful pre-operative These gastrectomies can be classified as follows: assessment and preparation, a meticulously per- formed operation by an experienced surgeon and SIMPLE RADICAL by expert anaesthesia. Lower Partial ('Gastro- Lower Partial ('Gastro-

Pre-operative Management duodenectomy') duodenectomy') Protected by copyright. It is advisable to admit cases for gastrectomy Gastro-duodenal anastomosis In view of the gland three days prior to operation. This enables the (Billroth I) clearance around car- patient to gain confidence in the staff, to become Gastro-jejunal anastomosis dia, even lower partial familiar with the and to be a (I) Antecolic Valved Balfour gastrectomymeansloss surroundings given (proximal jejunum' to of most ofvagal fibres. general explanation as to what to expect in the lesser curve) post-operative period. Instruction in deep breath- (2) Antecolic Valved Moyni- ing exercises can be given and the haemoglobin han (proximal jejunum and blood group estimated. In the presence of any to greater curve) acute respiratory or naso-pharyngeal infection it is Upper Partial ('Oesophago- Upper Partial ('Oeso- wiser to delay operation at least IO days. Patients gastrectomy') phago-gastrectomy') with disturbed physiological balance as a result Necessarily includes a vago- of pyloric stenosis, bleeding or'starvation, will need tomy a longer period of preparation. A preliminary period of bed-rest is of great value when there is The patient is received back from the theatrehttp://pmj.bmj.com/ acute exacerbation of an ulcer; it allows oedema into a warmed bed. The pulse rate and blood around the ulcer to subside, the fibrotic tissues hold pressure are recorded hourly, the emptied stitches better and the is easier. by aspiration and the volume and nature of the On the eve ofoperation a stomach tube is passed. contents noted. The aspirate usually contains Occasionally unsuspected gastric retention is ' coffee grounds' at this stage. Gastric aspiration brought to light by this procedure. The operative serves to draw off bloody fluid and swallowed air, field is and an enema After a which would lead to distension and prepared given. light gastric prolong on September 25, 2021 by guest. evening meal a sedative assures a restful night's post-operative paresis, particularly if vagotomized. sleep. It will also reveal bleeding from the suture line. On the day of operation the skin is prepared The stomach is aspirated hourly for the first 24 again. The stomach is emptied one and a half hours hours and the volume is recorded on a fluid balance before operation, using a trans-nasal Ryle's or chart. Unless the patient is already on an intra- oesophageal tube. The anaesthetic premedication venous infusion, a slow rectal drip of tap water is is given. The stomach is aspirated again immedi- commenced and continued for 24 hours. If the ately before leaving the ward and the tube left in patient sweats or the weather is hot, intravenous place. fluids may be used. Any untoward sign must be promptly reported, interpreted, evaluated and Types of Operation Performed acted upon. The onset of shock shortly after The operation performed may be simple: that operation may be due to excessively severe surgical February 1957 OWEN: Post-operative Management of Partial Gastrectomy 49 Postgrad Med J: first published as 10.1136/pgmj.33.376.48 on 1 February 1957. Downloaded from procedure, bleeding, lung collapse or pain. When chronic bronchitis and heart disease, it is better to the patient is conscious he is placed in a sitting-up keep the patient' a little on the dry side.' position and encouraged to breathe deeply and to cough. At this stage morphia is necessary to relieve Subsequent Management pain and small sips of cold water can be given to If progress is satisfactory, aspiration can cease allay thirst. To ensure a restful night morphia is on the third day except if the patient is uncomfort- given, but not more often than four-hourly. able in the evenings, or if he cannot face breakfast in the mornings. Aspirations at this stage are more First Post-operative Day often required after the Billroth I operation. At 8 a.m. a glass of cold water (8 oz.) is given to Fluids by mouth are increased so that the patient drink and five minutes later the stomach is emptied is able to take hourly milk feeds and liquids freely. by aspiration. This serves as a stomach wash-out Mild colicky lower abdominal pain, indicating the and at this stage the contents are usually ' coffee return of normal bowel activity, is usually relieved grounds ' or a few clots and mucus, and sometimes by a flatus tube and a small soap and water enema. bile. The tube is not kept in after this, but is By the fourth day the diet is increased by adding reinserted when indicated by nausea, epigastric milk, junkets, jellies, toast and eggs. The patient discomfort, bloating or repeated belching. Breath- is allowed up for short periods and is walking to the ing exercises are carried out with the patient in the toilet. Early ambulation by allowing the patient sitting-up position, lying flat, on one side and then to sit out of bed on the first and second days, on the other. If the bronchial secretions are ex- together with the deep breathing exercises, help to cessive, the foot of the bed is elevated for a period prevent venous stagnation in the limbs, with con- of o minutes with the patient on each side and. sequent risk of phlebothrombosis and pulmonary then he is encouraged to cough. This exercise is embolism. A daily inspection of the legs is carried most effective if done after an analgesic has been out. A low-grade temperature with painful, tense

given. or swollen calves indicate the need for active Protected by copyright. If there is doubt about full aeration of the lungs, treatment with anticoagulants. Pulmonary em- an X-ray should be taken. A new shadow in the bolism is heralded by chest pain and haemoptysis. lung fields may indicate collapse, pneumonia or an By the fifth day minced chicken, fish and nutrient infarct. In the case of lung collapse, an intravenous soups are given and gradually the food is increased, injection of nikethamide is given and the patient so that by the tenth day a full normal diet is being encouraged to cough. If the lung does not expand enjoyed. with this measure, tracheal and bronchial aspiration Skin clips or stitches are usually removed on the by trans-nasal catheter on strong intermittent suc- sixth or seventh day and the stay in hospital is I4 tion is performed. Antibiotic therapy is started if days for the average uncomplicated case. pneumonia is suspected. After this course of breathing exercises the patient is made comfortable Management After Emergency Operations in a sitting-up position and a hot, sweetened cup Post-operative care following emergency partial of tea is brought. This is a just reward for his gastrectomy for bleeding or perforation differs only trials and a great booster for the morale. The in that pre-operative preparation cannot be so http://pmj.bmj.com/ stomach tube is passed three times altogether in prolonged or extensive. The additional hazards the day and the breathing exercises carried out as of bleeding or perforation, such as infection and well. Audible intestinal peristaltic activity usually poor healing, are minimized by adequate replace- returns within 36 to 48 hours after operation and ment of blood and supportive antibiotics. It is our on account of this a cautious resumption of oral custom to give these patients penicillin, 500,000 feeding is indicated. Cold water or fruit juices are units intramuscularly, and streptomycin, 0.5 g. in to 6-oz. doses after the first hours for seven Vitamins C and given 4- two-hourly every I2 days. B, on September 25, 2021 by guest. 24 hours. If at any time the patient has hiccoughs, K are also given by injection on admission, as a feeling of fullness or a cramp-like pain in the peptic ulcer cases are amongst the few types of upper abdomen, the gastric tube is passed, the acute vitamin deficiencies still seen in clinical stomach emptied and the tube left in position. practice. Rectal or intravenous saline may be recommended. A urinary output of 30 to 50 oz. in 24 hours usually Some of the Complications and Their indicates that the body is receiving sufficient fluids Management and the appearance of the tongue and elasticity of One should be on the look out for the com- the skin give a guide to the state of hydration. plications that may follow partial gastrectomy, for Allowance must be made for extra loss of water their early recognition leads to easier control. through the skin in hot weather. To avoid over- Certain cases are associated with special risks: loading the circulation, particularly in cases with* for example, the effects of severe haemorrhage on 5o POSTGRADUATE MEDICAL JOURNAL February 1957 Postgrad Med J: first published as 10.1136/pgmj.33.376.48 on 1 February 1957. Downloaded from vital centres make cardiac, respiratory, and even spleen at operation to ensure that no capsular or cerebral complications a particular risk in emer- other injury has occurred.) Blood may collect also gency gastrectomy performed for bleeding. Tissue when many adhesions from previous operations are repair is slower as a consequence of the loss of divided. protein and poor oxygenation, so that wound in- fection, haematoma and disruption are commoner. Obstruction of the Stoma Many of these patients are elderly and in them This is recognized by excessive gastric aspira- post-operative bronchopneumonia, retention of tions and is more common after gastro-duodenal urine with its danger of ascending infection, bed anastomosis than after gastro-jejunal. It may be sores, faecal impaction and mental deterioration caused by oedema of the mucosa, particularly after are additional risks to life. coarse stitching or in hypoproteinaemic patients Post-operative shock is unusual, but may follow who have had emergency operations. Other rare if there has been much bleeding before or during causes may be accidental suturing of the mucosa of operation. Blood or plasma transfusion, if started the opposite side when completing the anterior during operation, is continued as indicated. 'all the coats' layer or stomal constriction from pressure of omental covering placed over the Haemorrhage anastomosis. The tendency to stomal blockage by Bleeding from the suture line is recognized early oedema is countered during the operation by close by the nature of the aspirations. The vomiting of stitching of the mucosal layers and by using at least bright red blood or large clots or continued bloody half the diameter of the stomach tailored to fit the aspirations is associated with a rising pulse rate, . A small longitudinal incision in the pallor, sweating, restlessness, air hunger or anterior wall of the duodenum (illustrated) is in- melaena. Serious bleeding is rare and is usually dicated when the duodenal lumen is small or the the result of failure of ' all the coats' suture to gastric folds excessively thick; this allows the control the bleeding vessels. Keeping the patient anterior suture line to lie at a different plane to Protected by copyright. the comfortable by correct hydration, sips of cold posterior line. The stoma is felt at the end of the water, morphia and a slow blood transfusion in operation to break away any mucosal attachment the majority of cases sees the bleeding ceasing of the posterior wall to the anterior suture line. spontaneously. However, if haemorrhage con- Provided physiological balance is maintained it is tinues severely, the abdomen must be reopened safe to await events and to keep the stomach empty and the gastric remnant exposed and inspected. by hourly aspirations. If after io days there is no An independent incision is made into an accessible progress, an X-ray examination is performed, 15 part of the anterior stomach wall and the suture minutes, one and three hours after injection of line inspected. A single bleeding point may be lipiodol into the stomach. If the obstruction is caught and tied or several bleeding points firmly absolute, operative correction is indicated. For undersewn with mattress sutures of catgut. The this it may be necessary to mobilize the whole of gastrotomy wound is carefully closed and the the duodenum so that the anastomosis can be abdominal wound resutured. To illustrate how remade or widened; alternatively, a gastro jejun- this complication can be minimized one ofthe staff, ostomy can be done. Obstruction to the lowerhttp://pmj.bmj.com/ who has done most of the gastrectomies, has only oesophagus may rarely result following removal of once in over 3,000 cases had to reopen for bleeding a juxta-cardia gastric ulcer. During this procedure after gastrectomy. On that occasion no bleeding a wide-bore stomach tube can be passed during point was found and the patient recovered. To operation to prevent encroaching too much on the the best of our knowledge, there has never been a oesophagus. 'death from suture-line bleeding since the clinic started. Suture-Line and Leakage Post-operative on September 25, 2021 by guest. Intraperitoneal bleeding from splenic capsular Peritonitis tears, slipped ligatures or from vessels in an ulcer Suture-line leakage, either from the duodenal crater-which have not been ' under-run,' may be stump or from the anastomosis, may occur, but is, suspected if the pulse rate remains high. The fortunately, rare. Both can be prevented by a abdominal signs of haemoperitoneum in the careful and painstaking technique. Avoidance of a immediate post-operative period can be decep- long afferent loop liable to obstruct, twist or tively absent or masked by wound pain. Immediate herniate; and ascertaining that the stoma lies blood transfusion and early exploration are carried without twist or kink, minimizes the risk of duo- out and the bleeding controlled. In our experience denal burst from the back pressure. Unsuspected the bleeding has been from delayed splenic bleed- injury to the duodenum from sharp forceps or ing and on two occasions a-late splenectomy had to *heavy handling may cause a duodenal leak. be performed. (It is our practice to inspect the Adequate mobilization of the duodenum.'and February I957 OWEN: Post-operative Management of Partial Gastrectomy 5I Postgrad Med J: first published as 10.1136/pgmj.33.376.48 on 1 February 1957. Downloaded from

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greater curve of the stomach allows a gastro- by intravenous drip of saline, blood and plasma. duodenal anastomosis to be without tension. A If a fistula will persists, reoperation be necessary on September 25, 2021 by guest. leakage in the absence of a drain may lead to local with a view to anastomosis of afferent to efferent or general peritonitis, and in such a case the loops. abdomen should be explored and the fluid aspirated. Peritonitis may also follow failure to drain an If the leak is at the stoma, it must be repaired ulcer crater which lies over the and into by suture and a rubber drain arranged to the site. which open small pancreatic duct radicals. Pooling If the duodenal stump is leaking, it should be of blood contaminated during operation may drained and continuous gentle suction made from initiate the development of subphrenic abscesses the drainage tube. The bile obtained, if bulky, which may develop into general peritonitis. In a should be returned to the stomach by the Ryle's very fat patient it is advisable to remove the great tube. The skin of the abdominal wall is protected omentum lest extensive fat necrosis should follow from the digestive enzymes by liberal applications its devascularization. Accidental injury to the mid- ofaluminium paste and the fluid balance maintained colic vessels or to the hepatic flexure when closing 52 POSTGRADUATE MEDICAL JOURNAL February 1957 Postgrad Med J: first published as 10.1136/pgmj.33.376.48 on 1 February 1957. Downloaded from the duodenal stump may become evident as a late vomiting of blood. Usually this is a much later general peritonitis. In the old or starved patients complication-and it calls for operative correction with a poor resistance general peritonitis may be as soon as diagnosed. Recurrence can be pre- present without a definite source to account for it. vented by suturing together the afferent and efferent loops. Post-operative Ileus and Mechanical Obstruction Post-operative Diarrhoea Following coeliotomy and handling ofbowel, one Mild diarrhoea is not uncommon after gas- usually expects complete physiological ileus for 36 trectomy and may be the sequel to loss of the to 48 hours. This normal ileus is to be expected hydrochloric acid antiseptic barrier. It responds more so after resection and anastomosis. Gastric readily to dilute hydrochloric acid and sulpha- dilatation, or even general intestinal distension, is phthalidine, which we give at an early stage. rare when gastric intubation is routinely per- Spurious diarrhoea as a result of faecal impaction fotmed; before its use gastric dilatation, persistent may develop in the old and frail and in patients vomiting and dehydration were not uncommon. who have barium a few days before operation. Persistent ileus should be treated by aspirating the Accidental gastrb- results in persistent gastric contents and swallowed air continuously diarrhoea and gradual inanition, but we are glad and by correcting the dehydration by intravenous to say that no gastro-ileostomy has yet been per- fluids. formed in this hospital to our knowledge. The surgeon should suspect mechanical obstruc- Severe diarrhoea or necrotizing enterocolitis is tion if shock, abdominal colic or local tenderness very serious and, in this unit, is now the commonest develop in addition to vomiting or excessive cause of death after gastrectomy. It may appear a aspiration. The afferent or efferent loops may be few days after operation and the first indication of obstructed by a band, adhesion to an abscess its presence may be collapse with a rapid pulse and around pedicles or, if retrocolic, may herniate into cold sweat. Soon afterwards there is diarrhoeaProtected by copyright. the lesser sac. By performing an antecolic anasto- with fluid offensive stools which may contain mosis obstruction to these loops by an unfixed blood, mucus and later even a membranous cast of mesocolon is avoided. The use of a short afferent necrotic mucosa. Occasionally the signs of peri- loop reduces the risk of afferent loop obstruction pheral circulatory failure may develop when the from herniation behind its own mesentery (illus- diarrhoea of itself seems insufficient to account for trated) or through the gap between the anastomosis it. Severe dehydration and dysuria become marked. in front and the transverse colon behind. Such a The cause of this complication is still unknown. herniation may just cause mechanical embarrass- In some cases virulent organisms can be isolated ment of the bowel, but may also cause strangula- and, in view of the possibility of Staph. aureus tion. The symptoms are often vague and difficult being the cause, the late Sir Alexander Fleming to interpret. The patient may complain of epi- suggested to Professor Charles Rob the use of gastric fullness and sometimes backache and usually penicillin in large doses by mouth. So far our most vomits. Fullness is followed by colicky pain. effective method of treatment has been to counter Auscultation of the abdomen may help to differ- the severe fluid loss by rapid infusion and to give http://pmj.bmj.com/ entiate between bowel paralysis and obstruction, massive doses of penicillin and sulphaphthalidine whilst a scout X-ray may show the position and by mouth, 5,000,000 units of penicillin (crystal- extent of any dilated, obstructed bowel. Absence line) dissolved in water, followed by 2,000,000 of bile from the gastric aspirate makes one suspect units two-hourly, as well as cremorthalidine in obstruction of the afferent loop. This is sometimes adequate doses. One patient was found to have relieved by turning the patient on to one or other sloughed a length of mucous membrane of the side with the foot of the bed raised and relief terminal ileum into an abscess around the may cavity on September 25, 2021 by guest. be confirmed by the diminution of pain and re- bowel and made an eventual full recovery following appearance of bile in the gastric contents. Acute resection of the necrotic bowel. As this condition pancreatitis should be excluded by a serum amy- may be related to the loss of the hydrochloric acid lase estimation, though the amylase may also be antiseptic barrier, we are, at St. James's, at present raised in afferent loop obstruction. If no relief is trying out the effect of giving dilute hydrochloric obtained, should be performed without acid to all post-gastrectomy cases for one week delay. Internal herniation is reduced and the gap after operation. closed and measures taken to prevent a recurrence. If reduction is impossible, the loops should be Late Complications short-circuited. Retrograde jejuno-gastric intus- These include gastro-jejunal or stomal ulcer, susception as a cause of post-operative obstruction gastrocolic fistula and post-cibal symptoms. is suspected if epigastric colic is associated with the These complications are, fortunately, rare and February 1957 OWEN: Post-operative Management of Partial Gastrectomy Postgrad Med J: first published as 10.1136/pgmj.33.376.48 on 1 February 1957. Downloaded from usually present with symptoms within two years of clude a feeling of excessive warmth, sweating, operation. Patients who develop stomal ulcers dizziness, epigastric discomfort and fatigue. These will complain of post-prandial pain relieved by patients are advised to eat slowly but well, par- alkalis, or they may bleed or perforate. Penetration ticularly of protein and fatty foods, to achieve a of the colon may cause a gastro-jejuno-colic fistula stable blood sugar level. Distension of the gastric to be established. This causes marked deteriora- remnant is less when the food is taken dry and tion as the gastric content passes directly into the fluids taken between meals. A rest, reclining for colon and the diarrhoea is made worse by faecal about 20 minutes after food, is also advised. In material irritating the small bowel. As a result of severe cases with persistent symptoms for over a loss of fluid and food, dehydration, starvation and year a further operation, such as a conversion to a vitamin deficiencies may be severe. Treatment of gastro-duodenal anastomosis, or rarely to a Roux- uncomplicated stomal ulcer is by with en-Y gastrectomy, if bilious vomiting is excessive, refashioning of the stoma if the distortion from may be effective in controlling these symptoms. fibrosis is great. Gastro-jejuno-colic fistula is best treated in stages, the first operation being diversion of the faecal stream by proximal . Acknowledgment I wish to record my indebtedness to Sister Post-cibal Disturbances Jackson and Sister Ridgway, who have nursed so About 60 to 70 per cent. of patients will com- many of our patients and upon whose invaluable plain of unpleasant symptoms after eating for the experience I have drawn in preparing this article. first few weeks or months after partial gastrectomy. I am very grateful to Mr. Norman Tanner for his In the majority these symptoms are mild and in- advice and constant help. Protected by copyright.

HEPATIC DISEASE (Postgraduate MedicalJournal, October, 1956) Price: 3s. 9d. post free http://pmj.bmj.com/ JAUNDICE ASCITES IN DISEASE Sheila Sherlock, M.D., M.R.C.P. Michael Atkinson, M.D. (Lond.) M.R.C.P. HEPATIC COMA J. M. Walshe, M.A., M.R.C.P. PSYCHIATRIC ASPECTS OF LIVER DISEASE SURGICAL TREATMENT OF PORTAL Esther A. Davidson, M.R.C.P.Ed., and on September 25, 2021 by guest. HYPERTENSION W. H. J. Summerskill, M.A., M.R.C.P. A. I. S. Macpherson, Ch M., F.R.C.S.E. PERCUTANEOUS PORTAL WILSON'S DISEASE VENOGRAPHY A. G. Beam, M.D. David Sutton, M.D., M.R:C.P., F.F.R. Published by THE FELLOWSHIP OF POSTGRADUATE MEDICINE 60, Portland Place, London, W.1