Early postoperative complications are often associated with improper intraoperative techniques or inadequate preoperative preparation, while late postoperative complications typically result from anatomical and physiological disruptions caused by the surgery.
Early Postoperative Complications
Postoperative Bleeding
This involves either intraluminal bleeding within the gastrointestinal tract or intra-abdominal bleeding. Intraluminal bleeding may originate from the gastric or duodenal stump, anastomotic site, or other regions and can be identified via endoscopy. Hemostasis may be achieved using conservative methods such as the application of hemostatic powders or blood vessel clips. If bleeding persists without significant improvement, surgical intervention may be necessary. Intra-abdominal bleeding is often the result of loosening of ligated gastric or omental vessels or scab detachment at sites cut with an ultrasonic scalpel. Diagnosis can be confirmed by observing changes in the characteristics of abdominal drainage fluid or performing abdominal puncture to extract non-coagulated blood. For confirmed cases, surgical hemostasis may be required.
Postoperative Gastroparesis
Postoperative gastroparesis, characterized primarily by delayed gastric emptying, is a syndrome seen after gastric surgery but can also occur following pancreatic and other abdominal surgeries, including gynecological operations. It often develops a few days post-surgery and is more likely to appear during the transition from fasting to a liquid or semi-liquid diet. Patients may experience nausea and vomiting, often with green-colored vomitus. Gastric decompression via nasogastric tube placement is required in such cases, with the tube typically left in place for 1–2 weeks, though in prolonged cases, it may remain for over a month. Prolonged fasting and loss of gastrointestinal secretions without timely supplementation can lead to dehydration, electrolyte imbalances, acid-base disturbances, and nutritional deficiencies. A decrease in nasogastric drainage volume, along with a change in color from green to yellow and then clear, indicates improvement of gastroparesis. Prokinetic drugs may be used for treatment.
Duodenal Stump Leak or Rupture
This complication arises from improper handling of the duodenal stump or obstruction of the afferent loop in a Billroth II reconstruction. Patients typically present with severe upper abdominal pain, fever, and signs of peritoneal irritation. Abdominal puncture may reveal bile-containing peritoneal fluid. In confirmed cases where peritonitis cannot be localized, immediate surgical intervention is required. Duodenostomy and abdominal drainage are performed during surgery, and if obstruction of the afferent loop is identified as the cause, it must also be resolved.
Ischemic Necrosis of the Gastrointestinal Wall, Anastomotic Dehiscence, or Leak
Partial gastrectomy requires preservation of an adequate blood supply to the gastric remnant. Insufficient blood flow to the anastomosed duodenum or jejunum can result in ischemia, leading to dehiscence or leakage at the anastomotic site. If gastrointestinal wall necrosis is identified, fasting and gastric decompression are necessary. In cases of suspected necrosis or leakage that cause peritonitis, prompt surgical exploration and management are required.
Postoperative Obstruction
Intestinal Obstruction
This is more common after Billroth II reconstructions and can be classified as either afferent loop obstruction or efferent loop obstruction. Acute afferent loop obstruction can lead to necrosis and rupture of the duodenal stump, as the obstruction occurs proximal to the duodenal stump. Symptoms include severe upper abdominal pain, vomiting, and palpable dilated intestinal loops. Efferent loop obstruction typically results from postoperative intestinal adhesions or compression caused by the mesentery in a retrocolic approach. Patients may report upper abdominal bloating and discomfort, with severe cases presenting bile-containing vomitus.
Anastomotic Obstruction
This often results from a small anastomotic caliber, excessive mucosal inversion, or postoperative edema at the anastomotic site. Management involves gastric decompression and resolution of edema. Symptoms may resolve with conservative treatment, but if conservative measures fail, reoperation may be necessary.
Late Postoperative Complications
Dumping Syndrome
Dumping syndrome refers to a series of clinical manifestations caused by the rapid emptying of gastric contents into the intestine due to the loss of pyloric control. It is more common after Billroth II reconstructions and can be classified into early and late types depending on the timing of symptom onset:
Early Dumping Syndrome
Symptoms occur within 30 minutes after a meal and include palpitations, cold sweats, fatigue, and pallor, indicative of transient hypovolemia. Other symptoms may include nausea, vomiting, abdominal cramping, and diarrhea. The pathophysiology may involve rapid entry of hyperosmolar gastric contents into the intestine, leading to the release of vasoactive substances by intestinal endocrine cells. Dietary adjustments, such as small, frequent meals and avoidance of overly sweet, hyperosmolar foods, are the mainstay of conservative treatment. Severe cases may benefit from somatostatin therapy, though surgery is rarely considered.
Late Dumping Syndrome
Symptoms manifest 2–4 hours after a meal and include dizziness, pallor, cold sweats, fatigue, and rapid weak pulse. This mechanism involves excessive insulin secretion triggered by food entering the intestine, causing reactive hypoglycemia, which is also referred to as "hypoglycemic syndrome." Treatment includes dietary adjustments to slow carbohydrate absorption, with severe cases potentially requiring subcutaneous somatostatin injections.
Bile Reflux Gastritis
Bile reflux into the gastric remnant results in mucosal congestion, edema, and erosion, disrupting the gastric mucosal barrier. Clinical symptoms include burning pain in the epigastrium or behind the sternum, bile-containing vomitus, and weight loss. Antacid medications are generally ineffective, and management typically involves measures to protect the gastric mucosa, suppress acid production, and regulate gastric motility.
Ulcer Recurrence
Incomplete resection of stomach tissue or inadequate vagotomy during partial gastrectomy contributes to ulcer recurrence. Standard conservative treatment for peptic ulcers should be adopted initially. If complications occur, appropriate management strategies should be implemented.
Nutritional Complications
Reduced gastric capacity and impaired digestive and absorptive functions following partial gastrectomy often lead to symptoms such as upper abdominal bloating, anemia, and weight loss. Treatment strategies include dietary modifications, small frequent meals, a high-protein and low-fat diet, and supplementation with vitamins, iron, and trace elements.
Remnant Gastric Cancer
Primary cancer developing in the gastric remnant more than five years after gastrectomy for benign disease is referred to as remnant gastric cancer, with an incidence of approximately 2%. The etiology may be associated with atrophic changes in the gastric mucosa. Clinical manifestations include postprandial bloating and weight loss. Diagnosis can be confirmed with gastroscopy.