Complications, risks, and consequences
Estimated frequency
Most significant/serious complications
Injury to mouth, teeth, pharynx or larynxa
1–5 %
Rare significant/serious problems
Bleeding/hematoma formationa
0.1–1 %
Perforationa
0.1–1 %
Infection
0.1–1 %
Failure to visualize parts of stomach or duodenuma
0.1–1 %
Failure to adequately biopsya
0.1–1 %
Aspiration pneumonitisa
0.1–1 %
Respiratory depressiona
<0.1 %
Less serious complications
Gas bloating (transient)
5–20 %
Discomfort, sore throat
5–20 %
Perspective
See Table 4.1. The risks and the incidence of complications of upper GI endoscopic diagnostic procedures, even including multiple tissue biopsies, are very low. However, the patient should ideally be made aware of the few serious complications in the unlikely event that these should occur, because the consequences may be serious and even require open surgery. Minor consequences such as gas bloating are more of inconvenience value for the patient; however, occasionally these may be significant. Failure to adequately biopsy a lesion of note may occur, and the patient should also be warned of this possibility and the need for a further procedure(s). The risks associated with therapeutic procedures are greater and include esophageal perforation associated with dilatation of strictures, stent insertion, and perforation and necrosis, which can complicate the treatment of bleeding ulcers.
Major Complications
Although rare, the major complications of endoscopy are perforation of the esophagus and less frequently still the stomach or duodenum. This can be serious, even if detected immediately, and can lead to mediastinitis and sepsis, organ failure, intensive care management, and death. If instrumental perforation occurs it may not be recognized immediately but should be suspected if the patient complains of pain. The presence of surgical emphysema would be virtually diagnostic of esophageal perforation. If perforation is suspected, a contrast study must be performed to define the site and size of perforation and the degree of contamination. Most instrumental perforations are small and managed conservatively. Open surgery is occasionally required to drain the area of contamination or to repair the defect. Delayed and unrecognized perforation carries a greater and more serious risk of adverse outcomes. Aspiration pneumonitis is less common in the partially awake and fasted patient. The risk of inhalation is increased in the patient with obstruction (achalasia, pyloric stenosis) or who has hematemesis. In such circumstances it may be prudent to protect the airway and perform the procedure with anesthesia and endotracheal intubation. Aspiration may be complicated by ARDS and/or secondary infection causing lobar or bronchopneumonia which sometimes progress to generalized sepsis, organ failure, intensive care support, and sometimes death. Aspiration pneumonitis is usually more serious after emergency endoscopy in the unprepared, unfasted patient or in patients with chronic upper gastrointestinal problems such as achalasia and gastric outlet obstruction. Significant respiratory depression is a potentially serious complication of sedation and endoscopy, and can lead to brain injury and even death, although now virtually abolished as a complication by good oximetric monitoring and anesthetic care during endoscopy. Failure to visualize or biopsy pathology is a risk of any endoscopic procedure, but in the elective setting, upper gastrointestinal tract endoscopy has high diagnostic yield. Disease processes (e.g., site and cause of acute hemorrhage) are more likely to be missed in emergency procedures or those where there has been difficulty achieving satisfactory sedation or airway control. Injury to teeth is uncommon and additional care will be required in the presence of crowns or bridgework. Patients with extensive dental caries must be warned of the risks of breakage of a decayed tooth.
Consent and Risk Reduction
Main Points to Explain
Discomfort and gas bloating
Injury to mouth and teeth
Bleeding
Problems with sedation
Failure to visualize parts of upper GI
Perforation
Infection
Further surgery; laparotomy
Percutaneous Endoscopic Gastrostomy
Indications
This therapeutic procedure is undertaken either for feeding or relief of obstruction (“venting gastrostomy”). When used for feeding a percutaneous endoscopic gastrostomy (PEG) may be temporary or permanent. Temporary placement is often used in patients about to undergo treatment for head and neck cancers. Permanent PEG insertion can be considered in patients with problems of deglutition (e.g., after stroke). Venting gastrostomies are sometimes used in as part of the management of the terminally ill with malignancy intestinal obstruction and persistent vomiting.
Description
Sedation and local anesthesia (spray or gargle) may be used, especially in high-risk patients, but general anesthesia is also acceptable. The aim is to establish a portal to the stomach from the exterior. With the patient lying supine, the endoscope is turned anteriorly inside the stomach so that the light is visible through the anterior abdominal wall where a needle is used to infiltrate local anesthetic over an area well away from the costal margin where the endoscope light can be seen clearly. The needle is pushed on down into the stomach. When it has been seen clearly by the endoscopist, the needle is removed, a small stab incision is made at the site of entry and a wide bore passed into the stomach. Under direct view, a guide wire is passed through this needle, grasped by the endoscopist and drawn through the anterior wall, into the stomach and pulled out through the mouth. A large-bore (20–24 FrG) catheter can now be passed through the mouth over the guide wire and brought out through the anterior abdominal wall. The gastrostomy tube is held in position by means of a plastic collar lying over the skin.
Anatomical Points
The colon, small bowel, liver, and omentum may overlie the stomach and make access more difficult. Perforation or transfixion of the transverse colon is a well-documented risk. Gastrostomy insertion can be more challenging in the obese and those who have had previous upper abdominal surgery. The procedure should be avoided or used with caution in those patients with massive ascites.
Table 4.2
Percutaneous endoscopic gastrostomy estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Infection | |
Wounda | 5–20 % |
Subcutaneous cellulitis; abscess | 1–5 % |
Intraperitoneal | 0.1–1 % |
Systemic | 0.1–1 % |
Bleeding/hematoma formation | 1–5 % |
Paralytic ileus | 1–5 % |
Gastric leakagea | 1–5 % |
Gastric fistulaa | 1–5 % |
Discharging abscess sinusa | 1–5 % |
Pneumoperitoneum | 5–20 % |
Free esophageal/gastric perforationa | 1–5 % |
Tube dislodgement (internalization or extraction)a | 5–20 % |
Gas bloating (transient) | 5–20 % |
Gastroesophageal reflux | 5–20 % |
Aspiration pneumonitis | 1–5 % |
Injury to mouth, teeth, pharynx or larynx | 1–5 % |
Rare significant/serious problems | |
Failure to perform endoscopically | 0.1–1 % |
Conversion to open operation (early or late) | 0.1–1 % |
Less serious complications | |
Hernia formation (incisional) | 0.1–1 % |
Perspective
See Table 4.2. Gastrostomy is used for drainage, feeding or both. Percutaneous endoscopic gastrostomy (PEG) is almost exclusively used for gastric access, where an endoscopy can be performed. Complications are few, but skin infection and irritation are common. Renewal of the gastrostomy catheter is often required for these complications or as a routine for catheter maintenance. Endoscopy may be required for this if the button on the end of the catheter has become rigid and inflexible.
Major Complications
These relate either to insertion of the tube or leakage or migration. Although PEG insertion is usually easy and safe, esophageal perforation or teeth injury can occur. Rarely, the catheter may migrate distally and could lead to stomach outlet obstruction. Separation of the stomach from the anterior abdominal wall is a more serious complication and may result in intraperitoneal leakage of stomach contents and peritonitis, with or without abscess formation or generalized sepsis. Occasionally the tube will migrate outwards, with accumulation of feed in the subcutaneous tissues or peritoneal cavity. Pressure necrosis of the stomach against the catheter balloon and free perforation is rare. The most frequent complication however, occurs around the exit of the catheter where minor infection and excoriation is very common. Associated abscess formation is not uncommon. Systemic sepsis is infrequent but may be severe, often related to the underlying condition(s), and can rarely lead to death.
Consent and Risk Reduction
Main Points to Explain
Discomfort and gas bloating
Injury to mouth and teeth
Bleeding
Problems with sedation
Failure to insert PEG
Perforation
Infection
Long-term PEG problems
Further surgery; laparotomy
Risks without surgery
Open Gastrostomy
Description
General anesthesia is usually used, but in high-risk patients local anesthesia infiltration may be satisfactorily used. The aim is to establish a portal to the stomach from the exterior. Older methods where a tube of stomach was constructed and brought out through the anterior abdominal wall are almost never used today. The commonest procedure today is to make a small upper midline incision and identify the anterior wall of the stomach where it is mobile enough to reach the anterior abdominal wall. The procedure can also be done laparoscopically. A large-bore (20–24 FrG) Foley balloon catheter is inserted through a separate abdominal wall incision several centimeters lateral to the midline incision. A nonabsorbable purse-string suture is inserted into the anterior wall of the stomach, and the Foley catheter is inserted into the stomach through a stab wound in the middle of the purse string. The balloon is inflated with about 10–20 ml of saline. The purse string is tightened and tied around the Foley catheter. The anterior wall of the stomach is brought into apposition with the inside of the anterior abdominal wall by gentle traction on the Foley catheter. Sutures are then placed to hold the stomach to the exit point of the catheter on the inside of the abdominal wall and the Foley catheter is secured into position against the skin.
Anatomical Points
The colon, small bowel, liver, and omentum may overlie the stomach and make access difficult. Although these organs are at risk, generally these can be displaced to enable the procedure to be performed. The procedure is more difficult in the obese and those who have had previous upper abdominal surgery.
Table 4.3
Open gastrostomy estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Infection | |
Wound | 5–20 % |
Subcutaneous cellulitis; abscess | 1–5 % |
Intraperitoneal | 0.1–1 % |
Systemica | 0.1–1 % |
Bleeding/hematoma formation | 1–5 % |
Paralytic ileus | 1–5 % |
Gastric leakagea | 1–5 % |
Gastric fistula | 1–5 % |
Discharging abscess sinus | 1–5 % |
Tube dislodgement (internalization or extraction) | 5–20 % |
Gastroesophageal refluxa | 5–20 % |
Aspiration pneumonitis | 1–5 % |
Less serious complications | |
Hernia formation (incisional) | 0.1–1 % |
Perspective
See Table 4.3. Open gastrostomy is used for drainage, feeding or anchoring the stomach to the anterior abdominal wall (e.g., as part of a hiatal hernia reduction and repair procedure). The procedure is performed infrequently and has almost completely been replaced by the endoscopic and radiological approaches. When used today, the open gastrostomy is usually part of a decompression procedure and may be used as an alternative to nasogastric intubation. An example of its use is to reduce the risk of reflux of gastric contents in patients with an esophageal rupture.
Major Complications
Occasionally, the balloon of a Foley catheter may migrate distally and can lead to stomach outlet obstruction. Separation of the stomach from the anterior abdominal wall may result in intraperitoneal leakage of stomach contents and peritonitis, with or without abscess formation or generalized sepsis. Pressure necrosis of the stomach against the catheter balloon and free perforation is rare. The most frequent complication, however, occurs around the exit of the catheter where minor infection and excoriation are very common. Associated abscess formation may occur but common. Systemic sepsis is infrequent, but may be severe, often related to the underlying condition(s), and can rarely lead to death.
Consent and Risk Reduction
Main Points to Explain
Discomfort and gas bloating
Bleeding
Problems with sedation/GA
Leakage
Infection (incl. peritonitis)
Long-term gastrostomy problems
Further surgery; laparotomy
Risks without surgery
Gastrectomy (Partial Gastrectomy; Billroth I; Billroth II; Roux-En-Y)
Description
General anesthesia is used. The aim is to remove part of the stomach with reconstitution of gastrointestinal continuity. These procedures are designed for lesions of the lower 2/3 of stomach. The amount of stomach removed is contingent upon the nature (benign or malignant), anatomy, and site of the pathology. The basic operation is mobilization of the distal stomach, with division of the left gastric and right gastroepiploic vessels. If a tumor is close to the pylorus, usually a Roux-en-Y procedure is preferred with the gastric remnant being anastomosed to the Y limb of a Roux-en-Y reconstruction. In benign situations or tumors with lower malignant potential (e.g., gastrointestinal stromal tumors), a Billroth I reconstruction where the gastric stump is joined to the duodenum can be undertaken but is associated with a greater degree of troublesome bile reflux. In the Billroth II reconstruction, the duodenal stump is closed and a loop enterostomy is anastomosed to the gastric remnant.
Anatomical Points
Vascular anomalies of the left gastric, gastroduodenal, and short gastric vessels may occur but are usually detected and dealt with at operation without difficulty. Massive left lobe of liver enlargement may restrict access. There are few other variations of any consequence for this procedure.
Table 4.4
Partial gastrectomy (including Billroth I, Billroth II, and Roux-en-Y) estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Infectiona | |
Subcutaneous/wound | 1–5 % |
Intra-abdominal | 0.1–1 % |
Intrathoracic (pneumonia; pleural) | 1–5 % |
Mediastinitis | 0.1–1 % |
Systemic | 0.1–1 % |
Late—post splenectomy sepsis (vaccination) | <0.1 % |
Bleeding/hematoma formationa | 1–5 % |
Intolerance of large meals (necessity for small frequent meals) | 50–80 % |
Paralytic ileus | 20–50 % |
Diarrhea | 20–50 % |
Unresectability of malignancy/involved resection marginsa | 5–20 % |
Reflux esophagitis/pharyngitis/pneumonitis | 1–5 % |
Delayed neo-gastric emptying | 1–5 % |
Bilious vomiting/bile refluxb | 1–5 % |
Dumping syndromea | 1–5 % |
Dumping (vasomotor) | |
Late dumping (osmotic; insulin surge) | |
Splenic injurya | 1–5 % |
Conservation (consequent limitation to activity; late rupture) | |
Splenectomy (may be part of procedure, i.e., 100 %) | |
Rare significant/serious problems | |
Stomal/anastomotic stenosis | 0.1–1 % |
Stomal/anastomotic ulceration | 0.1–1 % |
Common bile duct injury | 0.1–1 % |
Biliary fistula | 0.1–1 % |
Liver injury | 0.1–1 % |
Pancreatitis/pancreatic injury/cyst/leakage/fistula | 0.1–1 % |
Bowel injury (duodenum, small bowel, colon) | 0.1–1 % |
Dysphagia | 0.1–1 % |
Duodenal stump leak/fistulaa | 0.1–1 % |
Gastric ischemia (devascularization)/gastric-cutaneous fistulaa | 0.1–1 % |
Anastomotic breakdown | 0.1–1 % |
Colonic ischemia (middle colic arterial injury)/fistulaa | 0.1–1 % |
Renal/adrenal injury | 0.1–1 % |
Multisystem failure (renal, pulmonary, cardiac failure) | 0.1–1 % |
Small bowel obstruction (early or late)a [Anastomotic stenosis/adhesion formation] | 0.1–1 % |
Seroma formation | 0.1–1 % |
Subphrenic abscess | 0.1–1 % |
Deep venous thrombosis | 0.1–1 % |
Thoracic duct injury (chylous leak, fistula)a | <0.1 % |
Deatha | 0.1–1 % |
Less serious complications | |
Pain/tenderness [rib pain (sternal retractor), wound pain] | |
Acute (<4 weeks) | >80 % |
Chronic (>12 weeks) | 1–5 % |
Wound scarring (poor cosmesis/wound deformity) | 1–5 % |
Incisional hernia (delayed heavy lifting/straining for 8/52) | 0.1–1 % |
Nutritional deficiency—anemia, B12 malabsorption | 5–20 % |
Nasogastric tubea | 50–80 % |
Drain tube(s)a | >80 % |
Perspective
See Table 4.4. The main controversies surrounding partial gastrectomy for gastric malignancy have been whether a splenectomy should be performed and also how many lymph nodes should be removed. The situation with regard to splenectomy appears to have been resolved, and it is now accepted that the spleen should be preserved, if possible. The extent of lymph node resection remains controversial, with most Western surgeons not practicing extended lymphadenectomy, as developed and popularized by Japanese surgeons as part of a radical partial gastrectomy. Sentinel node tracing and biopsy is used in some centers.
Major Complications
As with most upper gastrointestinal operations, the most serious potential complication is anastomotic leakage. In Billroth II and Roux-en-Y reconstructions, such leakage is often as much from the duodenal stump, as it is from the anastomosis, and for this reason, a drain is often placed to the region of (or through) the duodenal stump. This does not to reduce the risk of leakage but does facilitate control of any leak. Infection and multisystem failure may then ensue, and this is the main cause of death, although a rare outcome. Bleeding is rarely severe and usually controlled at surgery. In the longer term, bile reflux has always bedeviled partial gastrectomy procedures of the Billroth I or Billroth II type. For this reason many surgeons use a Roux-en-Y procedure with a long limb (>50 cm) to try to prevent biliary reflux.
Consent and Risk Reduction
Main Points to Explain
Infection (incl. peritonitis)
Bleeding
Problems with sedation/GA
Anastomotic leakage
Long-term gastrectomy problems
Further surgery; laparotomy
Risks without surgery
Total Gastrectomy
Description
General anesthesia is used. The aim is to remove all of the stomach, including the gastroesophageal junction. This is usually carried out via a midline laparotomy incision, although in revisional cases, or when other difficulties are encountered, it may be necessary to extend the incision into the left thorax as a thoracoabdominal incision.
Anatomical Points
Vascular anomalies of the left gastric, gastroduodenal, and short gastric vessels may occur but are usually detected and dealt with at operation without difficulty. Obesity and massive left lobe of liver enlargement may restrict access, as can a narrow costal angle. The presence of small bowel adhesions, short mesentery, previous surgery, a hiatus hernia, and/or short esophagus may impede ease. There are few other variations of any consequence for this procedure.
Table 4.5
Total gastrectomy estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Infectiona | |
Subcutaneous/wound | 1–5 % |
Intra-abdominal | 0.1–1 % |
Intrathoracic (pneumonia; pleural) | 1–5 % |
Mediastinitis | 0.1–1 % |
Systemic | 0.1–1 % |
Late—post splenectomy sepsis (vaccination) | <0.1 % |
Bleeding/hematoma formationa | 1–5 % |
Paralytic ileus | 20–50 % |
Unresectability of malignancy/involved resection marginsa | 5–20 % |
Reflux esophagitis/pharyngitis/pneumonitis | 1–5 % |
Delayed neo-gastric emptying | 1–5 % |
Bilious vomiting/bile reflux | 1–5 % |
Dumping syndrome | 1–5 % |
Early dumping (vasomotor) | |
Late dumping (osmotic; insulin surge) | |
Intolerance of large meals (necessity for small frequent meals) | 50–80 % |
Stomal/anastomotic stenosis | 1–5 % |
Diarrhea | 20–50 % |
Splenic injurya | 1–5 % |
Conservation (consequent limitation to activity; late rupture) | |
Splenectomy (may be part of procedure, i.e. 100 %) | |
Rare significant/serious problems | |
Common bile duct injury | 0.1–1 % |
Biliary fistula | 0.1–1 % |
Liver injury | 0.1–1 % |
Duodenal stump leaka | 0.1–1 % |
Duodenal fistulaa | 0.1–1 % |
Gastric ischemia (devascularization)/gastric-cutaneous fistulaa | 0.1–1 % |
Pancreatitis/pancreatic injury/cyst/leakage/fistula | 0.1–1 % |
Bowel injury (duodenum, small bowel, colon) | 0.1–1 % |
Dysphagia | 0.1–1 % |
Anastomotic breakdown | 0.1–1 % |
Colonic ischemia (middle colic arterial injury)/colonic fistulaa | 0.1–1 % |
Renal/adrenal injury | 0.1–1 % |
Diaphragmatic injury/hernia | 0.1–1 % |
Pulmonary injury (direct or inferior pulmonary vein injury) | 0.1–1 % |
Multisystem failure (renal, pulmonary, cardiac failure) | 0.1–1 % |
Small bowel obstruction (early or late)a [Anastomotic stenosis/adhesion formation] | 0.1–1 % |
Seroma formation | 0.1–1 % |
Subphrenic abscess | 0.1–1 % |
Paraplegiaa | <0.1 % |
Thoracic duct injury (chylous leak, fistula)a | <0.1 % |
Deatha | 0.1–1 % |
Less serious complications | |
Pain/tenderness [rib pain (sternal retractor), wound pain] | |
Acute (<4 weeks) | >80 % |
Chronic (>12 weeks) | 1–5 % |
Wound scarring (poor cosmesis/wound deformity) | 1–5 % |
Incisional hernia (delayed heavy lifting/straining for 8/52) | 0.1–1 % |
Nutritional deficiency—anaemia, B12 malabsorption | 5–20 % |
Nasogastric tubea | 50–80 % |
Drain tube(s)a | >80 % |
Perspective
See Table 4.5. Total gastrectomy tends to be used in all proximal gastric tumors, including those close to the cardia. Esophagogastrectomy is usually used for any tumor which involves the cardia. Various substitute gastric pouches have been advocated as gastric replacements, following total gastrectomy, but none has really established a place over a simple Roux-en-Y interposition. There are some long-term reports suggesting that patients with a pouch do have superior nutrition to those without. As with partial gastrectomy, most Western surgeons do not practice extensive lymphadenectomy with total gastrectomy. Sentinel node tracing and biopsy is used in some centers. Splenectomy is often performed; however, some surgeons aim to retain the spleen. The duodenal stump is stapled or oversewn and the esophagus is anastomosed to a Roux-en-Y limb of jejunum for gastrointestinal reconstruction.
Major Complications
As with partial gastrectomy, anastomotic leakage is the major complication. And again, this includes duodenal blow-out. Foley catheter drainage of the stump may reduce this risk, but this practice is rarely followed. The major challenge of total gastrectomy is the esophago-jejunal anastomosis. Various maneuvers, including oral passage of the anvil of the stapling device, are used to reduce the difficulties associated with retraction of the cut end of the esophagus into the mediastinum. Mediastinitis from leakage into the mediastinum is often a more catastrophic event than when a gastrojejunal anastomotic leak occurs into the abdomen. Infection and multisystem failure may then ensue, and this is the main cause of mortality, when it occurs. Bleeding is rarely severe and usually controlled at surgery. Anastomotic stricture is not infrequent, as is the need for adjustment of food intake from the lack of a stomach. These can occasionally be major complications for the patient. A feeding jejunostomy is often performed as part of the operation of total gastrectomy—to allow enteral feeding during the immediate postoperative phase and to facilitate feeding in the unfortunate development of an anastomotic leak.
Consent and Risk Reduction
Main Points to Explain
Infection (incl. peritonitis)
Bleeding
Problems with GA
Anastomotic leakage
Long-term gastrectomy problems
Further surgery; laparotomy
Risks without surgery
Gastroenterostomy
Description
General anesthesia is used. The aim is to join the stomach to a proximal small bowel loop. The gastroenterostomy can be joined either to the anterior or posterior wall of the stomach, and the small bowel can be placed either in front of or behind the transverse colon. A GIA stapler or equivalent is commonly used for the anastomosis with manual suture closure of the holes created for the limbs of the stapling device. The procedure is often performed laparoscopically. A gastroenterostomy differs from a Billroth II because the stomach and duodenum remain intact.
Anatomical Points
There are essentially no variations that are of major influence in this procedure, except perhaps for adhesions or shortening of the mesentery, limiting the raising of the small bowel loop.
Table 4.6
Gastroenterostomy estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Infectiona | |
Subcutaneous/wound | 1–5 % |
Intra-abdominal | 0.1–1 % |
Intrathoracic (pneumonia; pleural) | 1–5 % |
Systemic | 0.1–1 % |
Bleeding/hematoma formationa | 1–5 % |
Paralytic ileus
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