Step 1: Surgical Anatomy
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Due to the multiplicity of gastric operations performed both for benign and malignant diseases, it is imperative that the reoperative surgeon obtain and review all prior operative reports relating to the index gastric procedures. Prior knowledge and understanding of the patient’s anatomy and symptoms will allow the surgeon to accurately decide which remedial operation is appropriate for which postgastrectomy syndrome.
Step 3: Operative Steps
1.
Dumping
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Classic early dumping, characterized by rapid postprandial weakness, dizziness, palpitations, diaphoresis, abdominal cramping, and explosive diarrhea, occurs as a result of increased gastric emptying after pyloroplasty or antrectomy.
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Roux-en-Y diversion after a previous complete vagal denervation will significantly delay gastric emptying and reverse the dumping syndrome, which is why it is the remedial surgery of choice for this ailment.
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Conversion prior truncal vagotomy and pyloroplasty to 50 cm Roux-en-Y anastomosis. ( Figure 16-1A )
Figure 16-1
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Conversion truncal vagotomy and antrectomy (Billroth I) to 50 cm Roux-en-Y anastomosis. ( Figure 16-1B )
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Conversion truncal vagotomy and antrectomy (Billroth II) to 50 cm Roux-en-Y anastomosis. ( Figure 16-1C )
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2.
Gastroparesis
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Chronic gastroparesis can present with nausea, vomiting, abdominal pain, postprandial bloating, and bezoar formation.
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The remedial operation should be predicated on the need to remove a portion of the atonic stomach.
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A previous truncal vagotomy with pyloroplasty will mandate a 50% gastrectomy with a Billroth II reconstruction. The addition of a Braun enteroenterostomy 25 cm distal to the Billroth II gastrojejunostomy will divert a major portion of bile from the stomach, preventing bile reflux gastritis. ( Figure 16-2A ).
