The effect of the anastomotic size on gastric emptying after hemigastrectomy with Billroth II reconstruction

OBJECTIVE

To determine if the size of the gastrojejunal anastomosis after Billroth II reconstruction was the rate-limiting factor in gastric emptying in the postoperative period.

METHODS

Twelve mongrel dogs were randomized to have either 1.5 cm or 5 cm gastrojejunal anastomoses prior to Billroth II hemigastrectomy. Each dog had three solid and three liquid radiolabelled emptying studies pre- and postoperatively. Data were collected using a gamma camera. For liquid studies, images were obtained at 0 min, 2 min, 4 min, 6 min, 8 min, 10 min, 20 min, 30 min, 40 min, 50 min and 60 min. For solid studies, images were obtained at 0 min, 5 min, 10 min, 20 min, 30 min, 40 min, 50 min, 60 min, 70 min, 80 min, 90 min, 100 min, 110 min and 120 min. Means were compared by analysis of variance using the repeated measures option.

RESULTS

Postoperative liquid emptying was significantly faster in the first 10 min with both 1.5 cm and 5 cm anastomoses compared with preoperative scans in the same animals (45% versus 20% and 48% versus 29%, respectively). On the other hand, solid gastric emptying was much slower postoperatively with the 1.5 cm anastomosis compared with preoperative scans (29% versus 65%) as well as compared with postoperative 5 cm anastomosis (29% versus 62%) at the end of 120 min.

CONCLUSIONS

Our model suggests that the gastric emptying of solids is affected by the size of the gastrojejunal anastomosis and not by the diameter of the efferent limb of the small intestine following Billroth II reconstruction.

Groin lymphatic complications after arterial reconstruction

PURPOSE

The purpose of this study was to better define the associated risks and optimal management of groin lymphatic complications (GLC) after femoral artery reconstructive operations.

METHODS

Retrospective review of a vascular surgery registry for the last 15 years identified 2679 arterial operations requiring a groin incision. Forty-one GLC were recognized, 28 lymphocutaneous fistulas (LF) and 13 lymphoceles.

RESULTS

The incidence of GLC was 1.5% per patient or 1.2% per incision. The highest incidence of GLC was in patients having an aortobifemoral bypass for aneurysmal disease in a previously operated groin (8.1% per patient) and in those undergoing an isolated femoral procedure in a previously operated groin (5.3%). The lowest frequency of GLC was after femoropopliteal/tibial bypasses (0.5%). Twenty-nine patients (71%) were treated without operation with bedrest, intravenous antibiotics, and aggressive local wound care. Operative therapy with wound reexploration attempted identification and control of the leak site, and meticulous wound closure was used in 12 patients (29%). Lymph fistulas in patients undergoing reoperation (10/28) resolved sooner than in patients treated without operation (18/28) (9 +/- 3 days vs 24 +/- 3 days). Infectious wound complications with one resultant graft infection developed in five of 18 patients with LF who did not undergo reoperation. There were no wound or graft infections in the patients in the LF group treated with operation. Operative exploration of lymphoceles did not reduce hospital stay or infectious wound complications. Repetitive lymphocele aspiration did not affect rapidity of resolution or increase the infectious complications.

CONCLUSION

GLC remain a troublesome complication of femoral arterial reconstruction. Early reoperation should be performed once a LF is diagnosed. Treatment for lymphoceles should be individualized, with neither operative nor nonoperative management showing clear superiority.