Reoperations on the Stomach and Duodenum

Recurrent Ulcer Disease

Recurrent ulcer disease is most commonly caused by continued use of ulcerogenic medications, Helicobacter pylori infection, or an incomplete vagotomy at the initial operation. In the United States, nonsteroidal antiinflammatory drug (NSAID) usage and H. pylori infection are the predominant causes of peptic ulcer disease, 24% and 48% of cases respectively. In the setting of recurrent ulcer disease or persistence of symptoms after an initial operation, it is important to rule out similar causes as the underlying etiology.

In the absence of NSAID usage or H. pylori infection, incomplete vagotomy may explain recurrent ulcer disease. The relationship between persistent acid production and recurrent ulcers is supported by measurement of increased acid production through pH probe monitoring. For NSAID-induced ulcers, however, there may be normal or decreased acid production because the medication produces the ulcers irrespective of acid production. This can be demonstrated by ulcer formation in patients using NSAIDs with suppressed acid secretions. Continued NSAID use places 80% to 90% of patients at risk for repeat ulceration.

In the absence of continued NSAID use, incomplete vagotomy, or recurrent H. pylori , a search for unusual causes of increased acid secretion should be undertaken. Possible causes include retained antrum or gastrinoma. Retained antrum should be suspected in patients with hypergastrinemia after antrectomy with Billroth II gastrojejunostomy. In this scenario, the remaining stump of antrum is continuously bathed in alkaline secretions from the duodenum and pancreas, resulting in increased gastrin secretion. When this diagnosis is suspected, a fasting serum gastrin level should be measured. If elevated, a secretin stimulation test will show a decrease in gastrin levels after administration of secretin, which confirms the diagnosis. Additionally, sodium 99m-technetium scans can facilitate identification of remaining antrum.

Another uncommon cause of hypergastrinemia and recurrent ulceration is gastrinoma, which can also present after an adequate acid-reducing operation. Patients may complain of diarrhea and abdominal pain. They may also have reflux symptoms, gastrointestinal (GI) bleeding, or weight loss. Family history may also provide diagnostic clues. Testing of fasting serum gastrin or total serum calcium (in the case of multiple endocrine neoplasia type 1 [MEN1] hyperparathyroidism) should be performed. A secretin stimulation test should be performed to exclude other causes of hypergastrinemia. In the case of gastrinoma, secretin stimulates a dramatic rise in serum gastrin; this is inhibited by secretin in normal gastric cells. On endoscopy, rugal hypertrophy may be present and prominent. Diagnosis is made with fasting serum gastrin and fasting pH levels. Confirmatory testing can be done with secretin stimulation if the previous studies are ambiguous. Treatment involves resection of the gastrinoma when possible; if not, then lifelong, high-dose proton pump inhibitors (PPIs) are required.

The initial step in the workup for recurrent peptic ulcer disease involves endoscopic evaluation of the esophagus, remnant stomach, and duodenum. This allows identification of multiple ulcers, anastomotic strictures, or bezoars. It is important to obtain adequate biopsy specimens of any ulcers because neoplastic disease can present as recurrent ulceration, with many reports of increased risk of neoplastic transformation in patients with a history of gastric surgery.

Upper GI contrast imaging can be beneficial in identifying motility or emptying disorders; however, gastric outlet obstruction in the presence of recurrent ulcer disease is often a product of, and not the cause of, the underlying problem. In the case of uncertain anatomy or unknown previous operation, contrast studies are essential.

Treatment of recurrent ulcer disease begins with cessation of any offending medications, including all NSAIDs, and smoking. Antisecretory medications, such as PPIs or H ₂ blockers, should be initiated for a minimum of 12 weeks. H. pylori testing is warranted, with confirmation based on biopsy, serology, or urea breath testing, to be followed by appropriate treatment. Medical management has the potential to resolve recurrent ulceration in these patients, with one report demonstrating improvement in 40% of patients on secretory therapy. However, most studies were performed before the development of PPIs. Once there is evidence of a healed ulcer on endoscopy, patients can resume acetaminophen or non-NSAIDs, as needed.

In patients with persistent symptoms, additional testing should be performed to exclude other causes. Surgical intervention, for the most part, is limited to patients with gastric outlet obstruction (discussed later). However, for patients with recurrent ulcer symptoms despite maximal medical therapy, an inability to comply with medical therapy, or after an elimination of causative factors, surgical intervention will depend on the initial index operation.

• Antrectomy or partial gastrectomy: The traditional approach to repeat operation in patients with a previous antrectomy or partial gastrectomy is a subtotal or total gastrectomy. This should be reserved for those patients who fail to improve despite maximal medical therapy, because morbidity and mortality are significantly higher than at index operation; 20% to 40% have significant symptoms after revision surgery.

• Retained antrum: The treatment for retained antrum is revision surgery to excise the remaining tissue. Frozen section should be performed to look for Brunner glands or duodenal glands at the distal resection margin, and to ensure that any retained antrum is removed prior to performing the anastomosis.

• Gastrinoma: In the case of gastrinoma from Zollinger-Ellison syndrome or MEN syndrome, operation should be performed to remove the gastrin-producing tumor when possible.

• Failed vagotomy: In the case of a failed or incomplete vagotomy with pyloroplasty and adequate gastric drainage, many patients can be treated with antisecretory medications. However, for the rare subset of patients for whom medical management is unsuccessful or who cannot tolerate the medical management protocols, reoperation may be performed for completion vagotomy. This can be approached through the abdomen or the chest, depending on the surgeon's comfort level. Frozen section demonstrating nerve tissue should be performed prior to leaving the operating room.

Gastric Outlet Obstruction After Pyloric or Duodenal Ulcer Surgery

Gastric outlet obstruction after pyloric or duodenal surgery can occur months to years after the index operation. The presentation and timing will be largely reflective of the primary operation, and this will also determine the treatment: antrectomy with or without a vagotomy with Billroth I, Billroth II, or Roux-en-Y reconstruction. Initial, nonoperative management includes nasogastric decompression, fluid resuscitation, and antisecretory therapy.

Occasionally, gastric outlet obstruction may occur due to hypertrophy at the pylorus. This may occur in patients who did not undergo a gastric drainage procedure with their acid-reducing operation, such as vagotomy with or without an omental patch. Endoscopic balloon dilation can provide modest short-term results with minimal pain and recovery time. This can allow passage of gastric contents through a strictured pylorus, at least temporarily. However, most patients will have recurrence of symptoms and will require surgery for adequate gastric emptying.

In situations where patients have a gastric anastomosis at the index operation, such as a Roux-en-Y or Billroth II, the underlying cause may be an anastomotic stricture, which will be discussed later in this chapter.

Gastric Outlet Obstruction at the Site of a Gastrojejunostomy

Anastomotic stricture at the site of a gastrojejunostomy can result in gastric outlet obstruction due to incomplete gastric emptying with symptoms of bloating, nausea, and nonbilious vomiting. This has a reported frequency of up to 20% of patients undergoing a Roux-en-Y and may be higher in Billroth II reconstructions because these anastomoses are more prone to stricture formation. Diagnosis is made with upper GI contrast studies, with emphasis on both head-on and profile images to assess the width and length of the anastomotic stricture. Conservative management begins with nasogastric decompression and intravenous hydration. Patients may be offered balloon dilation, with reports of success in up to 89% of patients. However, frequent recurrence and limited response to dilation are indications for surgical revision.

Gastric Outlet Obstruction From Gastric Bezoars

The physiologic changes in the operated stomach may result in decreased acid secretion and stasis resulting in bezoar formation from ingested fibrous material. This large mass has the potential to cause gastric outlet obstruction from mass effect, or rarely, result in small bowel obstruction if the fibrous material is unable to pass distally. These lesions can be distinguished from gastric tumors based on their free-floating appearance on upper GI imaging, in addition to air trapping within the mass and speculated surface. Treatment involves removal of the offending mass. Removal at endoscopy is often successful, but surgical excision may be required.

Anastomotic (Marginal) Ulcer

Ulceration at a gastroenteric anastomosis can occur due to multiple causes, including those associated with recurrent ulcer disease (discussed earlier) and those associated with altered anatomy, such as ischemia, presence of a foreign body (such as permanent suture or staples), or high acid content from gastric reservoir. Antrectomy with Roux-en-Y gastrojejunostomy is an ulcerogenic operation. In such patients, an ulcer may occur in the jejunum just distal to the gastric anastomosis. This is due to the jejunum being continually bathed in acid without alkaline bile present. Adequate gastric drainage and a small gastric remnant can help minimize symptoms. Patients may remain asymptomatic for many years; in one study, the mean time to development of symptoms was 12 years. A comprehensive evaluation including upper endoscopy is warranted, in which the location, size, and depth of the ulcer is noted, and the possible pre­sence of a foreign body is investigated. Additionally, causes of recurrent ulceration, such as those discussed earlier, including NSAID use, H. pylori infection, retained antrum, and gastrinoma, should be ruled out. It is important to also assess the patient for possible remnant gastric carcinoma, which can have many different presentations.

Medical management is the primary treatment and includes antisecretory therapy with PPI, sucralfate, and smoking cessation. Surgical therapy is recommended for patients with continued upper GI bleeding and those with nonhealing ulcers despite maximal medical therapy. The operative approach involves resection of the ulcer and creation of a gastroenteric anastomosis.