The Operated Stomach Endoscopically Identifiable Lesions and Diseases

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Alkaline Reflux Gastropathy u TO

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It is very common to find erythematous and sometimes bile-tinged mucosa just proximal to the stoma in the operated stomach. Histologically, inflammatory mucosal changes are found in 60-90 % of cases. It is likely that the reflux of bile and alkaline pancreatic juice has causal significance. The degree of macroscopic and histological changes does not correlate with the severity of the complaints, and many patients are asymptomatic. The endoscopic picture is characterized by edema, erythema, and mucosal fragility when biliary secretions are present.

■ Reflux Esophagitis

Inflammatory changes in the distal esophagus are particularly common after total gastrectomy but may also be seen after partial gastrectomy, especially in cases with stenotic or functional obstruction of the efferent loop (Fig. 3.119 a).

Anastomotic stenoses may result from a primary tight stoma or from recurrent ulceration with cicatricial stricturing. Stenoses are often difficult to identify endoscopically, and an upper gastrointestinal contrast series should be obtained in doubtful cases.

Ulcerations may develop after vagotomy as a recurrence of the underlying disease or may occur close to the stoma following partial gastrectomy (Fig. 3.119 b). They are usually found just beyond the stoma but occasionally occur proximal to it. Possible causes are residual antrum remaining in the stomach, an antral remnant at the duodenal stump, Zollinger-Ellison syndrome, hyperparathyroidism, a tight stoma, or ischemia.

■ Suture Granuloma

In rare cases, suture material may be found at the site of the anastomosis (Fig. 3.119 c). This can lead to chronic occult blood loss.

Bezoars are rounded, compressed aggregations of fruit and vegetable fibers (Fig. 3.119 d). They may be seen following vagotomy and partial resections. They probably result from a motility disorder, and a narrow gastric outlet may be contributory. Large bezoars can cause obstructive symptoms.

■ Gastric Remnant Carcinoma

Gastric remnant carcinomas occur from 10-15 years after a partial gastrectomy. Endoscopy may show erosions, ulcerations, mucosal fragility, or a polypoid lesion. Early diagnosis can be difficult. For this reason, generous biopsy specimens should be taken from around the stoma even when subtle mucosal changes are found. Carcinomas can occur anywhere in the gastric remnant, even at multiple sites.

■ Recurrent Carcinoma

Whereas gastric remnant carcinoma develops after a prolonged interval, recurrent cancer generally occurs within a few years after surgery for gastric carcinoma. Consequently, it is recommended that endoscopic follow-ups be scheduled at intervals from three months to one year after the primary operation.

Fig. 3.119 Lesions and diseases in the operated stomach a Inflammatory changes in the distal esophagus following gastrectomy

Fig. 3.119 Lesions and diseases in the operated stomach a Inflammatory changes in the distal esophagus following gastrectomy

b Anastomotic ulcer following a Billroth II gastroenterostomy

Granuloma Distal

Suture granuloma in a Billroth II stomach c

Anastomotic Ulcer

d Bezoar b Anastomotic ulcer following a Billroth II gastroenterostomy

Suture granuloma in a Billroth II stomach d Bezoar c

When the entire stomach is removed, the stump of the esophagus is anastomosed to the small intestine. This may take the form of an end-to-end anastomosis (Fig. 3.120 a) or end-toside anastomosis (Fig. 3.120 b), or a substitute gastric reservoir may be constructed (Fig. 3.120 c).

Fig.3.120 Reconstructive techniques after gastrectomy

Fig.3.120 Reconstructive techniques after gastrectomy

Anastomosis Ulcer

a End-to-end anastomosis with jejunal interposition

Suture Granuloma Endoscopy

b End-to-side anastomosis with a Roux-en-Y esopha-gojejunostomy

Roux Anastomosis

c Substitute gastric pouch a End-to-end anastomosis with jejunal interposition b End-to-side anastomosis with a Roux-en-Y esopha-gojejunostomy c Substitute gastric pouch

Normal findings (Figs. 3.121 a, b)

► The anastomosis is located at 35-40 cm.

► Grayish, small bowel mucosa, differing from the reddish-yellow gastric mucosa, is seen proximal to the ring.

► Usually the endoscope can be advanced another 3540 cm.

► Two lumina separated by a cardialike ridge are sometimes seen (depending on the surgical technique).

Checklist for endoscopic evaluation

Inspect the esophagus for inflammatory changes.

Locate the anastomosis.

Check distance from the incisor teeth in centimeters.

For primary malignant disease: evidence of recur-

rence?

Pathological findings (Fig. 3.121 c)

Erosions proximal to the anastomosis

Anastomotic ulcer

Anastomositis

Recurrent carcinoma

Pathological Changes Ulcer

Fig. 3.121 Gastrectomy b End-to-side anastomosis c Inflammatory changes in the distal a View of the anastomosis esophagus

Fig. 3.121 Gastrectomy b End-to-side anastomosis c Inflammatory changes in the distal a View of the anastomosis esophagus u TO

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The most common types of partial gastrectomy are the Billroth I operation (hemigastrectomy with gastroduodenostomy; Fig. 3.122 a), the Billroth II operation (hemigastrectomy with gastrojejunostomy; Fig. 3.122 b), with or without a Braun side-to-side anastomosis (Fig. 3.122 c), and the Roux-en-Y gastrojejunostomy (Fig. 3.122 d).

Billroth I. The Billroth I stomach can usually be examined endos-copically without difficulties. This is also true of a Roux-en-Y gastrojejunostomy, although the Y anastomosis usually cannot be inspected as it may be up to 50 cm distal to the gastrojejunos-tomy.

Billroth II. Examination of the Billroth II stomach is not always easy, as the afferent loop should be inspected as far as the stump, while the efferent loop should be inspected as far distally as possible. The Braun side-to-side anastomosis cannot always be visualized.

Fig. 3.122 Reconstructive techniques after partial gastrectomy

Endoscopic Appearance

Fig. 3.122 Reconstructive techniques after partial gastrectomy

Braun Jejunostomy

a Billroth I operation (partial gastrectomy with gastroduodenostomy)

b Billroth II operation (partial gastrectomy with gastrojejunostomy)

a Billroth I operation (partial gastrectomy with gastroduodenostomy)

b Billroth II operation (partial gastrectomy with gastrojejunostomy)

Roux Anastomose

c Billroth II operation with a Braun side-to-side anastomosis d Billroth II operation with a Roux-en-Y gastro-jejunostomy c Billroth II operation with a Braun side-to-side anastomosis d Billroth II operation with a Roux-en-Y gastro-jejunostomy

Normal findings

A large range of normal findings are seen at the anasto-

motic ring, which may appear flat, raised, or nodular.

The extent of the resection and course of the anastomosis are also highly variable.

Billroth I stomach (Fig. 3.123 a)

- Mucosal folds end abruptly at the stoma

- The stoma may have a nodular appearance

- The mucosa may appear normal

- Lesser curvature is usually deformed and sometimes creased

Billroth II stomach (Fig. 3.123 b)

- Highly variable

- Efferent loop is usually easier to intubate, generally lying in direct continuity with the gastric lumen

- Afferent loop is usually more difficult to intubate, terminates in a blind pouch; biliary secretions are found

- Anastomotic ring is highly variable in appearance

Roux-en-Y gastrojejunostomy

- Only one loop can be intubated

- Anastomosis of the afferent loop is up to 50 cm past the gastrojejunostomy, so usually it cannot be identified

- No evidence of biliary secretions in the stomach

- Little erythema at the anastomosis

Endometrial Ablation
Fig. 3.123 Normal findings after partial gastrectomy a Billroth I operation. View of the anastomosis
Billroth Endoscopy

Billroth II operation. View of the anastomosis, with afferent and efferent loops b

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