Though peptic ulcer of the jejunum is less frequent after posterior gastroenterostomy, only two cases having been recorded, when it does occur it is more likely to be acute and not to be limited by adhesions.
If, as in the greater number of cases, adhesions have formed, the condition will be less acute, although very distressing, from the associated pain due to perigastritis and adhesions. It will be necessary to detach adhesions and to repair the perforation, but probably in the greater number of cases, an excision of the portion of intestine involved and the performance of a Roux's operation will give the best results. In my case, which occurred three years and four months after an anterior gastroenterostomy, I excised the portion of jejunum involved and performed a Roux's operation as shown in the accompanying diagrams. The operation was followed by recovery. I have operated on two other cases of jejunal ulcer after gastroenterostomy performed elsewhere, but in neither of these cases had perforation taken place : both recovered.
Pneumonia or pleurisy are said to have followed operation on the stomach with greater frequency than in any other abdominal operations, the reason given being the difficulty of expanding the lungs in consequence of fixation of the ribs subsequent to operation.
My experience has not borne out this observation, for I have found chest complications to occur very seldom in my stomach operations, certainly not more frequently than after any other laparotomy. This may, perhaps, arise from the facts that I always have the patient enveloped in a gamgee tissue suit so as to avoid chilling during operation; have the head and shoulders well propped up by pillows after operation, and that chloroform is usually the anaesthetic employed. Moreover, in an old subject it is always desirable to turn the patient on the side from time to time, so as to avoid hypostatic congestion of the bases of the lungs.
This is an extremely serious complication, and probably almost universally fatal. I have never known it to occur after union by suture, but once saw it happen some years ago in one of the few cases in which I employed the Murphy button, and Dr. W. J. Mayo has reported two cases that occurred under similar conditions. In one the accident followed an epileptic seizure on the ninth day, in the other on the seventh day after gastroenterostomy for malignant disease of the pylorus.
Want of union used to be less rare when moribund patients were operated on, but it is seldom seen now except when the Murphy button has been used, in which case there is nothing to prevent extravasation if union be delayed beyond the first few days; whereas, if union is effected by a double line of sutures, delayed healing, if not too long', is not serious.
Mumford described a case of separation of the viscera in a case of posterior gastroenterostomy performed by the no-loop method, which he ascribed to a short ligament of Treiz, so that when the dilated stomach contracted it forcibly dragged on the attached jejunum and led to separation.
Perigastritis, or adhesive peritonitis, at a distance from the site of operation is probably uncommon after aseptic operations, though adhesions may result from the use of strong antiseptics, or if haemostasia is imperfect. Adhesions, the result of ulcer and cancer are extremely common, and I have seen them so extensive that it was almost impossible to find any healthy portion of the stomach to which the jejunum might be applied. Under these circumstances, a posterior gastroenterostomy, on account of obliteration of the lesser peritoneal cavity, may be impossible, and it is better to perform a Roux's anterior Y operation. In one case of this kind, though an immediate successful result was obtained by a Roux's operation, the symptoms recurred some months later, evidently due to the formation of further adhesions. In another case that came under my care in 1891 I had to operate for bilious vomiting1 that came on some months after gastroenterostomy, which I found on exploration was caused by a band stretching from the transverse colon and compressing the efferent jejunal loop, relief being given by the division of the band and an entero-anastomosis.
Internal hernise after gastroenterostomy may occur under three conditions :
(a) The passage of small intestine through the loop formed above the junction of the jejunum and stomach. This condition is only likely to occur after the anterior operation, as in a case reported by Dr. W. J. Mayo (12) in the Annals of Surgery, 1902. The accident happened a year after an anterior gastroenterostomy.
(h) There are several cases on record of the passage of small intestine through the slit in the meso-colon made for the anastomosis in posterior gastroenterostomy. A case of this kind occurred in one of Mr. Moynihan's patients, who died on the tenth day of acute intestinal obstruction, when a great part of the small intestines were found in the lesser peritoneal cavity (7).
In a second case occurring in his practice he opened the abdomen and reduced the hernia, the patient recovering.
The accident may be avoided by not making the opening too large and by suturing with two or three Pagensteeher's sutures the margin of the opening in the meso-colon to the line of junction of the stomach and jejunum.
Mr. A. E. Barker and Mr. W. Alexander have described cases of this accident (8).
(c) Mr. Barker (9) has recorded a case in which two years after a posterior gastroenterostomy nearly the whole of the small intestines passed over the afferent loop and became strangulated.
Dr. H. M. W. Gray (15) found, in a case of acute obstruction after gastroenterostomy in which he reopened the abdomen on the seventh day subsequent to the original operation, that practically the whole of the small intestine had insinuated itself from left to right through the ring formed by the peritoneum of the under layer of the meso-colon, lining the posterior abdominal wall and forming the upper layer of the mesentery, the ring being completed anteriorly by the gastro-jejunal junction. It was easily pulled back and the ring closed by suturing the under layer of the meso-colon to the upper layer of the mesentery to prevent recurrence of the hernia. The patient recovered.