Complications - Total gastrectomy, robotically assisted with D2 lymphadenectomy

Vascular Injury
Therapy: Suturing, vascular surgical reconstruction

Bile Duct Injury
Therapy: Suturing, if necessary, T-drainage, biliodigestive anastomosis

Pancreatic Injury
Therapy: Suturing and extensive drainage

Splenic Injury
Therapy: Coagulation using argon beam coagulator, fleece-supported tissue adhesion, e.g., with TachoSil® (see tab Medical Equipment), last resort: splenectomy

Pleura/Diaphragm Injury
Therapy: Suturing, insertion of a chest drain

Insufficiency of the esophagojejunostomy (3-10%)

• Detection by endoscopy; Caution: radiological detection with water-soluble contrast medium (e.g., Gastrografin) has only a sensitivity of 50%!
• Therapy:
  • Oral fasting, placement of a nasoenteral tube, broad antibiotic treatment and if necessary, antifungal coverage.
  • With early intervention and favorable tissue conditions, a direct closure by suturing is still possible in exceptional cases.
  • Fully covered self-expanding metal stent or plastic stent with adequate drainage of the insufficiency cavity for defects up to a size of 60% of the circumference. Advantage: With good defect coverage, the patient can eat.
  • For larger defects: endoscopic vacuum therapy (EsoSponge®).
  • For large, otherwise uncontrollable defects with mediastinitis: discontinuity resection with cervical mucus fistula.

Duodenal stump insufficiency (<3%)

• Therapy: Adequate drainage; usually, surgical revision is indicated (suturing, creation of a duodenojejunostomy, partial duodenopancreatectomy).

Insufficiency of the jejunojejunostomy (rare <1%)

• Therapy: Generally surgical revision.

Intraluminal bleeding

• Primary endoscopic hemostasis, if unsuccessful, indication for surgical revision.

Extraluminal bleeding

• Depending on the intensity of bleeding surgical revision.
• Bleeding source spleen: local hemostasis preferably with spleen preservation; last resort splenectomy.
• Caution: infection-related erosion bleeding in duodenal stump insufficiency!

Intra-abdominal hematomas/abscesses

• Ultrasound- or CT-guided puncture and drainage.
• Often associated with a suture insufficiency.

Lymphatic fistulas

• Possible after systematic (D2) or extended (D3) lymphadenectomy, rarely also chylous ascites.
• After removal of the inserted drains, the lymphatic fistulas usually cease spontaneously.
• In individual cases, temporary parenteral nutrition may be necessary.

Pancreatitis

• Mostly edematous pancreatitis with a good prognosis; fasting, conservative-medical treatment.
• Hemorrhagic-necrotizing pancreatitis, often due to intraoperative pancreatic injury; intensive care-interdisciplinary treatment, also surgical necrosectomy/lavage; Caution: high mortality!

Passage disorders of the esophagojejunostomy

• Causes: anastomotic edema, hematoma.
• Remission expected within 10-14 days.
• Surgical revision is very rarely indicated.

Wound healing disorders

• Therapy: wound opening, wound debridement, secondary wound healing, abdominal wall sealing.