Plate 20

Additional sutures of fine silk are taken around the edge of the mucosal opening until the end of the stomach has been puckered to fit relatively snugly around the surgeon's index finger. This opening should be approximately 2.5 to 3 cm wide (Figure 6). These sutures are then cut in anticipation of a direct end-to-end anastomosis with the duodenum (Figure 7). If the margins of the lesser and greater curvatures of the stomach as well as the superior and inferior margins of the duodenum have been properly prepared, it is relatively easy to insert angle sutures of 00 silk. Successful closure of the angles depends upon starting the suture on the anterior gastric as well as the anterior duodenal wall rather than more posteriorly. Interrupted sutures of 00 silk are then taken to close the stomach and duodenum together. Slightly bigger bites are necessary on the gastric side as a rule rather than on the duodenal side, depending upon the discrepancy in size between the two openings (Figure 8). The sutures should be tied, starting at the lesser curvature and progressing downward to the greater curvature. The angle sutures are retained while additional 0000 silk or fine absorbable synthetic sutures are placed to approximate the mucosa (Figure 9, A–A′ and B–B′). Some prefer a continuous synthetic absorbable suture to approximate the mucosa. No clamps are applied to the stomach or duodenum to control bleeding, since the sutures on the gastric side, if properly placed, should provide complete hemostasis as far as the stomach is concerned. Bleeding from the duodenal side is controlled by placing interrupted 0000 silk sutures. The anterior mucosal layer is closed with a series of interrupted sutures of 0000 silk or a continuous synthetic absorbable suture. The seromuscular coat is then approximated to the duodenal wall with a layer of interrupted mattress sutures (Figure 10). It has been found that a cuff of gastric wall can be brought over the duodenum, resulting in a “pseudo-pylorus,” if two bites are taken on the gastric side and one bite on the duodenal side. When this suture is tied (Figure 10), the gastric wall is pulled over the initial mucosal suture line.

The vascular pedicles on the gastric side are anchored to the ligated right gastric pedicle along the top surface of the duodenum as well as the ligated right gastroepiploic artery pedicle (Figure 10, A and B). A and B are then tied together to seal the greater curvature angle (Figure 11). A similar type of approximation is effected along the superior surface in order to seal the angle and remove all tension from the anastomosis (Figure 11). Cushing silver clips placed at the site of anastomosis will aid in identifying this area when future x-rays are obtained. The stoma should admit one finger relatively easily. There should be no tension whatsoever on the suture line.

The upper quadrant is inspected for oozing and thoroughly irrigated with saline.

Two liters of Ringer's lactate are given and the blood volume restored during the first 24 hours. The nasogastric tube is allowed to drain by gravity or is attached to low-pressure suction. Frequent irrigations of the tube with small amounts of saline are necessary to avoid obstruction and resultant gastric distention. Losses from the nasogastric tube are accurately recorded. Daily serum electrolyte levels are determined as long as intravenous fluids are given, and every two to three days thereafter.

When bowel activity has resumed, clear liquids are given by mouth and the nasogastric tube is clamped. Four hours after each of the first several meals the tube is unclamped and gastric residual measured. If there is no evidence of retention, a progressive feeding regimen is begun. This consists of five or six small feedings per day of soft food, moderately restricted in volume, high in protein, and relatively low in carbohydrate. Although many patients after gastric surgery dislike dairy products, the majority will tolerate milk, eggs, custards, toast, and cream soups, as the first step of the diet. Other soft foods are added as rapidly as the tolerance of the individual will permit. By the tenth day, a feeling of fullness may develop caused by mild retention and a tendency to overeat. Self-restriction of the dietary intake for a few days is indicated.

The patient's weight is recorded daily. The progressive regimen forms a basis for the discharge diet. Instructions are given to the patient to eat frequently, avoid concentrated carbohydrates, and to add “new” foods, including spices, and other food restricted preoperatively, one at a time. Eventually, the only limitations to the individual's diet are those imposed by his or her own intolerance.

Intermittent and regular follow-up discussions are essential over a long period of time to answer the many problems encountered by patients before the operation can be considered a complete success. Return to an unlimited diet and maintenance of ideal weight with freedom from gastrointestinal complaints are the goals.