Chinese Medical Journal

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INTESTINAL OBSTRUCTION FOLLOWING PARTIAL GASTRECTOMY Hah

restrictions, and was free from all previous gastric symptoms. Second follow up one and a half years after the first showed that the patient remained well. :

Case 2. Shen, a 26 year old unmarried male, technician at this hospital, was admitted on October 27, 1952 for treatment of chronic duodenal ulcer proved by x-ray studies with barium meal. He was operated upon under ether anesthesia on November 1, 1952. A partial gastrectomy was done with the removal of the ulcer bearing duodenum near the pylorus and about three fourths of the stomach followed by an antecolic gastrojejunostomy of the Balfour type (same as in Case 1). The proximal jejunal loop measured about 14 cm from the ligament of Treitz. The patient was discharged on December 2, 1952, thirty days after the operation.

He was readmitted on December 8, 1952, six days after discharge or thirty-six days after operation for sudden onset of vomiting with chills and fever after a long pedicab ride on the previous day. Paroxysms of colicky pain with increasing severity were experienced in the upper abdomen after the onset. Examination showed that the patient was acutely ill and weak. The entire abdomen was distended, spastic and tender, particularly on the left side near the umbilicus where a mass about the size of a fist was felt. Increased peristalsis was detected on auscultation. Gastric decompression and colonic irrigations gave no relief. On account of our experience with the previous case, a clinical diagnosis of intestinal obstruction due to internal hernia was made and the patient was prepared for immediate exploration. Under ether anesthesia, the abdomen was reopened through a left rectus incision. About 200 ce of dark red and slightly turbid fluid were removed from the peritoneal cavity. The proximal jejunal loop was found to have herniated from right to left through the gap made up by the gastrojejunostomy. The herniated loop was markedly distended, measuring 10 cm in diameter, bluish, and with patches of necrosis, a condition similar to that found in Case 1. To reduce the intraluminal pressure the distended loop was aspirated and blood tinged brownish-green foul smelling fluid was removed. Reduction of the internal hernia was then made possible, but because of the patches of necrosis part of the proximal jejunal loop had to be resected. The cut end of the jejunum near the gastrojejunostomy was closed and the cut end near the ligament of Treitz was anastomosed end-to-side to the distal jejunal loop. A few interrupted stitches were placed between the mesentery of the jejunum used for the gastrojejunostomy and the transverse mesocolon. The patient stood the operation well and his postoperative course was smooth. He was discharged on February 9, 1953, or sixty-two days after the second operation.

On the first follow up two years after the second operation it was found that the patient had not gained much weight and that he had occasional gastric discomfort after meals; but six months later his body weight had increased by 4 kg and his appetite was good.

DISCUSSION

The type of anastomosis is not in itself the cause of internal hernia following partial gastrectomy. This is evidenced by the fact that such complication has arisen irrespective of the type of anastomosis, whether done anterior or posterior to the colon, or whether the jejunal loop is placed from right to left or from left to right. Each surgeon or clinic has a preference for a certain type of anastomosis, and this complication has been reported by different surgeons using the type of anastomosis they favor(1-5). Our 2 cases were internal hernias following antecolic