Chinese Medical Journal

cee eer

INTESTINAL OBSTRUCTION FOLLOWING PARTIAL GASTRECTOMY 73

and his associates(5) surveyed the literature and found that since 1900 _ when internal hernia following gastroenterostomy was first reported by Peterson(6), approximately 70 cases had been reported beside their own d cases. ,

Such internal hernias, though infrequent, are serious conditions and usually end fatally unless diagnosed early and surgical intervention is carried out in time. Morton and others(5) gave the mortality among the reported cases as approaching 90 per cent. Herniation may occur a few days, a few months or years after gastrectomy and gastrojejunostomy. Its symptoms are characterized by sudden onset of severe upper abdominal pain and vomiting. The pain may be continuous or in paroxysms of increasing severity. Temporary relief may be obtained by gastric decompression but the symptoms will return with increased severity. When obstruction is due to a proximal jejunal loop hernia, the aspirated gastric content or vomitus contains no bile. Usually a mass can be felt in the left upper abdomen. When the strangulated bowel becomes gangrenous, signs of spreading peritonitis are evident. If a patient with a history of partial gastrectomy and gastrojejunostomy develops the above-mentioned symptoms, intestinal obstruction due to internal hernia should be considered.

The only treatment is early operation. If gangrene has not occurred, the herniated loop should: be reduced followed by closure of the opening. In case of gangrene, resection of the gangrenous bowel and reestablishment of the intestinal continuity followed by closure of the opening should be done.

The only rational and sure way to prevent the occurrence of such intestinal obstruction following partial gastrectomy is to close the opening or openings created by the gastrojejunal anastomosis at the time of the primary operation. Although closure of the opening in an antecolic anastomosis is never complete because placing of stitches in the wall of the colon should be avoided, yet a few interrupted stitches judiciously made could cause enough local inflammatory reaction that might seal up the opening by adhesions. Closure of the openings in a retrogolic gastrojejunostomy can be accomplished in the following way: the upper opening is closed by stitching the gastric stump along its lesser curvature to the posterior parietal peritoneum; the lower opening is closed by stitching the mesentery of the proximal or afferent jejunal loop to the posterior parietal peritoneum at the base of the transverse mesocolon.

SUMMARY

1. Among 97 partial gastrectomies and antecolic gastrojejunostomies, 2 cases of intestinal obstruction due to internal herniation of the afferent