What are the potential complications of gastrectomy (surgical removal of all or part of the stomach)?

Complications of Gastrectomy

Gastrectomy results in both immediate surgical complications and lifelong metabolic consequences that require active surveillance and management, with virtually all patients experiencing some degree of postgastrectomy syndrome affecting eating, nutrition, and quality of life. 1

Short-Term Surgical Complications (≤30 Days)

Life-Threatening Complications

• Anastomotic leakage occurs in approximately 4.2% of cases and carries significant mortality risk, requiring immediate surgical intervention 2
• Duodenal stump leakage develops in 3.1% of patients and represents a technical failure requiring reoperation 2
• Intraabdominal bleeding affects 9.3% requiring reoperation, with a hospital mortality rate of 26.7% when reoperation is needed 2
• Pulmonary complications including pneumonia are more common after open versus laparoscopic approach (19.4% vs. 10.9%) 3
• Deep vein thrombosis and pulmonary embolism occur in approximately 0.4% of cases 1
• Perioperative mortality ranges from 0.2-0.6% in experienced centers 1, 2

Common Early Complications

• Intestinal obstruction is the most frequent complication requiring reoperation (54.3% of all reoperations), primarily from adhesive formation 2
• Wound dehiscence or evisceration occurs in 9.3% of cases requiring reoperation 2
• Intraabdominal abscess without leakage develops in 3.1% of patients 2
• Acalculous cholecystitis affects 3.1% of patients postoperatively 2

Risk Factors for Complications

• Extended gastrectomy increases complication risk 3.92-fold compared to limited resection 4
• Total gastrectomy doubles complication risk (OR 1.97) versus subtotal gastrectomy 4
• Age ≥60 years increases overall complication risk by 66% (OR 1.66) 4
• Preoperative malnutrition significantly increases morbidity, particularly pneumonia 3
• ASA class 3-4 and cardiovascular/pulmonary comorbidities independently predict severe complications 4, 5

Postgastrectomy Syndrome (Early Phase: 0-3 Months)

These symptoms affect virtually all patients to some extent and typically improve but rarely resolve completely: 1

• Early postprandial satiety and inability to consume normal meal volumes 1
• Loss of appetite and altered taste perception 1
• Nausea and vomiting related to eating 1
• Diarrhea affecting most patients initially 1

Specific Postgastrectomy Syndromes

Dumping Syndrome

• Frequency depends on extent of resection and reconstruction type, with higher rates after total gastrectomy 1
• Results from rapid gastric emptying of hyperosmolar contents into small intestine 1

Loop Syndromes

• Afferent loop syndrome and efferent loop syndrome occur with specific reconstruction types 1
• Frequency varies by surgical technique and anastomotic configuration 1

Long-Term Metabolic and Nutritional Complications (>3 Months)

Hematologic Deficiencies

• Iron deficiency anemia develops in 17% of patients and requires lifelong monitoring 1
• Vitamin B12 deficiency causes anemia and requires oral or parenteral supplementation in most patients 1
• Protein deficiency occurs in 0.3-3.0% after extensive resections 1
• Zinc deficiency affects 6% of patients 1

Bone Metabolism Disorders

• Osteoporosis develops from malabsorption of vitamin D and calcium 1
• Vitamin D deficiency and elevated parathyroid hormone may exceed 40% of patients 1
• Osteomalacia occurs in inadequately supplemented patients 6

Weight and Body Composition

• Weight loss is most pronounced in the first 2 years, typically stabilizing but rarely returning to baseline 1
• Caused by both eating discomfort and malabsorption 1
• Malnutrition risk persists lifelong even in cancer-cured patients 6

Gastrointestinal Complications

• Steatorrhea from pancreatic exocrine insufficiency (PEI), small intestinal bacterial overgrowth (SIBO), and/or bile acid diarrhea (BAD) 1
• Postprandial pain commonly results from eating excessive portions at one sitting 1
• Internal herniation can occur at any time after surgery and represents a life-threatening emergency requiring immediate recognition 1

Late Surgical Complications Requiring Reoperation

• Incisional hernia affects 9.3% of patients, with rates up to 72% after open BPD procedures 1, 2
• Intestinal obstruction from adhesions is the most common long-term complication (75.8% of late reoperations) 2
• Anastomotic stricture may develop months to years postoperatively 1

Drug Absorption and Pharmacokinetic Complications

Total gastrectomy fundamentally alters medication absorption and requires systematic medication review: 1

• Delayed mixing with bile salts impairs drug solubility 1
• Reduced surface area for absorption decreases bioavailability 1
• Poor tablet/capsule disintegration necessitates liquid or dispersible formulations 1
• Avoid delayed-release medications due to shortened functional small intestine length 1
• Avoid medications requiring acidic environment (azole antifungals) and substitute alternatives 1
• Avoid NSAIDs, aspirin, oral bisphosphonates, and doxycycline due to intestinal irritation 1
• Oral contraceptive efficacy is impaired by altered enterohepatic cycling 1

Psychological and Quality of Life Impact

• Depression and anxiety scores are elevated but often neglected by medical teams 7
• Psychological support is crucial given disease severity and high recurrence risk 1
• Quality of life impairment persists long-term and requires multidisciplinary support 1, 6

Essential Surveillance and Management

Lifelong follow-up by an experienced multidisciplinary team is mandatory: 1

• Iron supplementation and monitoring 1
• Vitamin B12 oral or parenteral replacement 1
• Vitamin D and calcium supplementation 1
• Regular clinical assessment for medication efficacy given absorption variability 1
• Nutritional surveillance is critical to prevent severe metabolic disturbances 6
• Patient education about internal herniation symptoms 1

Critical Pitfall

Symptoms should never be attributed to irritable bowel syndrome until comprehensive investigation and targeted treatment trials have excluded organic causes including PEI, SIBO, and BAD, as these conditions frequently coexist. 1