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Figure 3.8. Duodenal stump blowout. CT scan of the upper abdomen shows a collection with extraluminal contrast medium in the right upper quadrant arising from the duodenal bulb. A drain is also present.
Figure 3.9. Gastric outlet obstruction secondary to edema at the anastomotic site. Supine view from an upper GI series 5 days after Billroth II shows that the stomach fails to empty secondary to edema at the anastomotic site. This condition resolved several days later.

Gastric Outlet Obstruction

Edema at the anastomotic site may lead to gastric outlet obstruction in the early postoperative period, but is usually self-limiting (Fig. 3.9). Obstruction may also be due to hematoma or an iatrogenic tight stoma.

Marginal Ulcer

Marginal ulcer (recurrent ulcer, stomal ulcer) may occur as soon as one week postoperatively. The incidence varies with the type of operation and the underlying condition for which the surgery was performed. The ulcer recurrence rate is highest with gastroenterostomy alone or antral exclusion procedures, and for this reason these techniques have been abandoned as therapy for PUD. The lowest recurrence rate (<1%), is for vagotomy and partial gastrectomy, with vagotomy and drainage about 5%. Traditionally, after Billroth II, marginal ulcers have been described as most commonly present in the efferent limb within the first 2 cm of the anastomosis, although they may develop in the gastric remnant as well (Figs. 3.10-3.12) [15]. In studies comparing the sensitivity of upper GI series with endoscopy for the detection of marginal ulcer, the UGI series performed poorly, identifying ulcers in only about 50% of cases [6]. Marginal ulcers may develop secondary to retained gastric antrum, incomplete vagotomy, or Zollinger-Ellison syndrome. Incomplete vagotomy is the major cause of recurrent ulcer at the present time.

Retained gastric antrum, an uncommon cause of marginal ulcer, occurs when portions of the antrum are unintentionally left behind after partial gastrectomy. Without acid bathing of the retained antrum, there is no inhibitory effect for the production of gastrin, and thus the parietal cells in the fundus and body of the stomach produce high levels of acid, with a resultant high incidence of ulcer recurrence. High blood levels of circulating gastrin are found. The diagnosis can be made on barium studies when there is filling of a portion of the antrum adjacent to the duodenal bulb [16,17]. Good opacification of the A limb is required for this to be seen. The retained gastric antrum may change position after surgery and instead of occupying its normal position to the left of the pylorus, it may be superimposed on the duodenum or to the right of it [16]. Retained gastric antrum can be simulated by the Bancroft procedure, in which the gastrin-producing mucosa is stripped, but the remaining antrum is left intact (Fig. 3.13). The Bancroft proce-

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