Post gastrectomy syndrome

Department of Surgery,Kathmandu Medical College

1. Dr. Uttam Laudari First Year Resident Post Gastrectomy syndromes

2. Dumping syndrome Dumping syndrome refers to a symptom complex that occurs following ingestion of a meal when a portion of the stomach has been removed or the normal pyloric sphincter mechanism has become disrupted . Dumping syndrome exists in either a late or an early form, with the early form occurring more frequently.

3. The early form of dumping syndrome usually occurs within 20 to 30 minutes after ingestion of a meal Late- late dumping appears 2 to 3 hours after a meal and is far less common than early dumping

4. Early dumping syndrome is accompanied by both GI and cardiovascular symptoms . The GI symptoms include nausea and vomiting a sense of epigastric fullness eructations cramping abdominal pain abdominal pain is usually absent from this symptom complex, unless associated alkaline reflux gastritis is present ( Mastery of surgery) explosive diarrhea

5. The cardiovascular symptoms palpitations, tachycardia, diaphoresis, fainting, dizziness, flushing, and occasionally blurred vision. The symptoms characteristically occur while the patient is seated at the table eating or shortly after eating.

6. This symptom complex can develop after any operation on the stomach more common after partial gastrectomy with the Billroth II reconstruction It is far less commonly observed following the Billroth I gastrectomy or after vagotomy and drainage procedures

7. gastrectomy or interruption of the pyloric sphincteric mechanism rapid passage of food of high osmolarity from the stomach into the small intestine rapid shift of extracellular fluid into the intestinal lumen to achieve isotonicity luminal distention occurs and induces the autonomic responses

8. Humoral agenst released causing symptom in early dumping  serotonin , bradykinin -like substances, neurotensin , and enteroglucagon Diagnosis can be made with symptoms alone if there is doubt, gastric emptying scans can be obtained that demonstrate rapid gastric emptying. a provocative test can also be done in the form of a 200-mL meal of 50% glucose solution and water.

9. Most patients subjected to gastric surgery complain of some dumping-like symptoms after surgery . Most, however, experience spontaneous relief and require no specific therapy. Symptom prolong--dietary measures are usually sufficient . avoiding foods containing large amounts of sugar, frequent feeding of small meals rich in protein and fat, separating liquids from solids during a meal. 90% resolution

10. Pharmacological agents Octreotide Inhibits the release of virtually all vasoactive intestinal peptides slow intestinal transit time contract the splanchnic circulation given 30 to 60 minutes before meals, relieve most of the vasomotor and many of the gastrointestinal symptoms that these patients experience side effects, burning at the injection site mild abdominal cramping immediately after subcutaneous injection.

11. surgery When aggressive dietary and medical treatment fails Objective decreasing the rapid gastric emptying restoration of the gastric reservoir Billroth II reconstruction to a Billroth I pyloroplasty reversal, creation of complex interposed jejunal pouches Isoperistaltic and antiperistaltic jejunal interposition

12. Patients with disabling dumping after gastrojejunostomy can be considered for simple takedown of this anastomosis provided that there is some vagal innervation to the antrum , the pyloric channel is open endoscopically

13. Isoperistaltic interpositions Isoperistaltic interpositions place a 10- to 20-cm limb of jejunum between the gastric remnant and the proximal small intestine in most cases, the duodenum interpositions place a 10- to 20-cm limb of jejunum between the gastric remnant and the proximal small intestine in most cases, the duodenum These segments regulate gastric emptying. With time, these segments dilate, and in so doing, increase gastric reservoir function.

14. Antiperistaltic interpositions Antiperistaltic segments positioned in the same anatomic location are shorter, no longer than 10 cm in length By reversing the direction of peristalsis, gastric emptying is effectively delayed. Severe gastric retention, obstructive symptoms, and even alkaline reflux gastritis may complicate the use of these longer segments, manifestations are much worse if the segments are longer than 10 cm.

15. long Roux-en-Y diversions success rates of 75% or better Roux limb should be long enough to prevent enterogastric reflux Roux-en-Y gastrojejunostomy is associated with delayed gastric emptying, probably on the basis of disordered motility in the Roux limb Care must be taken to ensure that truncal vagotomy has been or is being performed when this procedure is used, so as to avoid marginal ulceration

16. In the presence of significant gastric acid secretion, marginal ulceration is common after both jejunal interposition and Roux-en-Y procedures; thus vagotomy and hemigastrectomy should be considered

17. LATE DUMPING SYNDROME Uncommon induced by meals that have high carbohydrate contents. The symptoms from 1 to 4 hours after ingestion of such meals Feature of reactive hypoglycemia in addition to some of the vasomotor symptoms seen with early dumping syndrome patients generally do not have symptoms of abdominal cramping or pain

18. Pathogenesis rapid emptying of hyperosmolar chyme from the gastric remnant into the proximal small intestine sudden hyperglycemia release of enteroglucagon from mucosal epithelial cells, which in turn stimulates excessive release of insulin from pancreatic beta cells causes profound hypoglycemia catecholamines  from the adrenal glands  diaphoresis, palpitation, and confusion

19. Dietary modifications are usually sufficient treatment. Low-carbohydrate diets are essential. Delaying carbohydrate absorption with Pectin or Acarbose Over time, the small intestinal mucosa adapts and appropriately adjusts the secretion of enteroglucagon in response to carbohydrates Somatostatin Dietary and medical management of these patients is quite successful, and surgical intervention is almost never required revisional surgery if indicated like that of early dumping syndrome

20. Afferent and Efferent Limb Syndromes Partial or complete obstruction of the afferent or efferent jejunal limb produces a characteristic constellation of signs and symptoms Afferent and efferent limb syndromes are recognizable, bona fide postgastrectomy syndromes

21. a complication observed only after gastrectomy with a Billroth II reconstruction the afferent limb is greater than 30 to 40 cm in length and has been anastomosed to the gastric remnant in an antecolic fashion intermittent right upper quadrant or epigastric pain that is relieved by nearly projectile bilious vomiting that contains no food. acute and chronic

22. Causes of Afferent Loop Syndrome

23. Acute occurs in the immediate postoperative period, the afferent limb is completely obstructed, or nearly so symptoms develop quickly closed-loop obstruction- duodenum proximally has already been closed during the Billroth II gastrectomy the consequences of this syndrome can be disastrous, with necrosis and perforation The diagnosis of acute afferent limb syndrome is sometimes difficult to establish must be distinguished from that of acute gastroparesis .

24. seen with volvulus or herniation of the afferent loop posterior to the efferent limb

25. hyperamylasemia frequently occurs with complete obstruction of the afferent limb ( D/D pancreatitis dealys diagnosis) Water-soluble contrast studies and esophagogastroduodenal endoscopy can help make this diagnosis treatment  always surgical the primary goal of which is to relieve the obstruction lysis of adhesions resection of a portion of the afferent loop to shorten it or a complete revision of the reconstruction is necessary

26. In partial obstruction, the intraluminal pressure increases to forcefully empty its contents into the stomach Projectile bilious vomiting  offers immediate relief of symptoms no food contained within the vomitus because the ingested meal has already passed into the efferent limb obstruction accumulation of pancreatic and hepatobiliary secretion within the limb epigastric discomfort and cramping

27. If the obstruction has been present for a long period of time, -  development of the blind loop syndrome bacterial overgrowth occurs in the static loop bacteria bind with vitamin B 12 and deconjugated bile acids systemic deficiency of vitamin B 12  megaloblastic anemia

28. Diagnosis Plain Xray -On occasion, the dilated afferent loop may be seen on plain films of the abdomen contrast barium study of the stomach may delineate the presence of an obstructed loop UGI endoscopy-Failure to visualize the afferent limb Radionuclide studies imaging the hepatobiliary tree Normally , the radionuclide should pass into the stomach or distal small bowel after being excreted into the afferent limb If there is failure to do so, the possibility of an afferent loop obstruction should be considered distinguishes this syndrome from alkaline reflux gastritis

29. Surgery acute and chronic, operation is indicated because it is a mechanical problem treatment therefore involves the elimination of this loop converting the Billroth II construction into a Billroth I anastomosis enteroenterostomy below the stoma, which is technically easier Creation of a Roux-en-Y can also be done, but a concomitant vagotomy should also be performed to prevent marginal ulceration from the diversion of duodenal contents from the gastroenteric stoma.

30. The efferent limb syndrome, on the other hand, is much less frequent and even more difficult to diagnose complain of crampy left upper quadrant and epigastric pain that is associated with bilious vomiting occur with both antecolic and retrocolic gastrojejunostomies Partial efferent limb obstruction can be difficult to distinguish clinically from afferent limb obstruction and alkaline reflux gastritis. most commonly produced by internal herniation of the efferent limb behind the anastomosis right-to-left fashion

31. Barium upper gastrointestinal radiography is the most useful method of making this diagnosis. Endoscopy may also be helpful. The treatment is always surgical and is dictated by the findings at the time of operation

32. Metabolic Disturbances Anemia IDA and Megaloblastic IDA more common IDA decreased iron intake impaired iron absorption, chronic subliminal blood loss secondary to the hyperemic, friable gastric mucosa primarily involving the margins of the stoma where the stomach connects to the small intestine

33. Vitamin B12 deficiency secondary to poor absorption of the substance owing to lack of intrinsic factor secretion in the gastric Impaired fat absorption inadequate mixing of bile salts and pancreatic lipase with ingested fat because of the duodenal bypass deficiency in uptake of fat-soluble vitamins pancreatic replacement enzymes are often effective in decreasing fat loss

34. Osteomalacia / osteoporosis caused by deficiencies in calcium Aggravated by fat malabsorption Development of bone disease generally occurs about 4 to 5 years after surgery Supplement Calvit