Postgastrectomy Syndromes

Motility Complications

1. Dumping Syndrome
1. Early Dumping Syndrome
1. Symptoms
• most commonly occurs after a partial gastrectomy with Billroth II reconstruction
• symptoms occur 20 – 30 minutes after a meal
• GI symptoms predominate: nausea/vomiting, epigastric fullness, cramping abdominal pain, often explosive diarrhea
• cardiovascular symptoms include palpitations, tachycardia, diaphoresis, dizziness, flushing, fainting
• a high carbohydrate meal usually precipitates the attack, but it can occur after any meal


2. Pathophysiology
• destruction of the pylorus allows rapid emptying of hyperosmolar chyme, especially carbohydrates, into the intestine
• the net effect is rapid fluid shifts into the small intestine to achieve isotonicity
• this results in the release of vasoactive hormones such as serotonin and vasoactive intestinal peptide (VIP)
• gastric emptying studies often document rapid liquid emptying
• underlying cause may be related to the loss of receptive relaxation: gastric pressure increases during a meal and then decompresses through the gastric outlet procedure


3. Treatment
1. Medical
• great majority of cases resolve spontaneously
• some patients respond to eating frequent small meals low in carbohydrates
• separating solids and liquids at meals can help
• in refractory cases, the administration of octreotide, a somatostatin analog, is often beneficial


2. Surgery
• only used if dietary manipulations and octreotide fail to control the symptoms
• the operation of choice is conversion of the gastrojejunostomy to a Roux-en-Y
• a 45 - 60 cm Roux limb is constructed and placed in an antecolic fashion
• the gastric remnant should be less than 25% to avoid Roux stasis syndrome


2. Late Dumping Syndrome
1. Symptoms
• similar symptoms as early dumping, but occurs 1 to 2 hours after a meal
• related to hypoglycemia


2. Pathophysiology
• rapid emptying of carbohydrates into the intestine causes postprandial hyperglycemia
• hyperosmolar material in the intestine results in the release of enteroglucagon
• enteroglucagon sensitizes the pancreatic islets to release excessive amounts of insulin, resulting in an ‘overshoot’ hypoglycemia
• hypoglycemia results in catecholamine secretion


3. Treatment
• similar to that for early dumping
• patients should be placed on a low carbohydrate diet
• revisional surgery is almost never required


2. Postvagotomy Diarrhea
1. Clinical Manifestations
• diarrhea occurs is up to 30% of patients following truncal vagotomy
• most patients have mild symptoms; only 1% to 2% of patients have incapacitating symptoms


2. Pathogenesis
• etiology is unclear
• may be related to rapid transit of bile acids from the denervated biliary tree into the colon


3. Treatment
1. Medical
• dietary alterations can be helpful: smaller and more frequent meals and more dietary fiber
• cholestyramine has been used to bind bile salts
• antidiarrheal agents are used to reduce the number of stools
• octreotide has also been used with good results


2. Surgery
• used only as a last resort
• the goal of surgery is to slow intestinal transit
• a 10 cm antiperistaltic jejunal segment interposed 100 cm distal to the ligament of Treitz has been used with some success, but it may cause obstructive symptoms or bacterial overgrowth


3. Acute Gastroparesis
1. Clinical Manifestations
• incidence varies from 10% to 50% following gastric operations, especially if a truncal vagotomy was part of the procedure
• also seen after a Whipple resection and palliative gastrojejunostomy
• symptoms include persistently high nasogastric tube outputs or vomiting following oral intake


2. Treatment
1. Medical Therapy
• need to rule out mechanical obstruction with a barium study or endoscopy
• if the anastomosis is patent, then a period of nasogastric decompression, hyperalimentation, and administration of prokinetic agents is begun
• Reglan, Cisapride, and erythromycin may all be tried
• a percutaneous gastrostomy tube may be inserted so that the nasogastric tube can be removed
• most cases will resolve within 3 to 4 weeks


2. Surgery
• surgery is reserved for the most refractory cases
• surgical goal is to remove a portion of the atonic stomach by a further gastric resection
• if the remaining stomach is > 25%, then reconstruction should be with a BII; if it is < 25%, then a Roux-en-Y will be necessary
• if a BII reconstruction is performed, then a distal Braun enteroenterostomy should be done to divert bile away from the stomach, eliminating postoperative bile reflux


4. Chronic Gastroparesis
1. Clinical Manifestations
• characterized by nausea, ± vomiting, abdominal pain, bloating, frequent bezoar formation
• endoscopy and barium studies are necessary to rule out an anastomotic stricture


2. Treatment
1. Medical Therapy
• prokinetic agents are usually empirically started
• the efficacy of these agents can be evaluated by radionuclide gastric emptying studies


2. Surgery
• goal of surgery is to remove a portion of the atonic stomach
• if the patient has had a vagotomy/pyloroplasty, then a hemigastrectomy is performed
• if the patient has had a prior antrectomy or hemigastrectomy, then an additional resection is performed


5. Bile Reflux Gastritis
1. Clinical Manifestations
• symptoms include severe upper abdominal burning pain that worsens after a meal, chronic nausea, and bilious vomiting


2. Diagnosis
• diagnosis is primarily one of exclusion
• differential diagnosis includes marginal ulceration, afferent loop syndrome, anastomotic stricture, and chronic gastroparesis
• a barium study can be used to rule out an anastomotic stricture and afferent loop syndrome
• endoscopy will show marked gastritis that should be confirmed by biopsy
• gastric emptying studies should be performed to rule out chronic gastroparesis
• HIDA scan can demonstrate bile reflux into the stomach


3. Treatment
1. Medical Therapy
• no specific medical treatment has proven effective
• Carafate has been used to ‘coat and protect’ the stomach


2. Surgery
• 45 - 60 cm Roux-en-Y adequately diverts the bile away from the stomach
• must be certain that the patient does not have gastroparesis, since a Roux-en-Y diversion will only exacerbate this problem
• in patients with gastroparesis, an enteroenterostomy between the afferent and efferent limbs of the gastrojejunostomy should be sufficient


6. The Roux Stasis Syndrome
1. Clinical Manifestations
• severe gastroparesis following a Roux-en-Y gastrojejunostomy
• the early syndrome resolves with time and prokinetic agents, especially erythromycin
• the chronic syndrome presents with abdominal pain, vomiting, and often bezoar formation


2. Diagnosis
• endoscopy is usually normal
• barium studies may show a dilated Roux limb with no evidence of distal obstruction
• gastric emptying studies will show delayed gastric emptying
• GI motility studies show disordered motility in the Roux limb, with propulsive activity towards the stomach, rather than away


3. Treatment
1. Medical Therapy
• erythromycin is useful in the short-term, but it is less useful chronically


2. Surgery
• standard surgical approach is to convert the patient to a subtotal or near-total gastrectomy, recreating a new Roux-en-Y reconstruction
• another approach is to perform a subtotal gastrectomy, take down the Roux limb, and perform a Billroth II reconstruction with a distal Braun enteroenterostomy
• the goal of this second procedure is to restore gastric emptying, but at the same time maintain adequate biliary diversion