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

10.  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.

11.  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

12. 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

13. 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

14.  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

15. 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.

16. 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.

18. 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

19.  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

20. 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

21. 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

22.  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

23. 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

24.  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

25. Causes of Afferent Loop
Syndrome

26. 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.

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

28.  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

29.  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

30.  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 B12 and deconjugated bile
acids
 systemic deficiency of vitamin B12  megaloblastic
anemia

31. 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

32. 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.

34.  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

35.  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

36. 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

37.  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

38.  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