Post Gastrectomy Syndrome
Post Gastrectomy SyndromeKusuma Chinaroonchai, MD.
DefinitionSequelae after gastrectomy operation 3 main types
Gastric reservior dysfunctionVagal denervation Aberrations in
surgical reconstruction
Other complication post operationIntra-operative bleedingCommon
bile duct injury and difficult duodenal stumpDisruption of ampulla
of VaterLeakage of gastroduodenostomy (Billroth I) and
gastrojejunostomy (Billroth II)Ischemic necrosis of gastric
remnantAfferent loop obstructionStomal obstruction
Gastric reservior dysfunctionMetabolic aberrationsDumping
syndromeLoss of stomach volume and pyloric sphincter mechanism
>> premature discharge into small bowel2 types Early Late
Early Dumping syndromeRapid shift in extracellular fluid of SB
(rapid passage and hyperosmolarity) >> acute distension
>> ANS responseB II reconstructionPastprandial symptoms in
10-30 minsGI symptoms : N/V, epigastrium fullness, abdominal
cramping and diaarheaCVS : palpitation, tachycardia,
diaphoresis
Late Dumping syndromeCarbohydrate diet >> rapid pass to SB
>> hyperglycemia >> insulin shoot >>
cathecholamines stimulation
Dumping syndrome : Rx Conservative RxLow carbohydrate diet
(prefer complex carbohydrate)Separate meal with solid and liquid
foodAvoid some sort of food such as icecreamOctreotide 100 mcg IV
15-60 mins acAlpha glucosidase inhibitor medication in late
dumping
Dumping syndrome : Rx
Dumping syndrome : Rx Sx Rx < 1%Iso/anti peristaltic segment
of jejunum interposed bet stomach/SB (10-20 cm)Roux-en-Y
gastrojejunostomy
Metabolic aberrationB II > B IAnemiaBone diseaseWeight
loss
AnemiaIDA (Iron Deficiency Anemia)B12 deficiencyFolate
deficiency
IDAMost common anemia in anemia post gastric procedureFe
decreased absorption (Prefered acidic state)Rx : Iron
supplement
B12 deficiencyDecreased in absorptionIntrinsic factor from
parietal cell Acidic environmentRx : B12 supplement
B12 deficiency
Folate deficiencyImpaired digestion Malabsorption (duodenum)Rx :
Folate supplement
Metabolic Bone diseaseVit D absorption decreased in fat
malabsorptionCa decreased absorption (mostly at
duodenum)Unexplained aches and pains in back or long bonesMonitor
BMD q 1-2 Yr : Osteoporosis, penia and malaciaRx : Ca and Vit D
supplement
Metabolic Bone disease
Prevent Dose 250 mg calcium400 mg IU vitamin D OD
Weight lossThin womanCausesNot adequate caloric
intakeMalabsorption
Vagal Denervation30% of patientsDiarrheaGastric
stasisGallstone
Vagal Denervation : DiarrheaPresented with diarrheaMostly
diarrhea from dumpling syndrome, but some may notPost vagal
resection >> uncontrolled bowel movement >> increased
stool frequency Other machanism: bile acid malabsorption, rapid
gastric emptying time and bacterial overgrowth
Vagal Denervation : DiarrheaConservative Rx :
CholestyraminATBCodeineLoperamideSx Rx : 10 cm segment of reversed
jejunum anastomosis placed 70-100 cm from ligament of Treitz
Vagal Denervation : Gastric stasisConservative Rx :
MetoclopramideDomperidoneErythromycinNJ tube feed
Vagal Denervation : GallstoneDivision of hepatic branches of
anterioe vegal trunkGallbladder dysmotilitySx indicated only if
have pathologyNo indication for prophylaxis cholecystectomy
Abberation in ReconstructionBile reflux gastritisAfferent and
efferent loop obstructionJejunogastric intussusceptionRoux
syndrome
Bile Reflux GastritisMost patient no symptomsReflux symptoms:
epigastric pain, N/bilious vomitingDx by clinical + evidence of
bile reflux (scope or scan)Scope : mucosal erythema that involve
parastomal regionbile staining or poolingobserved enterogastric
reflux
Bile Reflux GastritisRx : no significant medication benefitSx :
divert bile and pancreatic secretion from stomachRoux-en-Y
gastrojejunostomy (Roux limb at least 45 cm)Interposition 40 cm of
isoperistaltic jejunal loopBraun enteroenterostomy
Bile Reflux Gastritis
Afferent and Efferent Loop ObstructionAfferent loop
syndromeAfferent limb length > 30-40 cm can be
obstructionChronic > acuteSevere postprandial epigastric
pain(30-60 mins)Projectile bilious vomitingDramatic clinical relief
after vomitingSome can be presented with diarrhea
Afferent and Efferent Loop Obstruction
Afferent and Efferent Loop Obstruction
Afferent and Efferent Loop Obstruction
Jejunogastric IntussusceptionRare complicationSimple
gastroenterostomy > B IIE limb intussuscepted into stomachCame
with upper gut obstruction symptomsSx treatment in Rx of choice
Roux SyndromeVomiting, epigastrium pain and weight loss after
distal gastrectomy with Roux-en-Y reconstructionScope : Dilate
remnant stomach and Roux limb No mechanical obstruction from CT or
upper GI seriesRx : Promotality agents VS Sx
Thank You
