Postgastrectomy Syndromes

1
Postgastrectomy Syndromes

• Surgery Grand Rounds
• Nathan Lytle, MD
• 10/6/2010

2
Objectives

• Review the types of gastric reconstructions
• Define postgastrectomy syndromes
• Outline presentation and diagnosis of each
  syndrome
• Present medical and surgical management options

3
Introduction

• Theodor Billroth (1829-1894)
• German born, Austrian surgeon
• Amateur musician
• friend of Johannes Brahms
• Played piano and violin

4
Billroth

• First esophagectomy (1871)
• First Laryngectomy (1873)
• Best known for first successful gastrectomy for
  cancer (1881)

5
In general

• Many studies and attempts to improve gastric
  resection and reconstruction since Billroth
• 25 of patients have postgastrectomy symptoms
• Most are minor, 2 4 are debilitating
• Due to loss of reservoir function, denervation,
  disruption of pylorus, and mechanics of
  reconstruction

6
In general

• Shift in management of these syndromes
• Was focused on acid and gastric hypersection
• Now focused on gastric function and emptying
• Disruption of the mechanics of emptying and
  peristalsis - cause of most of the current
  syndromes

7
Quick Review

• Types of reconstruction after gastrectomy
• Billroth I
• Billroth II
• Roux-en-Y

8
Billroth I

• Preserves duodenal passage
• Preserves pancreatic function
• Altered after gastrojejunostomy
• Better fat digestion
• Less incidence of gastritis and reflux
• Can use only with distal limited gastric
  resections
• tension

9
Billroth II

• Can be used for larger gastric resections
• Can result in dumping syndrome

10
Roux-en-Y

• Described by Cesar Roux
• Late 1800s
• Gastric outlet obstruction
• Better control of enterogastric reflux
• Method of choice for early dumping or reflux

11
The Syndromes

• Gastroparesis
• Bile alkaline reflux gastritis
• Efferent/Afferent loop syndromes
• Roux limb syndrome
• Dumping syndrome

• Post-vagotomy diarrhea
• Recurrent Ulceration
• Small-Capacity Syndrome
• Postvagotomy Dysphagia
• Gastric Remnant Carcinoma
• Anemia, Metabolic Disorders

12
Gastroparesis

• Most common syndrome
• 50 of pts thought to have symptoms
• Definition is highly variable
• Hard to get true incidence

13
Diagnosis

• Most pts diagnosed if not taking adequate po
  intake 7-14 days post-op after gastric procedure
• Symptoms nausea, bloating, fullness, early
  satiety, vomiting
• Gastric emptying studies normal 60 solid, 80
  liquid clearance at 60 min.
• Nuclear medicine or thin barium vs gastrograffin

14
Acute Gastroparesis

• Causes
• Metabolic/Neuronal
• Release of norepi and inhibition of acetylcholine
  in immediate post-op period
• Electrolytes hypomagnesemia, hypokalemia
• Endocrine hypothyroidism, DM
• Medications opiates, anticholinergics,
  antidepressants
• Functional
• Preoperative gastric outlet obstruction-affects
  contraction
• Effects of truncal vagotomy mostly solids
• Stomal edema, adhesions, kinking, hematoma,
  intussusception

15
Treatment

• Conservative
• NGT decompression
• Prokinetic agents
• Bethanechol, Reglan, Erythromycin Cisapride off
  market
• Correction of lytes
• patience

• After failed treatment
• Minimum of 3-4 wks
• No improvement re-explore
• Look for mechanical causes
• Place feeding tube jejunostomy
• Gastric pacing experimental

16
Chronic Gastroparesis

• Diagnosis of exclusion rule out stricture,
  internal hernia, stomal edema, intussusception
• 2 of patients after gastric surgery mostly
  after truncal vagotomy
• Symptoms start later in the post-op period

17
Chronic Gastroparesis

• Diagnosis
• Symptoms early satiety, nausea, vomiting,
  postprandial bloating, hiccups, belching
• Increase throughout the day
• Emesis of food ingested days earlier
  pathognomonic
• Need UGI and EGD to rule out other syndromes

18
Treatment

• Conservative treatment
• Same as acute gastroparesis
• More emphasis on maximizing response to
  prokinetic agents

• Surgical treatment
• Resection of atonic portion
• Using a different type of reconstruction
• Only total gastrectomy may be curative
• Gastric pacing some improvement at 6 mo, but
  disappears at 1 yr

19
(No Transcript)
20
Alkaline Reflux Gastritis

• Reflux of intestinal contents into the stomach
• Significant mucosal injury causing symptoms
• Debilitating in 1-2 of post gastrectomy pts.
• 20 of healthy controls have duodenogastric
  reflux
• Also increased in pts with cholelithiasis/cholecys
  tectomy
• More common in Billroth IIgt B I gt VP

21
Pathophysiology

• Refluxate contents bile, pancreatic enzymes,
  other intestinal secretions
• Some disagreement bile salts gastric acid
  decreased barrier function of mucosa
• Causes gastritis and symptoms

22
Diagnosis

• Again a diagnosis of exclusion
• Symptoms usually start 1yr post-op
• Fatigue, malaise, weight loss
• Constant, burning epigastric pain, worse with
  food
• Persistent nausea, always bilious emesis
• Pain characteristically not alleviated with emesis

23
Diagnosis

• EGD classic beefy red, edematous gastric mucosa
• Sharp demarcation of mucosa at anastomosis
• HIDA to evaluate gastric reflux index
• lt5 - healthy, normal
• 5 - 45 - asymptomatic, after BII
• gt60 - symptomatic
• Bernstein test reproduction of symptoms with
  gastric infusion of Na hydroxide

24
Treatment

• Conservative

• Surgical

• Doesnt work as well
• High fat/protein diet
• PPI, carafate, reglan
• Cholestyramine binds bile
• Most promising Ursodeoxycholic acid
• Resolution of symptoms

• Braun procedure
• Distal enteroenterostomy
• Henley loop
• Roux-en-Y reconstruction

25
Braun ProcedureDistal enteroenterostomy

• Both decrease amount of refluxant but not enough
  protection from reflux
• Goal should be to divert all intestinal contents
  away from gastric remnant

26
Henley Loop

• Described in 1950s to treat dumping syndrome
• When used for ARG, shown good results to relieve
  symptoms
• Some report recurrence of symptoms over time

27
Roux-en-Y Reconstruction

• Procedure of choice
• Long Roux limb 45-60cm
• Symptoms relieved in 80 of pts
• Ulcerogenic, 30 gastroparesis
• Evaluate original path for complete antrectomy
  and gastric motility

28
New Procedures

• Suprapapillary Roux
• duodenal switch
• Described by Demeester
• Better for pt with primary duodenogastric reflux
• Exclusion duodenojej
• Braun procedure with stapling off of afferent limb

29
(No Transcript)
30
Dumping Syndrome

• Most talked about syndrome, though less common
• Rarely need surgery
• Can occur with any gastric procedure but
  originally described with gastrojejunostomy
• Term that represents a collection of symptoms
  seen with rapid gastric emptying
• Exact cause has not fully been defined
• Two types early and late

31
Early Dumping

• Much more common than late
• 25 of gastric surgery have symptoms
• Vasomotor symptoms
• Highest incidence with BII
• 1-2 have debilitating symptoms requiring
  surgical treatment

32
Pathophysiology

• Exact mechanism is not completely understood
• Alterations in pyloric mechanism is integral
• Also loss of receptive relaxation after vagotomy
• Usually truncal vagotomy, not seen in highly
  selective
• Causes rapid entry of hyperosmolar chyme
• Rapid fluid shifts to maintain isotonicity by
  dilution
• Vasoactive substance release bradykinin,
  serotonin, insulin, motilin, neurotinsin,
  substance P

33
Diagnosis

• Usually made clinically classic history
• Onset of symptoms 10-30mins after meal
• Most commonly after high carb meal
• Crampy discomfort, belching, nausea, fecal
  urgency
• Light headedness, blurred vision, diaphoresis,
  flushing, dizziness, hypotension, syncope
• Usually no true abdominal pain
• 50 glucose solution reproduces symptoms
• Gastric emptying studies rapid emptying

34
Treatment

• 90 of pts symptoms resolve with diet changes
• Frequent, small meals
• Avoid meals rich in carbs
• Separate liquids and solids

35
Medical Treament

• Octreotide long acting somatostatin analogue
• Inhibits vasoactive peptides, slows intestine
• Give 30 min before meal
• Relieves most vasomotor and some GI symptoms

36
Surgical Treatment

• Only when aggressive dietary and medical
  treatment fail
• Primary goal is decreasing rapid gastric emptying
  and restoration of the gastric reservoir
• Two most common options are jejunal interposition
  procedures and long Roux-en-Y diversions
• Multiple other options conversion of BII to BI,
  pyloroplasty reversal, jejunal pouch
  interpositions

37
Jejunal Interposition

• Isoperistaltic
• 10-20cm
• Regulate rate of gastric emptying and dilate to
  inc reservoir
• Antiperistaltic
• No longer than 10cm
• Slow gastric emptying
• Gastric retention, reflux, obstructive symptoms

38
Roux diversion

• Becoming more common
• Length of limb long enough to prevent
  enterogastric reflux
• gt75 success rates for resistant dumping syndrome

39
Late Dumping

• Uncommon, hard to diagnosis
• Vasomotor symptoms 1-4 hrs after meals
• Usually high carb meals
• Always has reactive hypoglycemia
• Usually no abdominal complaints

40
Pathogenesis

• Again, rapid emptying of stomach
• Sudden hyperglycemia release of enteroglucagon
  to stimulate insulin release
• Overstimulation then causes hypoglycemia
• Adrenal gland stimulated to release
  catecholamines which cause diaphoresis,
  palpitations, flushing

41
Treatment

• Medical usually successful
• Low carb diet
• Pectin or arabose
• Slows carb absorption
• Octreotide not as effective in late dumping

• Surgery
• Unusual to have to operate
• Treatments are the same as early dumping

42
(No Transcript)
43
Afferent and Efferent Limb Syndromes

• Caused by partial or complete obstruction of
  jejunal limbs
• Characteristic signs and symptoms
• Afferent is more common than efferent

44
Afferent Limb Syndrome

• Occurs only with BII
• Almost always due to too long of a limb
• Acute and chronic forms
• Acute closed loop obstruction, usually
  immediately post-op, needs surgery

45
Diagnosis

• Symptoms of intermittent RUQ pain, relieved with
  vomiting
• Hyperamylasemia
• ?pancreatitis
• EGD, gastrograffin study, CT dilated loop
• HIDA delayed films can show /- obstruction

46
Chronic Afferent LimbSyndrome

• More common than acute
• Due to partial limb obstruction
• Increased incidence if anastomosis is retrocolic
  and above the mesocolonic defect
• Bacterial overgrowth blind loop syndrome, vit
  B12 deficiency

47
Manifestations of Chronic Afferent Limb Syndrome
and Alkaline Reflux Gastritis

• Chronic Afferent Limb Syndrome

• Alkaline Reflux Gastritis

• Pain after meals
• Vomitus Bile, no food, relieves pain, projectile
• Occult bleeding rare
• Cause limb obstruction

• Pain unrelated to meals
• Vomitus Bile and food, no change in pain,
  nonprojectile
• Occult bleeding common
• Cause enterogastric reflux

48
Treatment

• Surgical
• Two most accepted
• Convert BII to BI
• Can be difficult to get to duodenal stump
• Roux-en-Y important to remember to perform
  complete vagotomy
• Prevents marginal ulcers

49
Efferent Limb Syndrome

• Less common and harder to diagnose
• Symptoms of crampy LUQ and epigastric pain
  associated with bilious vomiting
• Most commonly caused by internal herniation of
  the limb behind the anastomosis
• Diagnosed with barium UGI and EGD
• Treatment is surgical and is determined at the
  time of exploration

50
(No Transcript)
51
Roux Limb Syndrome

• 25-30 incidence of nausea, vomiting,
  postprandial epigastric fullness, and upper
  abdominal pain
• Hard to differentiate from gastroparesis
• Usually a late complication
• True cause is unknown
• Thought to occur due to disrupted jejunal
  myoelectric propagation
• Loss of vagal stimulation that accompanies
  gastrectomy
• No true correlation between length of Roux limb

52
Diagnosis

• Symptoms months to years after gastrectomy
• UGI and EGD usually normal
• Gastric emptying significantly delayed
• Symptoms are not improved with prokinetic agents
• Main way to differentiate from gastroparesis
• Dont improve over time

53
Treatment

• Surgical
• Further gastric resection with new Roux-en-Y
• To remove atonic stomach
• Conversion to BII with Braun 30cm distal
• Uncut Roux
• Avoids defunctionalized intestine

54
In Summary

• Postgastrectomy syndromes well known
  complications of gastric surgery
• Common but rarely severe enough for surgery
• Diagnosis can be hard. UGI, emptying studies,
  EGD are main tests
• Treatments are focused mostly on function of
  reconstruction

• Conservative treatment for most common syndromes,
  but surgery for less common ones
• Surgical correction is based on prior
  reconstruction and studies evaluating current
  anatomy and function

55
(No Transcript)