POST GASTRECTOMY SYNDROME

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POST GASTRECTOMY SYNDROME

• By Karl

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1. Functional efferent /afferent loop syndrome
2. post gastrectomy asthenia
3. Post gastrectomy anemia

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Functional Efferent/ afferent loop syndrome
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• Afferent loop syndrome - is a violation of
  the afferent loop emptying.
• It is caused by acute (complete) or chronic
  (intermittent) obstruction of the afferent
  jejunal loop.

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Etiology.

• Factors that lead to the development of
  the syndrome are divided into 
• Organic
• functional.

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Organic causes

1. An acute angle is created, after
    gastro-jejunostomy, between the loop and the
   anastomosis line. As a result, the it bends and
   the food mostly comes into the resulting loop.

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1.  Infringement of afferent loop in the crevices of
   the mesentery and small intestine.
2. Volvulus, and rotation of a long afferent loop.

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1. Intussusception of the afferent loop .
2. Compression of the afferent loop forming adhesions
   
3.  compression by mesenteric artery onto the distal
   part of duodenum 
4. Compression of the afferent loop by tumor.
5. The capture of a large amount of the intestinal
   wall by stitches(sutures) during the operation.

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Functional causes are

• decrease in tone and motility of the
  duodenum (duodenostasis).

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Pathogenesis.
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• As a result of obstruction there is a pile up of
  bile, pancreatic juice and food in the loop.The
  non-participation of enzymes in digestion leads
  to a violation of the normal function. In the
  loop pressure increases. Bacteria from the loop
  go to the liver, gall bladder, pancreas.

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• Due to the increase in intracolonic
  pressure, vomiting develops. As a result of
  vomiting there is disruption of water and
  electrolyte balance. The function of  the lower
  esophageal sphincter is disrupted
  therefore reflux oesophagitis develops.

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• Also a result of acute afferent loop
  syndrome (resulting from invagination or
  inflection) the blood circulation can be
  disturbed and this may lead to gangrene of
   intestine and peritonitis.

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The clinical picture.
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• There are acute and chronic forms of afferent
  loop syndrome.
• The acute form - is characterized by intense pain
  in the epigastrium, nausea, vomiting
  without bile. In the case of bowel necrosis develo
  ps peritonitis.
• The chronic form - is characterized by upper
  quadrant pain, retching, vomiting bile.

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• There are three degrees of severity of the
  syndrome
• mild - the pain is not constant, and occurs
  during intake of large amounts of fatty foods.
  There is no loss of weight or if any its
  insignificant.
•  Moderate - the pain becomes more
  pronounced. Appears 10-15 minutes after eating. 

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• At the height of pain there is vomiting. Vomiting 
  occurs - 3-4 times a week. The deficit in body
  weight - up to 10 kg.
•  Severe - characterized by severe pain.  the
  phenomenon of cholecystitis, pancreatitis, esophag
  itis may occur. Person Vomits every day.

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Diagnosis.
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• Physical examination -palpable mass in abdomen
  . Find asymmetry of abdomen
• Ultrasound - expanding gut is visible, with
  accumulation of fluid and gas in it.

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• X-ray examination. Can see enlarged
   gut,  horizontally can see fluid levels.In some
  cases (due to increased pressure in
  the loop, compression and necrosis) the
  contrast media cant fill the affected loop.

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Treatment.
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• Conservative treatment is not so effective. 
• it involves- Dieting- Exclusion of fatty
  foods- Decompression of the stomach by probe-
  Intake of antacids, antispasmodics.

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• For surgical correction - the following
  operations are conducted
•  Gastroenterostomosis by Roux.
•  Reconstruction of the gastrojejunal anastomosis t
  o gastrodoudenal.
• Formation of the  Braun anastomosis.

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• If there is still a dumping syndrome - then
  a  reconstructive gastrojejunoduodenoplasty of Zak
  harov-Henley is performed  together
  with stem vagotomy.

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anastomosis_Roux-en-Y
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Braun anastomosis.
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Braun anastomosis.
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Prophylaxis
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• Afferent loop syndrome prevention
• during gastrojejunostomy, use  loop of
  jejunum, length of 8-10 cm, from the
  ligament Treitz
• suturing afferent loop to the lesser curvature
  of the loop in order to create a valve
• fixation of the gastric stump in the window of
  the mesentery of the transverse colon.

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Postgastrectomy (agastria) asthenia.
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Pathogenesis.
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• Removal of the stomach leads to the rapid
  emptying of the stomach contents. This means
  that little or no digestion occurs in the
  stomach. Thus theres no enzymatic breakdown of
  complex substances to simple blocks. 

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• This leads to metabolic disorders. The small
  intestine receives chemically and mechanically unp
  repared food. As a result there is Violation in
  vitamin absorption. There occurs anemia (iron
  and B12 deficiency).

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Clinical Picture
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• Violation of protein metabolism - leads to edema.
• Patients complains of diarrhea, skin changes,
  weakness, loss of appetite, weight loss.

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• There are three degrees of severity of
  asthenia (agastria)Grade 1 - mildGrade
  2 - moderate - with diarrhea, edema, anemiaGrade
  3 - severe - with cachexia, beriberi, osteopathy.

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Diagnosis 

• is based on the clinics.

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Treatment.
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Conservative treatment

• A balanced diet. 
• Use of anabolic hormones (retabolil, Anabol),
• enzymes (mezim).

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Surgical treatment 

• involves the inclusion of duodenum in
  the process of digestion ,
• Increasing the volume of gastric stump,
• Reducing the rate of gastric emptying. It is
  used in cases of severe athenia

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