POST GASTRECTOMY SYNDROME

By Karl

1. Functional efferent /afferent

loop syndrome

2. post gastrectomy asthenia

3. Post gastrectomy anemia

Functional Efferent/ afferent loop syndrome

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.

Etiology.Factors that lead to the development of the syndrome are divided into 

1.Organic2.functional.

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.

2.  Infringement of afferent loop in the crevices of the mesentery and small intestine.

3. Volvulus, and rotation of a long afferent loop.

4. Intussusception of the afferent loop .

5. Compression of the afferent loop forming adhesions

6.  compression by mesenteric artery onto the distal part of duodenum 

7. Compression of the afferent loop by tumor.

8. The capture of a large amount of the intestinal wall by stitches(sutures) during the operation.

Functional causes are:1. decrease in tone and motility of the

duodenum (duodenostasis).

Pathogenesis.

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.

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.

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.

The clinical picture.

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 develops peritonitis.

The chronic form - is characterized by upper quadrant pain, retching, vomiting bile.

There are three degrees of severity of the syndrome:

1.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.

2. Moderate - the pain becomes more pronounced. Appears 10-15 minutes after eating. 

At the height of pain there is vomiting. Vomiting occurs - 3-4 times a week. The deficit in body weight - up to 10 kg.

3. Severe - characterized by severe pain.  the phenomenon of cholecystitis, pancreatitis, esophagitis may occur. Person Vomits every day.

Diagnosis.

Physical examination -palpable mass in abdomen . Find asymmetry of abdomen

Ultrasound - expanding gut is visible, with accumulation of fluid and gas in it.

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 can’t fill the affected loop.

Treatment.

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

For surgical correction - the following operations are conducted:

§ Gastroenterostomosis by Roux.

§ Reconstruction of the gastrojejunal anastomosis to gastrodoudenal.

§Formation of the  Braun anastomosis.

4. If there is still a dumping syndrome - then a  reconstructive gastrojejunoduodenoplasty of Zakharov-Henley is performed  together with stem vagotomy.

anastomosis_Roux-en-Y

Braun anastomosis.

Braun anastomosis.

Prophylaxis

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.

Postgastrectomy (agastria) asthenia.

Pathogenesis.

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 there’s no enzymatic breakdown of complex substances to simple blocks. 

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

Clinical Picture

Violation of protein metabolism - leads to edema.

Patients complains of diarrhea, skin changes, weakness, loss of appetite, weight loss.

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

Diagnosis is based on the clinics.

Treatment.

Conservative treatment

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

enzymes (mezim).

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