Basic general condition in post operation to remove stomach out. And nutritional condition in this state.

1. Post Gastrectomy Syndrome
Kusuma Chinaroonchai, MD.

2. Definition
• Sequelae after gastrectomy operation
• 3 main types
– Gastric reservior dysfunction
– Vagal denervation
– Aberrations in surgical reconstruction

3. Other complication post operation
• Intra-operative bleeding
• Common bile duct injury and difficult duodenal
stump
• Disruption of ampulla of Vater
• Leakage of gastroduodenostomy (Billroth I) and
gastrojejunostomy (Billroth II)
• Ischemic necrosis of gastric remnant
• Afferent loop obstruction
• Stomal obstruction

4. Gastric reservior dysfunction
• Metabolic aberrations
• Dumping syndrome
– Loss of stomach volume and pyloric sphincter
mechanism >> premature discharge into small
bowel
– 2 types
• Early
• Late

5. Early Dumping syndrome
• Rapid shift in extracellular fluid of SB (rapid
passage and hyperosmolarity) >> acute distension >>
ANS response
• B II reconstruction
• Pastprandial symptoms in 10-30 mins
• GI symptoms : N/V, epigastrium
fullness, abdominal cramping and diaarhea
• CVS : palpitation, tachycardia, diaphoresis

6. Late Dumping syndrome
• Carbohydrate diet >> rapid pass to SB >>
hyperglycemia >> insulin shoot >>
cathecholamines stimulation

7. Dumping syndrome : Rx
• Conservative Rx
– Low carbohydrate diet (prefer complex
carbohydrate)
– Separate meal with solid and liquid food
– Avoid some sort of food such as icecream
– Octreotide 100 mcg IV 15-60 mins ac
– Alpha glucosidase inhibitor medication in late
dumping

8. Dumping syndrome : Rx

9. Dumping syndrome : Rx
• Sx Rx < 1%
– Iso/anti peristaltic segment of jejunum interposed
bet stomach/SB (10-20 cm)
– Roux-en-Y gastrojejunostomy

10. Metabolic aberration
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•
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B II > B I
Anemia
Bone disease
Weight loss

11. Anemia
• IDA (Iron Deficiency Anemia)
• B12 deficiency
• Folate deficiency

12. IDA
• Most common anemia in anemia post gastric
procedure
• Fe decreased absorption (Prefered acidic
state)
• Rx : Iron supplement

13. B12 deficiency
• Decreased in absorption
– Intrinsic factor from parietal cell
– Acidic environment
• Rx :
– B12 supplement

14. B12 deficiency

15. Folate deficiency
• Impaired digestion
• Malabsorption (duodenum)
• Rx :
– Folate supplement

16. Metabolic Bone disease
• Vit D absorption decreased in fat
malabsorption
• Ca decreased absorption (mostly at
duodenum)
• Unexplained aches and pains in back or long
bones
• Monitor BMD q 1-2 Yr : Osteoporosis, penia
and malacia
• Rx : Ca and Vit D supplement

17. Metabolic Bone disease
Prevent Dose
250 mg calcium
400 mg IU vitamin D OD

18. Weight loss
• Thin woman
• Causes
– Not adequate caloric intake
– Malabsorption

19. Vagal Denervation
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•
•
•
30% of patients
Diarrhea
Gastric stasis
Gallstone

20. Vagal Denervation : Diarrhea
• Presented with diarrhea
• Mostly diarrhea from dumpling syndrome, but
some may not
• Post vagal resection >> uncontrolled bowel
movement >> increased stool frequency
• Other machanism: bile acid malabsorption,
rapid gastric emptying time and bacterial
overgrowth

21. Vagal Denervation : Diarrhea
• Conservative Rx :
– Cholestyramin
– ATB
– Codeine
– Loperamide
• Sx Rx : 10 cm segment of reversed jejunum
anastomosis placed 70-100 cm from ligament
of Treitz

22. Vagal Denervation : Gastric stasis
• Conservative Rx :
– Metoclopramide
– Domperidone
– Erythromycin
• NJ tube feed

23. Vagal Denervation : Gallstone
• Division of hepatic branches of anterioe vegal
trunk
• Gallbladder dysmotility
• Sx indicated only if have pathology
• No indication for prophylaxis cholecystectomy

24. Abberation in Reconstruction
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Bile reflux gastritis
Afferent and efferent loop obstruction
Jejunogastric intussusception
Roux syndrome

25. Bile Reflux Gastritis
• Most patient no symptoms
• Reflux symptoms: epigastric pain, N/bilious
vomiting
• Dx by clinical + evidence of bile reflux (scope
or scan)
• Scope :
– mucosal erythema that involve parastomal region
– bile staining or pooling
– observed enterogastric reflux

26. Bile Reflux Gastritis
• Rx : no significant medication benefit
• Sx : divert bile and pancreatic secretion from
stomach
– Roux-en-Y gastrojejunostomy (Roux limb at least 45
cm)
– Interposition 40 cm of isoperistaltic jejunal loop
– Braun enteroenterostomy

27. Bile Reflux Gastritis

28. Afferent and Efferent Loop Obstruction
• Afferent loop syndrome
– Afferent limb length > 30-40 cm can be
obstruction
– Chronic > acute
– Severe postprandial epigastric pain(30-60 mins)
– Projectile bilious vomiting
– Dramatic clinical relief after vomiting
– Some can be presented with diarrhea

29. Afferent and Efferent Loop Obstruction

30. Afferent and Efferent Loop Obstruction

31. Afferent and Efferent Loop Obstruction

32. Jejunogastric Intussusception
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•
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Rare complication
Simple gastroenterostomy > B II
E limb intussuscepted into stomach
Came with upper gut obstruction symptoms
Sx treatment in Rx of choice

33. Roux Syndrome
• Vomiting, epigastrium pain and weight loss
after distal gastrectomy with Roux-en-Y
reconstruction
• Scope : Dilate remnant stomach and Roux limb
• No mechanical obstruction from CT or upper
GI series
• Rx : Promotality agents VS Sx

34. Thank You