Postgastroresectional disorders

According to literature data, post-gastrectomy disorders develop in 35-40% of patients who have undergone gastric resection. The most common classification of these disorders is the Alexander-WiUams classification (1990), according to which the following three main groups are distinguished:

1. Impaired gastric emptying as a result of resection of the pyloric section and, consequently, the transport of gastric contents and food chyme bypassing the duodenum.
2. Metabolic disturbances due to removal of a significant portion of the stomach.
3. Diseases to which there was a predisposition before surgery.

Impaired gastric emptying

Dumping syndrome

Dumping syndrome is an uncoordinated flow of food into the small intestine due to the loss of the reservoir function of the stomach.

A distinction is made between early dumping syndrome, which occurs immediately or 10-15 minutes after eating, and late dumping syndrome, which develops 2-3 hours after eating.

Early dumping syndrome

The pathogenesis of early dumping syndrome is the rapid entry of insufficiently processed food chyme into the jejunum. This creates extremely high osmotic pressure in the initial section of the jejunum, which causes fluid to flow from the bloodstream into the lumen of the small intestine and hypovolemia. In turn, hypovolemia causes excitation of the sympathoadrenal system and the entry of catecholamines into the blood. In some cases, significant excitation of the parasympathetic nervous system is possible, which is accompanied by the entry of acetylcholine, serotonin, and kinins into the bloodstream. These disorders cause the development of the clinical picture of early dumping syndrome.

The main clinical manifestations of early dumping syndrome:

• the appearance soon after eating of sudden general weakness, nausea, severe dizziness, and palpitations;
• sweating;
• pallor or, conversely, redness of the skin;
• tachycardia (less often - bradycardia);
• decrease in blood pressure (this is observed most often, but an increase is also possible).

These symptoms usually appear after eating a large amount of food, especially food containing sweets.

Late dumping syndrome

The pathogenesis of late dumping syndrome consists of excessive dumping of food, especially rich in carbohydrates, into the small intestine, absorption of carbohydrates into the blood, development of hyperglycemia, entry into the blood of excess insulin with subsequent development of hypoglycemia. A significant role in the excessive entry of insulin into the blood is played by an increase in the tone of the vagus nerve, as well as the loss of endocrine function of the duodenum.

Main clinical manifestations:

• a pronounced feeling of hunger;
• sweating;
• dizziness, sometimes fainting;
• trembling of the arms and legs, especially the fingers;
• double vision;
• redness of the skin of the face;
• heartbeat;
• rumbling in the stomach;
• urge to defecate or frequent stools;
• decrease in blood glucose levels;
• after the attack is over, there is severe fatigue and lethargy.

There are three degrees of severity of dumping syndrome:

• mild degree is characterized by episodic and short-term attacks of weakness after eating sweet and dairy foods; the general condition of the patient is satisfactory;
• moderate severity - the above symptoms develop naturally after each intake of sweet and dairy dishes, and persist for a long time; the general condition of patients may suffer, but there is no sharp limitation of work capacity or loss of body weight;
• severe degree - manifested by very pronounced symptoms, significant disruption of the general condition, a sharp decrease in performance, loss of body weight, disruption of protein, fat, carbohydrate, mineral, and vitamin metabolism.

With increasing time after surgery, the symptoms of dumping syndrome decrease. [ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ]

Post-resection reflux gastritis

The origin of post-resection reflux gastritis is caused by the reflux of intestinal contents with bile into the stomach. Bile has a damaging effect on the gastric mucosa, which is also facilitated by the cessation of gastrin production after removal of the distal part of the stomach. Post-resection reflux gastritis develops more often after gastric resection surgery according to Bilroth-II.

Clinically, reflux gastritis is manifested by dull pain in the epigastrium, a feeling of bitterness and dryness in the mouth, belching, and loss of appetite. FEGDS reveals a picture of atrophy of the mucous membrane of the gastric stump with signs of inflammation.

Post-gastroresection reflux esophagitis

Reflux esophagitis occurs due to insufficient locking function of the cardia. As a rule, there is also reflux gastritis. In this case, intestinal contents mixed with bile are thrown into the esophagus, causing alkaline reflux esophagitis. It manifests itself as a feeling of pain or burning (soreness) behind the breastbone, a feeling of heartburn. These symptoms usually appear after eating, but may not be associated with food intake. Dryness and bitterness in the mouth, a feeling of food “getting stuck” in the throat, a feeling of a lump are often disturbing. The diagnosis of reflux esophagitis is confirmed by esophagoscopy. In some cases, reflux esophagitis can be complicated by stenosis of the esophagus.

Afferent loop syndrome

Afferent loop syndrome is characterized by stasis of chyme with an admixture of gastric, duodenal contents and bile in the afferent loop.

The most common is chronic afferent loop syndrome. It is usually caused by dyskinesias of the duodenum and afferent loop or adhesions in this area.

There are three degrees of severity of the afferent loop syndrome:

• The mild degree is manifested by rare, inconstant regurgitation, vomiting with bile after eating. The general condition of patients does not suffer significantly.
• Moderate severity is characterized by pain and a pronounced feeling of heaviness in the right hypochondrium and epigastrium after eating, vomiting with bile often occurs, after which the pain may decrease, but not always.

Patients subjectively have poor tolerance for vomiting and often skip meals; body weight and performance decrease.

• The severe degree is manifested by frequent and profuse vomiting after eating, severe pain in the epigastrium and right hypochondrium. Along with the vomit, a large amount of bile and pancreatic juice is lost, which contributes to digestion disorders in the intestines and weight loss. The general condition of patients is significantly impaired, and work capacity is limited.

Afferent loop syndrome usually develops within the first year after surgery.

In the diagnosis of afferent loop syndrome, anamnesis and fluoroscopy of the stomach and intestines play a huge role. In this case, a long-term presence of contrast agent in the afferent loop of the jejunum and the stump of the duodenum is determined.

Abducens loop syndrome

The syndrome of the efferent loop is a violation of the patency of the efferent loop caused by the adhesive process. The main symptoms are repeated vomiting (almost after every meal and often unrelated to food), progressive weight loss, and pronounced dehydration. Thus, the clinical picture of the syndrome of the efferent loop corresponds to high intestinal obstruction.

Small stomach syndrome

Small stomach syndrome develops in approximately 8% of those who have undergone gastric resection and is caused by a decrease in the volume of the stomach. The clinical picture is characterized by a pronounced feeling of heaviness in the epiporium, a full stomach even after a small meal. Dull pain in the epigastrium, nausea, belching, and even vomiting are often observed. FGDS usually reveals gastritis of the gastric stump.

As the period after surgery increases, the clinical signs of small stomach syndrome decrease.

Metabolic disturbances due to removal of a significant portion of the stomach

The most striking manifestation of metabolic disorders after gastric resection is post-gastrectomy dystrophy. Its development is caused by impaired motor and secretory function of the resected stomach and intestine, impaired secretion of bile, pancreatic juice, formation of malabsorption syndromes and maldigestion. Post-gastrectomy dystrophy is characterized by general weakness, decreased performance, dry skin, significant weight loss, anemia, hypoproteinemia, hypocholesterolemia. Electrolyte disorders are very typical: hypocalcemia, hyponatremia, hypochloremia. Some patients develop hypoglycemia. Impaired absorption of calcium in the intestine leads to pain in the bones, joints, and the development of osteoporosis. With a sharp calcium deficiency, hypocalcemic tetany develops. Severe post-resection dystrophy predisposes to the development of pulmonary tuberculosis.

Diseases to which there was a predisposition before surgery

Peptic ulcer anastomosis

The development of a peptic ulcer of the anastomosis is caused by the preservation of gastrin-producing cells in the stump of the operated stomach, which leads to stimulation of the secretory function of the stomach. Acidic gastric contents enter the jejunum and cause the development of a peptic ulcer of the anastomosis. The preservation of the acid-forming function of the stomach is explained by the insufficient volume of resection, as well as the preservation of gastrin-producing cells in the fundus of the stomach. A peptic ulcer of the anastomosis develops in individuals who had a duodenal ulcer and high secretory activity of the stomach before the operation.

Preservation of gastrin-producing cells is observed only with classical gastric resection without vagotomy.

The main symptoms of peptic ulcer of the anastomosis are:

• intense, persistent pain in the epigastrium or left epigastric region, radiating to the left shoulder blade or back;
• severe heartburn;
• vomiting (intermittent syndrome).

Peptic ulcer of the anastomosis is easily detected by fibrogastroscopy and fluoroscopy of the stomach. Quite often, peptic ulcer of the anastomosis is complicated by bleeding and penetration (into the mesentery of the jejunum, transverse colon, body and tail of the pancreas).

The occurrence of an ulcer in the gastric stump occurs extremely rarely.

[ 7 ], [ 8 ], [ 9 ], [ 10 ], [ 11 ], [ 12 ], [ 13 ], [ 14 ]

Gastric stump cancer

Cancer of the gastric stump develops more often after gastric resection according to Bilroth-II than according to Bilroth-I, which is associated with bile reflux into the stomach. Anaerobic flora, which converts food nitrates into carcinogenic nitrosamines, also plays a certain role in the development of gastric stump cancer. Gastric stump cancer develops on average 20-25 years after gastric resection, but earlier development is also possible. As a rule, the tumor is located in the area of the gastroenteroanastomosis, and then spreads along the lesser curvature of the stomach to the cardiac section.

The main symptoms of gastric stump cancer are:

• constant pain in the epigastric region;
• a pronounced feeling of heaviness in the epigastrium after eating, rotten belching;
• decrease or complete loss of appetite;
• progressive emaciation of the patient;
• increasing weakness;
• development of anemia;
• Gregersen's reaction is consistently positive.

Cancer of the gastric stump has the form of a polyp or ulcer. For early diagnosis of gastric stump cancer, it is extremely important to conduct FGDS with mandatory biopsy of the gastric mucosa in a timely manner.

[ 15 ], [ 16 ], [ 17 ]

After resection, the patient should be under dispensary observation and undergo FEGDS 1-2 times a year. In the future, FEGDS is performed when "stomach" complaints appear or intensify.

[ 18 ], [ 19 ], [ 20 ], [ 21 ]