Post-gastro-resection disorders

According to the literature data, post-gastro-resection disorders develop in 35-40% of patients who underwent 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 disorders due to the removal of a large part 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.

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

Early dumping syndrome

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

The main clinical manifestations of early dumping syndrome:

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

These symptoms appear, as a rule, after eating a large amount of food, especially those containing sweets.

Late dumping syndrome

The pathogenesis of late dumping syndrome consists in excessive discharge of food, especially rich in carbohydrates, into the small intestine, absorption of carbohydrates into the blood, the development of hyperglycemia, the flow of excess insulin into the blood, followed by the development of hypoglycemia. An increase in the tone of the vagus nerve, as well as loss of the endocrine function of the duodenum, play a significant role in the excess flow of insulin into the blood.

The main clinical manifestations:

• pronounced feeling of hunger;
• sweating;
• dizziness, sometimes fainting;
• trembling hands and feet, especially fingers;
• double vision;
• redness of the skin of the face;
• palpitations;
• rumbling in the stomach;
• urge to defecate or frequent stools;
• decrease in blood glucose;
• after the end of the attack, severe weakness, lethargy.

There are three degrees of severity of dumping syndrome:

• a mild degree is characterized by episodic and short bouts of weakness after taking sweet and dairy foods; the general condition of the patient is satisfactory;
• moderate severity - the indicated symptomatology develops naturally after each intake of sweet and dairy dishes, persists for a long time; the general condition of patients may suffer, but there is no sharp limitation of working capacity and weight loss;
• severe degree - manifested by very pronounced symptoms, a significant violation of the general condition, a sharp decrease in working capacity, a decrease in body weight, a violation of protein, fat, carbohydrate, mineral, vitamin metabolism.

With an increase in the period after surgery, the symptoms of dumping syndrome decrease. [1], [2], [3], [4], [5], [6],

Post-resection reflux gastritis

In the origin of post-resection reflux gastritis, the reflux of intestinal contents with bile into the stomach plays a role. 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 the Billroth-II gastric resection operation.

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

Post-gastro-resection reflux esophagitis

Reflux esophagitis occurs due to insufficient obturator function of the cardia. As a rule, there is also reflux gastritis. In this case, the intestinal contents with an admixture of bile are thrown into the esophagus, and alkaline reflux esophagitis occurs. It is manifested by a sensation of pain or burning (rawness) behind the breastbone, a feeling of heartburn. These signs usually appear after eating, but may not be associated with food intake. Often worried about dryness and bitterness in the mouth, the feeling of "stuck" food in the throat, a feeling of a lump. The diagnosis of reflux esophagitis is confirmed by esophagoscopy. In some cases, rflux esophagitis can be complicated by esophageal stenosis.

Adductor loop syndrome

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

Most often, there is a chronic adductor loop syndrome. Usually it is caused by dyskinesia of the duodenum and the adductor loops or adhesions (adhesions) in this area.

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

• A mild degree is manifested by rare, intermittent regurgitation, vomiting with an admixture of bile after eating. The general condition of patients is not significantly affected.
• 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 do not tolerate vomiting and often skip meals; body weight and performance are reduced.

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

The adductor loop syndrome usually develops within the first year after surgery.

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

Abduction loop syndrome

Abduction loop syndrome is a violation of the patency of the abduction loop caused by the adhesions. The main symptoms are repeated vomiting (almost after every meal and often without regard to food), progressive weight loss, and pronounced dehydration. Thus, the clinical picture of abduction loop syndrome corresponds to high intestinal obstruction.

Small stomach syndrome

Small stomach syndrome develops in about 8% of those who underwent gastric resection and is caused by a decrease in stomach volume. The clinical picture is characterized by a pronounced feeling of heaviness in the epiporia, a full stomach even after a small meal. Dull epigastric pain, nausea, belching and even vomiting are often observed. When FEGDS is detected, as a rule, gastritis of the stomach stump.

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

Metabolic disorders due to removal of a large part of the stomach

The most striking manifestation of metabolic disorders after gastric resection is post-gastro-resection dystrophy. Its development is due to impaired motor and secretory function of the resected stomach and intestines, impaired excretion of bile, pancreatic juice, the formation of malabsorption and malvdigestion syndromes. Post-gastro-resection dystrophy is characterized by general weakness, decreased performance, dry skin, significant drop in body weight, anemia, hypoproteinemia, hypocholesterolemia. Electrolyte disturbances are very characteristic: hypocalcemia, hyponatremia, hypochloremia. Some patients develop hypoglycemia. Impaired absorption of calcium in the intestine leads to pain in the bones, joints, 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 peptic ulcers of the anastomosis is due to the preservation of gastrin-producing cells in the stump of the operated stomach, which leads to stimulation of the secretory function of the stomach. The acidic gastric contents enter the jejunum and cause the development of peptic ulcers 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. Peptic ulcer of the anastomosis develops in persons who had a duodenal ulcer before surgery and a high secretory activity of the stomach.

Preservation of gastrin-producing cells is observed only with classical resection of the stomach 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 scapula or back;
• severe heartburn;
• vomiting (intermittent syndrome).

Peptic ulcer of the anastomosis is well 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 ulcers in the stomach stump is extremely rare.

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

Stomach stump cancer

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

The main symptoms of gastric stump cancer are:

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

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

[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 with the appearance or intensification of "gastric" complaints.

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