Features of the assimilation of fats in patients with gastric cancer after gastrectomy

The stomach cancer occupies a leading position in the structure of oncological diseases of the digestive system, and the surgical method is the gold standard in its radical treatment. The proportion of gastrectomy among surgical interventions for gastric cancer is 60-70%, with the most reasonable from the oncological point of view and the most widely used version of the reconstruction of the gastrointestinal tract is the loop method of gastroplasty, in which food from the esophagus comes at once in the jejunum, avoiding the duodenum. After a complete removal of the stomach, not only new anatomical relationships develop, the natural reservoir for food intake is lost, gastric motility that provides a rhythmic intake of food is lost, but the processed food is treated with hydrochloric acid, which ultimately affects the assimilation of its main ingredients. Due to the development of new conditions for the functioning of the entire digestive system, one of the compensatory mechanisms after gastrectomy is an increased formation of intestinal hormones, increased secretion of the mucosa of the jejunum of the intestinal intestinal enzymes, which ensure the splitting of food. The catalyst in this case is the food taken, which acts on the extensive receptor field of the jejunum mucosa. An indispensable condition in the normalization of the rhythm of the liver and pancreas is the prolonged effect of food on the receptor field of the jejunum mucosa.

In the opinion of the researchers dealing with the problems of digestion adaptation, after a complete removal of the stomach, certain digestive disorders can be prevented by the creation of a food reservoir in the initial part of the jejunum, performing a number of functions, among which the main are the provision of food deposition and its rhythmic intake into the intestine. To date, a large number of methods for reconstructing a reservoir for food intake have been proposed, and some authors directly speak of the creation of a so-called artificial stomach. However, a large number of proposed options for gastroplasty only underlines the unsatisfactory functional results and the need to find new ways of reconstruction. One of the main criteria for the merits and demerits of one or other methods of restoring the continuity of the digestive tract after gastrectomy is to ascertain the degree of disturbance and compensation of metabolism. The processes of digestion after gastrectomy, especially the state of protein and carbohydrate metabolism, have been studied quite well. As for the peculiarities of fat metabolism in various variants of gastroplasty, the literature data are few and contradictory.

In the present work, we have emphasized the study of the characteristics of fat absorption in patients after gastrectomy in a comparative aspect with different variants of reconstruction, including a new version of gastroplasty.

The purpose of our study was to study the characteristics of fat absorption in patients with gastric cancer after gastrectomy with various variants of gastroplasty.

152 patients with gastric cancer who underwent gastrectomy with various variants of gastroplasty were examined, including 89 (58.6%) men and 63 (41.4%) women. The average age of patients was 59.1 ± 9.95 years (from 27 to 80 years). All patients were divided into two comparable groups of observations. The distribution of patients in groups was carried out blindly using envelopes, which included recommendations on the methodology of gastroplasty in the performance of gastrectomy. The main group included 78 patients with gastric cancer - 45 (57.7%) men and 33 (42.3%) women aged 58.8 ± 9.96 years who during the reconstructive phase with gastrectomy was used a new version of gastroplasty, It involves the formation in the initial department of the jejunum of a reservoir for food intake. The control group included 74 patients with stomach cancer - 44 (59.6%) men and 30 (40.5%) women aged 59.7 ± 9.63 years who under traditional gastrectomy used the traditional technique of loop gastroplasty, known in the literature as a way to Schlatter.

The investigations were carried out at the admission of patients to the hospital, on the eve of surgery, the data were considered as initial, as well as in remote observation periods. Survey of patients in hospital conditions has invaluable advantages, as it allows to conduct a complex of laboratory studies and to reveal in fullness deviations in digestion. Therefore, at various times from 6 to 36 months after the operation, we hospitalized our patients for a comprehensive examination. Dynamic functional examination in the long-term follow-up period was performed by those patients who, after ultrasound, radiological, endoscopic examinations, and CT scan data, did not detect distant metastases or relapse of the tumor.

An indispensable condition was uniformity in the nature of the food taken in all time periods. The nutrition of the patients of both groups was three meals a day and provided for a mixed type containing in moderate but sufficient quantities all the necessary food substances, including 110-120 g of protein, 100-110 g of fat, 400-450 g of carbohydrates with an energy capacity of 3000-3200 calories.

Existing methods for studying fat metabolism (the radioisotope method for determining the intake and excretion of radioisotope-labeled food, the determination of blood serum lipids, the calculation of chylomicrons, the determination of absorption of vitamin A) are extremely complex, time-consuming, inaccessible in daily practice, and the results sometimes contradictory. In the basis of the study of the nature of the assimilation of fats coming from food, we took an uncomplicated but very revealing method for determining the assimilation of basic food ingredients, based on coprological research. Of the residues of fatty foods in feces, only a few salts of fatty acids are normally found in feces. Neutral fat, fatty acids in normal feces are absent. Disturbance of fat absorption - steatorrhoea - may be due to either a lack of lipolytic activity of pancreatic enzymes, or a violation of bile flow into the intestine, or an accelerated transit of food through the intestine. When the external activity of the pancreas is disturbed, the steatorrhoea is expressed and is represented exclusively by neutral fat (the so-called type I steatorrhoea). If there is a violation of bile flow into the intestine, delayed activation of pancreatic lipase is observed and the emulsification of fat is broken, which in turn hinders the action of enzymes. Therefore, when there is a lack or absence of bile in the intestine, the steatorrhea manifests itself in a large number of fatty acids and neutral fat (the so-called type II steatorrhea). In contrast to fatty acids with a short carbon chain, which are freely absorbed in the proximal part of the small intestine, bypassing any transformations in the intestinal wall, sodium and potassium salts of fatty acids with a long carbon chain, so-called soaps, form micelles stable in the aqueous medium, for the absorption of which a more prolonged process of mi- cular diffusion is required. Consequently, the presence in the feces of a large number of fatty acids and soaps indicates a violation of absorption (the so-called type III steatorrhea), which happens with accelerated movement of food masses through the small intestine.

The quantitative evaluation of structures was carried out according to certain rules and was expressed by the number of pluses. Statistical processing of research materials was carried out in accordance with modern international standards for the practice of clinical trials.

When studying the characteristics of fat absorption, it is impossible not to take into account the preoperative baseline indicators. It is the indicators on the eve of the operation, and not in the early postoperative period, when the patients' diet can not be attributed to normal, were the initial ones. On the eve of surgery, neutral fat was detected in 9 (11.5%) of the 78 patients in the main group and 9 (12.1%) of the 74 controls, fatty acids were detected in 5 (6.4%) of the patients in the control group and in 5 (6.7%) patients in the control group, fatty acid salts in 8 (10.2%) and 7 (9.4%) patients, respectively. So, on the eve of treatment, in 5 (6,4%) patients of the main and 5 (6,7%) patients of the control group, violations of fat absorption caused by insufficiency of lipolytic activity of pancreatic enzymes were diagnosed, in 6 (7,7%) patients of the main group and 5 (6.7%) of patients in the control group, these disorders are caused by impaired bile flow into the intestine, which can be explained by the fact that in 12.3-12.9% of our patients there are violations of biliary tract motility in the hypokinetic type. Taking into account the number of diagnosed fatty acid salts in 4 (5.1%) patients of the control group and the 3 (4.1%) patients of the control group, the enteral nature of the violations of the assimilation of fat on the eve of the operation was less present. In general, as seen from the presented indicators, in 15 (19.2%) patients the main and 13 (17.5%) patients of the control group on the eve of surgical intervention, violations of fat absorption were diagnosed, which indicates the comparability of the study groups studied.

Based on the data presented, it can be noted that after gastrectomy, the processes of digestion of fat are deteriorating. Six months after the operation, normal digestion of fats was diagnosed in 40 (64.5%) patients of the main group and in 36 (61.1%) patients in the control group, which is significantly lower compared to preoperative data (80.8% and 82.4% respectively). In the future, as the time elapsed after the operation increases, the frequency of violations of fat absorption has a clearly expressed dependence on the type of applied gastroplasty. Thus, among patients in the main group for 24 months after gastrectomy, the number of patients with a violation of fat absorption fluctuated within 35.5-38.2%. By 36 months of observations, the number of patients with a violation of fat absorption decreased to 33.3%, which indicates a certain stabilization of the exchange of fats in patients with a small intestine reservoir. In patients of the control group, an increase in the number of patients with a violation of the assimilation of fat from 38.9% to 51.7% was noted during 24 months after the operation, which exceeded the similar parameters of the patients in the main group. By the third year after surgery, the number of patients with impaired fat metabolism decreased, but the number of patients with a violation of the absorption of fats in the control group was greater than in the main group. In this regard, it can be noted that in the first two years after gastrectomy in patients with an artificially formed small intestine, the processes of compensation for impaired digestion, primarily associated with the metabolism of fats, proceed better than patients who have been treated with the traditional method of gastroplasty.

In Fig. 2 presents data of a coprological study reflecting the assimilation of the main products of fat metabolism in patients of the examined groups both on the eve of the operation and in the long term after the operation.

On the eve of surgery in patients of both groups, the content of the main products of fat metabolism in feces was the same. Already 6 months after the operation in the main group, the number of patients with neutral fats in their feces was 4.6%, among patients in the control group - by 8.2%. There was an increase in the number of patients who had fatty acids, in the main group - by 9.7%, in the control group - by 11.9%. The number of patients diagnosed with feces of fatty acid in the feces increased by 4.3% in the main group, and by 12.6% in the control group. In the future, as the time elapsed after the operation increased, this difference only increased. Thus, the largest number of patients who had found neutral fats in the feces was registered in the main group for the second year of observations (20.5% of patients), in the control group - two years after the operation (31.0% of patients). Two years after the operation, the maximum number of patients with fatty acids in the feces was detected, both in the main (23.5% of patients) and in the control group (34.5% of patients). In turn, the greatest number of patients who have salts of fatty acids in the stool, account for an 18-month observation period - 20.0% of patients with a primary and 26.3% of patients in the control group. According to the data presented, several conclusions can be drawn. Firstly, in the control group in all periods of long-term follow-up after the operation, a greater number of patients were identified who had fat metabolism products found in the stool, which normally should not occur, which in turn indicates the inadequacy of fat digestion processes. Secondly, three years after the operation, both among the patients and the patients of the control group, there is a decrease in the basic indicators characterizing the insufficiency of fat metabolism, which may indicate some adaptation of compensatory processes.

The table shows the frequency and type of diagnosed steatorrhoea among patients in the surveyed groups at different observation periods.

On the eve of the operation, the number of patients with different types of violations of fat absorption did not differ significantly in the examined groups (19.2% of the patients with the main and 17.5% of the control group). Six months after the operation, the main group noted an increase in the number of patients with a lipolytic type of steatorrhea of 6.5%, with a cholemic appearance of steatorrhea - by 5.2%, with enteral steatorrhea - 4.6%. Among patients of the control group, an increase in the number of patients with lipolytic steatorrhea was observed at 6.8%, with a cholemic species - at 8.5%, with enteral steatorrhea - 6.1%. The data suggest that 6 months after the operation, among patients in the control group, the number of patients with different types of violations of fat absorption exceeds those of the patients in the main group. In the long-term observation period, this difference only increased. Thus, the greatest number of patients with lipolytic type of steatorrhea was registered among patients of the main group 24 months after the operation (14.7% of patients), among patients in the control group 18 months after the operation (15.8% of patients). The largest number of patients with cholemic steatorrhoea was registered both in the main and in the control group, 18 months after the operation (15.5% and 15.8%, respectively). The greatest number of patients with enteral type of steatorrhea among the patients of the main group was noted 6 months after the operation, and among patients in the control group after 24 months (9.7% and 20.7% of patients, respectively).

As to the ratio of the different types of violations of fat absorption among the patients of the examined groups, the following observation seems to us important. Among the patients of the main group, the share of steatorrhea associated with insufficiency of the lipolytic activity of digestive secretions or with a violation of bile flow to the intestine was 33.3% on the eve of the operation, 38.5% among the control group patients. Six months after the operation, this ratio among patients in both groups was approximately equal (36.4% and 34.8%, respectively). Throughout the observation period, it changed, patients of the main group prevailed, and with increasing time after surgery this ratio increased. At the same time, the share of steatorrhea associated with impaired absorption of fat-splitting products in the patients of the main group before the operation was 66.7%, in the control group - 61.5%. Throughout the observation period, this ratio also changed. Thus, after 6 months the number of patients with impaired fat absorption among the patients of the primary and control groups was 63.6% and 65.2%, respectively, 12 months after the operation - 63.2% and 68.4%, after 18 months - 64 , 7% and 66.7%, 24 months - 61.5% and 73%, and after three years - 60% and 75%, with a predominance of patients in the control group. Taking into account previous radiological and radioisotope studies demonstrating the accelerated advancement of the X-ray contrast food mixture and radionuclide-labeled natural food in the intestine in the control group, it can be concluded that patients with the traditional gastroplasty method have abnormalities in fat absorption associated with accelerated transit of nutrients through the gastro- intestinal tract. Thus, based on the data presented, the following conclusions can be drawn. In patients with stomach cancer, initially signs of impaired fat absorption are observed, and gastrectomy leads to an even worse deterioration in fat metabolism, especially in the first two years after surgery. The choice of the method of gastroplasty exerts its influence on the severity of the violation of the absorption of fats coming from food. Considering that in patients with gastric cancer, which during the reconstructive stage of gastrectomy was formed a reservoir in the initial part of the jejunum, the number of patients with enteral character of violations of absorption of fat-splitting products was 60%, which is significantly less in comparison with the number of patients with traditional gastroplasty - 75%, this makes it possible to conclude that the proposed variant of gastroplasty promotes an improvement in the metabolism of fats in patients with gastric cancer after gastrectomy.

Prof. Yu. A. Vinnik, Assoc. V. V. Oleksenko, Assoc. VI Pronyakov, Cand. Honey. Sciences TS Efetova, VA Zakharov, EV Strokova. Features of fat absorption in patients with gastric cancer after gastrectomy // International Medical Journal - №3 - 2012

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