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Disabling symptoms after gastric surgery are more often encountered in the
following:- female sex
- operation for peptic ulceration in the young (below 30 years of age)
- extensive gastrectomy with duodenal diversion .
Dumping
The syndrome which is one of the commonest sequelae of gastric surgery
consists of postprandial vasomotor (systemic) and gastrointestinal symptoms.
Manifestations of the dumping syndrome
Vasomotor (systemic) symptoms
- weakness, tiredness, dizziness
- headache, fainting, warmth, palpitations
- dyspnea, sweating
2.
Gastrointestinal symptoms
- fullness, epigastric discomfort, heaviness
- nausea, vomiting
- excessive distension, diarrhea
The dumping syndrome is associated with rapid gastric emptying although some
have postulated that enterogastric reflux of bile is responsible for some of the
symptoms.
The vasomotor symptoms occur within minutes of eating and are due to
hypovolemia which is accompanied by diminished cardiac output and peripheral
resistance.
The attacks are typically precipitated by high carbohydrate meals.
The hypovolemia is secondary to a massive outpouring of fluid from the vascular
compartment into the bowel lumen as a consequence of the hyperosmolar nature
of the intestinal contents resulting from the precipitous gastric emptying.
Several vasoactive peptides have been held responsible for the vascular and
gastrointestinal manifestations of the dumping syndrome. These include kinins,
enteroglucagon, etc.
The gastrointestinal symptoms occur later during the course of a dumping attack.
Treatment
- small dry meals rich in protein and fat but low in carbohydrate.
- additive which slow gastric emptying such as methoxy-pectin or bran, are
beneficial.
- remedial gastric surgery is required for patients with severe and persistent
dumping symptoms.
Reactive Hypoglycemia
This complication is rare and has an incidence of 1-6% of patients after gastric
surgery.
The symptoms which occur 2-3 hours after a meal are due to hypoglycemia and
include sweating, tremor, difficulty in concentration .Reactive hypoglycemia
often coexists with other symptoms including vasomotor dumping and diarrhea.
The diagnosis is best confirmed by an extended oral glucose tolerance test which
demonstrates an initial hyperglycemia. This is accompanied by an exagerated
insulin release with elevated plasma insulin and enteroglucagon which are
followed by hypoglycemia.
Reactive hypoglycemia usually responds to dietary measures including low-
carbohydrate, high protein meals.
Bile Vomiting
Vomiting of bile or bile-stained fluid before or after meals is a common
complaint after gastric surgery.
It may be a manifestation of the following disorders:
- recurrent ulceration
- enterogastric reflux
3.
Diarrhea
Three patterns of diarrhea are encountered after gastric surgery: frequent loose
motions, intermittent episodes of short-lived diarrhea and severe intractable
explosive diarrhea.
The latter is a serious but rare disability, being encountered in 2% of patients
after truncal vagotomy.
Severe intractable diarrhea is characterized by extreme urgency and often causes
incontinence during an acute attack.
Malabsorbtion of bile salts and fatty acids consequent on the intestinal
denervation has been implicated. The small bowel transit is markedly
accelerated.
Treatment
- low animal fat diet
- codeine phosphate, lomotil, imodium and bile-salt binding agents such as
cholestyramine.
4.
Other Complications
These include the formation of gallstones and bezoars and the development of
gastric carcinoma.
Vagotomy and partial gastrectomy may induce cholelithiasis. The factors
implicated in the formation of bezoars after gastric surgery include hypoacidity,
impaired proteolytic activity,inadequate mastication and loss of the antral pump.
There is now good evidence that previous gastric surgery predisposes to the
development of gastric carcinoma in the stomach remnant.
It is said that reflux gastritis with the development of intestinal metaplasia,
particularly of the type III variety, bacterial overgrowth with formation of
nitrosamines in the hypochlorhydric gastric stump have been implicated.
There is a long latent period of 15-20 years between gastric surgery and
carcinoma of the gastric stump.
Gastric Tumours
Gastric tumours may be benign or malignant.
Gastric Polyps
Gastric polyps are usually small benign adenomas of the gastric mucosa. Various
types of gastric polyps are recognized, the commonest being the regenerative
(hyperplastic) variety.
1. Regenerative polyps often occur in association with gastritis and peptic
ulceration form smooth nodules and consist of proliferating glands with no
cellular atypia.
2. The inflammatory fibroid polyps; are rare lesions which are most commonly
found in the gastric antrum and can be sessile or pedunculated.
3. Myoepithelial hamartomas are composed of glands surrounded by smooth
muscle and arise from the submucosal layer of the antrum and pylorus where
they form smooth sessile masses.
Polyps may be solitary or multiple and sessile or pedunculated in form. They
rarely grow to more than a few cm. in diameter and are usually asymptomatic.
Most are found only incidentally on radiological or endoscopic examination.
Up to 20% of gastric polyps show histological features of dysplasia.
Treatment is by endoscopic excision biopsy. Regular endoscopy is usually
arranged to monitor recurrence or the appearance of new lesions.
5.
Leyomyomas
Leyomyomas are benign tumours of smooth muscle and may arise anywhere in
the muscular wall of the GI tract. They are especially common in the stomach
and small bowel.
These lesions are usually discovered incidentally on endoscopy or barium
examinations.
Occasionally, large lesions are found to be the cause of chronic GI blood loss or
intermittent gastric outlet obstruction.
Leiomyomas are sessile or pedunculated lesions covered by normal mucosa.
This may ulcerate, causing insidious blood loss and anemia. Major hemorrhage
is rare.
Leiomyosarcomas, the malignant counterpart of leiomyomas are rare and present
with similar symptoms or as an abdominal mass.
Leiomyosarcomas spread locally and tend to metastasise early via the blood
stream. Treatment involves resection of the primary lesion plus palliative
chemotherapy if metastasis has occurred.
Lymphomas
Primary lymphomas may arise in the stomach or small bowel. In the stomach,
they constitute about 10% of malignancies.
Gastric lymphomas become extensive, either projecting into the lumen as a
bulky ulcerating mass of diffusely infiltrating the stomach wall. They closely
resemble gastric carcinomas in symptoms and endoscopic appearance but it is
particularly important to make the distinction because the prognosis of treated
lymphomas is much better than adenocarcinomas.
Biopsy is the only reliable means of diagnosis.
Diagnosis: - barium studies
- endoscopic biopsies
But only laparotomy can usually distinguish primary lymphomas from secondary
lesions.
Treatment
Primary lymphomas are often discrete and amenable to surgical excision.
Subsequent radiotherapy or chemotherapy or both may be necessary.
This is defined as a tumour which has involved the muscularis propria of the
stomach wall. In the vast majority of cases spread to the regional lymph nodes is
present alone or in association with peritoneal and hepatic deposits.
Clinical features
Early gastric cancer may be asymptomatic or may present with dyspepsia
simulating peptic ulceration.
The early symptoms are often vague and include indigestion, malaise, early
satiety, postprandial fullness and loss of appetite.
Weight loss is a significant feature of the disease but usually signifies an
advanced lesion which has involved the muscular coat of the stomach or beyond.
Lesions of the cardia may present with dysphagia and circumferential growth of
the middle third and the pyloric antrum cause obstructive symptoms with
vomiting after meals.
Acute presentation with hematemesis or melena is encountered more often with
advanced than early lesions.
The most common presentation is that of recent dyspepsia in a patient above the
age of 50 years.
The most frequent reason for the delay in the diagnosis of cancer of the stomach
is a period of symptomatic therapy with antacids or H2-receptor blockers often
lasting several months before referral for endoscopy is undertaken.
The key investigations are upper GI endoscopy with multiple biopsy and brush
cytology and air contrast barium meal.
Other tests are used to detect extragastric disease. These include chest X ray,
liver function tests, CT or ultrasound examination of the stomach to determine
the depth of involvement of the gastric wall by the neoplasm.
Laparoscopy has also been found valuable in the asessment of the stage and
curability of the disease.
9.
Reconstruction
When a subtotal gastrectomy has been performed then the reconstruction might
be a gastro-jejunal anastomosis or a Roux-en Y procedure.
When a total gastrectomy has been performed then a esophago-jejunostomy
restores the digestive continuity.
Adjuvant Treatment
The cytotoxic agents which have some activity against gastric cancer are 5FU,
mitomycin C, Doxorubicine.
Adjuvant radiotherapy is also used in some centres.
There is no evidence that the adjuvant treatment improves survival.
Study questions
1. A patient 23 years old underwent a partial gastric resection Reichel-Polya
type for pyloric stenosis. 2 weeks after discharge he has been complaining
of weakness, sweating, epigastric heaviness and diarrhea following eating
sweets. What do you think it is wrong with this patient ?
2. What are the premalignant conditions in gastric tumors ?
3. What are the ways of spread of tumor cell in gastric cancer ?
4. What is role of laparoscopy in the management of gastric cancer ?
5. What is meant by R2 resection ?