Editing Gastrectomy (section)

== '''Complications''' ==

=== '''Dumping     syndrome''' ===

** Combination of GIT and      vasomotor symptoms due to rapid post-prandial gastric emptying
** Can develop after any      operation on the stomach, but is common after partial gastrectomy with      Billroth II reconstruction, and RYGB
** Symptoms
*** GIT - abdominal pain, early       satiety, nausea/vomiting, diarrhoea, bloating
*** Vasomotor - diaphoresis,       tachycardia, palpitations, headache, syncope
** Early
*** Abrupt delivery of a       hyperosmolar, high-carb load into small intestine causing vasomotor       activation (light-headed, weak, diaphoretic, tachycardic)
*** Rapid shift of       extracellular fluid occurs into the small intestine to achieve       isotonicity
*** Luminal distension then       occurs, with the resultant symptoms
*** Occurs within 30 minutes of       a meal
*** Secondary to lack of       pyloric sphincter
*** Symptoms sometimes       ameliorated by recumbence or saline infusion
*** Dietary change is mainstay       of treatment - avoid all high-sugar foods and drinks, and don't eat and       drink at the same time. Octreotide can be considered.
** Late (less common)
*** Occurs 1-3 hours after a       meal
*** Related specifically to       carbohydrates being delivered rapidly to the small intestine. They are       quickly absorbed, resulting in hyperglycaemia. The large bolus of       endogenous insulin then causes an overcompensation, resulting in       profound hypoglycaemia, which activates the adrenal gland to release       catecholamines, leading to the vasomotor symptoms.
*** Most patients improve after       months or years of time, dietary modification and medication
*** Options for re-operation       are varied, with varied results.
** Management
*** Dietary measures are       usually sufficient
**** Avoid foods with large        amounts of sugar
**** Frequent small meals rich        in protein, fat and fibre
**** Separate liquids from        solids during a meal
*** Medical management
**** Loperamide for diarrhoea
**** Anticholinergics can slow        gastric emptying and treat spasms
**** Octreotide - inhibit        gastric emptying and prolong intestinal transit time -  effective but expensive
*** Surgery
**** Depends on initial        operation
**** Pyloric reconstruction is        an option
**** For patients with a        gastrojejunostomy but no gastrectomy, takedown of the gastrojejunostomy        can be done
**** For patients with a prior        gastrectomy, convert a loop gastrojejunostomy to a Roux-en-Y        reconstruction

=== '''Metabolic     disturbances''' ===

** Iron deficiency anaemia (30%      of patient)
*** Combination of decreased       iron intake, impaired iron absorption, and chronic blood loss
*** Generally corrected with       oral supplements
** B12 deficiency anaemia
*** Risk is dependent on the       amount of stomach removed
*** Occurs secondary to lack of       intrinsic factor meaning no B12 absorption
*** Subtotal gastrectomy       patients should have lifelong B12 supplementation
** Osteoporosis/osteomalacia
*** Appears to be caused by       deficiencies in calcium
*** Risk increases with the       extent of gastric resection, and is usually associated with a Billroth       II
*** Typically develops 4-5       years post-op
*** Give calcium and vitamin D       supplements
*** Patients with Billroth II       that bypasses the duodenum should also have vitamin ADEK supplements

=== '''Afferent     loop syndrome''' ===

** This is the duodenojejunal      loop proximal to the gastrojejunal anastomosis after either a Billroth II      or gastrojejunostomy. Occurs as a result of partial obstruction of the      afferent limb, which is then unable to empty its contents.
** A long afferent limb is      usually the underlying problem
** Pancreatic and hepatobiliary      secretions accumulate, resulting in distension and cramping
** The intraluminal pressure      eventually increases enough to empty the contents of the afferent loop      forcefully into the stomach, resulting in projectile bilious vomiting      that immediately relieves symptoms.
** Can be aggravated by blind      loop syndrome - bacterial overgrowth occurs in the static loop, and the      bacteria bind with vitamin B12 - leading to megaloblastic anaemia, fat      malabsorption and deficiency in fat-soluble vitamins.
** Investigation
*** Failure to visualise the       afferent limb on upper endoscopy is suggestive
*** Radionuclide studies       imaging the hepatobiliary tree have also been used with some success -       normally should pass into the stomach/distal small bowel after being       excreted; if this does not happen, consider afferent loop obstruction.
** Management
*** Surgical correction
**** Convert the Billroth II        into a Billroth I
**** Enteroenterostomy below        the afferent and efferent loops
**** Conversion to a Roux-en-Y        reconstruction

=== '''Efferent     loop obstruction''' ===

** Rare
** Mostly occurs within the      first post-op month
** Presentation
*** Colicky LUQ pain
*** Bilious vomiting
*** Abdominal distension
** Diagnosis
*** Upper GI series
*** CT with oral contrast, with       failure of contrast to enter the efferent limb
** Management
*** Needs surgery
*** Reduce the retroanastomotic       hernia (if this is the cause) and closing the retroanastomotic space to       prevent recurrence

=== '''Alkaline     reflux gastritis''' ===

** Presentation
*** Tends to occur after       Billroth II reconstructions
*** Severe epigastric abdominal       pain
*** Bilious vomiting
*** Weight loss
** Diagnosis
*** Technetium biliary scan       demonstrating bile reflux into the stomach
*** Gastroscopy - friable,       beefy red mucosa
** Management
*** Medical
**** Aimed at relief of        symptoms
**** Most medical therapies        haven't shown much benefit
*** Surgical
**** Conversion of the Billroth        II into a Roux-en-Y gastrojejunostomy, in which the Roux limb has been        lengthened to >40cm

=== '''Gastric     atony''' ===

** Occurs after truncal and      selective vagotomies, but not after highly selective vagotomies
** Diagnosis
*** Confirm by scintigraphic       assessment of gastric emptying
*** Consider other causes of       delayed gastric emptying, and post-operative adhesions, afferent or       efferent loop syndrome, and internal herniation
** Management
*** Prokinetics -       metoclopramide/erythromycin - see separate topic
*** Gastrectomy may be required       in rare refractory cases

[[Category:UGIS operations]]