Editing Gastrectomy (section)

=== '''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