Post Gastrectomy

Mini-Gastric Bypass

The Mini (Sleeve) Gastric Bypass Surgery

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POST GASTRECTOMY SYNDROMES

These may be due to either disruption of normal physiology of GI motility or due to nutritional defects occurring due to gastrectomy.

Changes after gastrectomy :

Decreased acid
Decreased pepsin
Decreased Intrinsic Factor
Decreased pancreatic enzymes
Decreased mixing of food with acid, pepsin, and bile.
Decreased absorption of proteins, calcium, Vitamin D & B, Fe, fat
Increased absorption of glucose (RAPID absorption).
Increased intestinal motility
Creation of a "blind loop" i.e. afferent loop.

Postgastrectomy syndrome classification :

Post Meal syndromes - these start within 1-2 weeks after the operation.

	Early Post Meal syndrome (Syn. Early dumping)
	Late Post Meal syndrome (Syn. Late dumping OR hypoglycemia)
	Bilious vomiting

Nutritional syndromes :

	Weight loss
	Steatorrhea
	Diarrhea
	Anemia - either Fe deficiency or megaloblastic
	Vit B deficiency
	Calcium deficiency
	Gross malabsorption syndrome

Post Meal SYNDROMES

	Classified as early & late according to the onset of symptoms after food. Both arise at about the same time span after operation.
	Both consist of attacks lasting about 30-40 min.

Early Post Meal syndrome -

Seen in most patients in convalescence but persists in 5-12%.

Common after Billroth II gastrectomy as compared to Billroth I.

Symptoms start immediately after meals.

Pathogenesis - primary defect of CHO metabolism. Rapid glucose absorption - hyperglycemia - no further absorption of glucose from gut - osmotic drawing in of water into lumen - distention of GIT due to fluid - increased intestinal motility & volume depletion from circulation.

C/F - Epigastric fullness, Sensation of warmth, sweating, tachycardia, vomiting or diarrhea. Aggravated by wet foods, foods with CHOs, and large amounts of food. Relief on lying down.

Treatment - often subsides on its own in the course of time.

	Small, frequent, dry meals
	Avoid milk & CHO rich foods
	Codeine to reduce intestinal hypermotility
	Maintain adequate Hb levels
	If does not subside - convert Billroth II into Billroth I OR slow transit time by interposition of 10 cm loop of anti-peristaltic jejunum.

Late Post Meal syndrome :

	Symptoms start 2 to 2 � hours after meals.
	Occurs after any type of gastrectomy (not only Billroth II)
	The pathology is a hypoglycemia. Initial rapid absorption of glucose - hyperglycemia - increased Insulin - fall in BSL to about 50 mg%.
	C/F - epigastric emptiness, faintness, tremors, nausea
	Aggravated by exercise, and relief by more food or glucose.
	Treatment - Small frequent meals, preferably dry. On symptoms glucose can be taken.

Bilious vomiting :

	Occurs in 10-15% of patients, may be associated with dumping.
	May be caused due to probable transient obstruction of the afferent loop in Billroth II gastrectomy.
	Food eaten passes on into efferent loop without any bile.
	Once food passes on, afferent loop (containing bile) empties into stomach & there is bilious vomiting.
	Treatment - may be relieved by relief of obstruction of afferent loop or Billroth II may be converted into Billroth I type.

NUTRITIONAL SYNDROMES

Weight loss :

	Always in total gastrectomy, frequently in Billroth II partial gastrectomy & rarely in Billroth I.
	Always reactivation of TB due to malnutrition should be excluded.
	Occurs due to reduced food intake & malabsorption.
	May be beneficial - post-gastrectomy pts have less incidence of IHD.

Steatorrhea :

	Poor mixing of food with digestive enzymes
	Formation of a blind loop syndrome.

Diarrhea :

	Most post-gastrectomy patients have improved motility but 5% have diarrhea.
	May be due to steatorrhea or intestinal hypermotility (dumping).
	Treated with Loperamide or diphenoxylate-atropine (Lomotil)

Anemia :

	May be Fe def or megaloblastic anemia.
	Fe def anemia common when duodenum is by-passed e.g. Billroth II. Treated by excluding occult blood loss and FSFA tablets.
	Megaloblastic anemia - common with total gastrectomy. May be due to atrophic gastritis or part of the Gross malabsorption syndrome. Managed by measuring Vit B₁₂ levels and treating with Inj Cyanocobalamine 1000 mcg IM weekly till serum levels normalize then given monthly. Post gastrectomy prophylaxis is usually 1000 micrograms Inj IM once a year.

Calcium deficiency :

	due to associated steatorrhea
	due to asso Vit D deficiency
	due to less acidic pH which causes less absorption per se.

Gross malabsorption syndrome :

	Combination of all of above deficiencies.
	Treated by conversion of Billroth II to Billroth I.

Small stomach syndrome :

	Common but mild condition - presents as early satiety, epigastric fullness, with consequent reduced food intake - with weight loss & other nutritional deficiencies.
	Treated with high energy meals with small volumes.

OTHER COMPLICATIONS OF GASTRIC SURGERY -

Early -

	Hemorrhage from anastomotic line.
	Stomal obstruction - may be initially due to tissue oedema immediately after surgery or later due to jejuno-gastric intussception.
	Duodenal "blow-out" - forms duodeno-cutaneous fistula.
	Paralytic ileus - treated with "suck + drip".

Later -

	Recurrent ulceration.
	Post gastrectomy syndromes
	Post vagotomy syndromes
	Residual abscess - may later lead to peritonitis or fistula.
	Recurrent neoplastic ulcer.
	Anemia
	Osteoporosis
	Gastro-jejuno-colic fistula.

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Contact Information: -Telephones: *** CLOS West: 702-456-4643; Trish Lanman 702-376-3446, Sandy Brubaker 702-376-3647; Jennifer Brubaker 702-376-9339, Dr. Rutledge 702-215-9550 *** CLOS Florida: Flo Ballengee 863-899-3463 Dr. Cesare Peraglie 407-922-3424

Email Us Anytime for Help: Email: Dr. Rutledge DrR@clos.net, *** CLOS West: Trish Lanman Trish@clos.net, Sandy Brubaker SandyB@clos.net Dr. Rutledge DrR@clos.net *** CLOS Florida: Flo Ballengee flo@clos.net, Dr. Peraglie drp@clos.net

Addresses: Address: *** CLOS West Office: Dr Robert Rutledge / CELOS, 98 E Lake Mead Parkway Suite 302, Henderson NV 89015, Office 702-456-4643, Office fax: 702-456-1173, Contacts: Trish Lanman 702-376-3446 Trish@clos.net, Sandy Brubaker 702-376-3647 SandyB@clos.net, Jennifer Brubaker 702-376-9339 Jen@clos.net, Dr. Rutledge 702-215-9550 Drr@clos.net *** CLOS Florida: 40124 Highway 27, Suite 203, Davenport, FL 33837, Flo Ballengee 863-899-3463, Flo@clos.net, Dr. Peraglie 407-922-3424 drp@clos.net

Warning: Gastric Bypass Surgery is a MAJOR surgical procedure. It can be associated with significant risks and complications, up to and including death. Weight loss surgery is a rapidly developing area of medicine. Bariatric surgery is filled with controversy. It is very important to take a careful and deliberate approach to considering surgery for the treatment of obesity.

Disclaimer Notice:-Information on this web site is provided for informational purposes only.
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