Postgastrectomy complications

• Lack of chyme stimulation → ↓ pancreatic enzyme levels → protein and carbohydrate maldigestion → fat-soluble vitamin deficiency and weight loss

• Loss of parietal cells → ↓/absent intrinsic factor production → vitamin B12 deficiency → pernicious anemia

• Critical reduction of the absorptive surface → ↓ time for chyme absorption → ↓ iron absorption → iron deficiency anemia

• Diet modifications

  • Increased protein intake

  • Supplementation of medium-chain triglycerides

  • Low carbohydrate diet

• Supplementation of pancreatic enzymes and deficient nutrients (e.g., vitamin B12, iron, fat-soluble vitamins)

a pathologically increased growth of bacteria in the small intestine

• Anatomic causes

  • Short bowel syndrome

  • Blind loop syndrome: bacterial overgrowth in the bypassed intestinal segment (blind loop) that occurs as a result of gastrectomy

  • Small bowel diverticulosis

  • Inflammatory bowel disease

• Motility disorders

  • Irritable bowel syndrome

  • Diabetes mellitus

  • Scleroderma

all resulting from bacterial overgrowth

• ↓ Absorption of vitamin B12, fat-soluble vitamins, zinc, and iron

• ↑ Production of folate

• ↑ Deconjugation of the bile acids

• Diarrhea, steatorrhea

• Weight loss, malabsorption

• Jejunal aspirate cultures collected during endoscopy

• Positive lactulose breath test

• Antibiotic therapy

• Parenteral supplementation of vitamins and proteins

• In some cases, surgical treatment

kinking or anastomotic narrowing of the efferent loop that causes emesis and/or a feeling of fullness

• Acute abdomen requires immediate surgical treatment.

• In uncomplicated cases: watch and wait

• Biliary and pancreatic obstruction due to stenosis, kinking, or incorrect anastomosis of the afferent loop

• Chyme enters the afferent loop instead of the efferent loop and causes loss of appetite, a feeling of fullness, and bilious vomiting with subsequent relief of nausea.

Afferent loop syndrome only affects patients undergoing Billroth II gastric resection, which is usually not used to treat gastric cancer.

Surgical management

• rapid gastric emptying as a result of defective gastric reservoir function, impaired pyloric emptying mechanisms, or anomalous postsurgery gastric motor function

dysfunctional or bypassed pyloric sphincter → rapid emptying of undiluted hyperosmolar chyme into the small intestine → fluid shift to the intestinal lumen → small bowel distention → vagal stimulation → increased intestinal motility

• Occur within 15–30 minutes after meal ingestion

• Include nausea, vomiting, diarrhea, and cramps

• Vasomotor symptoms such as sweating, flushing, and palpitations

• Dietary modifications: small meals that include a combination of complex carbohydrates and foods rich in protein and fat

• 30–60 min of rest in the supine position after meals

• Beta blockers may be helpful to ease tachycardia arising from hypovolemia.

dysfunctional pyloric sphincter → rapid emptying of glucose-containing chyme into the small intestine → quick reabsorption of glucose → hyperglycemia → excessive release of insulin → hypoglycemia and release of catecholamines

• Occur hours after meal ingestion

• Include signs of hypoglycemia (e.g., hunger, tremor, lightheadedness)

• GI discomfort

• Dietary modifications

• Second-line treatment: octreotide

• Third-line treatment: surgery

Suspect late dumping syndrome in a patient with previous gastric surgery and hypoglycemia.

the development of carcinoma in the remnant stomach after gastrectomy, regardless of the initial gastric condition or its duration

Studies suggest that duodenogastric reflux, chronic irritation due to biliary or pancreatic secretions, and the denervation of gastric mucosa after surgery result in chronic inflammation of the remnant mucosa.

total gastrectomy with Roux-en-Y anastomosis and radical lymph node dissection