Symposium on Surgery at the Lahey Clinic
Disability After Gastric Surgery John W. Braasch, M.D., * and Geoffrey L. Brooke-Cowden, M.B., B.S., F.R.A.C.S.t
Several decades ofresectional gastric surgery and more recent surgical procedures which denervate the parasympathetic supply of the stomach and intestines and which violate the pyloric sphincter mechanism have produced a large population of patients with disabilities. The extent of the disability is usually minor, and in time the disability usually improves. However, a significant group of these patients cannot function in a satisfactory manner and require special, possibly surgical, attention. Some of these patients had personality maladjustments before operation that are frequently accentuated by any surgical procedure on the gastrointestinal tract. In other patients this defect was not evident before gastric surgery but became clinically apparent after operation. In still other patients, a mechanical problem was created by the gastric procedure which is almost completely responsible for the subsequent disability. It is of utmost importance to differentiate between these three clinical settings since, at least in the first category, improvement after surgical treatment is most unlikely. Patients who are disabled after operation naturally return to the surgeon for treatment of their disability. Surgeons must therefore be prepared to deal with these postoperative problems by accurate diagnosis and classification and intelligent treatment. Symptom complexes, which were acceptable to patients in the past, are no longer acceptable to patients today. Poor nutrition after gastric surgery indicates that treatment of the ulcer has been unsatisfactory. Thirty or 40 years ago, if a patient's ulcer symptoms were no longer present, the result of operation was thought to be satisfactory despite serious gastrointestinal problems. Zollinger,14 Jordan,S and Woodward 13 have emphasized the disabling nature of post gastrectomy syndromes and have placed evaluation of surgical results in the proper perspective. The classification of post gastric surgical problems has assumed great importance. Those patients whose complaints fall into several groups of symptom complexes and those patients who have certain clinical, *Department of Surgery, Lahey Clinic Foundation, Boston, Massachusetts tFormer Fellow in Surgery, Lahey Clinic Foundation, Boston, Massachusetts
Surgical Clinics of North America-Vol. 56, No.3, June 1976
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radiologic, and laboratory findings of disease are more likely to benefit from surgical therapy. Therefore, it is important to separate from the large population of disabled patients those patients who had similar symptoms, such as vomiting without pain, previous to surgical treatment of ulcer disease, those patients who have unstable personalities, and those patients whose symptoms do not fit a rigid classification. In this way the negative results of the past in the treatment of postgastrectomy syndromes can be avoided. We further emphasize that the conservative approach should be adopted initially. Patients with these conditions should be treated conservatively for lengthy periods of time to allow those patients to improve who will improve without operation. The remediable syndromes produced by gastric surgery are alkaline gastritis, afferent loop obstruction, severe dumping, efferent loop obstruction, postvagotomy severe diarrhea, and late postvagotomy atonic stomach. Patients who have these syndromes can be helped by suitable surgical intervention if conservative measures fail; in most cases they cail"thereby expect normal gastrointestinal function. Other patients with peculiar vomiting or pain syndromes and recalcitrant dumping symptoms are difficult to manage surgically and should be treated conservatively in most instances.
ALKALINE GASTRITIS Alkaline gastritis, first described by du Plessis 4 in 1962 and later by Bartlett and Burrington 1 in 1968 and by van Heerden et al12 in 1969, is characterized by severe postcibal epigastric pain, and, on endoscopic examination of the stomach, congestion, ready contact bleeding, and adherent mucus with punctate erosions. Reflux of bile is noted, and the pH of gastric secretions is neutral or alkaline. At times this complex of symptoms and gastroscopic findings is associated with nausea and vomiting. Some dumping symptoms might also be mingled with those of alkaline gastritis. The patient's condition should be evaluated in terms of which symptoms are correctable by procedures for alkaline gastritis, and no claims should be made for complete relief after surgery. Alkaline gastritis is treated by a shunting procedureS so that the alkaline juices of the biliary tract, pancreas, and duodenum do not reflux into the stomach. This operation is best accomplished after a Billroth II procedure by a Roux-en-Y conversion and after a Billroth I procedure either by a Henley loop interposed between the stomach and the duodenum or by conversion of the Billroth I to a Billroth II Roux-en-Y. Concomitant vagotomy should be performed to prevent jejunal ulcer. The Lahey Clinic experience2 encompasses 20 patients, of whom 17 patients had the appropriate shunting procedure performed. Ofthese 17 patients, 14 had a satisfactory result. In three patients complications of drug dependency and psychiatric problems were recorded. In the third patient, severe diarrhea, malabsorption, and weight loss were noted .
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AFFERENT LOOP SYNDROME The afferent loop syndrome is seen in patients who have preferential filling of the afferent loop at mealtime and whose loop empties slowly at best. In some patients, the afferent loop was distended not so much with food but with accumulated biliary, pancreatic, and duodenal secretions. Distention and poor emptying of the afferent loop cause the symptoms of intermittent vomiting offood or bile. In many patients, the fear ofprovoking symptoms leads to a decreased oral intake and, consequently, marked weight loss. This-situation is chronic and is not related to acute afferent loop obstruction which occurs because ofintussusception of the jejunum or because of herniation ofthe jejunum behind an anterior gastrojejunostomy. The diagnosis of partial obstruction ofthe afferent loop is made by the characteristic symptoms of-vomiting and pain. Pain is relieved by vomiting. 7 Obstruction is seen on barium study, or intravenous cholangiographyll reveals distention, elongation, or tortuosity of the afferent loop. Endoscopic examination often shows partial obstruction of the afferent loop, but this finding is not necessary to establish the diagnosis. A group of 13 patients was treated surgically for afferent loop syndrome at the Lahey Clinic. 2 The majority of these patients were treated by side-to-side jejunojejunostomy between the afferent and efferent loops to provide drainage of the afferent loop. The theoretic disadvantage of this procedure in some patients is that gastric emptying depends on the passage of the food through an antiperistaltic limb of jejunum to reach the enteroenteroanastomosis and access to the middle and distal small bowel. Our clinical results with jejunojejunostomy in seven patients were satisfactory, but late minor symptoms developed in three. For these reasons, we suggest that a Roux-en-Y anastomosis with attention to the patency of the efferent loop of the gastrojejunostomy might be preferable. In addition, a vagotomy protects the jejunal mucosa from the development of a stomal ulcer.
STOMAL OBSTRUCTION At times obstruction of the efferent jejunal loop occurs without concomitant dilatation and tortuosity of the afferent loop. Efferent loop obstruction should probably be grouped with the afferent loop syndrome because of its distinguishing features. Food and fluid are retained within the stomach and vomiting relieves distention and pain. Barium study elicits stomal narrowing and gastric distention, and endoscopy confirms the presence of a narrowed or obstructed stoma. Weight loss is extensive because of the fear of eating. Obstructed stomas that occur fairly frequently in the postoperative period yield to conservative management with tube suction and intravenous fluid replacement. This chronic situation may follow relief of acute postoperative obstruction or it may become clinically evident months or years after gastric surgery because of continued narrowing of the stoma.
W. BRAASCH AND GEOFFREY L. BROOKE-COWDEN
Patients with stomal obstruction have mechanical problems requiring a mechanical solution. Dilations and plastic procedures to enlarge the stoma are not tenable procedures. The stoma must be reconstructed in its entirety. Of eight patients who had procedures for stomal obstruction, 2 the results were satisfactory in six patients who had complete or almost complete relief of symptoms. Other procedures, including bypass, plastic procedures, and dilation were unsatisfactory.
DUMPING SYNDROME The large majority of patients who have undergone gastric resection and even some patients who have had pyloroplasty or gastroenterostomy notice symptoms relating to dumping. 9 Fortunately, most patients respond to conservative measures 13 including a regimen of multiple small meals, meals low in carbohydrates, and recumbency after meals, and improve with time. Occasionally the symptoms of postcibal tachycardia, flushing, sweating, abdominal bloating, and urgency are incompatible with a reasonable life-style. At times the severity of these symptoms precludes satisfactory oral intake to the extent that marked weight loss takes place. An iron deficiency anemia is frequently associated with these symptoms. Rapid gastric emptying may be demonstrable on upper gastrointestinal barium study. Minor symptoms, other than those enumerated, were much less noticeable in the group of patients categorized. Surgical correction of the dumping syndrome should be considered after lengthy attempts at conservative management have failed. The surgical procedures are designed to improve the reservoir function of the stomach by increasing its capacity directly or to delay gastric emptying. The basis for dumping symptoms is the rapid delivery of fluid-solid mixtures of high osmotic pressure to the upper part of the jejunum. In this section of the bowel, rapid translocation of fluid into the lumen of the jejunum transforms high osmotic pressure to normal or lower levels. Thus, the jejunum is distended and the symptoms of dumping are produced. The stomach functions both as an organ of digestion and acts as an organ which normalizes the osmotic pressure of its contents. When the pyloric sphincter is lost, this function is also lost. Surgical procedures 5 useful for the control of these fluid shifts include the use of antiperistaltic jejunal limbs placed between the gastric reservoir and the upper jejunum or the conversion of a Billroth II gastrojejunostomy to a Billroth I gastroduodenostomy. We 2 have recently reported a study of 10 patients who were treated by a variety of revisionary procedures with six successful results and four failures. Six successes followed varieties of Billroth II to Billroth I conversions with only one failure (development of alkaline gastritis). Other physicians have used reversed jejunal segments with an acceptable success rate. 5 In view of mixed results of surgical treatment, the value of an intensive and lengthy trial (at least a year) of conservative management is emphasized.
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POSTV AGOTOMY DIARRHEA Mild diarrhea occurs after truncal or selective vagotomy and is usually a welcome respite from chronic constipation. 10 Severe postoperative diarrhea is lasting in less than 1 per cent of patients who have truncal vagotomy and (in some of these patients) is refractory to all conservative measures applied intensively for at least one year. Surgical correction is necessary when diarrhea interferes with the patient's livelihood and social functions and causes significant weight loss. Recent reports suggest that an antiperistaltic jejunal reversal, first reported by Craft and Venables 3 in 1968, is successful in the treatment of massive diarrhea. A 10 cm. segment of jejunum or upper ileum is reversed approximately 100 cm. distal to the ligament of Treitz. Of our two patients, one had a successful result, but the other has continuing disability despite two reversals. This patient's disability is the result of dumping symptoms and psychiatric problems.
ATONIC STOMACH AFTER VAGOTOMY A small group of our patients have symptoms we ascribe to late postvagotomy atonic stomach. These patients recovered from initial gastric surgery and resumed oral feedings, but they returned 18 months, three years, and five years after the initial operation, because of recurrent and distressing bloating, pain, nausea, and vomiting of recently ingested food. Barium studies and endoscopy in these patients demonstrated marked gastric stasis with widely patent stomas. The effects of vagotomy on the motility of the stomach and small bowel last only for periods .of months, and it is surprising that this situation is so chronic. Disturbances of motility of the stomach and upper small intestine are only recently receiving the attention they deserve. We have tried a variety of remedial procedures in the treatment of these patients. It appears that, if a simple drainage procedure fails in patients with these symptoms, further surgical maneuvers, short ofradical subtotal gastrectomy, are unlikely to succeed.
MISCELLANEOUS Another large group of patients with disabling symptoms after gastric surgery cannot be categorized readily into any of the previous classifications. Many patients complain mostly of chronic vomiting and admit that this was a problem before operation. Other patients suffer from mild to moderate symptoms of dumping, persistent epigastric pain, recurrent nausea or vomiting, and profound weight loss in various combinations. Still other patients present with more diffuse gastroenterologic symptoms which developed after gastric procedures. In a recent review at the Lahey Clinic,2 surgical attempts at correction were made in 15 of these patients. A variety of procedures, 19 in all,
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were undertaken to constrict or enlarge anastomoses, to change a Billroth I to Billroth II or to change a Billroth II to a Billroth I, to interpose lengths of jejunum, and to reresect gastric remnants. Of these 19 procedures, in only two patients were the results good to excellent. In 15 patients the procedures were failures, and the condition of some patients worsened. We believe that patients who vomit without clear-cut obstruction before the first procedure on the stomach and who complain of vomiting after the operative procedure are at definite risk for further operation. Secondly, patients whose symptoms defy classification into the syndromes mentioned should have exceptionally energetic attempts at conservative treatment, and surgical therapy should be discouraged.
SUMMARY Partial gastrectomy, truncal vagotomy, pyloroplasty, and gastrojejunostomy, singly and in combination, produce clinical disturbances in gastric reservoir function, gastric emptying, gastric mucosal integrity, small intestinal motility, and small intestinal fluid shifts. Ordinarily, these disturbances are of minor clinical importance and respond readily to conservative management. However, postoperative gastric surgical symptoms are, at times, annoying or disabling to the patient. Some of these clinical states are amenable to surgical treatment, and in others, operative intervention is definitely contraindicated. Therefore, it is important to recognize those syndromes which are amenable to an operative procedure. Alkaline gastritis, a syndrome of postcibal pain and diffuse endoscopic gastritis with or without vomiting of bile , is best treated by vagotomy and Roux-en-Y gastrojejunostomy. The afferent loop syndrome of relief of pain by vomiting and the demonstration of a dilated or tortuous afferent loop is likewise best treated by vagotomy and Roux-en-Y gastrojejunostomy or enteroenterostomy. Efferent loop obstruction causing vomiting and gastric distention requires a revision of the gastrojejunostomy. The dumping syndrome is best treated conservatively for at least a year. If this approach fails, loop reversal at the stoma or conversion of a Billroth II to a Billroth I anastomosis is effective. For postvagotomy diarrhea, loop reversal in the distal jejunum gives relief, and for the postvagotomy atonic stomach, a subtotal gastrectomy should be performed after failure of conservative management, although there is not enough experience with this condition to make accurate prognoses. Beware ofthe patient who does not fit any of these syndromes. A poor result is likely to follow attempts at surgical correction.
REFERENCES 1. Bartlett, M. K., Burrington, J. D.: Bilious vomiting after gastric surgery. Experience with a modified Roux-Y for relief. Arch. Surg., 97:43-49 (July) 1968. 2. Brooke-Cowden, G. L., Braasch, J. W., Gibb, S. P., et aI.: Postgastric surgery syndromes. Am. J. Surg., (in press).
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3. Craft, I. L., Venables, C. W.: Antiperistaltic segment of jejunum for persistent diarrhea following vagotomy. Ann. Surg., 167:282-286 (Feb.) 1968. 4. du Plessis, D. J.: Gastric mucosal changes after operations on the stomach. South Afr. Med. J., 36:471-478 (June 16) 1962. 5. Herrington, J. L., Jr.: Remedial operations for post-gastrectomy syndromes. Curro Probl. Surg., 1-63 (April) 1970. 6. Herrington, J. L., Jr., Sawyers, J. L., Whitehead, W. A.: Surgical management of reflux gastritis. Ann. Surg., 180 :526-537 (Oct.) 1974. 7. Jordan, G. L., Jr.: Afferent loop syndrome. Surgery, 38: 1027-1035 (Dec.) 1955. 8. Jordan, G. L., Jr.: Surgical management of postgastrectomy problems. Arch. Surg., 102:251-259 (April) 1971. . 9. Muir, A.: Postgastrectomy syndromes. Br. J. Surg., 37: 165-178 (Oct.) 1949. 10. Nobles, E. R., Jr.: Vagotomy and gastroenterostomy. 15-yearfollowup of 175 patients. Am. Surg., 32:177-182 (March) 1966. 11. Scott, J. E. S., Whiteside, C. G.: Postgastrectomy bilious vomiting investigated with biligrafin. Lancet, 2:1330-1332 (Dec. 15) 1956. 12. van Heerden, J. A., Priestley, J. T., Farrow, G. M., et al.: Postoperative alkaline reflux gastritis. Surgical implications. Am. J. Surg., 112 :427-433 (Sept.) 1969. 13. Woodward, E. R.: The Postgastrectomy Syndromes. Springfield, Illinois, Charles C Thomas, 1963, 56 pp. 14. Zollinger, R. M., Ellison, E. H.: Nutrition after gastric operations. J.A.M.A., 154 :811-814 (March 6) 1954. Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215