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Simpler surgery in the treatment of postgastrectomy malnutrition
Simpler Surgery in the Treatment of Postgastrectomy Malnutrition
Arthur R. Nelson, MD, Phoenix, Arizona
The search for an effective method of correcting the postgastrectomy syndrome has been a fascinating phase of surgical history, both in America and in Europe. Fortunately, the increasingly better understanding of gastrointestinal physiology and the rational, conservative operative treatment of peptic disease which exists today will progressively reduce the need for the operative maneuvers which are to be de: scribed. They are operations without a future. The postgastrectomy syndrome is a wastebasket description of several types of physiologic derangement, most of which can more clearly be defined and classified with present knowledge. The studies of Poth, Jordan, Woodward, Capper, and their associates [1-81 have contributed greatly to this clarification, and a recent monograph by Herrington [9] is an historical gem. (Table I.) The disastrous consequences to the occasional patient undergoing gastrectomy relate to certain combinations of disturbed physiology: (1) a profoundly reduced gastric reservoir, (2) an afferent loop syndrome, (3) an efferent loop syndrome, (4) early or late dumping, (5) the effect of vagotomy. Each of these may exist singly or in combination in any given patient, and great care must be exercised to delineate, insofar as possible, the elements of each that can be surgically corrected.
Reprint requests should be addressed to Dr Nelson, 926 East McDowell Road, Suite 32, Phoenix, Arizona 85006. Presented at the Twenty-Fourth Annual Meeting of the Southwestern Surgical Congress, Albuquerque:New Mexico, May 1-4, 1972.
750
It has been estimated that a third of patients subjected to the older types of high gastrectomy will have some degree of symptomatic decreased gastric capacity. A lesser number of these patients will be reduced to nutritional cripples. They represent true surgical catastrophies with the attendant great weight loss, diarrhea, anemia, psychic depression, and frequent narcotic addiction. The surgical rehabilitation of these unfortunate patients attempts to do the following: (1) produce a sensation of increased food capacity; (2) present to the undigested food a large interface of jejunal mucosa for an artificially prolonged time, and thus allow more complete absorption of essential nutriments; (3) slow “jejunal hurry” and extend transit time to near normal levels, thus halting perpetual diarrhea; (4) provide a sense of well being that comes with enjoyment of food, evident weight gain, and restoration of strength. Although the dumping syndrome does not relate directly to the loss of gastric capacity, the familiar vasomotor and gastrointestinal symptoms are a frequent accompaniment to the destruction of the pyloric mechanism by any of a variety of operative procedures. Despite a knowledge of the dumping phenomenon that was first noted in 1907 by Denechau [IO] and the extensive studies made subsequently [11131, the final answers remain elusive. The postgastrectomy cripple will more often seek repair of the severe symptoms of dumping than of the symptoms relating to loss of gastric capacity alone. The operation to be described is a modification of many previous technics [2,14-161. Basically, the Lawrence-Woodward pouch [8,16] principle is used
The American Journal of Surgery
Postgastrectomy Malnutrition
which is added a reversed jejunal segment at the pouch outlet. (Figures 1 through 7.) The major advantages are simplicity and broad applicability. The patients are all considered poor surgical risks. A shortened time of surgical exposure by complete avoidance of the old gastrectomy site, particularly the takedown and reconstruction maneuvers required by so many of the other procedures, is its single greatest advantage [I 7-191. I performed the first of these procedures in 1965 in a sixty-two year old woman who had undergone high gastrectomy (80 per cent) for benign ulcer disease ten years previously. She had lost weight from a norm of 114 pounds to a preoperative weight of 84 pounds. Diarrhea1 stools occurred ten times daily with associated severe dumping. Suicide attempts, both of which were related to progressive disability and depression, were documented on two occasions. Her ability to eat was sorely restricted. She was anemic, hypoproteinemic with pedal edema, and wasted to the point of being bedridden. After surgery, she gained weight to 106 pounds, began to enjoy a regular diet which has remained unrestricted, and has
to
a
TABLE I Year
antlperlstoltic
outlet
Reconstructions
Author
1896 1911
Mall Shoemaker
1927
1934 1948 1951 1953 1955 1957
Bohmansson Tanner Farman Steinburg Tanner Henley Hays Zelmanowitz Poth
1960
Christeas
Procedure Reversed segments of dogs Gastric reconstruction with isoperistaltic jejunum Conversions of Billroth I to Billroth I I Pantaloon anastomosis Modified Roux lsoperistaltic jejunal interposition Plioated jejunal pouch First antiperistaltic jejunum Antiperistaltic jejunum between stomach and duodenum Antiperistaltic segment in efferent loop
one stool a day. Currently she manages a liquor store where it is reported she “medicates” herself frequently without any untoward effects. Table II reports the present ‘series and the recent status of each who underwent operation. One of the twenty-one patients has been lost to late follow-up
a
Path
Historical
a
pouch
Christeas Antiporisfoltic
Figures 1 through 7. Illustrated are several historical reconstructions treatment of postgastrectomy malnutrition.
Volume 124, December 1972
isolated segment
and currently used procedures
in the surgical
751
Nelson
Chronologic Development of Basic Reparative Procedures
TABLE II
Pouch/ Reversal
Weight Gain (lb)
Billroth II, 1955 Billroth I I, 1965 Billroth I, 1952 Billroth I, 1956 Billroth I, 1956 Billroth I I, 1’960 Billroth II, 1955 Billroth II, 1960 Multiple, 1958 Multiple, 1962 Billroth I I, 1964 Billroth I, 1965 Multiple, 1963 Multiple, 1960 Billroth II, 1956 Billroth I I, 1967 Billroth I, 1956 Colon interposition, 1965
3165 3166 8166 8166 9166 5167 6/67 7167 8167 10167 11167 l/68 l/69 l/69 2169 5169 6168 l/69
18 22(?) 14 40 18 16 11 23 Died* 20 8 11 26 18 9 14 24 6
Billroth I I, 1957 Multiple, 1964 Multiple, 1961
6169 9170 11171
12 16 12
Age (yr) Patient
and Sex
MM FW FZ WA DD RI-! CM WT SL MC GR JM AT RY GO vc MP LG
62, 35, 75, 59, 37, 55, 39, 57, 68, 53, 31, 65, 18, 52, 58, 55, 47, 49,
JT MD MR
65, M 57, F 62, F
F M M M F M F M M F M M M F M F F F
Previous Surgery
Figure 8. The completed jejunal segment.
jejunal
pouch
with
reversed
* Death two days postoperatively from indeterminate cause. Five additional patients have been treated since this presentation.
TABLE III
Jejunal Pouch/Reversed in Twenty-One Patients* Results
Good Fair Postoperative Total
Number
mortality
17 3 1 21
Segment Results
Per cent 80 14.2 4.8
* Five subsequent patients have been operated on since this presentation. All have responded with continuing weight gain and freedom from dumping. There was no mortality.
study. One patient died two days postoperatively of indeterminate causes. The operative schema indicates its simplicity. Three limb jejunal pouches have been used routinely, although a two limb long-segment pouch has occasionally been sufficient. The measured length of reversed segment was 5 to 9 cm before anastomosis was begun. In one patient with a 14 cm reversal, physiologic obstruction developed in the pouch, and early secondary operation was required to foreshorten the length of reversed segment. Late follow-up study has shown no recurrence of diarrhea, and none of the pouches has required revision or resection as yet. There have been no recognized pouch ulcers, as reported with other types of jejunal pouches. (Figures 8,9, and 10).
752
Figure 9.
Operative schema.
The results in these patients have not all been uniformly good, and it is obvious from a perusal of the data that some have been less dramatically rehabilitated than others. It remains a useful procedure, one that as yet no patient has found to be less than worthwhile. Physiologic parameters in pre- and postoperative studies indicate weight gain from 6 to 40 pounds, extension of transit times, increased absorption of tagged triolein, diminution of seventy-two hour fecal fat, and, in the great majority, total relief of the vasomotor dumping phenomenon. Cinefluorography, performed as late as four years postoperatively, shows continuing function of the reversed segment. Hypertrophy and dilatation to variable degrees have occurred in the pouches after some time, but no pa-
The Amertcan Journal of Surgery
Postgastrectomy
Figure 10. Relative decrease in diarrhea/ frequency preand postoperative/y in the first ten patients. Subsequent patients show similar patterns.
tient has required pouch. (Table III.)
excision
or enterostomy
of the
Summary
An operative procedure devised for simplif’ied treatment of the postgastrectomy syndrome is described. In twenty-one patients it has proved a safe and reasonably effective approach to a difficult problem. References Poth EJ: Surgical correction of severe dumping and post gastrectomy malnutrition: a therapeutic and diagnostic test. Ann Surg 160: 488, 1964. Poth EJ, Cleveland BR: A functional substitution pouch for the stomach. Arch Surg 83: 58, 1961. Poth EJ: The dumping syndrome and its surgical manage-
Volume 124, December 1972
Malnutrition
ment. Amer Surg 23: 1097, 1957. 4. Poth EJ: The use of gastrointestinal reversal in surgical procedures. Amer J Sorg 118: 893, 1969 loop syndrome. Surgery 38: 1027, 5. Jordon, GL: Afferent 1955. 6. Jordon, GL: The post gastrectomy syndromes. JAMA 163: 1485,1957. 7. Capper WM, Butler TJ: Clinical study of the early post gastrectomy syndrome. Brit J Surg 11: 265, 1951. 8. Woodward ER, Hastings N: Surgical treatment of the post gastrectomy dumping syndrome. Surg Gynec Obstet 115: 420,196O. 9. Herrington JL Jr: Remedial operations for post gastrectomy sundromes. Curr Pro&V in Surg April, 1970. D: Les suites medicoles eloignees de la gas10. Denechau troenterostomie au tours de I’ulcere d’estomac et de ses complications. Thesis for a doctorate in medicine, Faculte de medicine de Paris. vol 1, p 192, 1907. 11. Hertz AF: The course and treatment of certain unfavorable aftereffects of gastroenterostomy. Ann Surg 58: 466, 1913. 12. Mix, CL: “Dumping syndrome” following gastrojejunostomy. Surg C/in N Amer 2: 617, 1922. 13. Moll FP: Reversal of intestine. Johns Hopkins Hosp Rep 1: 93, 1896. 14. Steinberg ME: Prevention of some post gastrectomy difficulties by a new gastrectomy technique. J Int Co// Surg 14: 194,195o. 15. Willms RF: Effect of reversed jejunal segments upon gastric emptying, nutrition, and plasma volume following subtotal gastrectomy. Surg Forum 12: 317, 1961. 16. Lawrence WJ, Kim M, lssacs M, Randall HT: Gastric reservoir construction for severe disability after subtotal gastrectomy. Surg Gynec Obstet 119: 1219, 1964. 17. Henley FA: Gastrectomy with replacement. Ann Roy Co// Surg Eng 13: 141, 1953. 18. Tanner NC: Results of operations for post gastrectomy symptoms. Gastroenterology92: 146, 1959. 19. Nelson AR, Bright D: Surgical rehabilitation of the post gastrectomy cripple. J Arizona Med Assoc 24: 211, 1967.
753
Arthur R. Nelson, MD, Phoenix, Arizona
The search for an effective method of correcting the postgastrectomy syndrome has been a fascinating phase of surgical history, both in America and in Europe. Fortunately, the increasingly better understanding of gastrointestinal physiology and the rational, conservative operative treatment of peptic disease which exists today will progressively reduce the need for the operative maneuvers which are to be de: scribed. They are operations without a future. The postgastrectomy syndrome is a wastebasket description of several types of physiologic derangement, most of which can more clearly be defined and classified with present knowledge. The studies of Poth, Jordan, Woodward, Capper, and their associates [1-81 have contributed greatly to this clarification, and a recent monograph by Herrington [9] is an historical gem. (Table I.) The disastrous consequences to the occasional patient undergoing gastrectomy relate to certain combinations of disturbed physiology: (1) a profoundly reduced gastric reservoir, (2) an afferent loop syndrome, (3) an efferent loop syndrome, (4) early or late dumping, (5) the effect of vagotomy. Each of these may exist singly or in combination in any given patient, and great care must be exercised to delineate, insofar as possible, the elements of each that can be surgically corrected.
Reprint requests should be addressed to Dr Nelson, 926 East McDowell Road, Suite 32, Phoenix, Arizona 85006. Presented at the Twenty-Fourth Annual Meeting of the Southwestern Surgical Congress, Albuquerque:New Mexico, May 1-4, 1972.
750
It has been estimated that a third of patients subjected to the older types of high gastrectomy will have some degree of symptomatic decreased gastric capacity. A lesser number of these patients will be reduced to nutritional cripples. They represent true surgical catastrophies with the attendant great weight loss, diarrhea, anemia, psychic depression, and frequent narcotic addiction. The surgical rehabilitation of these unfortunate patients attempts to do the following: (1) produce a sensation of increased food capacity; (2) present to the undigested food a large interface of jejunal mucosa for an artificially prolonged time, and thus allow more complete absorption of essential nutriments; (3) slow “jejunal hurry” and extend transit time to near normal levels, thus halting perpetual diarrhea; (4) provide a sense of well being that comes with enjoyment of food, evident weight gain, and restoration of strength. Although the dumping syndrome does not relate directly to the loss of gastric capacity, the familiar vasomotor and gastrointestinal symptoms are a frequent accompaniment to the destruction of the pyloric mechanism by any of a variety of operative procedures. Despite a knowledge of the dumping phenomenon that was first noted in 1907 by Denechau [IO] and the extensive studies made subsequently [11131, the final answers remain elusive. The postgastrectomy cripple will more often seek repair of the severe symptoms of dumping than of the symptoms relating to loss of gastric capacity alone. The operation to be described is a modification of many previous technics [2,14-161. Basically, the Lawrence-Woodward pouch [8,16] principle is used
The American Journal of Surgery
Postgastrectomy Malnutrition
which is added a reversed jejunal segment at the pouch outlet. (Figures 1 through 7.) The major advantages are simplicity and broad applicability. The patients are all considered poor surgical risks. A shortened time of surgical exposure by complete avoidance of the old gastrectomy site, particularly the takedown and reconstruction maneuvers required by so many of the other procedures, is its single greatest advantage [I 7-191. I performed the first of these procedures in 1965 in a sixty-two year old woman who had undergone high gastrectomy (80 per cent) for benign ulcer disease ten years previously. She had lost weight from a norm of 114 pounds to a preoperative weight of 84 pounds. Diarrhea1 stools occurred ten times daily with associated severe dumping. Suicide attempts, both of which were related to progressive disability and depression, were documented on two occasions. Her ability to eat was sorely restricted. She was anemic, hypoproteinemic with pedal edema, and wasted to the point of being bedridden. After surgery, she gained weight to 106 pounds, began to enjoy a regular diet which has remained unrestricted, and has
to
a
TABLE I Year
antlperlstoltic
outlet
Reconstructions
Author
1896 1911
Mall Shoemaker
1927
1934 1948 1951 1953 1955 1957
Bohmansson Tanner Farman Steinburg Tanner Henley Hays Zelmanowitz Poth
1960
Christeas
Procedure Reversed segments of dogs Gastric reconstruction with isoperistaltic jejunum Conversions of Billroth I to Billroth I I Pantaloon anastomosis Modified Roux lsoperistaltic jejunal interposition Plioated jejunal pouch First antiperistaltic jejunum Antiperistaltic jejunum between stomach and duodenum Antiperistaltic segment in efferent loop
one stool a day. Currently she manages a liquor store where it is reported she “medicates” herself frequently without any untoward effects. Table II reports the present ‘series and the recent status of each who underwent operation. One of the twenty-one patients has been lost to late follow-up
a
Path
Historical
a
pouch
Christeas Antiporisfoltic
Figures 1 through 7. Illustrated are several historical reconstructions treatment of postgastrectomy malnutrition.
Volume 124, December 1972
isolated segment
and currently used procedures
in the surgical
751
Nelson
Chronologic Development of Basic Reparative Procedures
TABLE II
Pouch/ Reversal
Weight Gain (lb)
Billroth II, 1955 Billroth I I, 1965 Billroth I, 1952 Billroth I, 1956 Billroth I, 1956 Billroth I I, 1’960 Billroth II, 1955 Billroth II, 1960 Multiple, 1958 Multiple, 1962 Billroth I I, 1964 Billroth I, 1965 Multiple, 1963 Multiple, 1960 Billroth II, 1956 Billroth I I, 1967 Billroth I, 1956 Colon interposition, 1965
3165 3166 8166 8166 9166 5167 6/67 7167 8167 10167 11167 l/68 l/69 l/69 2169 5169 6168 l/69
18 22(?) 14 40 18 16 11 23 Died* 20 8 11 26 18 9 14 24 6
Billroth I I, 1957 Multiple, 1964 Multiple, 1961
6169 9170 11171
12 16 12
Age (yr) Patient
and Sex
MM FW FZ WA DD RI-! CM WT SL MC GR JM AT RY GO vc MP LG
62, 35, 75, 59, 37, 55, 39, 57, 68, 53, 31, 65, 18, 52, 58, 55, 47, 49,
JT MD MR
65, M 57, F 62, F
F M M M F M F M M F M M M F M F F F
Previous Surgery
Figure 8. The completed jejunal segment.
jejunal
pouch
with
reversed
* Death two days postoperatively from indeterminate cause. Five additional patients have been treated since this presentation.
TABLE III
Jejunal Pouch/Reversed in Twenty-One Patients* Results
Good Fair Postoperative Total
Number
mortality
17 3 1 21
Segment Results
Per cent 80 14.2 4.8
* Five subsequent patients have been operated on since this presentation. All have responded with continuing weight gain and freedom from dumping. There was no mortality.
study. One patient died two days postoperatively of indeterminate causes. The operative schema indicates its simplicity. Three limb jejunal pouches have been used routinely, although a two limb long-segment pouch has occasionally been sufficient. The measured length of reversed segment was 5 to 9 cm before anastomosis was begun. In one patient with a 14 cm reversal, physiologic obstruction developed in the pouch, and early secondary operation was required to foreshorten the length of reversed segment. Late follow-up study has shown no recurrence of diarrhea, and none of the pouches has required revision or resection as yet. There have been no recognized pouch ulcers, as reported with other types of jejunal pouches. (Figures 8,9, and 10).
752
Figure 9.
Operative schema.
The results in these patients have not all been uniformly good, and it is obvious from a perusal of the data that some have been less dramatically rehabilitated than others. It remains a useful procedure, one that as yet no patient has found to be less than worthwhile. Physiologic parameters in pre- and postoperative studies indicate weight gain from 6 to 40 pounds, extension of transit times, increased absorption of tagged triolein, diminution of seventy-two hour fecal fat, and, in the great majority, total relief of the vasomotor dumping phenomenon. Cinefluorography, performed as late as four years postoperatively, shows continuing function of the reversed segment. Hypertrophy and dilatation to variable degrees have occurred in the pouches after some time, but no pa-
The Amertcan Journal of Surgery
Postgastrectomy
Figure 10. Relative decrease in diarrhea/ frequency preand postoperative/y in the first ten patients. Subsequent patients show similar patterns.
tient has required pouch. (Table III.)
excision
or enterostomy
of the
Summary
An operative procedure devised for simplif’ied treatment of the postgastrectomy syndrome is described. In twenty-one patients it has proved a safe and reasonably effective approach to a difficult problem. References Poth EJ: Surgical correction of severe dumping and post gastrectomy malnutrition: a therapeutic and diagnostic test. Ann Surg 160: 488, 1964. Poth EJ, Cleveland BR: A functional substitution pouch for the stomach. Arch Surg 83: 58, 1961. Poth EJ: The dumping syndrome and its surgical manage-
Volume 124, December 1972
Malnutrition
ment. Amer Surg 23: 1097, 1957. 4. Poth EJ: The use of gastrointestinal reversal in surgical procedures. Amer J Sorg 118: 893, 1969 loop syndrome. Surgery 38: 1027, 5. Jordon, GL: Afferent 1955. 6. Jordon, GL: The post gastrectomy syndromes. JAMA 163: 1485,1957. 7. Capper WM, Butler TJ: Clinical study of the early post gastrectomy syndrome. Brit J Surg 11: 265, 1951. 8. Woodward ER, Hastings N: Surgical treatment of the post gastrectomy dumping syndrome. Surg Gynec Obstet 115: 420,196O. 9. Herrington JL Jr: Remedial operations for post gastrectomy sundromes. Curr Pro&V in Surg April, 1970. D: Les suites medicoles eloignees de la gas10. Denechau troenterostomie au tours de I’ulcere d’estomac et de ses complications. Thesis for a doctorate in medicine, Faculte de medicine de Paris. vol 1, p 192, 1907. 11. Hertz AF: The course and treatment of certain unfavorable aftereffects of gastroenterostomy. Ann Surg 58: 466, 1913. 12. Mix, CL: “Dumping syndrome” following gastrojejunostomy. Surg C/in N Amer 2: 617, 1922. 13. Moll FP: Reversal of intestine. Johns Hopkins Hosp Rep 1: 93, 1896. 14. Steinberg ME: Prevention of some post gastrectomy difficulties by a new gastrectomy technique. J Int Co// Surg 14: 194,195o. 15. Willms RF: Effect of reversed jejunal segments upon gastric emptying, nutrition, and plasma volume following subtotal gastrectomy. Surg Forum 12: 317, 1961. 16. Lawrence WJ, Kim M, lssacs M, Randall HT: Gastric reservoir construction for severe disability after subtotal gastrectomy. Surg Gynec Obstet 119: 1219, 1964. 17. Henley FA: Gastrectomy with replacement. Ann Roy Co// Surg Eng 13: 141, 1953. 18. Tanner NC: Results of operations for post gastrectomy symptoms. Gastroenterology92: 146, 1959. 19. Nelson AR, Bright D: Surgical rehabilitation of the post gastrectomy cripple. J Arizona Med Assoc 24: 211, 1967.
753