Surgical treatment of severe dumping syndrome.

Dumping syndrome is a common post-operative complication following gastric surgery. Clinically, severe dumping can be a serious medical condition with a negative impact on the patient's life. In our case report, we present a case of refractory dumping syndrome which developed after laparoscopic subtotal gastrectomy with gastrojejunoanastomosis due to massive gastroptosis with stomach evacuation problems. Conservative gastroenterology treatment was not successful. Due to the progression of weight loss and life-threatening hypoglycaemia, the decision for surgical treatment was made. After the corrective gastro-duodenal and jejuno-jejunal anastomoses, all clinical symptoms resolved completely. With regard to the presented case, we discuss the common treatment options for dumping syndrome: the standard recommendations for dietary habits, pharmacological treatment and finally the surgery and its pitfalls. Due to the absence of randomized trials and guidelines, every patient should be treated in a personalized way.

[Ultrasonic examination of gastric stump and gastroenteroanastomosis in complex diagnosis of postresection dumping syndrome]. / Ul'trazvukovoe issledovanie kul'ti zheludka i gastroénteroanastomoza v kompleksnoi diagnostike postrezektsionnogo demping-sindroma.

Long-term results of laparoscopic resections of the stomach were studied, a comparative analysis with similar open surgeries was carried out. The comparative analysis was based on the results of ultrasonic examination (USE) of the gastric stump (GS) and gastroenteroanastomosis (GEA). Basing on ultrasonic parameters of GS, digital parameters of GEA in mild, moderate and severe degree of dumping-syndrome were determined. Ultrasonic examinations of the gastric stump permitted to study its function in dumping-syndrome of different degree, to reveal sizes of GEA in relaxation and contraction stage, and based on these data to determine its gradients of contractility. Ultrasonic method in long-term period after resection of the stomach has advantages compared with gastroscopic and X-ray methods.

Measurement of superior mesenteric artery flow by means of Doppler ultrasound in early dumping syndrome.

OBJECTIVE: Dumping occurs in about 10% of patients after gastric surgery. It has been suggested that early dumping is associated with an abnormal increase in postprandial splanchnic flow, but data from controlled studies are lacking. Therefore we have studied basal and postprandial superior mesenteric artery (SMA) blood flow in patients with dumping and in two control groups. METHODS: Three groups were studied, one group of patients after gastric surgery with early dumping (n = 6), one surgical control group with patients after gastric surgery without dumping symptoms (n = 7), and a healthy control group without previous gastric surgery (n = 10). Blood glucose and heart rate were measured after dumping provocation by oral ingestion of 50 g glucose. SMA blood flow was measured both basally and 20 min after glucose ingestion. RESULTS: Basal SMA flow was similar in the three groups. After glucose ingestion SMA flow was not significantly different between dumping patients and surgical controls. However, stimulated SMA flow in both groups after gastric surgery combined was significantly (p < 0.05) higher than in healthy controls. CONCLUSION: The systemic symptoms associated with early dumping do not result from increased SMA blood flow per se. After gastric surgery patients have an increased postprandial SMA flow irrespective of the presence of dumping.

Isotope gastric emptying tests in clinical practice: expectation, outcome, and utility.

Tests of gastric emptying with modern scintigraphic methods are recommended in the clinical management of gastric disorders. An audit of 472 gastric emptying tests carried out over a 10 year period was performed to discover the reasons for requests from consultant clinicians, their anticipation of the results of tests, and the influence of the results upon the subsequent management of their patients. Excluding control (n = 47) and research (n = 50) studies, there were 375 clinical referrals that could be grouped under the headings: non-ulcer dyspepsia (n = 72), suspected diabetic gastroparesis (n = 18), peptic ulcer (n = 15), suspected delayed gastric emptying after surgery (n = 154), dumping and diarrhoea (= 107), and other indications (n = 9). Although the results were abnormal for 55 (48%) of the 'medical' patients, they did not seem to influence clinical management. Delayed gastric emptying after surgery was confirmed in only 20% of patients referred with this clinical diagnosis. Conversely, most (79%) o the patients referred with dumping and diarrhoea exhibited abnormally rapid emptying. Isotope gastric emptying studies may be useful in clinical practice. The results are often at variance with the clinical diagnosis. Clinicians must take into account the nature of the test meal used when results are correlated with clinical features.

Dumping syndrome after combined pyloroplasty and fundoplication.

Dumping syndrome in infancy is a rare complication following gastric surgery. We describe an 11-month-old infant affected by recurrent peptic oesophagitis who underwent a combined Nissen fundoplication and pyloroplasty. Early dumping symptoms such as irritability, pallor, sweating, abdominal distension and watery diarrhoea were observed postoperatively after bolus feeding. Gastric emptying, measured after the administration of 150 ml of regular cow milk mixed with 200 microCi (8 MBq) of technetium-99m sulfur colloid (99mTc-SC), demonstrated an early rapid and massive emptying of the isotopes into the small intestine, followed by duodenogastric reflux and a second wave of emptying and reflux at 9 min. The initial pattern of gastric emptying and duodenogastric reflux was followed by a slow emptying phase with half-emptying time of 81 min. Isotope studies should be used to investigate motility disorders caused by this type of anti-reflux operation.

Clinical and radionuclide evaluation of Roux-Y diversion for postgastrectomy dumping.

From 1973 to 1986, 22 patients underwent Roux-Y gastrojejunostomy for the early postgastrectomy dumping syndrome. In the early years, five patients underwent Roux-Y conversion with the addition of a 10 cm antiperistaltic jejunal segment interposed between the Roux-Y limb and the stomach. Within 4 years, all five patients had the jejunal segment removed due to severe symptoms of gastric retention. These patients underwent reconstruction to create Roux-Y limb only and joined the pool of 17 patients who underwent Roux-Y diversion only for the dumping syndrome. Overall, 19 of 22 patients (86 percent) had almost complete resolution of their dumping symptoms on long-term follow-up. Three patients showed no improvement, two with severe gastric retention and one with recurrent dumping symptoms. Overall, 5 of 22 patients (23 percent) had moderate to severe early and late postoperative gastric retention necessitating medical treatment in three and subsequent near-total gastrectomy in two. Although other procedures such as pyloric reconstruction or the addition of isoperistaltic or antiperistaltic jejunal interpositions have been reported to be equally successful in delaying gastric emptying and resolving dumping symptoms, we have preferred Roux-Y diversion for the treatment of combined alkaline reflux gastritis and dumping or the pure early vasomotor postgastrectomy dumping syndrome. As reported, we have abandoned the use of an antiperistaltic jejunal segment interposed between the stomach and the Roux-Y limb due to the high rate of postoperative gastric retention.

[Roentgenologic aspects after (total) gastrectomy for malignant tumours (author's transl)]. / Röntgenologische Aspekte nach (totaler) Gastrektomie wegen maligner Tumoren.

Pre-operatively, radiological examination is important for the diagnosis of malignant tumours in the stomach. Postoperatively, it can be used to demonstrate the state of the anastomosis and possible defects of the suture, for the early recognition of recurrences or other abnormalities, and for the diagnosis of reflux oesophagitis and the dumping syndrome. Changes in the oesophagus following various types of reconstruction were examined, both clinically and radiologically, in 40 patients who had had gastrectomies. Following jejunal interposition with a proximal end-to-side anastomosis and a long blind segment, there may be reflex into the oesophagus, but symptoms of reflux oesophagitis only occur if there is also duodeno-jejunal reflux. Patients with a Roux loop show few symptoms, while the worst radiological and clinical results were achieved with a double-barrelled jejunal loop, despite a low anastomosis.

The evaluation of dumping and diarrhoea after gastric surgery using a physiological test meal.

A test meal consisting of food (Galactomin 18), and a barium preparation (Raybar) was given to 47 patients who had undergone truncal vagotomy combined with either antrectomy or gastric drainage, and to five normal subjects. The radiological findings were correlated with the symptomatology. Total gastric emptying was not significantly different between normal controls, post-operative but asymptomatic cases, or those in whom dumping of diarrhoea was provoked. Small intestinal transit was significantly faster in cases of post-cibal diarrhoea than in other groups, and was also more rapid than normal when dumping was provoked. Colonic entry time was also faster than normal in these two groups. Marked dilution of the meal in the small bowel only occurred in the presence of the dumping syndrome. Jejunal interposition prevented the occurrence of dumping and restored the radiological appearances in the intestine to normal. The test meal gave excellent correlation with the patients' symptomatology. The relationship of the findings to the mechanisms of post-cibal diarrhoea and the dumping syndrome is discussed.

[Radiologic demonstration of esophageal and gastric motility phenomena]. / Radiologische Erfassung von Motilitåtsphänomenen an Osophagus und Magen

Indication and significance of roentgenological procedures referring to esophageal and gastric motility are discussed with special reference to a number of functional disorders. Cinematography and tape-recording are necessary for fast peristaltic motion as in vascular, neurological and myogenic diseases of the upper esophageal sphincter. Pharmacological response may for instance help to differentiate functional from morphological disorders or postoperative complains. Combinations of roentgenological and radioisotopical studies or manometry may be usefull for special diagnostic problems.