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Post Vagotomy Syndromes

Post Vagotomy Syndromes

  1. Loss of Reservoir:
    • Early and Late Dumping Syndrome
    • Metabolic Derangements
  2. Due to Vagal Denervation:
    • Diarrhea
    • Gallstones
    • Gastric Stasis
  3. Due to Reconstruction:
    • Bile Reflux Gastritis
    • Roux Syndrome
    • Afferent and Efferent Loop Obstruction
    • Jejuno-Gastric Intussusception

DUMPING SYNDROME

1. Early Dumping Syndrome

  • More common than late dumping
  • 10% incidence
  • Associated with Billroth I > Billroth II
  • Confirmation:
    • Gastric emptying study with radiolabeled solid meal
    • More than 50% empties in 1 hour
  • Timing: Occurs 10-30 minutes after a meal
  • Mechanism:
    • Hyperosmolar chyme in the small bowel
    • Luminal distension leading to GI symptoms:
      • Eructations, epigastric fullness, cramps, nausea, vomiting, diarrhea
    • Hypovolemia causing cardiovascular symptoms:
      • Tachycardia, palpitations, diaphoresis, lightheadedness

2. Late Dumping Syndrome

  • Less common than early dumping
  • Occurs 2-3 hours after a meal
  • Mechanism:
    • Rapid delivery of mono- and disaccharides to the small intestine
    • Leads to hyperglycemia, which triggers GLP-1 release → hyperinsulinemia → insulin shock → adrenal response → catecholamine release
  • Symptoms:
    • Predominantly cardiovascular symptoms:
      • Lightheadedness, tachycardia, palpitations, diaphoresis
    • Minimal GI symptoms

Medical Management:

  • Small frequent meals
  • Separate solids from liquids
  • Low-calorie diet
  • Lying down during symptoms
  • Pectin: Gels carbohydrates in the diet
  • Acarbose: Alpha-glucosidase inhibitor
  • Octreotide:
    • Used when conservative measures fail
    • Dose: 50-100 mcg, 15-60 minutes before meals
    • Restores fasting motility pattern (MMC)
    • Very effective in late dumping

Surgical Management:

  • 1% of cases ultimately require surgery
  • Pyloroplasty:
    • Pyloric reconstruction
  • Conversion from Billroth II to Billroth I or Roux-en-Y:
    • Roux limb: 60 cm
    • Isoperistaltic jejunal segment: 20 cm
    • Antiperistaltic jejunal segment: 10 cm
    • These segments are not very effective and may cause obstruction

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Early vs Late Dumping Syndrome

Dumping Early Late
Aggravating Factor More food Exercise
Relieving Factor Lying down Food
Major Symptoms GI symptoms Non-GI symptoms

Metabolic Derangements

  • Most Common Complication:
    • Billroth II > Billroth I
  • Iron Deficiency:
    • Most common metabolic derangement, occurring in >50% of cases
    • Iron and calcium are absorbed in the duodenum and require an acidic environment
  • Vitamin B12:
    • Requires an acidic environment for absorption
  • Folate Deficiency:
    • Due to poor intake rather than absorption issues
    • Folate deficiency is rare
  • Fat Malabsorption:
    • Leads to chelation of calcium and poor absorption of fat-soluble vitamin D
    • Bone disease can take years to manifest

Diarrhea Post Vagotomy

  • Incidence:
    • Occurs in 30% of cases
    • Clinically significant post-vagotomy diarrhea: 5-10%
    • Need for surgery: 1%

Mechanism:

  • Intestinal denervation (though not entirely responsible as SV also causes diarrhea)
  • Bile acid malabsorption
  • Rapid gastric emptying
  • Bacterial overgrowth

Treatment:

  • Post-vagotomy stool contains twice as much chenodeoxycholic acid
  • Responds well to cholestyramine
  • Surgery is typically delayed until 1 year after vagotomy

Surgical Management:

  • Antiperistaltic 10 cm jejunal segment
    • Placed 70-100 cm from the ligament of Treitz

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Bile Reflux Gastritis

  • Incidence:
    • Bile reflux is common, but symptoms are less common, occurring in 2% of reflux cases
    • Parietal cell and gastrin cell mass are decreased, leading to intestinal epithelialization
  • Clinical Triad:
    • Postprandial pain
    • OGD shows bile in the stomach
    • Biopsy reveals gastritis

Management:

  • Revision surgery:
    • Convert Billroth II to Roux-en-Y
    • Use an isoperistaltic jejunal limb (40 cm) - Henley loop
    • Braun JJ

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MCQ: Best Surgical Option for Alkaline Reflux Following Billroth II

Question:

What is the best surgical option for alkaline reflux following Billroth II?

  • a) Total gastrectomy & Roux-en-Y EJ
  • b) Roux-en-Y GJ
  • c) Convert Billroth II to Billroth I
  • d) Interposition of loop of jejunum

Answer:

b) Roux-en-Y GJ

Explanation:

  • Roux-en-Y gastrojejunostomy (GJ) is the preferred surgical option as it effectively diverts bile away from the stomach, resolving symptoms of alkaline reflux.

Afferent Loop Syndrome

Afferent Loop Syndrome - Causes

  • Adhesions: Scar tissue from previous surgeries can cause mechanical obstruction of the afferent loop.
  • Volvulus: Twisting of the loop can impede the flow of contents, leading to obstruction.
  • Kinking: The afferent loop may become bent or twisted, creating a blockage.
  • Herniation: The loop can become trapped in a hernia, leading to obstruction.
  • Stenosis of the Gastrojejunostomy: Narrowing at the anastomotic site can obstruct the loop.

  • Long Afferent Limb: A long afferent limb increases the risk of mechanical issues and bile accumulation.

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Key Points on Afferent Loop Syndrome:

  • Chronic > Acute
  • Typically occurs with a long afferent limb (usually 30-40 cm)
  • Pain occurs 30-40 minutes after eating
  • Vomitus contains bile, but no food
  • Can present as:
    • Blind loop syndrome
    • Stomal ulceration
  • Diagnostic tools:
    • OGD (Upper GI Endoscopy)
    • HIDA Scan
  • Causes include:
    • Adhesions
    • Volvulus
    • Kinking
    • Herniation behind efferent limb
    • Stenosis of GJ
    • Long afferent limb

Efferent Loop Obstruction

  • 50% of cases present within the first month
  • Presents similarly to small bowel obstruction
  • Vomiting includes both food and bile
  • Diagnosis is made via barium contrast series

MCQ: Efferent Loop Obstruction

Question:

All are true regarding efferent loop obstruction except:

  • a) Caused only in anterior GJ
  • b) Mainly due to retroanastamotic herniation
  • c) Surgical management is needed most of the time
  • d) A complication following gastrectomy

Answer:

a) Caused only in anterior GJ

Explanation:

  • Efferent loop obstruction is not limited to anterior gastrojejunostomy (GJ); it can occur in various anatomical setups post-surgery. Other causes include retroanastomotic herniation, kinking, or adhesions, and surgical intervention is often necessary.

Roux Stasis Syndrome

  • Symptoms:
    • Pain
    • Vomiting
    • Weight loss
  • Risk Factors:
    • Previous vagotomy
    • Large gastric remnant
    • Long Roux limb
  • Mechanism:
    • Disconnecting jejunum from the duodenal pacemaker
  • Management:
    • Some patients benefit from promotility agents

    • Many require surgical intervention:

      • Reduce gastric remnant size, in some patients, consider 95% gastrectomy
      • If the Roux limb is unusually dilated or flaccid, it should be resected

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MCQ’s

MCQ 1: True Statements Regarding Dumping and Afferent Limb Syndrome

Question:

All are true except?

  • A) Early dumping occurs around 30 minutes after a meal
  • B) Early dumping has more cardiac and less GI symptoms
  • C) Afferent limb syndrome is characterized by pain that is relieved by vomiting
  • D) Marginal ulcers are more common with Roux-en-Y than Billroth II reconstruction

Answer:

B) Early dumping has more cardiac and less GI symptoms

Explanation:

  • Early dumping typically presents with more GI symptoms such as nausea, cramps, vomiting, and diarrhea, rather than predominantly cardiac symptoms.
  • Afferent limb syndrome is indeed characterized by pain relieved by vomiting.
  • Marginal ulcers are more common with Roux-en-Y than with Billroth II reconstruction due to the exclusion of the duodenum in Roux-en-Y.

MCQ 2: Identify the Wrong Statement

Question:

Pick the wrong statement:

  1. GI symptoms are severe in early dumping
  2. Diarrhea is choleretic
  3. Malignancy risk in remnant stomach is more in Billroth I than Billroth II reconstruction after partial resection
  4. Vomitus in afferent loop obstruction is bile without food

Answer:

3) Malignancy risk in remnant stomach is more in Billroth I than Billroth II reconstruction after partial resection

Explanation:

  • The risk of malignancy is actually higher in Billroth II than in Billroth I after partial gastric resection due to the prolonged bile reflux into the stomach in Billroth II.
  • Early dumping is indeed associated with severe GI symptoms.
  • Choleretic diarrhea (due to bile acid malabsorption) is a known cause of diarrhea post-surgery.
  • In afferent loop obstruction, vomitus contains bile but no food.

MCQ 3: Most Common Metabolic Disorder After Gastric Resection

Question:

The most common metabolic disorder after gastric resection is a deficiency of:

  • a) Iron
  • b) Vitamin B12
  • c) Folate
  • d) Calcium
  • e) Vitamin D

Answer:

a) Iron

Explanation:

  • Iron deficiency is the most common metabolic disorder after gastric resection due to impaired absorption in the duodenum, which requires an acidic environment for proper iron uptake.

MCQ 4: Post Vagotomy Diarrhea

Question:

Regarding post vagotomy diarrhea, all are true except:

  1. Bacterial overgrowth
  2. Incidence is 30%
  3. Wait for 6 months before surgical intervention
  4. Cholestyramine may be useful

Answer:

3) Wait for 6 months before surgical intervention

Explanation:

  • Surgical intervention is generally delayed for at least 1 year post-vagotomy to allow for possible improvement of symptoms.
  • Bacterial overgrowth and choleretic diarrhea are common causes of post-vagotomy diarrhea, and Cholestyramine may provide symptom relief.

MCQ 5: Retained Antrum Syndrome

Question:

All are true regarding retained antrum syndrome except:

  • a) Seen most commonly after Billroth I
  • b) Radionuclide study can be used as investigation
  • c) Surgical excision is the only effective treatment
  • d) It causes hypergastrinemia

Answer:

a) Seen most commonly after Billroth I

Explanation:

  • Retained antrum syndrome is typically seen after Billroth II or Roux-en-Y procedures, not Billroth I.
  • It causes hypergastrinemia due to the retained antral mucosa continuing to produce gastrin.
  • Radionuclide studies can help diagnose the condition, and the only effective treatment is surgical excision.