Postgastrresection syndrome The cathedra of the faculty and hospital surgery of the treatment faculty of the Tashkent medical academy Postgastrresection syndrome Lector Khakimov M.Sh.

operations are performing In our republic about 10 000 operations are performing

Physiology of digestion Secretor function of the stomach Cardiac glands – product mucin. Fundal, main glands content from 4 types of cells: main – product pepsinogen, parietal – solt acis and internal Kassle’s factor, additional – mucin and not differentiate. Antral glands product mucin.

= Factors of protection Factors of agression resistance of the wall of the stomach of the antoduodenal part Alkaline secretion Food Pepsin and acid(НСl) Gastroduodenal dysmotoric Defeats of the mucous

Pathogenesis of the ulcer disease Reducing of the resistance of the mucous of the stomach and duodenum Increasing of the by-pass diffusion of the hydrogenium ions Liberation of the histamin and acethylcholin Stimulation of the secretion of the salt acid and pepsin ULCER

Resection of the stomach by Bilrot 1

Resection of the stomach by Bilrot 2

The reasons of the development of the postgastrresection syndrome Technical defects of the performing of primary operations at the stomach (inferioity vagotomy, not enough resection of the antral part of the stomach, technically inferioity performed resection of the stomach by Bilrot 2 – small size of the anastomosis, short of long spur, irritation of the mucous of the stomach with bile and pancreatic juice).

Classification of the postgastrresection syndrom ORGANIC (when occurs organic changes) FUNCTIONAL (when occurs functional changes)

Organic а) peptic disease of operated stomach (peptic ulcer of the anastomosis of the small intestine, recidive ulcer, not healing ulcer) b) cancer of the cult of stomach c) scar stricture of the gastroenteroanastomosis d) syndrome of the bringing loop e) Stenosis of the bringing loop f) Complications as a result of not correct method of operation

FUNCTIONAL а) dumping-syndrome b) hypo- hyperglycemic syndrome c) Enterogenous syndrome d) Functional syndrome of the bringing loop e) Postgastrresection anemy f) Postgastrresection astheny g) gastrostasis h) diarrhea k) dysphagia l) Alkaline reflux-esophagitis

METHODS OF THE RESEARCH Esophagogastroduodenofibroscopy Contrasting X-ray рH-metry Analysis of the gastric juice US research CT, angiography

Frequency of the appearance of the peptic ulcers Resection of the ⅔ of the stomach - 1 – 7% Economic resection of the stomach with vagotomy - 0 – 4% Drainage operations at the stomach with vagotomy - 8 – 12% Селективная проксимальная ваготомия - 6 – 10%

Reasons of the appearance of the peptic ulcers Economic antrumectomy Not full vagotomy Gastrinoma of the pancreas (Zollinger-Ellisone syndrome), Primary hyperparathyreoidism

Treatment algorithm at the peptic ulcers Conservative anti-ulcer therapy Thoracoscopic subdiaphragmal vagotomy Reconstructive reresection of the stomach by Ru At the Zollinger-Ellissone syndrome the operation of choose is gastrectomy

Cancer of the cult of the abdomen Reason – absence of the salt acid, presence of the atrophic gastritis and regurgitation of a bile into the cult of the stomach. Diagnosis state on the base of endoscopy and hystoligical researhe of bioptate Treatment – surgical (gastrectomy)

Syndrome of the bringing loop

Reasons of the syndrome of bringing loop Mechanical factors 1) too long bringing loop without Brown’s mouth; 2) too short bringing loop, which may create the bend of the intestine as a result of additional fixing to the small curvature; 3) horizontal location of the lines of gastro-intestinal anastomosis, due to the part of food comes to the bringing loop, then to the duodenum, inducting the duodenostasis in it; the strength of constriction of the cult of the stomach more than duodenum and food may stay there more long; 4) fallout of the mucous of the bringing loop into the stomach or conducting loop; 5) rotation of the bringing loop around its longitudinal axis; 6) scars, soldering, tumors or ulcerous stenosis of the bringing or conducting loop; 7) antiperistaltic location of the intestine for the anastomosis.

Reasons of the bringing loop Functional factor 1) spasms of the bringing and conducting loops or sphinters of the duodenum; 2) defeat of the nervous regulation of the duodenum and small intestine as a result of bandaging of the nervous branches during the operation; 3) the duodenostasis in the predoperative period.

Pathogenesis of the bringing loop syndrome Fermentation of the food, creation of gases and liquid in a big volume, increasing of the intraperitoneal pressure, sluggishness and increasing of pressure in the bile ducts and ducts of the pancreas, defeat of the microcirulation and reflector narrowing or spasm of the bringing department of the intestine Coming of the food into the bringing loop Swelling in the projection of the bringing loop after feeding, sense of weight, pain, retching with the bad smelled mass, fair of feeding, general weakness, belch.

Clinic of the bringing loop syndrome The first degree patients, that have light defeats by type of belch, retching with a bile 1-2 in a month, connected with the drinking milk. Dyspeptic defeats and pain nearly don’t disturb the patient, the general status is quite. The second degree characterized with the middle hard manifestation of the disease. Retching with a bile 2—3 in a months, the volume of the retching masses raises to 200-300 ml. The sense of fullnes in the right underrib is prevalence above the retching. The general status is hard, loss of weight.

Clinic of the bringing loop syndrome At the third degree of the syndrome there are those cases when retching appears every day, the volume of retching masses is about 400-500 ml and more. After feeding the ballooned pain in the underrib and epigastria. To relief the state the patients induct the retching by themselves. The significant loss of weight and ability to work. At the forth degree of the disease except these complaints, the significant defeat of feeding and methabolism appear, and also dystrophic changes in the parenchimatous organs.

Methods of the surgical correction of the bringing loop syndrome 1. Reconstructive gastroejunoduodenoplastic; 2. Reconstructive U-form anastomosis by Ru; 3. duodenoejunoanastomosis; 4. entero-enteroanastomosis by Brown; 5. Resection of the duodenum; 6. Sewing of the bringing loop to the small curvature of the stomach; 7. Transition of the resection by Bilrote 2 to the Bilrot 1; 8. Sewing of the bringing and conducting loops to the posterior parietal peritoneum.

Treatment of the bringing loop syndrome Reconstructive reresection of the stomach with the gastroenteroanastomosis by Ru

Stenosis of the bringing loop

Stenosis of the gastroenteroanastomosis

Clinic of the stenosis of the gastroenteroanastomosis Light degree – absence of the passibility of the hard food Middle degree – absence of the passibility of the ordinary food Hard degree – absence of the passibility of the fluid food.

Dumping syndrome (сlumping (англ) – сброс, провал) At the patients after the resection of the stomach the obturate function of the pyloric muscle. Hyperosmolar solutions come at short time and in a big volume (as a dumping) into the beginning department of the small intestine, the dyscoordination of the vasomotor reactions appears. The increasing osmotic pressure in the intestine with the fast suction of the carbohydrates promotes the increasing of the blood circulatiion in liver and admit to the intestine the contents of plasma, that conducts with the spasm of the peripheral vessels, reducing of the brain circulation.

Symptoms of the dumping syndrome Cardiac-vessels and neurovegetative symptoms: attacks of weakness, tachycardia, sense of tide, pallor of skin, tremor of hands, dizziness, cold perspiration. Dyspeptic and abdominal discomfort: loss of appetite, sickness, retching, liquid excrement or constipation. Symptoms connected with the defeats of methabolic system: sliding, dyspeptic complaints. Symptoms of the inflammation of the hepato-pancreatoduodenal system: duodenostasis and pain in the abdomen with the soldering process in the abdomen. Symptoms specific to the defeats of asthenisation and psycho-neurological status: sensitivity, insomnia, headaches, defeat of the balance, neurastheny.

Treatment of the dumping syndrome 1) reducing of the sizes of the gastroenteral mouth at the operation by Bilrot 2; 2) putting of the additional intraintestinal anastomosis between the bringing and conducting loops by Brown; 3) formation of the additional intestinal reservoir from the twiced between each other intestinal loops (operation of Rotte); 4) fixation of the bringing loop to the small curvature of the stomach; 5) reconstruction of the gastrointestinal mouth by Bilrot 2 inti the operation Bilrot 1; 6) reconstruction with the isoperistaltic intestinal transplantate between the cult of the stomach and duodenum (operation of Kupriyanov-Zaharov-Genley); 7) reconstruction with the antiperistaltic segment of the small intestine between the cult of the stomach and duodenum (operation of Gerringtone); 8) reconstruction with the thick intestinal с толстокишечной пластикой; 9) narrowing of the gastroduodenal anastomosis after the resection of the stomach by Bilrot 1 (operation of Makarenko);

Treatment of the dumping syndrome Gastroejunoplastic by Kupriyanov –Zakharov-Genley

Alkaline reflux-esophagitis Hypoglycemic syndrome Syndrome of the «small» stomach Aliment dystrophy Diarrhea Postresection anemy