POSTGASTROREZEKTSIONNY COMPLICATIONS (Latin post after + grech, gaster a stomach + lat. resectio an obrezyvaniye, a srezyvaniye) — the early and remote complications after operation of a resection of a stomach, vagisection and antrectomy.
Frequency of complications of a resection of a stomach averages 10 — 15%. Extent of postgastrorezektsionny disturbances depends on the size of the deleted part of a stomach. Therefore at operational treatment of a piloro-duodenal ulcer preference of an economical resection of a stomach — antrectomy is given (see. Stomach, operations ) with vagisection (see) as functionally more favorable and less traumatic in comparison with a resection 2/3 — 3/4 stomachs. In the most physiologic way of recovery of a continuity went. - kish. a path after a resection operation Billroth of I is (see. Billroth operation ), if to it there are no special contraindications (e.g., existence of a duodenostaz).
Complications of the early postoperative period
belong disturbance of evacuation from a stump of a stomach To complications of the early postoperative period and acute impassability of the bringing loop of an anastomosis.
Disturbance of evacuation from a stump of a stomach in the postoperative period — one of the most frequent complications. Its reasons — oppression of motor activity of a stomach owing to an operational injury and damage of the neuromuscular device, vagisection, disturbances of water and electrolytic and protein metabolism. In development of this complication the presurgical condition of motor function of a stomach is of great importance. At stenoses of piloroduodenalny department the probability of disturbance of evacuation from a stomach considerably increases in the postoperative period. Besides, it can be result of dysfunction of an anastomosis owing to inflammatory hypostasis of fabrics — a so-called anastomositis. Also the secondary disorders of evacuation of contents of a stomach coming in connection with other postoperative complications are possible (insufficiency of seams of an anastomosis, acute pancreatitis, etc.).
Clinically disturbance of evacuation from a stump of a stomach is shown by complaints of the patient to feeling of weight in epigastric area, nausea, vomiting, vomiting. Through a gastric tube for many days about 2 — 3 l of congestive gastric contents separate.
Diagnosis is simple; the diagnosis usually is confirmed by data rentgenol, researches.
Treatment of the expressed disturbances of evacuation from a stomach consists in continuous aspiration of contents of a stomach (see. Aspiration drainage ), parenteral food (see), and also purpose of actions for correction of disturbances of water and electrolytic balance and acid-base balance. Treatment of an anastomositis conservative (antiinflammatory therapy, and also a roentgenotherapy on 30 — 50 I am glad, 3 — 4 sessions, on a course 100 — 200 I am glad). At long disturbance of evacuation when it is impossible to exclude the mechanical nature of a complication, repeated operation is shown. Prevention of this complication — thorough preoperative training and strict observance of the operational equipment.
Acute impassability of the bringing loop of an anastomosis develops seldom. Its reasons can be mechanical character: infringement of the long bringing loop between an anastomosis and a cross colon at a front gastroenteroanastomosis (see. Gastroenterostomy ); excess of the bringing loop if it is too short. Stretching of the bringing loop congestive contents and the subsequent disturbance of its blood supply can be led to a necrosis and perforation of a wall of a gut.
For a wedge, pictures of this complication are characteristic suddenly arising sharp pains in upper parts of a stomach, repeated vomiting gastric contents without impurity of bile, jaundice, symptoms of irritation of a peritoneum develop later at the general serious condition of the patient.
Diagnosis of acute impassability of the bringing loop is difficult; most often the diagnosis is made only during operation.
Treatment of this heavy complication of a resection of a stomach operational. It shall be directed to elimination of the reason of impassability of the bringing loop of an anastomosis. Even at timely performed repeated operation the high lethality is observed.
Late complications (effects of a resection of a stomach — a postgastrorezektsionny syndrome) are patol, syndromes of the functional nature (a dumping syndrome, a syndrome of the bringing loop, etc.); various metabolic disturbances (malabsorption of fat, digestion of vitamins), lose of weight, disturbances of a hemopoiesis; a recurrence of a peptic ulcer (see. Round ulcer ). After an economical resection of a stomach with vagisection and in particular after organ-preserving operations with vagisection along with the nek-ry mentioned frustration also the disturbances caused by vagisection which combine under the general name «postvagotomichesky syndrome» are possible.
Dumping syndrome — the most widespread functional frustration after stomach operations; weight of its manifestation depends on the sizes of the resected part of a stomach. It is often combined with other frustration.
The pathogeny of a dumping syndrome is difficult. The fundamental pathogenetic units of this difficult symptom complex — bystry evacuation of food masses from the operated stomach, a prompt passage on a small bowel with the subsequent inadequate osmotic and reflex influences, the joining disturbances of humoral regulation (first of all intra secretory function of a pancreas), activation of sympathoadrenal system, and also psychological disturbances which are often found at such patients.
Signs of a dumping syndrome can be divided into three groups: vasculomotor, intestinal and psychological. Their expressiveness depends on severity of a dumping syndrome. Sharp weakness, perspiration, headache, heartbeat, uncontrollable desire to lay down, coming soon after food are characteristic. Quite often after food there are abdominal pains of the cutting character, a hyperperistalsis of intestines that can be followed by a diarrhea.
In mild cases attacks of a dumping syndrome proceed 10 — 20 min., arise 1 — 2 time a week usually after reception of sweet or milk food. At a heavy dumping syndrome the described frustration arise after each meal, 1,5 — 2 hours last that completely deprives of patients of working capacity.
The diagnosis of a dumping syndrome is based on detailed clinical and psychoneurological inspection of patients. At the same time find increase of pulse, fluctuation of the ABP, reduction of volume of the circulating blood, disturbances of a peripheral blood-groove and EEG. At a special research often find vegetovascular and psychological disturbances. Gradually astenisation of mentality of the patient develops.
Rentgenol. a research went. - kish. a path reveals bystry gastric emptying, the accelerated passage on a jejunum, and also the expressed symptoms of dyskinesia of all departments of intestines.
Conservative treatment of a dumping syndrome shall be complex. Its basis is the dietotherapy: frequent receptions of high-calorific food in the fractional portions, restriction of carbohydrates and liquid, full-fledged vitamin structure of food. It is not necessary to appoint an antiulcerous diet which can aggravate manifestations of a dumping syndrome.
From means of fortifying therapy intravenous injections of solution of glucose with insulin, hemotransfusions, vitamin therapy are recommended. In nek-ry cases purpose of pepsin and Pancreatinum is reasonable, especially at clinically expressed insufficiency of function of a pancreas.
Sedatives are shown to patients with the expressed psychoneurological frustration. Appoint also the drugs promoting delay of evacuation from a stomach and reducing a peristaltics of a jejunum (atropine, ganglioblokator, novocainic blockade, etc.).
Conservative therapy is effective only at easy degrees of a dumping syndrome. Heavy manifestations of a syndrome are the indication to operational treatment, the main sense to-rogo consists in delay of emptying of a gastric stump and recovery of a passage through a duodenum. The widespread operation applied for this purpose is reconstructive gastroyeyunoplastika (see).
Efficiency of treatment of a dumping syndrome considerably depends on severity of this suffering. Patients with a severe form of a dumping syndrome badly give in not only to conservative, but also surgical treatment and with firmness lose working capacity.
According to most of researchers, prevention of a dumping syndrome consists in the reasonable choice of a method of operation, especially when it is possible to state predisposition of patients to development of a dumping syndrome in the preoperative period (vegetovascular and psychological disturbances).
Hypoglycemic syndrome — the characteristic symptom complex developing after stomach operations. Sharp fluctuations of level of sugar in blood with the subsequent are the cornerstone of it hypoglycemia (see).
Many researchers connect development of a hypoglycemia with the strengthened function of the insulyarny device of a pancreas when in response to an initial hyperglycemia reflex comes hyper dysinsulinism (see). The frequent combination of a hypoglycemic syndrome and a dumping syndrome testifies to a community of pathogenetic mechanisms of these sufferings.
Clinically hypoglycemic syndrome is shown by the feelings of weakness, dizziness which are sharply developing in 2 — 3 hours after meal, sharp feeling of hunger; patients note the sucking pains in epigastric area, a shiver, perspiration, heartbeat. Decrease in the ABP level and delay of pulse is characteristic. Level of sugar in blood, as a rule, falls at this time to low figures (75 — 50 mg / 100 ml). All these phenomena usually quickly pass after reception of a small amount of food, especially carbohydrate.
Manifestations of a hypoglycemic syndrome are usually easily stopped by a diet.
Syndrome of the bringing loop (synonym: the syndrome of bilious vomiting, a syndrome of bilious regurgitation, duodenob silt a pair syndrome) as hron, suffering can develop after a resection of a stomach on a way Billroth of II when the so-called blind department of intestines (a duodenum and a segment of a jejunum before connection with a stomach) performing very important functions after operation is formed.
Disturbance of evacuation of contents from the bringing loop is the cornerstone of a pathogeny of this syndrome, as the mechanical moments (its excesses, commissural process, defects of the operational equipment), and disturbances of motor function of the bringing loop owing to denervation and change of normal anatomic relationship can be the cause of what.
Special researches proved existence of gastritis and an atrophic jejunitis at a syndrome of the bringing loop that proves value of an inflammatory component in the nature of this suffering.
Clinically the syndrome is shown by heavy feeling, arching pains in epigastric area and the right hypochondrium which amplify soon after food. Intensity of pains gradually increases, and they soon come to the end with plentiful bilious vomiting (sometimes with impurity of food) then there comes simplification. Frequency of bilious vomiting and its abundance define severity of a syndrome. So, at a heavy syndrome of the bringing loop the cholemesis arises daily, sometimes 2 — 3 times a day, at the same time amount of the thrown-out bile reach 500 ml that causes bystry exhaustion of the patient.
The diagnosis of a syndrome of the bringing loop is based first of all on characteristic a wedge, a picture. From objective data sometimes it is possible to note noticeable asymmetry of a stomach due to protrusion in right hypochondrium, disappearing after plentiful vomiting, easy yellowness of scleras, weight reduction.
Data of laboratory researches can indicate an abnormal liver function. Rentgenol, a research went. - kish. a path can find cicatricial deformation or a round ulcer in the field of the bringing loop and an anastomosis, a massive reflux of a contrast agent from a stump of a stomach in the bringing loop, long staz it in the atonichny bringing loop, symptoms of hyper motor dyskinesia of the bringing and taking away loop.
Possibilities of conservative therapy of a syndrome of the bringing loop are limited. Manifestations of a syndrome sometimes decrease after purpose of a diet, repeated gastric lavages, antiinflammatory therapy a little.
The expressed syndrome of the bringing loop with frequent and plentiful bilious vomiting is the indication to surgical treatment. The most reasonable operation — reconstruction of the existing anastomosis in gastroenteroenteroanastomoz with enteroenteroanastomozy across Ru that provides reliable drainage of a duodenum.
Prevention of a syndrome of the bringing loop consists in careful observance of the technology of surgery, and also the choice of adequate operation taking into account presurgical disturbances of motive function of a duodenum.
Chronic post-resection pancreatitis. Reasons of its development: the operational injury leading to developing of the acute pancreatitis passing then in chronic; disturbance of evacuation from the bringing loop; the disturbance of secretory regulation of gland coming owing to switching off of a passage of food masses through a duodenum.
Wedge, a picture of post-resection pancreatitis consists of a number of signs, the painful symptom complex is conducting from to-rykh. Its constant expressiveness and intensity, irradiation of pains in a back, upper parts of a thorax are typical. Sometimes pains have the surrounding character. Quite often patients suffer from periodic ponosa, lose flesh.
Diagnosis of post-resection pancreatitis (see) it is difficult first of all owing to limited opportunities physical and radiological researches of methods.
At survey of patients are noted morbidity in a projection of a pancreas, a hyperesthesia of integuments in the field of the left hypochondrium. From laboratory methods researches of a glycemic curve with double loading (two-humped glycemic curves), and also definition of pancreatic enzymes by sounding of the taking-away loop (decrease of the activity of enzymes) are most informative.
Conservative treatment hron, post-resection pancreatitis includes a diet, replacement therapy (Pancreatinum, panzinorm, festal), novocainic blockade of the left big splanchnic nerve, sedative and anesthetics. Operational methods of treatment are usually poorly effective.
Metabolic disturbances develop more often after an extensive resection of a stomach, edges are broken significantly by a functional synergism of bodies of the alimentary system. In a pathogeny of these disturbances, apparently, an essential role is played not only by removal of a considerable part of body, but also and switching off of a passage through a duodenum if the resection is executed on a way Billroth of II.
Metabolic disturbances can sometimes be combined with the listed above frustration.
The most characteristic manifestation of metabolic disturbances is deficit of weight. Weight reduction is lower normal or the impossibility to gain presurgical weight is observed approximately at 1/4 operated.
Besides, decrease in volume of the eaten food, intolerance of separate products, disturbance of absorption of fat and protein is noted, im of vitamins and mineral substances is acquired. All this is rather demonstrative when the operated patients have the expressed diarrhea, hypovitaminoses, bone pathology (osteoporosis or osteomalacy).
Treatment of metabolic disturbances — the complex problem, and shall be its cornerstone a dietotherapy. In hard cases hospitalization (a special high-calorific diet, replacement therapy, androgens) is shown.
Anemia after a resection of a stomach has, as a rule, iron deficiency character. In a pathogeny of this disturbance essential value has falloff of products salt to - you the resected stomach and a bystry passage on a jejunum, the breaking absorptions of iron and digestion of vitamins (see. Iron deficiency anemia ).
Megaloblasticheskaya (B12 - scarce) anemia after a resection of a stomach meets seldom and more often arises after a gastrectomy.
Treatment of anemia includes hemotransfusion, iron preparations, vitamins C, B1, B12, appointment salt to - you or a gastric juice.
Bibliography: Busalov A. A. and Komorowski Yu. T. Pathological syndromes after a resection of a stomach, M., 1966; Vasilenko V. of X., etc. Postgastrorezektsionny frustration, M., 1974, bibliogr.; Mait V. S., etc. Resection of a stomach and gastrectomy, M., 1975; Pantsyrev Yu. M. Pathological syndromes after a resection of a stomach and a gastrectomy, M., 1973; Spiro H. M of Clinical gastroenterology, N. Y., 1977.
Yu. M. Pantsyrev.