Prevalence and intensity of dumping symptoms and their association with health-related quality of life following surgery for oesophageal cancer

BACKGROUND & AIMS

This study aimed to investigate the prevalence and intensity of symptoms of dumping syndrome (early and late) experienced by oesophageal cancer survivors one year after surgery and their association with health related quality of life (HRQL).

METHODS

A prospective cohort study of patients who underwent surgery for oesophageal cancer in Sweden from January 2013 to April 2018, included at one year after surgery with follow-up at 1.5 years. Common symptoms of dumping syndrome were the exposure, classified as early and late onset, further divided into 'moderate' or 'severe' based on symptom intensity, and no dumping symptoms (reference group). The primary outcome was mean summary score of HRQL, and secondary outcomes were global quality of life, physical, role, emotional, cognitive and social function measured using the EORTC QLQ-C30 1.5 years after surgery. An ANCOVA model, adjusted for potential confounders was used to study the association between dumping symptoms and HRQL, presented as mean score differences (MD) with 95% confidence intervals (CI).

RESULTS

Among 188 patients, moderate early dumping symptoms was experienced by 45% and severe early dumping by 9%. Moderate late dumping symptoms was reported by 13%, whereas 5% reported severe late dumping symptoms. Severe early dumping symptoms was associated with worse HRQL in 4 out of 7 aspects with worse global quality of life (MD -16, 95% CI: -27 to -4) and social function (MD -17, 95% CI: -32 to -3), which showed clinically large differences compared to having no such symptoms. Patients with moderate late dumping symptoms reported poorer HRQL in 6 out of 7 aspects compared to those with no dumping symptoms. Cognitive function (MD -27, 95% CI: -47 to -7) and emotional function (MD -24, 95% CI: -47 to -2) were significantly declined (clinically large relevance) in those with severe late dumping symptoms.

CONCLUSIONS

Patients who have undergone curative treatment for oesophageal cancer experience reduced HRQL from early and late dumping symptoms at one year after surgery that indicate clear implications for clinical routine. Medical support and additional dietary counselling are required as potential ways to alleviate dumping symptoms on clinical repercussions.

International consensus on the diagnosis and management of dumping syndrome

Dumping syndrome is a common but underdiagnosed complication of gastric and oesophageal surgery. We initiated a Delphi consensus process with international multidisciplinary experts. We defined the scope, proposed statements and searched electronic databases to survey the literature. Eighteen experts participated in the literature summary and voting process evaluating 62 statements. We evaluated the quality of evidence using grading of recommendations assessment, development and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 of 62 statements, including the definition and symptom profile of dumping syndrome and its effect on quality of life. The panel agreed on the pathophysiological relevance of rapid passage of nutrients to the small bowel, on the role of decreased gastric volume capacity and release of glucagon-like peptide 1. Symptom recognition is crucial, and the modified oral glucose tolerance test, but not gastric emptying testing, is useful for diagnosis. An increase in haematocrit >3% or in pulse rate >10 bpm 30 min after the start of the glucose intake are diagnostic of early dumping syndrome, and a nadir hypoglycaemia level <50 mg/dl is diagnostic of late dumping syndrome. Dietary adjustment is the agreed first treatment step; acarbose is effective for late dumping syndrome symptoms and somatostatin analogues are preferred for patients who do not respond to diet adjustments and acarbose.

Upper GI Disorders: Pathophysiology and Current Therapeutic Approaches

Symptoms referable to the upper digestive tract are associated with abnormalities of upper gastric neuromuscular function including abnormalities of motility, sensation, and absorption. Of the upper digestive tract, the stomach is of particular importance in its role in symptom generation and is highlighted in this chapter. Gastric symptoms can be associated with alterations in the rates of gastric emptying, impaired accommodation, heightened gastric sensation, or alterations in gastric myoelectrical activity and contractility. Treatment of gastric neuromuscular disorders requires an understanding of pathophysiology of the disorders, the appropriate use and interpretation of diagnostic tests, and the knowledge of effective treatment options. This chapter covers the pathophysiology and current treatment approaches to disorders of the upper gastrointestinal tract, focusing on classic disorders of the stomach, particularly gastroparesis and functional dyspepsia.

Early dumping syndrome is not a complication but a desirable feature of Roux-en-Y gastric bypass surgery

Early dumping syndrome after gastric bypass surgery due to rapid delivery of hyperosmolar nutrients into the bowel causing intense symptoms is often described as a complication. Twelve patients, mean age 47 years, were interviewed approximately 9 years post-operation. The interviews were audiotaped and transcribed verbatim, followed by an inductive content analysis to reveal patients' experience of the dumping syndrome. The core category 'Dumping syndrome is a positive consequence of Roux-en-Y gastric bypass surgery and a tool to control food intake' was identified based on the following four sub-categories: (i) 'The multidimensional emergence and effects of dumping syndrome', (ii) 'Dumping syndrome as something positive although unpleasant', (iii) 'Developing coping mechanisms and ingenious strategies' and (iv) 'My own fault if I expose myself to dumping syndrome'. From the patients' perspective, dumping syndrome gives control over food intake; although the symptoms were unpleasant, patients considered dumping syndrome as a positive protection against over-consumption. Hence, healthcare professionals should not present dumping syndrome as a complication but rather as an aid to control eating behaviour and excessive food intake.

Pregnancy Following Bariatric Surgery-Medical Complications and Management

Bariatric surgery is most commonly carried out in women of childbearing age. Whilst fertility rates are improved, pregnancy following bariatric surgery poses several challenges. Whilst rates of many adverse maternal and foetal outcomes in obese women are reduced after bariatric surgery, pregnancy is best avoided for 12-24 months to reduce the potential risk of intrauterine growth retardation. Dumping syndromes are common after bariatric surgery and can present diagnostic and therapeutic challenges in pregnancy. Early dumping occurs due to osmotic fluid shifts resulting from rapid gastrointestinal food transit, whilst late dumping is characterized by a hyperinsulinemic response to rapid absorption of simple carbohydrates. Dietary measures are the mainstay of management of dumping syndromes but pharmacotherapy may sometimes become necessary. Acarbose is the least hazardous pharmacological option for the management of postprandial hypoglycemia in pregnancy. Nutrient deficiencies may vary depending on the type of surgery; it is important to optimize the nutritional status of women prior to and during pregnancy. Dietary management should include adequate protein and calorie intake and supplementation of vitamins and micronutrients. A high clinical index of suspicion is required for early diagnosis of surgical complications of prior weight loss procedures during pregnancy, including small bowel obstruction, internal hernias, gastric band erosion or migration and cholelithiasis.

Incretin effects, gastric emptying and insulin responses to low oral glucose loads in patients after gastric bypass and lean and obese controls

BACKGROUND

After laparoscopic Roux-en-Y gastric bypass (LRYGB), many patients suffer from dumping syndrome. Oral glucose tolerance tests are usually carried out with 50-75 g of glucose. The aim of this study was to examine whether minimal glucose loads of 10 g and 25 g induce a reliable secretion of satiation peptides without dumping symptoms after LRYGB. In addition, lean and obese controls were examined.

OBJECTIVE

The objective of this study was to determine the effects of low oral glucose loads on incretin release and gastric emptying.

SETTING

All surgical procedures were performed by the same surgeon (RP) at the St. Claraspital Basel in Switzerland. Oral glucose challenges were carried out at the University Hospital of Basel (Phase 1 Research Unit).

METHODS

Eight patients 10±.4 weeks after LRYGB (PostOP; body mass index [BMI]: 38.6 kg/m²±1.7) as well as 12 lean controls (LC; BMI: 21.8 kg/m²±.6) and 12 obese controls (OC; BMI 38.7 kg/m²±1.3) received 10 g and 25 g of oral glucose. We examined clinical signs of dumping syndrome; plasma glucose, insulin, glucagon-like peptide 1, glucose-dependent insulinotropic peptide, and peptide tyrosine tyrosine concentrations; and gastric emptying with a ¹³ C-sodium acetate breath test.

RESULTS

No signs of dumping were seen in PostOP. Compared with OC, LC showed lower fasting glucose, insulin, and C-peptide, and lower homeostasis model assessment (HOMA) and AUC-180 for insulin and C-peptide. In PostOP, fasting insulin, HOMA and AUC-180 for insulin was lower and no difference was found in fasting C-peptide or AUC-180 for C-peptide compared to OC. There was no significant difference in fasting glucose, insulin, C-peptide, HOMA and AUC-180 for insulin in PostOP compared to LC, but AUC-180 for C-peptide was higher in PostOP. AUC-60 for gut hormones was similar in OC and LC and higher in PostOP compared to OC or LC. gastric emptying was slower in LC and OC compared with PostOP.

CONCLUSION

After LRYGB, 25 g oral glucose is well tolerated and leads to reliable secretion of gut hormones. Fasting glucose, insulin and C-peptide are normalized, while glucagon-like peptide 1, glucose-dependent insulinotropic peptide and peptide tyrosine tyrosine are overcorrected. Pouch emptying is accelerated after LRYGB.

Rapid gastric and intestinal transit is a major determinant of changes in blood glucose, intestinal hormones, glucose absorption and postprandial symptoms after gastric bypass

OBJECTIVE

To evaluate the effect of modulating pouch emptying (PE) and SI transit of glucose after Roux-en-Y gastric bypass (RYGB) on blood glucose, incretin hormones, glucose absorption and gastrointestinal (GI) symptoms.

METHODS

Ten RYGB patients were studied twice in random order, receiving either a 150 ml glucose drink (200 kcal) or the same solution infused into the proximal Roux-limb at 4 kcal/min. Data were compared with 10 healthy volunteers who received a 4 kcal/min duodenal infusion. PE, cecal arrival time (CAT), blood glucose, plasma 3-O-methylglucose (3-OMG), insulin, glucose-dependent insulinotropic polypeptide (GIP), and glucagon-like peptide-1 (GLP-1), and GI symptoms were measured.

RESULTS

In RYGB subjects, the glucose drink emptied very rapidly (PE t50 = 3 ± 1 min) and intestinal glucose infusion was associated with higher blood glucose and plasma 3-OMG, but lower plasma GLP-1, GIP, insulin, and GI symptoms than oral glucose (all P < 0.001), and comparable to volunteers. In RYGB subjects, CAT correlated inversely with peak GLP-1 (r = -0.73, P = 0.01), and plasma 3-OMG correlated tightly blood glucose (r = 0.94, P < 0.0001).

CONCLUSIONS

After RYGB, reducing intestinal glucose delivery to 4 kcal/min is associated with higher blood glucose, greater glucose absorption, lower incretin responses, and less GI symptoms, supporting rapid transit contribution to the exaggerated incretin responses and "dumping symptoms".

[Prevalence of early and late dumping after gastric bypass]

Gastric bypass surgery is an effective treatment of obesity, bringing a significant weight loss and a major improvement of carbohydrate profile. However, in some patients, a deregulation in carbohydrate metabolism between insulin secretion and sensitivity is observed, whereupon early and late dumping happen. Their prevalence isn't well studied, although it seems that 10 to 20% of patients are affected. We've studied a cohort of 70 patients who undergone gastric bypass surgery at the CHUV. 18 (25.7%) patients have a positive anamnesis for early dumping and 10 (14.3%) for late dumping, being it superior as what is described in the literature.

Advances in the surgical treatment of morbid obesity

Due to the rapidly expanding prevalence of obesity, bariatric surgery is becoming an increasingly popular treatment option. Bariatric surgeries including Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) produce long-term weight loss and metabolic improvement, reducing mortality. This review discusses the important benefits and risks of RYGB and VSG, highlighting hypothesized mechanisms for these effects. We present data suggesting that VSG, albeit a newer procedure, may be as effective as RYGB with fewer adverse effects including less surgical risk, reduced nutritional deficiency, and less incidence of dumping syndrome. This may position VSG as an increasingly important procedure, particularly for the treatment of pediatric obesity.

Medical and surgical management of esophageal and gastric motor dysfunction

he occurrence of esophageal and gastric motor dysfunctions happens, when the software of the esophagus and the stomach is injured. This is really a program previously established in the enteric nervous system as a constituent of the newly called neurogastroenterology. The enteric nervous system is composed of small aggregations of nerve cells, enteric ganglia, the neural connections between these ganglia, and nerve fibers that supply effectors tissues, including the muscle of the gut wall. The wide range of enteric neuropathies that includes esophageal achalasia and gastroparesis highlights the importance of the enteric nervous system. A classification of functional gastrointestinal disorders based on symptoms has received attention. However, a classification based solely in symptoms and consensus may lack an integral approach of disease. As an alternative to the Rome classification, an international working team in Bangkok presented a classification of motility disorders as a physiology-based diagnosis. Besides, the Chicago Classification of esophageal motility was developed to facilitate the interpretation of clinical high-resolution esophageal pressure topography studies. This review covers exclusively the medical and surgical management of the esophageal and gastric motor dysfunction using evidence from well-designed studies. Motor control of the esophagus and the stomach, motor esophageal and gastric alterations, treatment failure, side effects of PPIs, overlap of gastrointestinal symptoms, predictors of treatment, burden of GERD medical management, data related to conservative treatment vs. antireflux surgery, and postsurgical esophagus and gastric motor dysfunction are also taken into account.

[Postgastrectomy syndromes in therapeutic practice ]

AIM

To specify policy of nutritive support late after radical gastric resection.

MATERIAL AND METHODS

Patients with postgastroresectional dystrophy were examined using standard techniques and estimation of intestinal electric activity (registration of body surface biopotentials on Conan-M myngograph).

RESULTS

Frequency-amplitude parameters of the intestine serve the basis for choice of mixtures for enteral correction. Nutritive support provided for on demand pharmaconutrients--microbiotic correctors.

CONCLUSION

Myography gives additional information for decisions on the policy of nutritive support.

[Modifications of the glucose curves and gastric voiding of children with Dumping syndrome after laparoscopic Nissen surgery]

INTRODUCTION

There has been an important evolution of surgical treatment in recent years due to the progressive generalization of laparoscopic surgery. All of the available techniques can be done laparoscopically with similar results to those of open surgery. In 1978, Villet et al. described the Dumping syndrome (DS) as a frequent complication of Nissen fundoplication. DS is a group of signs and symptoms that appear shortly after surgery, including abdominal pain, paleness, sweating, diarrhea, nausea, even weight loss. These symptoms can be differentiated into early dumping that occurs between 30 to 60 minutes after eating and late dumping that occurs 92-240 minutes after the postprandial period.

MATERIAL AND METHODS

A total of 8 patients (3 boys and 5 girls) have been studied. Their ages ranged from 3 to 12 years (mean 9 years), and they were diagnosed of dumping syndrome after performing the laparoscopic Nissen-Rossetti. All underwent a gastric voiding study by scintigraphy after administration of a volume of milk adjusted to their weight labeled with 99Tc-DTPA and oral glucose overload test with 1.75 g/kg of glucose, determining the baseline glycemia and every 30 minutes post-intake, at 0, 30 and 90 minutes. Insulin was also measured to obtain the glucose/insulin ratio. This study was conducted for all patient diagnosed of dumping syndrome before and after laparoscopic Nissen-Rossetti surgery.

RESULTS

The following results were obtained: Glucose Curve: 1. Maximum glycemia. PreNissen. The mean of the maximum glycemia values before surgery was 133.9+/-32.11 mg/dl. Post-Nissen. Mean maximum glycemias after surgery was 208.5 +/- 45.07 mg/dl with a range of 147-276 mg/dl. These differences of maximum glycemia were clearly significant with a p <0.002. Minimum glycemia. The mean value of the minimum glycemias after the surgery, compared with the previous value, did not show significant differences: 62.6+/- 11.51 mg/dl versus 71.8 +/- 28.04 mg/dl. Glucose/insulin ratio. The hyperinsulinism values after the intervention studied by means of the glucose/insulin ratio were abnormal in 70.5% (defined as ratio under 3). The mean value was also characteristic of hyperinsulinism (2.3 +/- 1.62). The mean value of the coefficient prior to the surgery was 4.6 with a deviation of 3.04, the differences not being statistically significant with a p= 0.097. Measurement of gastric voiding: The T1/2 (decay) value in post-Nissen patients was significantly lower than in pre-Nissen patients. The postsurgical mean and standard deviation was 29.74 +/- 7.92 min, while in the presurgical group, the mean and standard deviation was 73.75 +/- 28.34 min with p< 0.011; statistically significant.

CONCLUSIONS

From the values obtained, we can state that a significant increase in maximum glycemia has been found in all children after surgery who were diagnosed of dumping syndrome and a significant decrease in the mean time of gastric voiding and therefore an increase in the acceleration of gastric voiding after the performance of the Nissen regarding the previous values. The dumping syndrome is a frequent side effect that we must keep in mind in patients who have been previously operated for anti-reflex surgery, the symptoms being greater in most of the transitory cases. Furthermore, it is important to keep in mind because it has an easy treatment that reverts the symptoms in a short time

Gastric motor disorders

Gastric motor disorders constitute an important part of clinical gastroenterological practice. Normal gastric motor function includes gastric accommodation which provides a reservoir during meal ingestion, gastric emptying at a rate that matches small bowel absorptive function and interdigestive motility that eliminates indigestible particles. Disorders of gastric motor function include impaired accommodation, gastroparesis and dumping syndrome. This review summarises current knowledge on the pathophysiology, diagnostic approach and treatment for these disorders.

Gastric emptying after pylorus-preserving gastrectomy: assessment using the 13C-acetic acid breath test

BACKGROUND/AIMS

Gastric emptying after PPG is directly associated with postoperative QOL. Few studies have investigated gastric emptying after a gastrectomy for stomach cancer using carbon-labeled acetic acid breath test.

METHODOLOGY

We analyzed gastric emptying in 28 patients who underwent a gastrectomy for gastric carcinoma. Among the patients, 14 underwent pylorus-preserving gastrectomy and 14 underwent distal gastrectomy. We recruited 15 healthy subjects as controls. Gastric emptying was evaluated with the 13C-Acetic acid breath test was performed. Postprandial breath samples were collected at a 15-min interval for 2 hours and at a 30-min interval thereafter. We calculated the ratio of (13)CO2 expired per hour and determined the time required to reach peak (13)CO2 expiration level.

RESULTS

The time required to reach peak (13)C02 expiration level were 1.78 hours for the patients who underwent pylorus-preserving gastrectomy, 1.19 hours for the control group and 0.70 hours for the patients who underwent distal gastrectomy.

CONCLUSIONS

Our 13C-Acetic acid breath test following an intake of solid foods showed that gastric retention can be preserved after a pylorus-preserving gastrectomy.

Nutrition and motility disorders

The purpose of this article is to give an overview of the relation between feeding and gastrointestinal symptoms and complaints, and to review different motility disorders that have implications for food intake. We also report the consequences for nutrition state and the evidence-based principles of dietary modification in patients with motility disorders.

Dumping syndrome: pathophysiology and treatment

Anatomic and physiologic changes introduced by gastric surgery result in clinically significant dumping syndrome in approximately 10% of patients. Dumping is the effect of alteration in the motor functions of the stomach, including disturbances in the gastric reservoir and transporting function. Gastrointestinal hormones play an important role in dumping by mediating responses to surgical resection. Treatment options of dumping syndrome include diet, medications, and surgical revision. Poor nutrition status can be anticipated in patients who fail conservative therapy. Management of refractory dumping syndrome can be a challenge. This review highlights current knowledge about the mechanisms of dumping syndrome and available therapy.

[Postalimentary hypoglycaemia in post-gastrectomy late dumping syndrome]

HISTORY AND CLINICAL FINDINGS

A 48-year-old patient had been suffering from postalimentary hypoglycemias for several months, occurring regularly 2 hours after a meal. 5 years before, repeated fundaplications as well as a selective proximal vagotomy due to reflux oesophagitis had been performed.

INVESTIGATIONS

Physical examination revealed no pathological findings. The diurnal blood sugar profile with hourly capillary glucose measurement showed a physiological fasting glucose homeostasis and two-hour postprandial decrease of blood glucose down to 20 mg/dl. The oral glucose tolerance test revealed a noticeable insulin secretion with a pathologically increased insulin/glucose index. Scintigraphy demonstrated an initially delayed, then accelerated gastric emptying as a consequence of the selective proximal vagotomy.

DIAGNOSIS, TREATMENT AND COURSE

A postalimentary hypoglycemia by hypersecretion of insulin in the context of a post-gastrectomy late dumping syndrome was diagnosed. A surgical pyloroplasty was not effective. In addition to the modification of eating habits, treatment with subcutaneous applied octreotide (Sandostatin), a somatostatin-analogue, was initiated.

CONCLUSIONS

Postalimentary hypoglycemia can be assigned to late dumping syndrome in most cases already by ascribed history taking. The correct diagnosis can be achieved by an oral glucose tolerance test with measurement of insulin secretion and gastric emptying scintigraphy. Beside other therapeutical options the treatment with octreotide is a promising alternative with manageable side effects.

Gastric motility disorders: management that optimizes nutritional status

Gastric motility disorders are relatively common, and treatment is often challenging. Various etiologies account for numerous clinical sequelae, with weight loss and severe protein-calorie malnutrition often seen in advanced stages of these disorders. In addition to gastrointestinal motor function, an appreciation of visceral sensation is essential to better understand the symptoms found in these patients, as well as possible therapeutic alternatives. This article provides an overview of gut motor and sensory function, techniques available for diagnosing motor disorders, and the principles of nutritional and medical management. Specific nutritional recommendations and a review of pharmacologic agents and novel treatment modalities are provided.

[Ultrasonic examination of gastric stump and gastroenteroanastomosis in complex diagnosis of postresection dumping syndrome]

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.

Advances in gastrointestinal electrical stimulation

Electrical stimulation of the gastrointestinal (GI) tract, analogous to pacing the human heart, is an attractive idea. This is because these organs, like the heart, have their own natural pacemakers, and the electrical signals they generate can be altered by externally delivering certain types of electric currents via intraluminal or serosal electrodes to certain areas of the GI tract. A number of studies on animals have been accomplished successfully to treat a variety of disease models, including gastroparesis, dumping, and short bowel syndrome. Over the past 10 years or so, electrical stimulation of the GI tract has received increasing attention among researchers and clinicians because of new techniques, such as implantable devices, and promising results achieved in treatment of gastroparesis and morbid obesity. The objective of this article is to review the advances in electrical stimulation of the gastrointestinal tract. First the electrophysiology of the GI tract and history of GI electrical stimulation are introduced. Then various methods of electrical stimulation of the stomach and small bowel in healthy animals and models of GI diseases are reviewed. Finally clinical applications of electrical stimulation to GI disorders and their possible mechanisms are discussed.

Studies on gastrointestinal hormone and jejunal interdigestive migrating motor complex in patients with or without early dumping syndrome after total gastrectomy with Roux-en-Y reconstruction for early gastric cancer

BACKGROUND

There has been no report concerning fasting Roux limb motilities and gut hormone in patients with early dumping syndrome (EDS) after total gastrectomy with Roux-en-Y reconstruction. The present study investigated interdigestive migrating motor complex, phase III (IMMC-pIII) in the Roux limb, changes in the plasma gut hormone levels, and the relationships among those parameters and EDS.

METHODS

Forty-eight patients (35 men, 13 women; aged 33 to 69 years, mean, 59.8) 1.5 to 2.0 years (mean 1 year, 8 months) after total gastrectomy with Roux-en-Y reconstruction for early gastric cancer were allocated to two groups based on the presence or absence of EDS. The occurrence of IMMC-pIII was compared and changes in the plasma levels of both motilin (MT) and somatostatin (SOM) were monitored.

RESULTS

None of the patients with EDS (n = 8) were recognized as having IMMC-pIII. In the IMMC-pIII positive group, MT and SOM increased sequentially from phase I through IMMC-pIII. In the IMMC-pIII negative group, MT and SOM were significantly lower than in the IMMC-pIII positive group during phases I, II, and IMMC-pIII (P <0.05, P <0.01, P <0.01, respectively).

CONCLUSIONS

There is an absence of IMMC-pIII in patients with EDS, and both MT and SOM might be necessary for IMMC-pIII generation.

Postprandial GLP-1, norepinephrine, and reactive hypoglycemia in dumping syndrome

Rapid gastric emptying and exaggerated plasma concentrations of the insulinotropic hormone GLP-1 precede reactive hypoglycemia after oral glucose in gastrectomy patients. We suspected that the plasma volume drop associated with rapid gastric emptying (early dumping) would be accompanied by elevated plasma concentrations of norepinephrine. In order to study any relationship between postprandial norepinephrine, the enteroinsular axis, and plasma glucose, twelve patients with dumping syndrome and nine controls were studied. The plasma concentrations of norepinephrine, GLP-1, GIP, glucagon, insulin, and glucose were measured following a 1.5 g/kg lean body mass glucose meal. The early (0-30 min) integrated norepinephrine concentration was significantly higher in dumpers (22.1 +/- 3.8 nmol/ml/min) compared to controls (14.7 +/- 3.1 nmol/ml/min; P < 0.001) and correlated closely with the postprandial hematocrit increment (r = 0.71; P < 0.05). Early immunoreactivities of GLP-1, GIP, and glucagon peaked 30 min after glucose ingestion and were significantly higher in dumpers. Insulin peaked after 60 min and correlated with early GLP-1. In 11 of the patients glucose fell below baseline after a median interval of 120 min. Glucose at 120 min, when most of the nadirs occurred was lowest in patients with high early GLP-1 concentrations (r = 0.78; P < 0.001). Gel filtration chromatography of the dumpers' plasma revealed that pancreatic glucagon was detectable at time 0 and after 20 min, but not after 120 min. It is concluded that in dumpers pancreatic glucagon is augmented in the early postprandial period, probably through stimulation by catecholamines. At 120 min, when most of the hypoglycemias are encountered, pancreatic glucagon is no longer detectable, probably through inhibition by GLP-1.

Sympathoadrenal activation and the dumping syndrome after gastric surgery

Dumping symptoms suggest concomitant sympathoadrenal activation. To evaluate the relation between dumping symptoms and postprandial plasma catecholamine changes, standardized dumping-provocation tests with use of oral glucose were performed for 16 gastric surgery patients with dumping, for 14 gastric surgery patients without dumping, and for 14 healthy control patients. Early dumping symptoms were present for all patients with dumping, and late symptoms developed in three patients with dumping after glucose ingestion. Patients without dumping and healthy control patients had slight complaints or no complaints. Systolic and diastolic blood pressure remained unaffected for the three groups. Positive breath-hydrogen tests, heart rate increments, and reactive plasma glucose decrements were present for patients with dumping and for patients without dumping, but not for control patients. Plasma noradrenaline and adrenaline increased for patients with dumping and for patients without dumping, but not for control patients. The noradrenaline increment was higher for patients with dumping (98%) than for patients without dumping (78%; p <0.05). The noradrenaline increment was related to the dumping score and to the heart rate increment for the first hour after glucose ingestion, whereas the adrenaline increment was related to the plasma glucose decrement for the third hour. Therefore, dumping symptoms clearly are accompanied by postprandial sympathoadrenal activation, but sympathoadrenal activation cannot account completely for development of dumping symptoms.

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.

Hypoglycemia unawareness in a patient with dumping syndrome: report of a case

We report the case of a 49-yr-old man affected by coma and hypoglycemia unawareness following repetitive hypoglycemic episodes due to dumping syndrome. The dumping syndrome, which was due to partial gastrectomy and vagotomy performed for recurrent peptic ulcer, was responsible for reactive hyperinsulinemia as demonstrated by an oral glucose tolerance test. While the glucose counterregulatory hormones were all normally sensitive to specific stimulation tests, insulin-induced hypoglycemia failed to induce an adequate counterregulatory response, causing no response in plasma norepinephrine, a slight and short increase in plasma cortisol, ACTH and glucagon and an insufficient increase in plasma epinephrine and GH. This case demonstrates that hypoglycemia unawareness has to be taken into account not only in patients affected by IDDM or insulinoma but also in any case of reactive hypoglycemia.

Benefit of uncooked cornstarch in the management of children with dumping syndrome fed exclusively by gastrostomy

OBJECTIVES

Children with dumping syndrome fed exclusively by gastrostomy are difficult to manage because liquid diets are given directly into the antrum. The gastric contents are emptied rapidly into the small intestine, with consequent hyperglycemia followed by a delayed hypoglycemia and multiple, often debilitating, symptoms. Uncooked cornstarch is a complex carbohydrate that provides a slow and continuous glucose source and may delay gastric emptying. The objective of this study was to determine the efficacy of uncooked cornstarch in the treatment of these children.

METHODS

The medical records of eight children with dumping syndrome fed exclusively by gastrostomy were reviewed. Dumping syndrome was diagnosed if there was consistent symptomatology, rapid gastric emptying, and abnormal glucose measurements after a glucose tolerance test. Enough uncooked cornstarch to match hepatic glucose production for 4 h was added to control hypoglycemia, and the feeding formula was modified to control hyperglycemia.

RESULTS

All patients had debilitating symptoms. Weight z-score on admission was -2.31 +/- 0.29. Glucose shifts were controlled in all. There was a significant difference between the maximum (221.3 +/- 19.3 mg/dl vs 121.3 +/- 6.9 mg/dl; p < 0.008) and minimum serum glucose (47 +/- 7.8 mg/dl vs 65.6 +/- 4 mg/dl; p < 0.04) before and after uncooked cornstarch. Weight increased from 11.87 +/- 1.4 kg to 15.10 +/- 2.3 kg (p = 0.06). In seven patients, bolus feedings were successfully administered, and symptoms improved or resolved.

CONCLUSIONS

Uncooked cornstarch controlled the glucose shifts, resolved most of the symptoms, allowed bolus feedings, and enhanced weight gain in these children.

Surgical aspect of enteroinsular axis after gastrointestinal surgery with reference to incretin secretion

An alteration of the enteroinsular axis (EIA) may be an important etiologic factor in postsurgical changes in gastrointestinal (GI) function. In this review, we present recent works, both from our laboratory and others, on how changes in the EIA function may be involved in postsurgical GI complications, especially late dumping syndrome (LDS). We found no or minimal direct role for vagal signals in the control of gastric inhibitory polypeptide (GIP) and enteroglucagon secretion, which regulate EIA function. In gastrectomized patients, it is suggested that the hypersecretion of glicentin and glucagon-like peptide-1 (GLP-1) induced by a rapid arrival of nutrients to the distal gut suppresses glucagon secretion and may be a cause of LDS. In patients who underwent proctocolectomy, we observed no significant postoperative changes in EIA function, although there are some conflicting reports. It seems unlikely that ordinary pancreaticobiliary diversion would cause a significant change in EIA function after an oral glucose load. Our experimental model of ileojejunal transposition produced marked hypersecretion of incretin secreted from the distal gut, which may alter EIA function. Further elucidation of the regulatory mechanism of EIA may provide a new strategy for the medical and surgical treatment of LDS.

Gastric emptying of the liquid, solid and oil phase of a meal in normal volunteers and patients with Billroth II gastrojejunostomy

BACKGROUND

The relationship between gastric emptying of different phases of a meal in humans has only been partly studied in normal subjects and in patients with previous gastric surgery.

METHODS

In the present study, gastric emptying of the liquid, solid and oil phase and the relationship between the phases was evaluated in 10 normal control subjects and in seven patients with Billroth II gastrojejunostomy using breath test technology.

RESULTS

Gastric emptying in normal subjects showed a clear separation between the emptying of the liquid, solid and oil phase. In healthy volunteers, the liquid phase emptied in the same manner in the presence of a solid phase as in the presence of an oil phase. In contrast, the oil phase emptied more slowly with liquids than with solids. The emptying rate of the oil phase was not only inversely related to the amount administered but was also dependent on its chemical composition. Gastric emptying in patients with Billroth II gastroenterostomy was characterized by a complete loss of discrimination between the different phases of the meal, with an extremely fast emptying of the oil phase compared with normal control subjects.

CONCLUSION

In normal subjects, the liquid, solid and oil phase of a meal are emptied differently. In patients with Billroth II gastrojejunostomy, dumping of the oil phase is the most pronounced difference from the normal physiology of gastric emptying. This could be one of the reasons why Billroth II gastrectomy may be associated with fat malabsorption.

Gastrointestinal motility considerations in patients with short-bowel syndrome

Short-bowel syndrome results from large resections of the small intestine that result in the malabsorption of nutrients and fluids. Following intestinal resection both morphological and functional adaptations of the residual intestine occur. While we have witnessed progress in the understanding of morphological adaptation, little is known about the effects of gastrointestinal motility in short-bowel syndrome. This article reviews what is currently known about gastrointestinal motility in the context of short-bowel syndrome and the motility considerations that impact on clinical management.

Gastrointestinal hormone in dumping syndrome and reflux esophagitis after gastric surgery

Several problems are associated with gastric resection, including the dumping syndrome, reflux esophagitis, and malabsorption. A better understanding of the pathophysiological changes will shed light on new and improved therapy. Serum levels of seven circulating gastrointestinal hormones following a standardized solid meal and a brief score of symptoms were evaluated in 10 patients after partial distal gastrectomy and 12 patients after total gastrectomy, both groups reconstructed by Billroth II anastomosis, and 9 age-matched healthy controls. Patients underwent resection for gastric cancer and were studied 45 +/- 10 months after surgery. At the time of study, the patients had adapted well to surgery and no longer exhibited the severe symptoms of dumping seen immediately post-operatively. In contrast, the total gastrectomy patients exhibited the symptoms of reflux esophagitis. The gastrointestinal hormone changes could be divided into three patterns; obtunded responses (gastrin, PP), normal release (motilin, GIP) and increased secretion (CCK, neurotensin, PYY). In these, the early reaction of neurotensin correlated with the scores of late dumping syndrome and reflux esophagitis. In the literature, many gastrointestinal hormones have been shown to respond as an enhancement rather than adaptation. In other gastrointestinal hormones, secretin belonged to the obtunded type and enteroglucagon were classified in the increased type. However, pathophysiological significance of these hormonal changes remained uncertain. The late adaptive changes in gastrointestinal hormone secretion may help to compensate for loss of gastric motor function which accompanies gastric resection. On the other hand, these hormonal changes may exacerbate the esophageal reflux following gastrectomy.

The dumping syndrome. Current insights into pathophysiology, diagnosis and treatment

The dumping syndrome is encountered in approximately 10% of patients after gastric surgery. A postprandial peripheral and splanchnic vasodilatation and ensuing relative hypovolaemia are pivotal in the pathophysiology of early systemic symptoms. Late dumping symptoms are a consequence of a reactive hypoglycaemia, which results from an exaggerated insulin and glucagon-like peptide-1 release. The diagnosis of dumping syndrome can reliably be made with the aid of a provocation test using 50 g glucose orally. Most patients with dumping can be treated with advice on diet and lifestyle. Octreotide effectively controls the signs and symptoms of dumping in patients refractory to standard therapy. It acts through its inhibitory effects on insulin and gut hormone release, a delay of intestinal transit time and inhibition of food-induced circulatory changes. Its long-term use is somewhat limited by side effects, particularly diarrhoea and steatorrhoea.

Diagnostic value of dumping provocation in patients after gastric surgery

BACKGROUND

In patients after gastric surgery it is often difficult to discern symptoms from dumping from other postcibal complaints. Strict criteria for dumping provocation test have not been defined.

METHODS

The sensitivity and specificity of a dumping provocation using 50 g of glucose orally was assessed in 48 patients after gastric surgery, of whom 19 had a typical history of early dumping and 11 had a history of late dumping. Factors were heart rate, packed cell volume, breath hydrogen excretion, and blood glucose concentration.

RESULTS

An increase in heart rate of > or = 10 beats/min in the 1st h had a sensitivity of 100% and a specificity of 94% in detecting early dumping. An early rise in breath H2 excretion showed a sensitivity of 84% and specificity of 94%. The nadir blood glucose concentration was not a sensitive or specific indicator for late dumping.

CONCLUSIONS

Both an increase in heart rate of > or = 10 beats/min and a positive breath hydrogen excretion are sensitive indicators for early dumping. Late dumping is better recognized by the occurrence of subjective symptoms during provocation.

[Treatment methods for the dumping syndrome]

An incidence was determined of dumping syndrome after various operations while studying results of surgical treatment of gastric and duodenal ulcer in 135 patients. In dumping syndrome, two variants of association of motility of the stomach stump and efferent intestinal loop were identified. Modes of conservative treatment are proposed, such as transcutaneous electrostimulation of the ileocecal portion of the intestine and prescription of Zbruchansk (naftusia-type) mineral water.

Mechanisms by which octreotide ameliorates symptoms in the dumping syndrome

Octreotide reduces abdominal and vasomotor symptoms in dumping syndrome by unknown mechanisms. Effects of octreotide (50 microgram) on symptoms, hemodynamic parameters and plasma glucose and insulin levels after glucose meals were tested in double-blind, placebo-controlled, crossover fashion in eight patients with dumping syndrome. Gastric scintigraphy tested whether octreotide reduces symptoms by slowing gastric emptying. Octreotide reduced diarrhea, lightheadedness and palpitations after 75 g of glucose, compared with placebo (P < .001). Orthostatic pulse increases after glucose decreased from 36 +/- 6 beats/min after placebo to 9 +/- 5 beats/min after octreotide (P < .05), and standing blood pressure decreases after glucose were abolished (P < .05), but octreotide had no effect on increase in hematocrit or plasma osmolarity after glucose. Late hypoglycemia was prevented by octreotide, and peak fed insulin levels were reduced from 87 +/- 15 to 26 +/- 9 microU/ml after octreotide (P < .05). Times to maximal plasma glucose levels after meals were prolonged from 28 +/- 4 to 78 +/- 6 min after octreotide (P < .05). Octreotide had no effect on gastric emptying of liquids or solids. In conclusion, amelioration of dumping symptoms by octreotide is associated with reduced orthostasis, which is not a consequence of prevention of hemoconcentration. Prevention of late hypoglycemia may be due to blunted insulin release. Octreotide does not reverse rapid gastric emptying, indicating a limited role for this purported mechanism of action.

Axial forces during gastric emptying in health and models of disease

The propulsive forces involved in gastric emptying of solid and liquid chyme are incompletely characterized, and the contribution of the proximal region of the stomach to overall propulsion has not been quantifiable. We have used an axial force catheter to characterize longitudinally directed forces during gastric emptying in man. The topography of these forces has been described relative to circumferential contractions, and the contribution of axial forces in experimental models of dumping and gastric stasis were quantified by assessing the effects of intravenous erythromycin and intraduodenal lipid, respectively. There is an excellent correlation between axial forces and gastric emptying of solids in health and in models of gastric dysmotility, suggesting that the axial force catheter semiquantitatively measures propulsive forces during emptying of the human stomach.

The successful application of jejunal interposition for severe dumping syndrome: report of a case

We report herein the case of a 76-year-old man with intractable dumping syndrome which had manifested itself 3 years after he underwent a gastric resection and Billroth I reconstruction for a gastric ulcer. Despite aggressive medical therapy by the time of admission, he had suffered from disabling dumping symptoms for 9 years. In an attempt to relieve these symptoms, a 15-cm segment of the jejunum was placed isoperistaltically between the lesser curvature of the remnant stomach and the duodenum, and a selective vagotomy was performed. The dumping symptoms that he had experienced preoperatively completely disappeared after the revisory surgery. Postoperatively, an upper gastrointestinal series demonstrated a larger gastric pouch and slower gastric passage into the small intestine than what was seen preoperatively, while gastric emptying studies using the acetaminophen method also showed normal patterns in both the early and late postoperative phases. Thus, we consider that this surgical procedure is a simple and effective way to inhibit rapid gastric emptying and to slow intestinal transit in the treatment of dumping syndrome.

[Neurohumoral regulation of gastric secretion in postvagotomy syndromes]

The secretion of hormones stimulating and inhibiting gastric secretory activity was studied in 85 patients with postvagotomy syndromes. The somatropin level was found to increase significantly in gastrostasis. The lower values of the blood insulin and C-peptide content in patients with recurrent ulcers was evidently associated either with insufficiency of the pancreatic insular apparatus or with partial vagal denervation, increased STH level, and plausible inhibiting effect of glucagon. Increased somatostatin secretion in the dumping syndrome, gastrostasis, and peptic ulcers may be due to the encountered hypergastrinemia.

[Postgastrectomy dumping treated with octreotide (Sandostatin)]

Somatostatin and the long acting somatostatin analogue Sandostatin have been shown to be effective in the management of dumping syndrome. We describe a patient with early dumping in whom this management provided total symptomatic relief. The doses was reduced from 50 micrograms to 12.5 micrograms s.c., t.i.d. At this dose clinical and biochemical parameters (blood pressure, pulse rate, packed cell volume, hematocrit, and blood glucose) were found to be within normal levels.

Atrial natriuretic peptide in dumping syndrome

The significance of atrial natriuretic peptide (ANP) was investigated in the maintenance of the fluid volume in hypovolemia associated with dumping syndrome following gastric resection. The study was performed on 10 patients who had undergone a Billroth II procedure. Ten age- and sex-matched patients without previous gastric surgery served as control. Each patient underwent an oral glucose challenge. The patients with gastric resection underwent another glucose challenge with intravenous infusion to maintain the fluid volume. All patients with gastric resection showed subjective symptoms of the early dumping syndrome with significant (p < 0.001) increases (initial and maximum rates; mean +/- SD) in heart rate (from 70 +/- 3 to 122 +/- 4 beats/min) and in hematocrit (from 0.40 +/- 0.005 to 0.45 +/- 0.003). The plasma ANP level decreased significantly from 27.24 +/- 5.01 to 15.94 +/- 3.61 fmol/ml (p < 0.01). A significant negative correlation was found between the changes in hematocrit and the changes in plasma ANP level (r = 0.68; p < 0.001). Neither the subjective symptoms characteristic of the early dumping syndrome nor changes in laboratory parameters were noted in the patients during the challenge with infusion. The results show that the hypovolemia in dumping syndrome is associated with a significant decrease in ANP activity. The regulation of ANP release is also affected: apart from the well-known stimulating effect of hypervolemia, there exists an inhibition of secretion in volume-depleted states.

Postgastrectomy syndromes

Anatomic and physiological changes introduced by gastric surgery result in postgastrectomy syndromes in approximately 20% of patients. Most of these disorders are caused by operation-induced abnormalities in the motor functions of the stomach, including disturbances in the gastric reservoir function, the mechanical-digestive function, and the transporting function. Division of the vagal innervation to the stomach and ablation or bypass of the pylorus are the most significant factors contributing to postgastrectomy syndromes. Either rapid or slow emptying may result, depending on the relative importance of lack of a compliant gastric reservoir, loss of an effective contractile force, and loss of controlling factors that slow or speed gastric emptying and result in duodenal-gastric reflux. Clearly defining which syndrome is present in a given patient is critical to developing a rational treatment plan. In syndromes with slow gastric emptying, bilious vomiting, or alkaline reflux gastritis, the use of endoscopy is essential to rule out mechanical causes of the syndrome. Contrast radiography and scintigraphic gastric emptying studies are useful to document rapid or delayed gastric emptying. Postgastrectomy syndromes often abate with time. Conservative measures, including medical, dietary, and behavioral therapy, should be given at least a 1-year trial. If these nonoperative measures fail, surgical therapy is recommended. The Roux-en-Y gastrojejunostomy is useful for patients with dumping, because it slows gastric emptying and the transit of chyme through the Roux limb. The same operation helps patients with alkaline reflux gastritis, because it diverts pancreaticobiliary secretions away from the gastric remnant. Near-total gastrectomy, which reduces the size of a flaccid gastric reservoir, can be used to treat delayed gastric emptying. This operation should be combined with the Roux procedure to prevent postoperative reflux gastritis and esophagitis. Newer techniques, such as gastrointestinal pacing and the uncut Roux operation, may improve the treatment of the postgastrectomy syndromes in the future.

Clinical relevance of scintigraphic measurement of gastric emptying of a solid-liquid meal in the dumping syndrome

Gastric emptying of the solid and liquid components of an ordinary meal was evaluated by a dual isotopic technique in 36 patients referred to our hospital for early postprandial symptoms induced by various esophageal and/or gastric operations. Patients were classified as typical (n = 11), equivocal (n = 9) or improbable (n = 16) dumpers, in accordance with their presenting symptoms, as assessed before gastric emptying measurement. Patients with typical dumping symptoms displayed, as expected, significant acceleration of gastric emptying of liquids (t1/2: 18 +/- 6 min. vs. 48 +/- 7 min. in healthy controls; p less than 0.02), and also exhibited a dramatic enhancement of gastric emptying of solids (t1/2: 11 +/- 1 min. vs. 126 +/- 12 min. in healthy controls; p less than 0.001) and a complete loss of solid-liquid discrimination (7 +/- 6 min. vs. 78 +/- 7 min. in healthy controls; p less than 0.01). Mean gastric emptying rates for equivocal and improbable dumpers were not significantly different from those of healthy controls, but individual results were very heterogeneous; they included stasis, acceleration, or both disorders, and were not predictable by analysis of symptoms alone. Thus gastric emptying of solids as well as liquids is accelerated in symptomatic dumping patients, and objective evaluation of the emptying of both solid and liquid gastric emptying is essential in atypical dumpers, in order to characterize their disorders and prescribe the most rational treatment.