Basics of Compounding: Providing Pharmacy Services to Bariatric Surgery Patients

With the rise in obesity, more individuals are choosing bariatric surgery as a means to successfully lose weight and resolve co-morbidities. These patients need lifelong support from friends, family, and healthcare providers. Pharmacists need to be knowledgeable of the unique needs of these patients in order to provide information and recommendations on drug therapies and supplements. When a patient is wheeled out of the operating room following bariatric surgery, his or her life instantly changes. Like an infant, the patient has to slowly learn how to eat and drink again. Physical activity significantly increases. Taste perception changes. Serious medical problems, such as hypertension, type II diabetes, and hypercholesterolemia completely resolve within a couple of months. The patient has to be disciplined and follow the instructions of the bariatric team and other healthcare providers. Since the patient's gastrointestinal tract has been significantly altered, drug therapies may require some modifications too. Bariatric or weight loss surgery is definitely not the easy way to lose weight, but it is a very powerful tool for the patient. Weight loss, and maintaining that weight loss, is a lifelong journey for the patient that requires support from the bariatric team, healthcare provider(s), co-workers, friends, and family. Pharmacists may also provide support for these patients through counseling about their supplements, medications, and compounding medications to meet their specific needs.

[Many complications after Roux-en-Y gastric bypass surgery can be prevented and treated]

A wide range of complications may occur after Roux-en-Y gastric bypass (RYGB) surgery, including surgical, medical/nutritional, and psychiatric complications. Some of the nutritional complications such as anaemia, dumping and hypoglycaemia may present rather unspecific symptoms that may easily not be diagnosed as complications after RYGB. Focus on diagnosis and treatment of these complications is important.

ASSESSMENT OF THE GASTRO-JEJUNO-DUODENAL TRANSIT AFTER JEJUNAL POUCH INTERPOSITION

BACKGROUND

The jejunal pouch interposition between the gastric body and the duodenum after the gastrectomy, although not frequent in the surgical practice today, has been successfully employed for the prevention and treatment of the postgastrectomy syndromes. In the latter, it is included the dumping syndrome, which affects 13-58% of the patients who undergo gastrectomy.

AIM

Retrospective assessment of the results of this procedure for the prevention of the dumping syndrome.

METHODS

Fourty patients were selected and treatetd surgically for peptic ulcer, between 1965 and 1970. Of these, 29 underwent vagotomy, antrectomy, gastrojejunalduodenostomy at the lesser curvature level, and the 11 remaining were submitted to vagotomy, antrectomy, gastrojejunal-duodenostomy at the greater curvature level. The gastro-jejuno-duodenal transit was assessed in the immediate or late postoperative with the contrasted study of the esophagus, stomach and duodenum. The clinical evolution was assessed according to the Visick grade.

RESULTS

Of the 40 patients, 28 were followed with the contrast evaluation in the late postoperative. Among those who were followed until the first month (n=22), 20 (90%) had slow gastro-jejuno-duodenal transit and in two (10%) the transit was normal. Among those who were followed after the first month (n=16), three (19%) and 13 (81%) had slow and normal gastric emptying, respectively. None had the contrasted exam compatible with the dumping syndrome. Among the 40 patients, 22 underwent postoperative clinical evaluation. Of these, 19 (86,5%) had excellent and good results (Visick 1 and 2, respectively).

CONCLUSIONS

The jejunal pouch interposition showed to be a very effective surgical procedure for the prevention of the dumping syndrome in gastrectomized patients.

Optimal size of jejunal pouch as a reservoir after total gastrectomy: a single-center prospective randomized study

BACKGROUND

In order to improve a patient's quality of life after total gastrectomy, jejunal pouch reconstruction has been employed. However, little information exists regarding the optimal size of the jejunal pouch after total gastrectomy.

METHODS

The study was designed as a single-center randomized trial in which the results of double-tract reconstruction with pouches of two different sizes were compared, i.e., short and long pouch double tract (SPDT and LPDT, respectively). We conducted a clinical assessment with standard questionnaire after surgery. The amount of residual food in the jejunal pouch was determined by endoscopy.

RESULTS

No demographic differences were noted between the two groups. The eating capacity per meal was higher in the SPDT group than in the LPDT group. The postoperative weight loss 24 months after surgery was lower in SPDT group than that in the LPDT group. Although the incidence of early dumping symptoms was higher in the SPDT group, no difference was noted in the other postprandial abdominal symptoms between the two groups.

CONCLUSIONS

We conclude that the optimal pouch should be relatively short, as a short pouch improves the eating capacity per meal and the weight loss ratio to the preoperative value.

Physical activity predicts weight loss following gastric bypass surgery: findings from a support group survey

BACKGROUND

Patient adherence to recommended eating and physical activity behaviors is considered important to weight loss outcomes following gastric bypass surgery, but there has been little systematic research in this area to investigate behavioral predictors of weight loss.

METHOD

We developed a measure of postsurgical behaviors, the bariatric surgery self-management questionnaire (BSSQ). A survey was conducted of 200 patients attending postsurgical support groups (mean time since surgery 14 months, mean age 40 years, 85% female, presurgical weight 150 kg). Patients completed the BSSQ and measures of treatment regimen distress, perceived benefits of weight loss, and weight-related physical symptoms.

RESULTS

Mean BSSQ adherence was in the 70% range, with subscale scores varying considerably. Distress levels associated with the new lifestyle were consistently low (approximately equal to 20%) and perceived benefits of weight loss were high early on and maintained consistently (70-90%). A final predictive model showed premorbid weight, time since surgery, and BSSQ physical activity subscale were significant predictors of weight loss, accounting for 73% of variance.

CONCLUSIONS

Physical activity adherence was the sole significant behavioral predictor of weight loss, although maladaptive dietary habits and patient selection issues were identified for future research. It will be important to replicate the current study in prospective, longitudinal studies with representative patient cohorts. A challenge for researchers will be to develop novel, intensive recruiting and retention strategies to allow closer examination of these issues.

Vagal-Sparing Esophagectomy

OBJECTIVE

Our aim was to compare outcome of vagal-sparing esophagectomy with transhiatal and en bloc esophagectomy in patients with intramucosal adenocarcinoma or high-grade dysplasia.

SUMMARY BACKGROUND DATA

Intramucosal adenocarcinoma and high grade dysplasia have a low likelihood of lymphatic or systemic metastases and esophagectomy is curative in most patients. However, traditional esophagectomy is associated with significant morbidity and altered gastrointestinal function. A vagal-sparing esophagectomy offers the advantages of complete disease removal with the potential for reduced morbidity and a better functional outcome.

METHOD

Retrospective review of outcome in patients with intramucosal adenocarcinoma or high grade dysplasia that had a vagal-sparing (n=49), transhiatal (n=39) or en bloc (n=21) esophagectomy.

RESULTS

The length of hospital stay and the incidence of major complications was significantly reduced with a vagal-sparing esophagectomy compared with a transhiatal or en bloc resection. Further, postvagotomy dumping and diarrhea symptoms were significantly less common, and weight was better maintained postoperatively with a vagal-sparing esophagectomy. Recurrent cancer has developed in only 1 patient.

CONCLUSION

Survival with intramucosal adenocarcinoma or Barrett's with high-grade dysplasia is independent of the type of resection. A vagal-sparing esophagectomy is associated with significantly less perioperative morbidity and a shorter hospital stay than a transhiatal or en bloc esophagectomy. Further, late morbidity including weight loss, dumping, and diarrhea are significantly less likely after a vagal-sparing approach. Consequently a vagal-sparing esophagectomy is the preferred procedure for patients with intramucosal adenocarcinoma or high grade dysplasia.

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.

[Evaluation of the preserved function of the remnant stomach in pylorus preserving-gastrectomy by gastric emptying scintigraphy]

This study evaluated the preserved function of the remnant stomach by gastric emptying scintigraphy 1 year postoperatively in 49 patients who underwent pylorus-preserving gastrectomy (PPG), and it investigated whether this examination method is a useful tool for evaluation. The residual stomach function was classified as rapid, intermediate, and delayed emptying types according to gastric emptying curves. Then, the relationships were examined between the gastric emptying types and postprandial symptoms, food intake status, body weight changes, and endoscopic findings. Seventy-three percent of the PPG patients were classified as belonging to the intermediate emptying type, and the remainder (27%) to the delayed type. The frequencies of complaints such as epigastric fullness, nausea, and vomiting were high in the delayed emptying-type patients. The intermediate emptying-type patients consumed larger amounts of food and gained more weight than the delayed emptying-type patients. In conclusion, gastric function was evaluated by gastric emptying scintigraphy in PPG patients. This method might be useful not only for evaluating the motor function of the remnant stomach, but also for predicting postoperative status. Although PPG is a function-preserving operation, it should be considered that a quarter of the patients showed delayed emptying type which related to poor quality of life.

Functional Conduit Disorders After Esophagectomy

Unfortunately normal gastrointestinal function after an esophagectomy is rare. Most patients will never eat the way they did before their illness. Most patients require smaller more frequent meals. It is common for patients to loose up to 15% of their body weight from the time of diagnosis through the first 6 months postoperatively, but fortunately this trend levels off after 6 months. Dumping syndrome, delayed gastric emptying, reflux, and dysphagia can all contribute to nutritional deficiency and poor quality of life. There is no one surgical modification to eliminate any one of these complications, but several guidelines can help reduce conduit dysfunction. Most patients seem to benefit from a 5-cm-wide greater-curvature gastric tube brought up through the posterior mediastinum. The gastric-esophageal anastomosis should be placed higher than the level of the azygous vein. Drainage procedures seem to be helpful, especially when using the whole stomach as a conduit. Early erythromycin therapy significantly aids in the function of the gastric conduit. Proton-pump inhibitors are important for improvement of postoperative reflux symptoms and to help prevent Barrett's metaplasia in the esophageal remnant. Single-layer hand-sewn or semi-mechanical anastomoses provide greater cross-sectional area and fewer problems with stricture. When benign strictures occur, early endoscopy and dilation with proton-pump inhibition greatly reduces the morbidity. Patients should be instructed to eat six small meals a day and to remain upright for as long as possible after eating. Simple sugars and fluid at mealtime should be avoided until the function of the conduit is established.

A novel surgical procedure of vagal nerve, lower esophageal sphincter, and pyloric sphincter-preserving nearly total gastrectomy reconstructed by single jejunal interposition, and postoperative quality of life

BACKGROUND/AIMS

For early gastric cancer total gastrectomy (TG) has so far been essentially unavoidable. We performed the nearly TG reconstructed by single jejunal interposition preservation of the vagal nerve, lower esophageal sphincter (LES) and pyloric sphincter (D1 or D2 lymph node dissection, curability A) as a function-preserving surgical technique (i.e. NTG) to improve postoperative quality of life (QOL). In this report, the application criteria and points of the technique are outlined. QOL in patients after NTG was also compared with those after TG.

METHODOLOGY

Sixteen subjects who underwent NTG (12 men and 4 women subjects at age 30 to 70 years, mean 55.6 years) were interviewed to inquire about abdominal symptoms and compared with 20 patients after conventional TG (excision with D2 lymph node, radical curability A) reconstructed by single jejunal interposition without preserving the vagal nerve, LES, and pyloric sphincter (i.e. TGI; 14 men and 6 women at age 26 to 70 years, mean 54.8 years). The former was named group A and the latter group B. Included were cases with early cancer localizing at the upper third and middle stomach, 2cm or further in distance from oral-side margin of the cancer to esophagogastric mucosal junction; and 3.5cm or further in distance from anal-side margin of the cancer to the pyloric sphincter. In excision with the lymph node, hepatic and celiac branches were preserved. To preserve LES, the abdominal esophagus was completely preserved. The pyloric antrum was also preserved at 1.5cm from the pyloric sphincter. The substitute stomach was created as a 30-cm-long single jejunal segment having orthodromic peristaltic movement.

RESULTS

The operative procedure in group A significantly improved postoperative gastrointestinal symptoms such as appetite loss (p=0.0004), weight loss (p=0.0369), reflux esophagitis (RE) (p=0.0163), early dumping syndrome (p=0.0163), endoscopic RE (p=0.0311), and postgastrectomy cholecystolithiasis (p=0.0163) compared with group B. Oral intake per one meal 5 years after operation compared with that before operation was better in group A than in group B (p=0.0703). Postoperative epigastric fullness was significantly detected in group A compared with group B (p=0.0072).

CONCLUSIONS

The proposed surgical technique of NTG is a function-preserving surgery appropriate to improve QOL of subjects with early gastric cancer. There was a defect in this technique of postprandial feeling of epigastric fullness. We think that a gut motility improvement agent is necessary to improve postprandial epigastric fullness after NTG.

[Resection with pyloric retention as a method for prophylaxis of dumping syndrome]

The aim of the study was the evaluation of efficacy of the resection with pyloric retention proposed by the authors as a method for prevention of post gastroresectional damping syndrome in patients with ulcers. Resection with pyloric retention is performed in six modifications of three basic methods of resections. We have the experience of using this approach in 712 clinical cases. Among them 237 were women and 475 were men 19-75 years of age. It was shown that resection with pyloric retention provides rhythmic evacuation and prevents development of damping syndrome and duodenal reflux. It was found that the main reasons of the development of postgastroresectional syndromes include wide-area mobilization of the stomach and resection of the small curvature, which induce insufficiency of cardia, atony, chronic disturbances of the duodenal passing. Due to the retention of pyloric function damping syndrome have been developed only in 3 patients. In all these cases the syndrome was mild. It may be concluded that gastric resection with pyloric retention represents the most "physiological" intervention and has many advantages in comparison with other methods.

Bariatric surgery options

There are multiple surgical procedures used for weight loss. The concept of achieving malabsorption through manipulation of the gastrointestinal contract is briefly discussed. Various surgical options are considered with their advantages and disadvantages, namely vertical banded gastroplasty, gastric banding, Roux-en-y gastric bypass, distal gastric bypass billiopancreatic diversion, and duodental switch.

Ileocecal valve as substitute for the missing pyloric sphincter after partial distal gastrectomy

OBJECTIVES

Accelerated gastric emptying (including dumping syndrome) occurs frequently after gastric resections, largely resulting from rapid entry of meal contents into the small intestine. The authors hypothesized that an ileocecal segment used as an interpositional graft placed between the remaining part of the stomach and the small intestine would slow down food transit and thus replace pyloric function.

METHODS

Thirty Göttingen minipigs were randomized into three groups. Group 1: partial gastrectomy and Roux-en-Y reconstruction; Group 2: partial gastrectomy and ileocecal interpositional graft; and Group 3: sham laparotomy. Gastric emptying in the nonsedated animals was quantified using radioscintigraphy at 3 and 6 months postoperatively. The animals ingested 300 grams of soft food containing 99mTc labeled resin- pellets using a technique previously described. Data were analyzed using ANOVA.

RESULTS

Three months postoperatively, the ileocecal group had a significantly prolonged gastric emptying time compared with the Roux-en-Y group, but gastric emptying time was also significantly faster compared to the control group (sham laparotomy). After 6 months no significant difference was seen between the ileocecal group and the controls, while emptying rates were still significantly faster in the Roux-en-Y group.

CONCLUSIONS

Reconstruction of the gastric reservoir with an ileocecal segment largely restores gastric emptying patterns of food in minipigs. Six months postoperatively, gastric emptying time is similar to that of controls, and significantly slower when compared with the group with Roux-en-Y reconstruction. These results suggest that the ileocecal interposition graft could offer specific advantages over current reconstruction procedures.

A novel operative technique on proximal gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of the vagal nerve and lower esophageal sphincter

BACKGROUND/AIMS

This article describes the surgical techniques and postoperative status for proximal gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of the vagal nerve and lower esophageal sphincter.

METHODOLOGY

We have performed a new technique for reducing postgastrectomy sequelae such as reflux esophagitis, early dumping syndrome, and microgastria in early gastric cancer located in the proximal third of the stomach. The technique consists of proximal gastrectomy with preservation of the hepatic, pyloric, celiac branch of the vagal nerve, and abdominal esophagus (lower esophageal sphincter), and reconstruction by interposition of a jejunal J pouch. To reserve pyloric function, pyloroplasty can be omitted by preservation of the pyloric branch from the vagal nerve. To restore loss of reservoir function, the reconstruction is performed with an interposed jejunal J pouch. Sacrifice of the mesenteric arcades is kept to a minimum to preserve the autonomic nerve and blood flow in the mesentery.

RESULTS

All of the patients who underwent this operation were able to eat an adequate amount of food at 6 months after surgery and they were satisfied with their postoperative status. And that, we have not experienced postgastrectomy disorders such the dumping syndrome and reflux esophagitis.

CONCLUSIONS

Therefore, this method is useful for preventing the postoperative disorders in patients with early gastric cancer located in the proximal third of the stomach.

Jejunal interposition to prevent postgastrectomy syndromes

BACKGROUND

Postgastrectomy syndromes include reflux gastritis and oesophagitis, dumping syndrome, intractable diarrhoea and afferent loop syndrome. To prevent such syndromes, since January 1994 jejunal interposition has been used following distal gastrectomy. The aim of this study was to evaluate the benefit of this procedure.

METHODS

A consecutive series of 42 patients who underwent distal gastrectomy for gastric cancer was studied. Twenty-two patients had a Billroth I procedure before January 1994, and 20 patients had isoperistaltic jejunal interposition using a 10-12-cm segment after January 1994.

RESULTS

The mean operating time was 260 min for Billroth I and 352 min for jejunal interposition. No serious postoperative complications arose. Reflux gastritis occurred in 19 patients after Billroth I but in none after jejunal interposition. Five patients in the Billroth I group had complaints consistent with dumping syndrome, compared with none after jejunal interposition. The barium gastric emptying time was significantly shorter after Billroth I (mean(s.d.) 269(225)s) than after jejunal interposition (736(479) s) (P < 0.01).

CONCLUSION

Jejunal interposition prevented reflux gastritis and inhibited rapid gastric emptying. Postgastrectomy syndromes were effectively prevented by this reconstruction procedure.

[Truncal vagotomy using videothoracoscopy without gastric drainage. A prospective study of 250 cases surgically treated in Senegal]

AIM OF THE STUDY

The aim of this prospective study was to report early results of videothoracoscopic truncal vagotomy in non-complicated chronic duodenal ulcers.

PATIENTS AND METHODS

From 1995 to 1998, 250 patients suffering from chronic duodenal ulcer without pyloric stenosis were operated on in the main hospital of Dakar. They underwent videothoracoscopic truncal vagotomy without gastric drainage. The quality of gastric emptying and the incidence of secondary side-effects were assessed in the postoperative course and after one and three months.

RESULTS

There were two intraoperative deaths, one due to aortic wound and the other one due to a poor surveillance after premature extubation. Postoperative complications included bronchopulmonary infection (n = 9), one septic pleural effusion and one chylothorax. A postoperative gastroplegia occurred in 12 patients, which was always spontaneously regressive without endoscopic pyloric dilatation. After one month, 204 patients (82%) were classified Visik 1, and 44 (18%) classified Visik 2. An endoscopic control examination showed a healed peptic ulcer and open pylorus in all patients, and a gastric stasis present in 40 cases (16%). After three months and a new evaluation, 234 were classified Visik 1 (94%) and 14 Visik 2 (6%). Dumping syndrome was not observed in this series and the incidence of diarrhea, which was 40% after one month, decreased to 3% after three months.

CONCLUSION

The functional results of truncular vagotomy without gastric drainage were good or very good and improved with time. The quality of digestive comfort and the low frequency of side-effects are good arguments in favor of this procedure as an elective treatment of duodenal ulcers in developing countries.

Clinical outcome and quality of life after gastric and distal esophagus replacement with an ileocolon interposition

Mainly because of the loss of reservoir function, loss of sphincter function, and exclusion of the duodenal route, patients who undergo gastrectomy suffer from many adverse effects postoperatively. The ileocecal interpositional graft is an attractive method to use as a gastric substitute after gastrectomy and distal esophagectomy. A pedunculated ileocecal graft is placed between the esophagus and the duodenum. The cecum acts as a reservoir while the ileocecal valve protects against enteroesophageal reflux. The duodenal passage is also preserved. Fourteen patients underwent this operation. The technique-related morbidity was low and the quality of life was good. During a mean follow-up of 6 months, no evidence of severe dumping syndrome or reflux esophagitis was observed. Further prospective randomized studies are warranted to compare this technique with the standard methods of gastric reconstruction.

[Critical evaluation of the reconstruction of the intestinal continuity after total gastrectomy by the Moricca technique]

The authors analyze a series of 48 total gastrectomies for gastric carcinomas performed between 1987 and 1994. Seven out of these 48 gastrectomies were performed adopting the double circuit esophagojejunoduodenal plasty according the procedure described in 1976 by Francesco Moricca. The double jejunal loop represents a sort of "digestive reservior" allowing to avoid the sensation of epigastric fullness after eating. Moreover, this technique permits a better absorption of the liquids and the partial mixing of the bolus with the bilio-pancreatic secretion stimulates the duodenal secretin and cholecystochinin release. The possibility of a "dumping syndrome" is diminished by the presence of the double possibility of diversion of the alimentary bolus. On the contrary the segment of jejunum transposed between the esophagus and duodenum is antiperistaltic and this fact can cause sometimes an esophagitis at the lower third of the esophagus due to the prolonged alkaline reflux. This study is aimed at verifying the entity and frequency of the esophagitic complication in patients who underwent a total gastrectomy and at analyzing the procedures adopted to cure this severe complication that seriously affects the wellness and the nutritional status of the gastrectomized patients.

The effect of reconstruction after subtotal gastrectomy on release of vasoactive intestinal peptide

To avoid dumping after Billroth gastrectomy, we designed pylorus and antroseromuscular-flap preserving subtotal gastrectomy (PAFPG). The mean maximal plasma level of VIP (vasoactive intestinal peptide) in PAFPG after oral hypertonic glucose was close to that in the control. Compared with PAFPG group, the plasma VIP concentrations after hypertonic glucose ingestion in BI and BII group were significantly higher, and the concentration of plasma VIP in dumpers was significantly higher than that in non-dumpers after BI or BII gastrectomy. The results suggest that the amount of VIP release is related to the type of reconstruction after gastrectomy.

Control of dumping symptoms by somatostatin analogue in patients after gastric surgery

Octreotide acetate is a long-acting analogue of the naturally occurring inhibitory gastrointestinal peptide, somatostatin. We tested the efficacy of octreotide in controlling the symptoms of dumping syndrome in response to a provocative meal in a randomized, double-blinded, crossover trial in nine severely affected patients. Pretreatment with octreotide acetate (100 micrograms injected subcutaneously) reduced postprandial dumping symptoms from a mean +/- SEM score of 15.7 +/- 1.6 (placebo treatment day) to 4.6 +/- 1.7. With placebo treatment, all nine patients became symptomatic in response to the meal, whereas with octreotide treatment, symptoms occurred in only two of nine patients. Similarly, all placebo-treated patients showed a postprandial increase in pulse rate to a mean +/- SEM of 105 +/- 6 beats per minute, whereas only one of nine octreotide-treated patients showed an increase in pulse rate (mean +/- SEM, 80 +/- 3 beats per minute). These differences were also statistically significant. While no significant changes were observed in postprandial hematocrit values or osmolality between placebo and octreotide treatments, octreotide prevented hypoglycemia in four affected patients and significantly inhibited insulin release. We conclude that octreotide is a useful tool in the treatment of patients with severe, refractory dumping syndrome.

Efficacy of octreotide acetate in treatment of severe postgastrectomy dumping syndrome

The present study evaluates the acute and chronic use of a long-acting somatostatin analog, octreotide acetate, in the treatment of patients with severe postgastrectomy dumping syndrome. In the acute phase, 10 patients with severe dumping were studied over 2 consecutive days before and for 3 hours after the ingestion of a 'dumping breakfast' in a randomized double-blind fashion. On one day octreotide (100 micrograms) was given subcutaneously 30 minutes before the test meal and on the other day an equal volume of vehicle was injected. An additional group of six postgastrectomy patients without dumping were studied in a similar fashion and these acted as controls. During placebo treatment the test meal resulted in an immediate increase (p less than 0.01) in the pulse rate and in plasma levels of glucose, glucagon, pancreatic polypeptide, neurotensin, and insulin. Similar changes were seen in the control group with respect to placebo; however glucagon and neurotensin (p less than 0.05) did not show the same magnitude of increase as seen with placebo. Treatment with octreotide acetate prevented the development of both vasomotor and gastrointestinal symptoms and completely ablated all of the above responses in plasma peptides. These changes were associated with complete ablation of diarrhea (p less than 0.001). Pretreatment with octreotide acetate completely suppressed the rise in plasma insulin response to the meal and this ablated the late hypoglycemia of dumping. Treatment with octreotide acetate resulted in delayed gastric emptying and transit time (578 +/- 244 minutes) versus 76 +/- 23 minutes with placebo and 125 +/- 36 minutes in controls (p less than 0.05). Chronic daily treatment with octreotide acetate resulted in minimal side effects. These patients demonstrated a stable fasting plasma glucose, normal liver function tests, and an average weight gain of 11% during a 12-month period. In addition most patients were able to resume employment. The long-acting somatostatin analog, octreotide acetate, is highly effective in preventing the development of symptoms of severe dumping syndrome, both vasomotor and gastrointestinal.

[Prevention of dumping syndrome after distal gastrectomy in peptic ulcer]

Operations were performed on 386 patients with peptic ulcer by a method suggested by the authors for gastric resection with formation of a sphincter in the region of the anastomosis. In 18 patients a Billroth II anastomosis was reconstructed into a Billroth I anastomosis by the authors' modification in severe dumping syndrome. Complex examination was conducted in late-term postoperative periods in 324 patients after primary resection and in 18 after reconstructive operation. A mild dumping syndrome was found in 9 (2.8%) and 3 patients, respectively. The results of the study show that if the authors' requirements regarding the volume and method of gastric resection are abided by, there is no doubt that the suggested method has advantages over the classical method in that the reservoir function of the stomach is maintained, hydrochloric acid secretion reduces to a state of hypo- or normoacidity, and the peristaltic component of evacuation is preserved due to the formed functionally active anastomosis.

[Pathogenesis, prevention and treatment of dumping syndrome]

The work presents results of treatment of 123 patients with a severe dumping-syndrome following resection of the stomach for ulcer disease. The author considers that there is not any predisposition for the dumping-syndrome in resection of the stomach. This pathology is a result of inconsiderable errors in operation and can be prevented by strict observation of the rules of performing the operation. The reconstructive operation aimed at the creation of favorable conditions for the functioning of the gastric stump is indicated if the conservative treatment failed during 6-10 months.

Postgastrectomy syndromes

The most common types of postgastrectomy disorders are the dumping syndromes (early postprandial and late or hypoglycemic) and alkaline reflux gastritis. Both are caused by destruction of the pyloric mechanism. A third problem, Roux-en-Y duodenal diversion, frequently results in delayed gastric emptying.

[Ways of preventing dumping syndrome after surgical treatment of stomach and duodenal ulcer]

An analysis of results of the examination and surgical treatment of 310 patients have shown that in patients with high predisposition to dumping-syndrome the following operations should be used: Billroth-I resection of the stomach (for gastric ulcers), selective proximal vagotomy or vagotomy with draining operations (for duodenal ulcers). Indications for the above operations should be determined with special reference to the state of the secretory and motor-evacuatory function of the stomach.

[Prevention and treatment of early complications of selective proximal vagotomy]

When performing the selective proximal vagotomy the operations draining the stomach were shown to aggravate the existing disturbances of the motor-evacuatory function of the stomach, to result in the development of the dumping syndrome, duodenogastral reflux. The exclusion of the duodenum with the formation of gastroentero- and Y-shaped enteroenteroanastomoses is indicated in cases with the pronounced cicatricial-ulcerous alterations of the pylorobulbar zone preventing the performing of pyloroplasty after Finney and Miculicz.

Efficacy of guar gum in preventing the dumping syndrome

The occurrence of dumping symptoms during 1 wk of use of 5 g of guar gum or placebo in meals was examined in a double-blind study in 11 patients, who had undergone gastric resection and were suffering from the dumping syndrome. The results show that guar gum prevented the dumping syndrome and increased tolerance to foods not previously tolerated in nine of the 11 patients.

[Reconstruction of the digestive tract after total gastrectomy. Comments and results in 27 patients operated on by a personal procedure]

The author presents the results obtained from his procedure of reconstruction of the gastro-intestinal tract after total gastrectomy. Only one patient presented a serious oesophagitis. Blood and stool examinations and esophagoscopic and radiological investigations were very satisfactory. The author concludes by outlining the advantages of this procedure, used by him since 1975 and which was proposed in the Journal of Surgery in 1976.

Intestinal pacing for canine postgastrectomy dumping

Our aim was to determine whether or not postprandial retrograde duodenal pacing would abolish the canine postgastrectomy dumping syndrome. Five dogs underwent truncal vagotomy, distal hemigastrectomy, gastroduodenostomy, and circumferential proximal duodenal myotomy to facilitate pacing. Bipolar stimulating electrodes from an implanted pacing unit were attached to the bowel 35 cm distal to the gastroduodenostomy, and six monopolar recording electrodes were applied at 5-cm intervals proximal to the pacing electrodes. After recovery, gastric emptying was assessed in the fasted conscious dogs using 300-ml gastric instillates of 25% dextrose marked with [14C]polyethylene glycol, while pulse, hematocrit, and defecation were monitored. Each dog underwent five tests with and five tests without retrograde duodenal pacing. Without pacing, the dogs emptied a mean +/- SEM of 237 +/- 14 ml of the instillate by 20 min and developed tachycardia (change in pulse, 45 +/- 4), hemoconcentration (change in hematocrit, 8 +/- 1), and diarrhea in 13 of 25 tests. Retrograde duodenal pacing slowed gastric emptying (157 +/- 20 ml, p less than 0.05) and minimized the adverse cardiovascular sequelae (change in pulse, 25 +/- 5, change in hematocrit, 6 +/- 1; p less than 0.05) and the diarrhea (only 2 of 25 tests, p less than 0.01). We concluded that intestinal pacing ameliorated the postgastrectomy dumping syndrome in dogs. Such an approach may be applicable to humans.

The incidence of the dumping syndrome following gastrojejunostomy with Roux-en-y anastomosis

A clinical study was undertaken to determine the incidence of the dumping syndrome following partial gastrectomy and Roux-en-y gastrojejunostomy. Twenty-three patients were scored according to a clinical diagnostic index. There were no dumpers identified. A theoretical explanation for these findings is offered. A Roux-en-y conversion should be considered for patients with disabling dumping symptoms following gastric surgery.

Anterior lesser curve seromyotomy and posterior truncal vagotomy in the treatment of chronic duodenal ulcer

The value of anterior lesser curve seromyotomy with posterior truncal vagotomy as a simple and safe method of denervating the parietal cell mass without the need for a drainage procedure was assessed in 143 patients with chronic duodenal ulcer at two different centres. There were no early complications directly attributable to the gastric surgery and the operation took less time than truncal vagotomy and pyloroplasty. Postoperative diarrhoea and dumping were not significant difficulties. Basal acid output was reduced by 84.4% and an early positive insulin response within the first three months occurred in 8.75% of patients tested. Satisfactory Visick grades (I and II) were recorded in 93.8% of patients during the early postoperative period.

[(Influence of somatostatin (SS-14) on early dumping reaction in patients after partial gastrectomy) ]

In seven patients suffering from early dumping syndrome after partial gastrectomy (Billroth II operation) an early dumping reaction was provoked by 100 g dextrose per os and the influence of somatostatin-14 (SS-14) infusion on clinical appearance of dumping syndrome was evaluated. SS-14 in contrast to the control trial resulted in total suppression of insulin release and slightly delayed and lowered increase of blood glucose which was not statistically significant, but with SS-14 there was no change in clinical symptoms of dumping reaction and compared to the control test no significant difference was found between the decrease of blood pressure, the increase of pulse frequency, the small increase of hematocrit and plasma free fatty acids.

The albatross syndrome--how to prevent it

While no single test or historical feature will allow the physician to predict the patients who will have poor results from ulcer surgery, certain factors may alert the physician to a possible poor result and encourage careful re-evaluation of the need for surgery. Any patient with intractable pain should be assessed carefully in an attempt to establish the cause of the intractability, and this assessment should include endoscopy. The endoscopist may help to identify those patients with structural disease that is too minimal to explain the intractable complaints. Careful attention should also be given to the evaluation of the patient's personality, work record, and relationship to spouse, family, and friends. Patients who have previously been disabled by other medical problems such as low back injury should be approached with caution. While newer procedures in ulcer surgery may alter the incidence of standard postgastrectomy complications it will not alter the incidence of the albatross syndrome, which is more directly related to the selection of the patient rather than the selection of the surgeon or surgical procedure.