Early Dumping Syndrome Research Articles

Relation between gastroduodenal interdigestive migrating motor complex and postoperative gastrointestinal symptoms before and after cisapride therapy following distal gastrectomy for early gastric cancer.

A total of 30 patients (18 men, 12 women; 43-79 years, mean 58.9 years) 1.0 to 1.5 years (mean 1.25 years) after distal gastrectomy for early gastric cancer (Billorth I, D2 lymph node dissection, curability A) were divided into two groups based on the occurrence of interdigestive migrating motor complex (IMMC) phase III (pIII) from the duodenum and their postoperative gastrointestinal symptoms. They were compared before and after cisapride therapy (at an oral dose of 7.5 mg/day for 3 months). Results were as follows. Before cisapride therapy: (1) Patients in the IMMC-pIII-positive group (n = 20) had more appetite and ate more food with less decrease in body weight than those in the IMMC-pIII-negative group (n = 10); (2) patients in the IMMC-pIII-positive group clearly had fewer symptoms, such as early dumping (systemic) symptoms, symptoms of reflux esophagitis (e.g., heartburn, feeling of regurgitation, difficult swallowing), nausea, abdominal pain, diarrhea, abdominal distension, and borborygmus, than the IMMC-pIII-negative group. After cisapride therapy: eight patients (80%) in the IMMC-pIII-negative group became IMMC-pIII-positive, and their appetite and food consumption were obviously improved; body weight increased in six patients (60%), with alleviation of other abdominal symptoms and disappearance of the early dumping syndrome. These results showed a more satisfactory condition in regard to gastrointestinal symptoms in the IMMC-pIII-positive group than in the IMMC-pIII-negative group. It is concluded that cisapride therapy results in the occurrence of IMMC-pIII and subsequently alleviates various abdominal symptoms, contributing to the improved postoperative gastrointestinal condition of patients after gastrectomy.

Quality of life after laparoscopy-assisted Billroth I gastrectomy.

To evaluate the quality of life of patients who had undergone laparoscopy-assisted Billroth I gastrectomy (LAG) for cure of cancer. In 1994, the authors reported the first case of LAG for early gastric cancer, and this approach quickly has been adopted by Japanese surgeons. However, little is known about the subjective clinical results of this less invasive surgery. Quality of life was estimated using the 24-item questionnaire with a scoring system of 1, 2, and 3 and was compared between 41 consecutive patients with LAG and 35 with conventional open gastrectomy. All patients underwent Billroth I gastrectomy for early gastric cancer from January 1993 to July 1997 and were alive without recurrence. Patients who had undergone LAG were taking a normal diet (100%) with >66% of volume at each meal (90%), showed no decreased performance status (90%), and were satisfied with their surgical results (88%). Patients with LAG, when compared with open gastrectomy, showed significantly better results with regard to weight loss, difficulty in swallowing, heartburn and belch, early dumping syndrome, and total score. LAG was better accepted by the patients. Quality of life after Billroth I gastrectomy was significantly better in patients in whom a laparoscopic technique was used than in those who underwent a conventional method. LAG is less invasive and better accepted by patients and is the procedure of choice for the treatment of early gastric cancer.

Measurement of superior mesenteric artery flow by means of Doppler ultrasound in early dumping syndrome.

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. 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. 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. 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.

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.

Is superior mesenteric artery flow increased in patients with early dumping syndrome

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 blood flow but controlled data are lacking. We have studied basal and postprandial splanchnic blood flow (Doppler ultrasound) in patients with proven early dumping and in two control groups. The dumping group consisted of patients after Billroth II gastrectomy (n=6; age 51 ± 6 yr; body mass index 22 * 1 kg/m2), the surgical control group consisted of patients after Billroth II gastrectomy without dumping symptoms (n=7; age 58 ± 7 yr; body mass index 23 ± 1 kg/m 2) and the third group consisted of healthy controls without previous gastric surgery (n=10; age 52 ± 7 yr; body mass index 23 -+ 1 kg/m2). Blood glucose and heart rate were measured after oral dumping provocation with 50 g glucose in 200 ml. Superior mesenteric artery (SMA) blood flow was measured both basally and 20 min after the glucose ingestion. Basal SMA flow was similar in the three groups 0.36 ± 0.06 l/min (dumping), 0.39 ± 0.05 l/min (surgical controls), 0.43 ± 0.02 l/min (healthy controls). After glucose ingestion SMA flow increased significantly in all groups (p < 0.05). Stimulated SMA flow was not significantly different between dumping patients and surgical controls (1,0 ± 0.2 vs 1.0 ± 0.1 l/rain). However, stimulated SMA flow in both groups after gastric surgery combined was significantly (p < 0.05) higher than in healthy controls (1.0 ± 0.I vs 0.7 ± 0.2 l/min). Conclusion: The systemic symptoms associated with early dumping do not result from increased splanchnic blood flow per se. Patients after gastric surgery have an increased postprandial SMA flow irrespective of the presence of dumping.

Complications of Biliopancreatic Diversion Surgery as Proposed by Scopinaro in the Treatment of Morbid Obesity.

BACKGROUND: This study concerns 33 patients treated for morbid obesity with the procedure proposed by Scopinaro. Results are reviewed retrospectively in terms of complication rates. METHODS: The group consisted of ten men and 23 women with a mean age of 34 years (range 20-51 years), and a mean BMI of 49.5 kg/m(2) (range 37-77). Adequate attempts at medical management had failed repeatedly. The operative procedure involved a 2/3 partial gastrectomy and biliopancreatic diversion by Roux-en-Y reconstruction 50 cm before the ileocecal valve. In one patient, a cholecystectomy was added. RESULTS: The mean weight loss after 6 months was 18.9% of the initial weight, with mean BMI 41 kg/m(2) (range 29-60). Early complications included four wound infections (15%), while two patients complained of an early dumping syndrome (6%), treated by dietary measures. There were no respiratory infections and no pulmonary embolism, likely as a result of the thoracic epidural anesthesia and high doses of prophylactic heparin used. There was no mortality. As to late complications, nine patients complained of diarrhea due to bacterial overgrowth (27%) and were treated with antibiotic therapy. There were five incisional hernias (15%). Five patients had a peptic ulcer (15%) and required medical treatment. Two patients had acute cholecystitis (6%). One patient had an afferent loop obstruction (3%), requiring reoperation. CONCLUSIONS: Overall, this series of intestinal diversion procedures by the method of Scopinaro had a larger complication rate than generally accepted.

Postgastrectomy symptoms and early dumping syndrome after pyloruspreserving gastrectomy or Billroth- I gastrectomy.

Postgastrectomy symptoms and early dumping syndrome after pyloruspreserving gastrectomy or Billroth- I gastrectomy.

Acute vasodilatation in early dumping syndrome

The acute hemodynamic effect of cyclosporine in man is controversial. A randomized, double blind, placebo-controlled, cross-over study was undertaken to evaluate the effect of a single oral dose of cyclosporine (20 mg/kg body weight) on mean blood pressure (MBP), heart rate (HR), forearm blood flow (FBF), and vascular resistance (FVR) in 16 healthy adult subjects. Subjects were studied twice, with an intervening period of 2 weeks, before and after the administration of either cyclosporine or the vehicle olive oil. Blood pressure was measured on brachial and digital arteries. After 30 min of rest, basal measurements were obtained and individuals were randomly assigned to receive either cyclosporine or the vehicle, and the same measurements were repeated 2 h later. Mean whole blood levels of cyclosporine were 1542 ± 387 ng/mL (range 1000 to 2550) 2 h after the administration of a single oral dose of cyclosporine. Cyclosporine did not cause any significant change in the hemodynamic parameters when compared with vehicle. Pre- and post–cyclosporine data were as follows (means ± SD): MBP (determined by Finapres on the digital artery), 92 ± 10 v 95 ± 11 mm Hg; HR, 66 ± 10 v 68 ± 11 beats/min; FBF, 3.9 ± 1.3 v 3.8 ± 1.8 mL/100 mL/min; and FVR, 28 ± 9 v 33 ± 18 units, respectively. For the vehicle the results were: MBP, 94 ± 9 v 94 ± 9; HR, 67 ± 9 v 67 ± 11; FBF, 3.3 ± 1.6 v 3.2 ± 2.0; FVR, 35 ± 14 v 37 ± 15, respectively. These figures did not differ from those obtained with the auscultatory method applied to the brachial artery among 10 selected subjects studied with Finapres. In conclusion, we found no evidence that at supratherapeutic doses cyclosporine causes acute increase in blood pressure or peripheral vasoconstriction in humans.

Role of Somatostatin and Octreotide in Esophageal Varices, Dumping Syndrome and Diarrhea

Bleeding from esophageal varices has a high mortality rate. Sclerotherapy is the most appropriate treatment, but is not always available. Alternatively, somatostatin and octreotide may be used for the treatment of variceal bleeding. They seem to be as effective as vasopressin but have fewer adverse effects. Their role as adjuvant treatment to emergency sclerotherapy for active variceal bleeding must be further investigated. Somatostatin and octreotide reduce symptoms of the early and late dumping syndrome. Their therapeutic benefit is probably associated with a slower gastric emptying and small bowel transit time and inhibition of the release of peptide hormones mediating vasomotor symptoms. In refractory diarrhea, octreotide is able to promote intestinal absorption and inhibit gastric, pancreatic and intestinal secretion. Octreotide positively affects short bowel syndrome, secretory diarrhea resulting from neuroendocrine tumors, intestinal infections in AIDS patients, and motility disorders in diabetes mellitus and systemic sclerosis.

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.

Octreotide acetate induces fasting small bowel motility in patients with dumping syndrome

The long acting somatostatin analogue octreotide acetate has been effective in the treatment of early dumping syndrome. We hypothesized that this may be related to its effects on inhibiting gastric emptying and delaying intestinal transit. To study the effects of octreotide acetate on intestinal motility in patients we carried out a randomized, double-blinded study using a subcutaneous injection of either octreotide acetate (100 μg) or placebo given 20 min prior to ingestion of a high carbohydrate “dumping” meal in six patients with known severe dumping syndrome. Prior to each study a multilumen polyethylene tube was inserted into the efferent limb to study small intestinal contractions using low compliance pneumo-hydraulic water-perfused manometry. Octreotide acetate prevented dumping symptoms in all six patients and induced the appearance of migrating myoelectric complexes (MMC) characteristic of interdigestive motility. After ingestion of the dumping meal the postprandial “fed” motility pattern lasted for 141 ± 9 min while after octreotide acetate the fed motility lasted for 29 ± 5 min ( P < 0.03). The vigor of the fed motility pattern as measured by the motility index (MI = log e{sum of amplitudes × No. of contractions + 1}) was lower after octreotide acetate than after placebo (15.1 ± 0.1 vs 13.4 ± 0.2, P < 0.03). The induction of fasting MMC motility pattern and reduction in the duration and vigor of fed motility may explain the symptomatic relief these patients obtained with octreotide acetate. It is not known whether the induction of the MMC is a direct effect of octreotide acetate or secondary to the concomitant inhibition of peptide release (neurotensin, insulin, glucagon, pancreatic polypeptide) that has been demonstrated in earlier studies.

Extracellular space, blood volume, and the early dumping syndrome after total gastrectomy

Extracellular space and blood volume were measured using 82Br dilution and 51Cr-tagged erythrocytes in 24 tumor-free patients after total gastrectomy. Eleven of the patients suffered from early dumping. Age, blood volume, and extracellular space were significantly smaller in dumpers (P < 0.05). The dumping score could be predicted by a multiple regression model considering blood volume per lean body mass and extracellular space (r = 0.637; P = 0.0039). Rapid (t1/2 < 360 seconds) emptying of the gastric substitute, assessed using a 99Tc-labeled solid test meal, was significantly associated with dumping in addition to extracellular space and blood volume (r = 0.876; P = 0.0018). Both rapid emptying and a narrow extracellular space seem to contribute to the early dumping syndrome.

Studies on the pathogenesis of the early dumping syndrome induced by intraduodenal instillation of hypertonic glucose.

A reaction indistinguishable from the early dumping syndrome was induced in four of nine normal volunteers by intraduodenal instillation of a hypertonic glucose meal. Tachycardia and marked peripheral vasodilatation were demonstrated in 'dumpers' by Doppler ultrasound measurements of the arterial blood flow signal. The dumping reaction was not detectably altered by the addition of guar to the meal. Plasma VIP concentration rose and plasma volume fell to a similar degree in 'dumpers' and 'non-dumpers', suggesting that neither event is an integral component of the dumping mechanism. In contrast, the rates of rise of blood glucose and enteroglucagon concentration were markedly greater in 'dumpers'. The results are inconsistent with the conventional explanation that the early dumping syndrome is caused by a large osmotic fluid shift, but are compatible with a mechanism involving an initial period of intestinal hypermotility.

Clinical and radionuclide evaluation of Roux-Y diversion for postgastrectomy dumping

From 1973 to 1986, 22 patients underwent Roux-Y gastrojejunostomy for the early postgastrectomy dumping syndrome. In the early years, five patients underwent Roux-Y conversion with the addition of a 10 cm antiperistaltic jejunal segment interposed between the Roux-Y limb and the stomach. Within 4 years, all five patients had the jejunal segment removed due to severe symptoms of gastric retention. These patients underwent reconstruction to create Roux-Y limb only and joined the pool of 17 patients who underwent Roux-Y diversion only for the dumping syndrome. Overall, 19 of 22 patients (86 percent) had almost complete resolution of their dumping symptoms on long-term follow-up. Three patients showed no improvement, two with severe gastric retention and one with recurrent dumping symptoms. Overall, 5 of 22 patients (23 percent) had moderate to severe early and late postoperative gastric retention necessitating medical treatment in three and subsequent near-total gastrectomy in two. Although other procedures such as pyloric reconstruction or the addition of isoperistaltic or antiperistaltic jejunal interpositions have been reported to be equally successful in delaying gastric emptying and resolving dumping symptoms, we have preferred Roux-Y diversion for the treatment of combined alkaline reflux gastritis and dumping or the pure early vasomotor postgastrectomy dumping syndrome. As reported, we have abandoned the use of an antiperistaltic jejunal segment interposed between the stomach and the Roux-Y limb due to the high rate of postoperative gastric retention.

Somatostatin and the dumping syndrome.

Infusion of somatostatin reduced the symptoms of the early dumping syndrome after oral glucose was given and also reduced the associated tachycardia and rise in packed cell volume. It inhibited the secretion of enteroglucagon, neurotensin, and vasoactive intestinal polypeptide, which are raised in patients with the dumping syndrome and may have an aetiological role. It also prevented the reactive hypoglycaemia of late dumping by inhibiting the release of gastric inhibitory polypeptide and insulin. Somatostatin, possibly through its inhibitory effects on hormonal secretion, may have a role in the management of patients with the early and late dumping syndrome.

Catecholamines in the early dumping syndrome.

Catecholamines in the early dumping syndrome.

Circulatory hemodynamic changes in the early dumping syndrome

It seemed that the early dumping syndrome might occur in patients with unstable vegetative nerves and psychoneurotic characters, who sensitively responsed to altered blood flow in various parts of the body and a reduction in circulating blood volume, which was thought to arise from the rapid influx of the hypertonic foodstuff into the jejunum. As the surgical treatment, we emphasized the excellent effect of Tomoda’s gastrectomy for the prevention of the early dumping syndrom.

The Postgastrectomy Syndromes.

This small book is a review from a surgical viewpoint of the several syndromes and their pertinent physiology arising after gastrectomy. The author and the publisher pleasantly assemble this material in more detail than is present in either the textbooks or the literature. The discussion of the early postprandial dumping syndrome, the late postprandial dumping syndrome, and the afferent loop syndrome is well done. Overall I was troubled in knowing for whom the book was intended. The review is insufficiently exhaustive or critical to serve as a reference source and much longer than several good reviews on the subject inSurgical Clinics of North Americato compete with their conciseness.

INCIDENCE AND MECHANISM OF THE EARLY DUMPING SYNDROME AFTER GASTRECTOMY A CLINICAL AND RADIOLOGICAL STUDY

INCIDENCE AND MECHANISM OF THE EARLY DUMPING SYNDROME AFTER GASTRECTOMY A CLINICAL AND RADIOLOGICAL STUDY