ASSESSMENT OF THE GASTRO-JEJUNO-DUODENAL TRANSIT AFTER JEJUNAL POUCH INTERPOSITION / AVALIAÇÃO DO TRÂNSITO GASTROJEJUNODUODENAL APÓS INTERPOSIÇÃO DE ALÇA JEJUNAL

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.

Racional : A interposição de alça jejunal entre o corpo gástrico e o duodeno após a antrectomia, apesar de pouco frequente na prática cirúrgica atual, tem sido empregada com sucesso na prevenção e tratamento das síndromes pós-gastrectomias. Entre estas se inclui a síndrome de dumping, que acomete 13-58% dos pacientes gastrectomizados. Objetivo : Avaliação retrospectiva dos resultados desse procedimento na prevenção da síndrome de dumping. Métodos : Foram selecionados 40 pacientes todos encaminhados para tratamento cirúrgico de úlcera cloridropéptica entre 1965 e 1970. Destes, 29 foram submetidos à vagotomia, antrectomia, gastrojejunoduodenostomia no nível da pequena curvatura, e os 11 restantes à vagotomia, antrectomia, gastrojejunoduodenostomia no nível da grande curvatura. O trânsito gastrojejunoduodenal foi avaliado no pós-operatório imediato ou tardio por meio do estudo contrastado de esôfago, estômago e duodeno. A evolução clínica no pós-operatório foi avaliada segundo a classificação de Visick. Resultados : Dos 40 pacientes, 28 foram acompanhados com o estudo contrastado no pós-operatório tardio. Entre aqueles de até o 1º mês de pós-operatório (n=22), 20 (90%) apresentaram o trânsito gastrojejunoduodenal lento e dois (10%) tiveram o trânsito normal. Entre os que puderam ser acompanhados após o 1º mês (n=16), três (19%) e 13 (81%) mostraram o esvaziamento gástrico lento e normal, respectivamente. Nenhum apresentou o estudo contrastado compatível com a síndrome de dumping. Entre os 40 doentes, 22 foram submetidos à avaliação clínica pós-operatória. Destes, 19 (86,5%) apresentaram excelentes e bons resultados (Visick 1 e 2, respectivamente). Conclusões : A interposição de alça jejunal mostrou-se procedimento cirúrgico bastante eficaz na prevenção da síndrome de dumping em pacientes gastrectomizados.

Avaliação da síndrome de dumping em pacientes obesos mórbidos submetidos à operação de bypass gástrico com reconstrução em Y de Roux / Analysis of the dumping syndrome on morbid obese patients submitted to Roux en Y gastric bypass

OBJETIVO: Determinar a prevalência da síndrome de dumping em uma série de casos submetidos ao bypass gástrico, baseado em critérios clínicos, e caracterizar seus principais aspectos. MÉTODOS: Foi realizada uma análise dos sintomas descritos como dumping em 34 pacientes obesos mórbidos submetidos ao bypass gástrico com reconstrução em Y de Roux, por meio do preenchimento de um questionário que incluiu um sistema de escore para o diagnóstico clínico da síndrome de dumping, descrito por Sigstad. RESULTADOS: A ocorrência de dumping com base em critérios subjetivos foi de 44 por cento. Aplicando o escore para diagnóstico clínico, a ocorrência foi de 76 por cento. Os sintomas mais freqüentes foram "vontade de deitar" (88 por cento), cansaço (69 por cento) e sono (69 por cento). Apenas 28 por cento dos pacientes com dumping se sentiram incapacitados para a realização das atividades cotidianas. Não foi observada diferença entre o percentual de perda de peso dos pacientes dumpers e não-dumpers. CONCLUSÃO: O escore de Sigstad se mostrou uma ferramenta útil para o diagnóstico de dumping, embora uma visão crítica deva ser adotada quando utilizado em pacientes submetidos ao bypass gástrico. A síndrome de dumping foi frequente nesta população, embora geralmente subestimada, não sendo incapacitante para a realização das atividades cotidianas dos pacientes, assim como não se mostrou um fator relevante no auxílio à perda de peso.

OBJECTIVE: The objective of this research was to determine the real prevalence and characteristics of dumping syndrome in a series of cases submitted to laparoscopic Roux-en-Y gastric bypass for morbid obesity. METHODS: We assessed dumping symptoms in 34 patients who had undergone that procedure; they filled a questionnaire, which included the dumping clinical diagnosis score proposed by Sigstad. RESULTS: regarding patients' complaints, dumping prevalence was 44 percent. This number increased to 76 percent when applying the Sigstad's score. The most frequent symptoms were "need for lying down" (88 percent), fatigue (69 percent) and sleepiness (69 percent). Only 28 percent of the dumpers felt incapable of performing everyday activities. There was no difference in weight loss percentage between dumpers and non-dumpers. CONCLUSION: The Sigstad score is an usefull tool for the diagnostic of dumping, but a critic vision must be adopted when using in pacients submited to the Roux en Y gastric bypass. The dumping syndrome was frequent in this group, although usually under-diagnosed; it neither hampers patients' everyday activities considerably, nor helps in the weight-loosing process.

Síndrome de vaciamiento rápido en pacientes sometidos a resección gástrica / Dumping syndrome in patients submitted to gastric resection

BACKGROUND: We undertook this study to establish the incidence of dumping syndrome after partial or total gastric resection and its association with patient's preoperative nutritional status as well as the clinical behavior with dietary management during a short-term follow-up period. METHODS: This was a prospective study of consecutive patients >30 years of age and who were submitted to gastrectomy for gastric cancer or complicated ulceropeptic disease during a 48-month period in a highly specialized hospital. RESULTS: A total of 42 patients were evaluated with a slight female predominance (n = 22, 52.4%). Twenty-nine cases (69%) had subtotal gastrectomy and 13 (31%) had a total gastrectomy. Patients had a medium age of 54.38 +/- 7.56 vs. 66 +/- 13.99 years, respectively (p = 0.034). Reconstruction techniques were Roux-en-Y gastrojejunostomy in 70% and Roux-en-Y esophagojejunostomy in 28.5%. We found dumping syndrome in 45% of the cases associated with acute or chronic undernutrition (p = 0.003). Fifty-three percent of the patients with dumping syndrome improved with adequate dietetic manipulation during a follow-up period of 211 days. CONCLUSIONS: Although the majority of reconstructions were performed with dysfunctionalized small bowel segments, the incidence of dumping syndrome was 45%. Patient's preoperative nutritional status influenced the presence of clinical manifestations. Adequate dietary management reduced, in 53% of the patients, the presence of dumping symptoms during a short-term follow-up period.

Causas da desnutrição pós-gastrectomia / Causes of malnutrition in post-gastrectomy patient

The stomach through its mechanical and chemical processes has an unique role in the food processing and bioavailability. Hence gastrectomy has predictable and modifiable nutritional consequences depending upon its knowledge and the post-surgery therapies. OBJECTIVE: To point out the impact of gastrectomy on the nutritional status focusing on both mechanical and chemical actions of stomach on intaked foods. RESULTS: The protein-energy malnutrition and consequent body-weight loss follow reversely the remainer gastric volume and post-operatory length and have anorexy and intestinal malabsorption as their main causes. Lower food intake is probably due to either emotional factors or chemical mediators acting centrally on hypothalamus. The diarrhea may be due to either increased peristalsis or bacterial overgrowth both aggravated by exocrine-pancreas deficiency and gallbladder overflow. The intestinal malabsorption leading to fecal losses of fat and or nitrogen as well as lower utilization of dietary calcium and liposoluble vitamins. The gastrectomy-related anemia is consequent to lower secretion of both HCl and intrinsic factor leading to a decreased solubilization of iron and lower absorption of vitamin B12, respectively. CONCLUSION: Body-weight loss and anemia are the protein-energy malnutrition findings often found in these patients whose severity and lasting depend upon the type of surgery, post-surgery length and received nutritional care, being strongly recommended a supervisioned dietary care

Dumping syndrome in a young Jamaican child

The dumping syndrome in childhood is an uncommon complication of gastro-oesophageal surgery, principally Nissen fundoplication. A Jamaican child developed the syndrome after fundoplication and pyloroplasty to relieve gastro-oesophageal reflux complicating the repair of a congenital tracheo-oesophageal fistula. He developed marasmus and failed to gain weight on the standard remedial milk-based high-energy diet. An oral glucose tolerance test confirmed the diagnosis of dumping syndrome. A low sugar low milk diet based on adult type meals with continuous nibbling of fried dumplings relieved his diarrhoea and hypoglycaemia and he gained weight. This is a cheaper and more practical dietary therapy than the regimens described previously.

Linfoma no Hodgkin del estómago: evaluación del tratamiento quirúrgico en 24 pacientes / Non Hodgkin lymphoma of the stomach: evaluation of surgical treatment in 24 patients

This is a retrospective review of 24 patients with Non Hodgkin lymphoma of the stomach operated between 1959 and 1991. The diagnosis was reached with a radiological study in 12 of 15 (80 percent) patients and with endoscopy in 11 of 16 (69 percent) of patients. Eleven of 14 (78 percent) preoperative biopsies available at the moment of the revision were positive for non Hodgkin Lymphoma. Clinical staging was performed using Ann Arbor Classification and the histological type was defined according to the Working Formulation. Diffuse large cell lymphoma (intermediate grade) was the most frequent histological subtype. Eleven patients were in clinical stage I, 10 patients in stage II and 3 in stage IV. Eight total gastrectomies and 16 subtotal gastrectomies were performed. Twenty one percent of patients had a postoperative complication and operative mortality was 12 percent served. Stage II patients received adjuvants chemotherapy, the tumor recurred in three and two died due to disease progression. Five years disease free survival was 64 percent. It is concluded that surgical treatment achieves a good disease control in stage I patients but must be complemented with chemotherapy in stage II tumors

Síndrome de Dumping en pediatría / Dumping syndrome in pediatrics

Se describen 2 pacientes con síndrome de dumping como complicación de la cirugía antirreflujo gastroesofágico. El diagnóstico se sospechó por la presencia de síntomas postprandiales inmediatos y tardíos junto con el antecedente quirúrgico. La detección de hiperglucemia seguida de hipoglucemia durante la prueba oral de tolerancia a la glucosa, junto a una evacuación gástrica acelerada demostrada por seriada gastroduodenal y cámara gamma con Tc 99, permitió la confirmación diagnóstica. Los pediatras deberán estar alerta sobre esta complicación en el postoperatorio inmediato y mediato de la cirugía antirreflujo gastroesofágico