H. D. Becker W.F. Caspary Postgastrectomy and Postvagotomy Syndromes With 84 Figures (Mainly in Two Colors) Springer-Verlag Berlin Heidelberg New York 1980
Professor Dr. med. H. D. Becker KlInik und PolIklImk fur Allgemeinchlrurgle, Robert-Koch-Str. 40, D-3400 GottIngen. Federal RepublIc of Germany Professor Dr. med. W. F. Caspary II. MedlzInische Kiinik, Stadtkrankenhaus, LelmenstraBe 20, D-6450 Hanau, Federal RepublIc of Germany ISBN-13: 978-3-642-67352-8 e-isbn-13: 978-3-642-67350-4 DOl: 10.1007/978-3-642-67350-4 Library of Congress Cataloging in Publication Data. Becker. Horst-DIeter. 1941, Postgastrectomy and postvagotomy syndromes. Includes bibliographies and Index. 1 Postgastrectomy syndromes. 2. Postvagotomy syndromes. I Caspary, Wolfgang F, 1940, JOInt author. II. TItle. [DNLM: 1. Postgastrectomy syndromes. 2. Vagotomy - Adverse effects 3 Stomach - Surgery WI380 B395p] RD540 5 B45 617:5530180-11186 ThIS work IS subject to copynght. All nghts are reserved, whether the whole or part of the matenalls concerned, specifically those of translation, reprinting, re-use of J!lustratlOns, broadcasting, reproduction by photocopylllg machllle or similar means. and storage III data banks Under 54 of the German Copynght Law. where copies are made for other than pnvate use, a fee IS payable to the publisher. the amount ofthe fee to be determined by agreement with the publisher. by Springer-Verlag Berlin Heidelberg 1980 Softcover reprint of the hardcover I st edition 1980 The use of registered names. trademarks. etc. III this publication does not Imply. even III the absence of a specific statement. that such names are exempt from the relevant protective laws and regulations and therefore free for general use. IllustratIOns: Adnan Cornford.
To our wifes and children Hedda, Christian, Tina, Brigitte, Ulrike, Martin
Foreword Besides the mortality rate the value of an operative procedure is measured against the incidence and the degree of undesirable postoperative sequelae. In the surgical treatment of gastroduodenal ulcerations vagotomy is now competing with the successfully established resection therapy. Since this latter method has been further developed during the last years and late results are rare, a comparison between both types of operation is difficult. Meritoriously, the authors have tried to perform a comprehensive analysis. Due to the complexity of postoperative syndromes the diagnostic procedure and treatment can be successful only after integrated cooperation by gastroenterologists and surgeons. This is documented by the current monograph which originates from a cooperation of several years and an active exchange of scientific and practical experience. The monograph will facilitate the indication for the primary surgical procedure by critical confrontation of the postoperative syndromes and provide advice in treating postoperative complaints. We hope that the monograph will have the expected impact, which means the spreading of the actual knowledge of postgastrectomy and postvagotomy syndromes. W. CREUTZFELDT H. J. PEIPER
Contents Part I Gastric Surgery and its Results. 1 1 Short Historical Survey... 1 2 Results of Gastric Surgery. 2 2.1 Gastric Resection in Peptic Ulcer Disease 2 2.2 Truncal Vagotomy plus Drainage in Duodenal Ulcer Patients 6 2.3 Comparison of Truncal Vagotomy and Gastric Resection.. 6 2.4 Comparison of Different Drainage Procedures in Vagotomy. 7 2.5 Comparison of Truncal Vagotomy and Selective Gastric Vagotomy. 11 2.6 Selective Proximal Vagotomy................. 13 2.7 Comparison of Selective Gastric Vagotomy and Selective Proximal Vagotomy 15 2.8 Summary. 16 References.. 16 Part II Diagnostic Procedures 19 3 X-ray Findings.. 19 References.... 21 4 Postoperative Endoscopy. 22 5 Gastric Secretory Analysis 23 5.1 Pentagastrin Test.. 23 5.1.1 Gastric Secretion after Billroth I and Billroth II Resection. 24 5.1.2 Gastric Secretion after Vagotomy...... 25 5.1.3 Acid Secretion in Zollinger-Ellison Syndrome. 25 5.2 Insulin Test...... 26 6 Endocrine Provocation Tests 27 6.1 Calcium Infusion Test 27 6.2 Secretion Test. 27 6.3 Glucagon Test. 28 References.... 28 7 Gastric Emptying. 29 7.1 Mechanism and Regulation 29 7.2 Isotope Tests...... 30
x 7.3 Gastric Emptying after Gastric Surgery. References...... 8 Measurement of Reflux..... References........... 9 Laboratory Tests for Malabsorption 9.1 Absorptive Function Tests.. 9.1.1 Upper Small Intestine.. 9.1.1.1 Oral Glucose Tolerance Test. 9.1.1.2 D-Xylose Test.... 9.1.1.3 Lactose Tolerance Test 9.1.1.4 Faecal Fat Excretion 9.1.1.5 Breath Tests.... 9.1.1.6 Small-Bowel Biopsy 9.1.2 Ileum.......... 9.1.2.1 Schilling Test... 9.1.2.2 14C-Glycocholate Breath Test 9.2 Measurement of Enteric Loss of Protein. References................ Contents 31 36 37 38 39 39 41 42 42 43 44 45 47 47 47 48 50 50 Part III Postgastrectomy Syndromes. 51 10 Dumping....... 51 10.1 History and Definition 51 10.2 Early Dumping. 52 10.2.1 Symptoms.. 52 10.2.2 Incidence... 52 10.2.3 Natural Course 53 10.2.4 Aetiology... 54 10.2.5 Medical Treatment. 58 10.2.6 Surgical Treatment. 59 References....... 66 10.3 Late Dumping... 69 10.3.1 Pathogenesis 69 10.3.2 Therapy.. 71 References....... 71 11 Afferent-Loop Syndrome 72 11.1 Acute ALS.. 73 11.2 Chronic ALS... 74 11.2.1 Therapy.. 77 11.2.1.1 Braun's Jejunojejunal Entero-anastomosis. 78 11.2.1.2 Roux-en-Y Anastomosis....... 78 11.2.1.3 Conversion of Billroth II to Billroth I.. 79 11.2.1.4 Removal of a Simple Gastro-enterostomy 79 11.2.1.5 Jejunoplasty. 80 References....... 80 12 Efferent-Loop Syndrome 81 References....... 84
Contents XI 13 Postoperative Reflux Gastritis................ 84 13.1 Pathogenesis..................... 84 13.1.1 Differentiation from Chronic Afferent-Loop Syndrome 86 13.1.2 Measurement of Bile Reflux.......... 87 13.1.3 Experimental Results............. 89 13.1.4 Mechanisms Involved in Gastric Mucosal Damage 91 13.1.5 Lysolecithin - a Pathogenetic Factor? 93 13.2 Symptoms and Diagnosis 94 13.3 Medical Treatment. 95 13.4 Surgical Treatment... 97 References......... 100 14 Postoperative Reflux Oesophagitis 102 14.1 Incidence......... 102 14.2 Pathogenesis....... 103 14.3 History and Clinical Symptoms 104 14.4 Therapy.. 105 References.... 105 15 Gastro-Ileostomy. 107 References.... 108 16 Recurrent Peptic Ulceration 109 16.1 Incidence...... 109 16.2 Aetiology...... 110 16.2.1 Inadequate Surgery 110 16.2.2 Hypersecretion of Acid. 112 16.2.3 Ulcerogenic Agents 112 16.3 Diagnosis.......... 112 16.3.1 Clinical Symptoms... 113 16.3.2 Radiological Examination. 113 16.3.3 Gastroscopy.. 113 16.3.4 Gastric Analysis. 113 16.4 Conservative Treatment. 114 16.5 Surgical Therapy.... 114 16.6 Therapy of Gastrojejunocolic Fistula 116 References......... 118 17 Gastric Remnant Carcinoma...... 119 17.1 Definition........... 119 17.2 Incidence, Risk and Interval After Operation 119 17.3 Pathogenetic Factors. 121 17.4 Symptoms..... 122 17.5 Diagnostic Procedures 122 17.6 Therapy Prognosis.. 123 References........ 124 18 Postgastrectomy Malabsorption 125 18.1 Incidence of Weight Loss and Steatorrhoea 125 18.2 Physiology of Fat Digestion and Absorption. 127 18.3 Pathophysiology of Postgastrectomy Steatorrhoea 128 18.3.1 Gastric Mechanism.... 128 18.3.2 Pancreaticocibal Asynchrasy....... 131
XII 18.3.3 Small-intestinal Factors..... 18.3.4 Bacterial Overgrowth....... 18.3.5 Bacteria and Bile Acid Metabolism. 18.4 Diagnosis. 18.5 Treatment.... References....... 19 Postgastrectomy Anaemia 19.1 Incidence...... 19.2 Iron-Deficiency Anaemia 19.3 Vitamin B12 Deficiency. 19.4 Folate Deficiency... References......... 20 Postgastrectomy Bone Disease 20.1 Incidence....... 20.2 Osteomalacia and Osteoporosis 20.3 Metabolic Findings.. 20.4 Diagnosis and Treatment... References............ 21 Special Aspects of Total Gastrectomy References............. Part IV Postvagotomy Syndromes......... 22 Postvagotomy Dysphagia....... 22.1 Incidence, Symptoms and Aetiology 22.2 Experimental Findings 22.3 Treatment...... References......... 23 Vagal Denervation Syndrome 23.1 Pathophysiology. 23.2 Treatment.... References....... 24 Postvagotomy Diarrhoea 24.1 Definition and Incidence 24.2 Aetiology. 24.3 Therapy....... References......... 25 Cholelithiasis after Vagotomy 25.1 Incidence.. 25.2 Pathogenesis..... References......... 26 Recurrent Ulcer after Vagotomy 26.1 Incidence...... 26.2 Pathogenetic Factors. 26.3 Diagnostic Procedure. 26.4 Treatment References. Subject Index... Contents 133 134 138 141 141 144 147 147 148 149 152 152 154 154 154 156 157 159 160 162 163 163 163 166 167 167 168 168 170 170 170 170 172 176 176 178 178 178 182 183 183 184 185 186 186 187