[Principal reasons for repeated surgery in gastroduodenal ulcer and ways of preventing it].
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Clinical follow-up results of 876 patients with operated stomach malady, 342 of whom were operated on, were analyzed. In 58% of patients after the perforation closure the ulcer recurrence occurred, in 26% after gastric resection--peptic ulcer, in 26%--functional pathological syndrome. Surgical tactics depended on character of previously conducted procedure, general condition and age of the patient, secretory function of stomach and operative situation. Complications occurred in 6.1% of patients. Mortality was 1.2%.
The dumping syndrome is a very troublesome problem to some patients after gastric surgery. Gel-forming carbohydrates have recently been used to modify glucose absorption. The addition of 14.5 g of pectin to a 50-g oral glucose load prevented the occurrence of hypoglycemic symptoms and maintained the blood glucose levels above control values by 64% at 90 min (P less than 0.002) and 46% at 120 min (P less than 0.01) in postgastric surgery patients whose 120-min values after 50 g of glucose alone had fallen below 50 mg per 100 ml (2.8 mmoles per liter). Breath H2 production, used as an index of bacterial fermentation of glucose, was abolished or reduced by pectin in all 5 cases in which this had previously occurred. A trial of 10 g of pectin per day prevented recurrent postprandial hypoglycemic attacks in the most severely affected individual. Pectin and perhaps other unabsorbable polysaccharides are likely to prove useful in the treatment of abnormal carbohydrate absorption after gastric surgery.
A patient who had a 50% gastrectomy with a Billroth II gastrojejunostomy one and a half years previously, complained of recent severe weakness as the only symptom was found to have an iron deficiency anemia with a periumbilical mass. A gastrointestinal series showed a soft tissue density in the epigastric area which, by ultrasonography, was found to be fluid-containing. Laparotomy revealed obstruction of the afferent loop caused by a marginal ulcer.
Comparative evaluation of single-dose finoptin, corinfar and falicor by effect on gastric evacuation was conducted in 33 peptic ulcer and 48 postgastrectomy dumping syndrome patients. Finoptin was found to prolong the evacuation in contrast to corinfar which stimulated it. Nonsignificant delay in gastric evacuation occurred in falicor administration. When designing therapy of cardiovascular diseases associated with gastric evacuation, due consideration should be given to pharmacokinetic action of calcium antagonists and functional status of gastric evacuation. Finoptin is preferable in dumping syndrome, corinfar in slow gastric evacuation. In view of the above corinfar treatment is undesirable in postgastrectomy patients, otherwise they could develop rapid gastric stump evacuation and dumping syndrome.
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We investigated the nutritional state and pathophysiologic mechanisms involved in the malabsorption of 27 patients with total gastrectomy and esophagojejunostomy reconstruction without reservoir; they were first evaluated after a median period of 9 months after surgery and were not receiving either nutritional or pharmacologic support. Mean postoperative weight loss was -13.7 +/- 1.59%; mean daily caloric intake was 31.7 +/- 2.41 kcal/kg/day, with 70% of subjects ingesting less than 30 kcal/kg; P/kg was 1.2 +/- 0.09, with 21% of patients ingesting less than 1 g P/kg/day; mean ratio of nonprotein energy to 1 g nitrogen intake was 142 +/- 8.74:1, with only 24% of patients attaining a ratio greater than 150:1; and mean fat malabsorption was 37.4 +/- 4.6%. Hemoglobin (Hb), serum albumin, prealbumin iron, and folate were more often abnormal in the early postoperative period, whereas transferrin and vitamin B12 concentrations deteriorated later. alpha 1-Antitrypsin clearance was abnormal in almost all patients (indicating an intestinal protein loss), and the pancreolauryl test was abnormal in 60%. Neither morphological nor absorptive alterations of the small bowel nor an abnormal transit time or bacterial overgrowth was found. We conclude that inadequate caloric intake appears to be the main cause for malnutrition after total gastrectomy, but that caloric losses caused by steatorrhea and enteric protein leakage must be subtracted from intake, thus decreasing the amount of available calories.
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Complete or partial removal of the stomach results in considerable anatomical and physiological changes, which, in turn lead to more or less pronounced dietary problems. For this reason, patients should receive comprehensive postoperative counseling. In the majority of cases, the major problems can be avoided or symptoms ameliorated. The selection of suitable foods must be discussed, as also the particular importance of drinking. Preprandial exercise to stimulate the appetite is just as important as postprandial resting to avoid diarrhea and the dumping syndrome. A central aspect is the distribution of the food ingested over six to ten small portions. Some nutrients may need to be substituted--for example, vitamin B12, the fat-soluble vitamins, calcium and iron. With increasing time after the operation, alimentation problems usually abate, but in the individual case may persist for years.
The Authors present two cases of Wernicke-Korsakoff Disease following gastric surgery. This clinical occurrence hasn't been previously described in Literature. The pathogenetical role of nutritional factors deficiency is discussed.
Gastric resection or vagotomy plus drainage are not easy alternatives for the treatment of duodenal ulcer. More complications are met after resection, more relapses after vagotomy, whereas the postoperative sequelae are the same for both operations. Vagotomy of the parietal cells is designed to prevent all such sequelae by leaving the innervation of the antrum intact so that drainage can be omitted. Experience has so far shown that very few complications occur, whereas severe and slight dumping and diarrhoea are virtually eliminated. Gastric emptying times are slightly affected (a little longer for solids and a little quicker for fluids), but drainage in non-stenosing cases of duodenal ulcer is not necessary. The true average incidence of recurrences after this operation cannot yet be determined, since the results of the published series vary considerably. This may be due to the continuous progress being made in the development of the surgical technique. Random studies comparing this operation with other forms of duodenal management are urgently required. It is, of course, essential for surgeons practising the new operation must, as in the case of other delicate surgial procedures, to receive a proper training at specialised centres.
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