Gastrectomy is an operation to completely or partially remove the stomach. Consequences of resection of the stomach

After the end of the operation, the patient wakes up in the intensive care unit or department intensive care. This is a standard event after major operations. As soon as the doctor is convinced that the patient's condition is stable, he is transferred to a regular ward. This usually happens within a day or two. The patient is monitored continuously in the intensive care unit nurses and his condition is carefully monitored. It is important to understand that this is a standard technique that does not mean any violations of the patient's condition.

The surgeon and anesthesiologist closely monitor the patient's recovery after surgery. You may feel sleepy after anesthesia and pain medications.

IV fluids and drainage

When recovering from anesthesia, the patient may find several installed catheters. It's a bit strange. However, it will be easier to adapt to this, knowing what they are for.

The patient may have:

Around the surgical wound, one or more drains can be installed: they prevent the accumulation of blood, bile and tissue fluid at the site of the operation.

A nasogastric tube is passed through the nose into the stomach to drain gastric contents to reduce nausea.

IV catheters: These are needed to transfuse blood and fluids until the patient can eat and drink normally again.

AT bladder a catheter (tube) is installed to remove urine and measure its volume.

A drainage tube is also inserted into the chest if the patient has had an esophagogastrectomy. It can be connected to a suction tank. His work ensures the restoration of uniform inflation of the lungs with air after chest surgery.

After awakening from anesthesia, the patient may also find a cuff on the arm to measure blood pressure. A pulse oximeter, a small clip that measures the pulse and oxygen content in the blood, will be installed on one of the fingers of the hand. An oxygen mask may be on the face for some time. After coming out of anesthesia, the pressure is measured quite often in the first few hours. Nursing personnel measure the amount of urine produced, as this indicates the presence of dehydration (dehydration) or, conversely, an excess of fluid in the body.

Painkillers

Several automated pumps can be attached to an intravenous catheter. One of them controls the introduction of an anesthetic drug into the body. The patient may be given manual control of this pump. If necessary, pressing the button provides additional introduction pain reliever. This principle of pain relief is called "patient-controlled analgesia". If you have a self-administered pain reliever on hand, use it as soon as you need it. You will not be able to overdose the drug: the system is configured to avoid such situations. If you need to use the analgesic system too often, tell your doctor. You may need to increase the dose of the drug.

In the first days after the operation, epidural anesthesia is performed in some hospitals. She usually helps the patient very well. In this case, a very thin tube is inserted into the spinal canal and connected to a pump, which provides a constant supply of painkillers to the body. If pain persists, the nurse may increase the dose of the incoming drug.

For a week or so after surgery, in almost all cases, you will be in pain. However, a variety of painkillers help to cope with this. Very important immediately after the occurrence pain notify the medical staff. The doctor needs your help in order to choose the right drug for you and its dose. Painkillers usually work better with regular administration.

Intake of liquids and food

Intestinal activity stops for some time after surgery in any department gastrointestinal tract. You can not drink and eat before he starts working normally again.

Before the patient is allowed to resume food and fluid intake about a week after surgery, an x-ray is taken. This is necessary to detect the failure of the surgical connection of the stomach with the intestines. Before the study, the patient drinks a dye called Gastrografin. This substance is clearly visible on the x-ray, and therefore the doctor will easily see its leakage from the intestine.

Nutrition is given intravenously and through a central catheter until the patient is allowed to take food and fluids on their own. This catheter is inserted into a large vein chest. This type of nutrition is called parenteral. In addition, with the help of the so-called "nourishing" stoma, liquid food can be introduced directly into the intestine. Another way to introduce liquid food is to use a tube that goes through the nose into the intestines, called a nasojejunal tube.

Self-feeding after surgery on the stomach, which may be accompanied by its complete removal, should begin very slowly and carefully. First you are allowed to drink plain water little sips. If the patient tolerates it well, then the volume of fluid increases very slowly. Then you can switch to other liquids, such as milk, tea or soup. Once the patient begins to tolerate fluids without nausea or vomiting, the IV catheter and nasogastric tube are removed.

Wound after surgery

After the operation, a sterile dressing is applied to the wound. The wound will be closed with it within a few days. Then dressing is carried out with a change of dressing and cleaning of the wound. until the discharge stops coming out of the wound, there will be drainage in it. If the drainage is connected to the bottle, then it must be changed every day. Usually, the drainage tubes are removed 3-7 days after the operation. The suture or surgical clips are usually left on for at least 10 days.

Physical activity

In the first days after the operation, movement will seem simply impossible. However, for the recovery of the body, movement is essential and must begin gradually. After the operation, the patient must be visited by a physiotherapist every day. He spends with the patient breathing exercises and training for the lower extremities.

The doctor should motivate the patient to sit in bed and get up within 1-2 days after the operation. Nurses will teach how to handle catheters and drains. Gradually, a few days after the operation, the tubes, vials and bags will begin to be removed. After that, it will become much easier to move, and you will really feel that you are on the mend.

Improvement of the postoperative condition

You will be able to get out of bed and start moving in a few days. Your health will gradually improve. Soon you will start, there are more. At first, you will need many small meals instead of the usual three large meals a day. It may take a long time to return to three meals a day. Some patients prefer to continue to eat little and often. A nutritionist will advise you before discharge and help you plan your new diet. He will definitely advise you to take your vitamins regularly and eat more. rich in iron food.

During your stay in the hospital, you will be given vitamin B12. You will no longer be able to get vitamin B12 from food if a significant part of the stomach or an entire organ was removed during the operation. That is why, in order to avoid its deficiency in the body, this vitamin will need to be regularly administered in the form of injections.

Many people believe that after the removal of the stomach, or most of it, it is no longer possible to return to the previous active life. That man forever remains dependent on strict diet, he cannot travel, play sports and needs to spend most of his time at home (in winter to hide from the cold, in spring from slush, in summer from the sun, in autumn from rain). There is an opinion that a person who has undergone such an operation remains disabled forever.

This is completely wrong. If you behave correctly in the first few months and follow a number of simple rules in the future, a return to a full life is not only possible, but also mandatory.

The daily routine should not be "protective", that is, aimed at maximum protection of a person from movement, housework. On the contrary, doing household chores, walking in the fresh air, active behavior and communication is very useful for both sociological rehabilitation and physical rehabilitation. But don't overdo it. In the first months after the operation, the body still does not have enough strength to take on an unbearable burden (hard physical labor, constant communication with people, intense labor activity). At the same time, one should not forget that the final fusion of the aponeurosis (tendon "corset" of the abdominal cavity) passes in a few months and therefore doctors recommend limiting physical activity for 6 months.

Activities associated with heavy lifting (gardening, professional and domestic activities) can lead to the formation postoperative hernia which often requires a second operation to eliminate it.

Also, to prevent hernia, it is necessary to avoid constipation, severe cough and sneezing. Light general strengthening gymnastics is allowed, but without training abdominals. For additional strengthening of the postoperative wound for the period of scar formation, it is recommended to wear the so-called abdominal bandage - an elastic belt similar to sciatica. This is especially necessary if you are not an athlete and the muscular "corset" of the abdomen is not trained.

Apart from physical activity The right mental attitude is also very important. Requires the maximum amount positive emotions(books, films, humor, pleasant relatives, neighbors, acquaintances).

A favorite hobby is a very useful mechanism to help restore the habits and lifestyle that was before the operation. Of course, here it is necessary to remember about the "golden mean" - daily guests and trips to the cinema, and theaters can very soon cause psychological fatigue.

It is very important to monitor defecation (the so-called bowel movement). This, as it seems, far from the stomach and delicate problem is also very important. It is necessary to strive and achieve daily stool (at least 1 time per day) with a diet, occasionally - light laxatives (long-term use of laxatives is harmful). With a persistent tendency to constipation, it is necessary to consult a coloproctologist, who will talk about foods that help regulate stools and, if necessary, select the necessary medications.

It is especially important to avoid constipation in the first 2-3 months after surgery. This is due to the fact that during a bowel movement with constipation, the pressure in the abdominal cavity increases significantly (with constant and strong straining), which further contributes to the formation of a postoperative hernia. In addition, an increase in intra-abdominal pressure leads to various kinds of reflux (reverse reflux), cause reflux gastritis of the stump (remaining part) of the stomach or reflux esophagitis (inflammation of the esophageal mucosa).

Restrictions after surgery

It is highly undesirable to visit a solarium or tan under the sun. You do not need to be often exposed to thermal stress (bath, sauna, etc.). These procedures create an unnecessary burden on the body, weakened after the operation, on the heart and blood vessels, and some of the above effects (most of all for physiotherapy) can even provoke a return of the disease and the appearance of metastases or relapse.

Special mention should be made of pregnancy. If a woman who has undergone surgery for stomach cancer wants to have a child, then this situation must be discussed with both the gynecologist and the oncologist. Such alertness is due to the fact that during pregnancy in the body of a woman comes the strongest hormonal changes, which can also give impetus to the return of cancer (often against the background of pregnancy cancerous tumors grow especially fast and aggressively). In general, we can say that pregnancy in the first 3-5 years after the operation is very undesirable.

Spa treatment is not contraindicated if the operation was successful and the tumor was completely removed. After examination by an oncologist, therapist and other necessary specialists, as a rule, you can undergo spa treatment in a gastroenterological sanatorium in your climatic zone, that is, in some local institution, of course, refraining from physiotherapeutic procedures. Clean air, tasty and healthy food, beautiful nature and pleasant communication have a very beneficial effect on both psychological state man, and on his physical form.

Features of nutrition after surgery

The most common surgeries performed for stomach cancer are gastrectomy (removal of most of the stomach) and gastrectomy (removal of the entire stomach).

Pursuing the goal of ridding a person of a tumor, when performing these operations, it is often not possible to avoid digestive disorders, since the function of the stomach as a reservoir for food, which doses the food eaten into the intestine, is lost. The consequence of this is a faster flow of food from the esophagus to the intestines, which may cause discomfort- the patient may experience a feeling of heaviness in the epigastric region, weakness, sweating, dizziness, palpitations, dry mouth, bloating (flatulence), drowsiness, desire to lie down. These phenomena are called dumping syndrome. In severe cases, it can lead to disability.

To avoid such a condition or reduce the intensity of its manifestation, those who have undergone stomach surgery should observe the following rules:

Nutrition for stomach cancer is an important part of the treatment process. To maintain strength and recovery, you need to get enough calories, protein, vitamins and minerals. After your stomach surgery, you will need nutritional supplements with vitamins and minerals such as vitamin D, calcium and iron. Injections of vitamin B12 are also needed. Eat small meals, but often (6-8 times a day). Eat slowly, chewing food thoroughly.

It is necessary to limit the intake of those products that contain easily and quickly absorbed carbohydrates. These are jams, sweet milk porridges, honey, sugar and the like. It is not necessary to completely abandon these products.

It is advisable to take the third dish not immediately, but ½ -1 hour after eating, so as not to overload the stomach (if a small part of it is preserved) or the initial sections of the intestine, if the stomach is completely removed. The amount of liquid at one time should not exceed 200 ml.

It is very important that the food after stomach surgery is tasty, varied, and includes all the main nutrients. Particular importance is attached to complete animal proteins (found in lean meat, chicken, fish, eggs, cottage cheese, cheese) and vitamins (included in vegetable dishes, which are constituent elements of fruits, berries, vegetable and fruit juices, rosehip broth, etc. ).

Particular attention should be paid to nutrition in the first 2-3 months after discharge from the hospital: it is at this time that the digestive system and the body as a whole adapt to new conditions in connection with the operation. The diet is physiologically complete, with high content protein, a sharp restriction of easily digestible carbohydrates, a normal fat content. Limited chemical irritants of the mucous membrane and receptor apparatus of the gastrointestinal tract. Foods and dishes that can cause dumping syndrome are excluded. Food is cooked in a boiled, steamed, baked form without a rough crust, not mashed. Avoid eating excessively hot and cold foods - they can have an additional irritating effect on the intestinal mucosa.

At first, food should be fractional: 6 - 7 - 8 - 9 times a day in small portions. The diet should be complete in composition, especially in terms of proteins (meat, fish). Necessarily fresh vegetables and fruits, except for those that cause pronounced "fermentation" in the intestines, soups and cereals. At first, try to avoid fried foods. Food should be gentle thermally (not hot), mechanically (not rough, well chewed, or pre-cooked, scrolled, etc.) and chemically (not spicy, not greasy). Need to be borne in mind poor tolerance after resections of the stomach of whole milk (but fermented milk is possible) and sweets - sweets, chocolate, halva, etc. Restrictions are mainly for the first 2-3 months, then the diet must be persistently expanded. It will also be necessary to gradually increase the one-time volume (regardless of soreness, nausea - the stomach stump must be trained in order to return to the usual 3-4 meals a day by the end of the year after the operation) with a reduction in the frequency of food intake. If you want to try some new food, then eat a small piece and wait a while (about 30 minutes). If there are no unpleasant sensations (pain, nausea, vomiting, bloating, cramps), then you can gradually introduce this product into the diet.

As a rule, in the near future after the operation, it is useful to take a course of any drug that restores the normal intestinal microflora (euflorin, normoflorin, bactisubtil, colibacterin, lactobacterin, bificol - and the like). This is especially true if the patient was prescribed antibiotics before or after the operation. To choose the right drug and choose the dose and duration of administration, you need to consult a gastroenterologist.

Of course, alcohol is excluded from the products consumed, especially strong (vodka, cognac, etc.) and carbonated (beer, champagne) drinks. Possessing a strong irritant effect, it is able to increase digestive disorders.

Thus, the rules of nutrition after surgery for stomach cancer are quite simple and affordable. Following them will allow you to avoid many problems associated with postoperative violation of the digestive processes. Highly important role the discipline of the patient plays, since it is necessary to avoid not only neglecting the diet (this leads to even greater violations of bowel function), but also deliberately tightening it because of the fear of returning to the previous framework of food intake.

It must be remembered that your doctor, a gastroenterologist, will be able to resolve any issues related to nutrition, diet, and treatment that helps digestion.

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• After stomach cancer surgery

Resection of the stomach, although it is a radical method of treatment, often becomes the most effective therapeutic measure. Indications for resection include the most severe lesions when therapeutic intervention is powerless. Modern clinics carry out such surgical operations quickly and efficiently, which allows defeating diseases that previously seemed incurable. In some cases, certain postoperative complications are possible, but properly performed rehabilitation measures allow them to be eliminated.

The operation for resection of the stomach is the removal of the affected area with the subsequent restoration of the continuity of the digestive canal. The main goal of such a surgical intervention is to completely eliminate the focus of pathological destruction of the organ with the maximum possible preservation its main functions.

Types of surgery

The classic method of surgery is distal resection, when the lower part of the organ is removed (from 30 to 75%). The most sparing option of this type is the antral variety with the removal of 1/3 of the lower zone of the stomach (antral region). The most radical way is a distal subtotal resection of the stomach with the removal of almost the entire organ. Only a small stump 2.5–4 cm long remains in the upper zone. One of the most common operations is gastropylorectomy, when up to 70% of the lower part of the stomach, the antrum (completely) and the pylorus are eliminated.

If the removal is performed on the upper section, then such an operation is called a proximal resection of the stomach. In this case, the upper gastric part is removed along with the cardia, while the distal portion can be completely preserved. A variant with excision of only the middle zone is possible. This is a segmental resection, and the upper and lower parts are not affected. If necessary, a total gastrectomy is performed, i.e. complete removal organ without leaving a stump. In the treatment of obesity, surgery is used to reduce the volume of the stomach (SLIV-resection).

According to the method of restoring the esophageal canal and the tactics of the impact, the following types of gastric resection are distinguished:

1. Billroth-1 technique. The anastomosis is formed according to the “end to end” principle, by connecting the remainder of the stomach with the duodenum and preserving the anatomy of the esophageal canal, as well as the reservoir function of the remaining part of the stomach, while eliminating the contact of the mucous membranes of the stomach and intestines.
2. Billroth-2 technique. Installation of an extended anastomosis according to the "side-to-side" principle, when the borders of the stomach resection are connected to the beginning of the jejunum.
3. Operation on Chamberlain-Finsterer. Improvement of the Billroth-2 method with blind stitching of the duodenum and the formation of an anastomosis according to the "end-to-side" principle, i.e., by connecting the stomach stump with the jejunum in the isoperistaltic direction, and the area jejunum joins with the rest of the stomach behind the colon through an opening in its mesentery.
4. Roux method. The proximal end of the duodenum is completely closed, and the anastomosis is established between the gastric residue and the distal end of the jejunum with its dissection.

Improvement of operating technologies

In the almost 140 years since the first gastrectomy, improved techniques have been developed for use in specific settings:

• distal excision with the formation of an artificial pyloric sphincter;
• distal resection with the installation, in addition to the specified sphincter, invagination valve formed from the tissues of the mucous membrane;
• distal resection with the formation of a pyloric sphincter and a flap-like valve;
• resection with preservation of the pyloric sphincter and installation of an artificial valve at the entrance to the duodenum;
• distal resection of the subtotal type with primary jejunogastroplasty;
• subtotal or complete resection using the Roux-en-Y technique and the formation of an invagination valve on the outlet area of ​​the jejunum;
• resection of the proximal type with the installation of esophagogastroanastomosis with an invagination valve.

Specific operations

There are different indications for gastrectomy. Depending on the types of pathologies, some specific operations are used:

1. Laparoscopic resection of the stomach in its purpose does not differ from the classical operation. Removal of the affected area of ​​the stomach with the formation of the continuity of the esophageal canal. This procedure is indicated for complicated peptic ulcer, polyposis, malignant and benign formations, in many ways similar to the above technologies. The difference lies in the fact that laparoscopic resection of the stomach is carried out through 4–7 trocar punctures. abdominal wall with the help of special devices. This technology has a lower risk of injury.
2. Endoscopic resection of the gastric mucosa (ERS) is one of the most modern minimally invasive methods of surgical treatment. The intervention is performed under general anesthesia using specific endoscopic instruments - resectotomes. There are 3 main types of instrument used: a needle resect with a ceramic tip; a hook-shaped resectotome and a loop-shaped device. Greatest Application the method is found in the removal of polyps and the treatment of various dysplastic lesions of the stomach, as well as neoplasms at an early stage by deep excision of the mucous layer.
3. Longitudinal resection of the stomach for obesity (vertical resection or SLIV) is aimed at reducing gastric volume, for which part of the side wall is removed. During such an operation, a significant volume of the stomach is removed, but all the main functional elements of the organ (pylorus, sphincters) remain intact. As a result operational manipulations with DRAIN, the body of the stomach turns into a tube with a volume of up to 110 ml. In such a system, food cannot accumulate and is rapidly sent to the intestines for disposal. Already this circumstance contributes to a decrease in body weight. When the stomach is resected for weight loss, the glands that produce the "hunger hormone" - ghrelin, turn out to be in a remote area. So DRAIN provides a reduction in the need for food. The operation does not allow you to gain weight, after a short period of time a person begins to weigh less, and losses overweight reach 65–70%.

What is the danger of surgical treatment

Any radical surgical intervention cannot pass without a trace human body. During resection of the stomach after surgery, the structure of the organ changes significantly, which affects the functioning of the entire digestive system. Violations in the work of this part of the body can lead to other disorders in different organs, systems and the whole body as a whole.

Complications after resection of the stomach depend on the type of operation and the area of ​​​​excision of the organ, the presence of other diseases, individual characteristics body and the quality of the procedure (including the qualifications of the surgeon). In some patients, surgical intervention after rehabilitation measures leaves practically no consequences. However, many patients have a characteristic category of so-called post-gastroresection syndromes (adductor loop syndrome, dumping syndrome, anastomosis, etc.).

One of the leading places in the frequency of postoperative pathologies (approximately 9% of patients have this complication) is occupied by the afferent loop syndrome. This pathology occurs only after gastroenterostomy and resection of the stomach according to Billroth-II. The adductor loop syndrome was identified and described almost immediately after the spread of resection operations. In order to prevent this complication, it is recommended to impose an anastomosis between the afferent and efferent loops of the jejunum. Description of this pathology can be found under various titles- syndrome of bilious vomiting, biliary regurgitation, duodeno-biliary syndrome. Roux in 1950 called this disease adductor loop syndrome. In most cases, this complication is treated conservatively, but if the symptoms continue to increase, surgery is prescribed. Adductor loop syndrome has a positive prognosis.

In addition to specific phenomena, there may be consequences general. Dysfunction of some organs leads to the development of anemia after gastric resection. Hematogenous disorders can provoke a change in the composition of the blood and even anemia.

Post-resection syndromes

There are several of the most common complications that often cause the removal of part of the stomach:

1. Conduction loop syndrome. Such a phenomenon is possible after resection according to the Billroth-2 method. The conduction loop syndrome is caused by the appearance of a blind spot in the intestine and a violation of its motility. As a result, there are problems with the excretion of processed food. The conduction loop syndrome is manifested by heaviness, discomfort and pain in the epigastric zone and in the hypochondrium on the right, vomiting with bile. If conduction loop syndrome is manifested, then treatment is provided by diet therapy, gastric lavage and the appointment of anti-inflammatory drugs.
2. Dumping syndrome or failure syndrome. The complication is associated with shortening of the stomach and excessively rapid transport of food, which disrupts the process of digestion and leads to malabsorption of nutrients and hypovolemia. The main symptoms are dizziness, increased heart rate, nausea, vomiting, impaired stool, general weakness, neurological disorders. In severe cases of the syndrome, a second operation is performed.
3. Anastomosis after resection of the stomach. This complication is due to the appearance inflammatory response at the site of the anastomosis. In the focus of inflammation, the lumen of the canal narrows, which makes it difficult for food to pass. The result is pain, nausea, and vomiting. The advanced stage leads to the deformation of the organ, which requires surgical intervention.
4. Problems with body weight. If the vertical resection of the stomach (DRAIN-resection) is aimed at losing weight, then after most other operations another problem arises - how to gain weight with a truncated stomach. This problem solved by methods of diet therapy and vitamin therapy. The diet is compiled by a specialist, taking into account the impact.

Resection refers to radical effects, but often only such an operation can eliminate the pathological process. After this surgical treatment, it is possible serious consequences, but properly carried out rehabilitation measures can solve this problem.

This operation has so far often become the method of choice for the treatment of cancer and some forms of gastric polyposis, and in PU it is widely used in complicated forms and in cases that are difficult to treat conservatively. About 60-70 thousand resections of the stomach are performed annually in our country for PU. True, in last years this figure begins to gradually decrease as organ-preserving operations become more widespread (vagotomy with pyloroplasty, selective proximal vagotomy in combination with anthroectomy, etc.). Due to the sharp changes in the anatomical and physiological relationships and relationships of the digestive organs as a result of surgery, a number of such patients experience severe post-resection disorders.

According to the currently most common classification, the latter can be divided into organic, functional and combined complications after gastric resection [Vasilenko V. X., Grebenev A. L., 1981]. Functional disorders include: early and late (hypo-hyperglycemic) dumping syndromes and conditionally afferent loop syndrome, caused by a violation of its evacuation activity (it sometimes has an organic condition), postgastro-resection asthenia (dystrophy) and anemia.

Complications of an organic nature include: peptic ulcer of the anastomosis or jejunum, cancer and ulcer of the stomach stump, cicatricial deformities and narrowing of the anastomosis, fistulas, as well as various organ damage associated with technical errors during the operation.

A somewhat less defined group of associated disorders include: anastomositis, gastritis of the stump, cholecystitis, pancreatitis, etc.

Among all post-resection disorders, the leading place is occupied by dumping syndrome, which combines a number of symptom complexes similar in clinical picture that occur in patients with different periods time after eating. It occurs with one or another severity in 50-80% of persons who have undergone surgery.

The first description of the "resetting stomach" after the imposition of gastroenteroanastomosis belongs to C. Mix (1922), but the term "dumping syndrome" was proposed only 25 years later by J. Gilbert, D. Dunlor (1947). Distinguish between early (comes immediately after a meal or 10-15 minutes after it) and late (develops 2-3 hours after a meal) variants of the dumping syndrome, which have a different development mechanism. It should be noted that early and late dumping syndromes can occur in isolation or combined in the same patients who underwent surgery. The pathogenesis of the dumping syndrome is complex and largely unexplained. Its development is due to the loss of the reservoir function of the stomach, the lack of portioned intake of food masses into the small intestine, due to the elimination of the pyloric mechanism, as well as the shutdown of the passage of food through the duodenum, where, under its influence, the production of important digestive hormones (gastrin, secretin, cholecystokinin, etc.). According to the most accepted point of view, in patients who have undergone gastric resection, there is a rapid discharge, "failure" of unprocessed food from the stomach stump into the small intestine; at the same time, the osmotic pressure sharply increases in its upper section, which leads to a reflex change in the microcirculation in the intestine (vasodilation, slowing of blood flow) and diffusion of blood plasma and intercellular fluid into the intestinal lumen. The resulting hypovolemia is accompanied by irritation of press receptors in the vascular bed, followed by excitation of the sympathetic-adrenal system, accompanied by an increased release of catecholamines, serotonin, and bradykinin. Violated hemodynamics, there is hypotension, tachycardia. In such patients, almost immediately after eating a meal rich in easily digestible carbohydrates, a kind of "vegetative storm" develops, in many ways reminiscent of a sympathetic-adrenal crisis. Sometimes a "dumping attack" can have the features of a vagotonic crisis, which is important to keep in mind when developing an adequate treatment strategy. It is believed that in such patients there is a re-irritation of the interoreceptor apparatus of the jejunum; overexposed biologically active substances, gastrointestinal hormones, which enter the blood in excess, which leads to a "vegetative explosion" involving various organs and systems.

The development of late dumping syndrome is explained as follows: the accelerated entry of food chyme into the jejunum is accompanied by increased and rapid absorption of carbohydrates with insufficient glycogen synthesis in the liver, hyperglycemia (usually asymptomatic), followed by hypoglycemia caused by uncoordinated excessive release of insulin by the pancreas. The latter may be due to excessive vagal stimulation. In contrast to the early dumping syndrome, this symptom complex is characterized by inconstancy, short duration, occurrence before or against the background of its onset of an excruciating feeling of hunger. In severe cases, it ends with a prolonged fainting. During less formidable attacks, the patient is forced to lie down, take carbohydrate food. After an attack, weakness and adynamia usually persist. We should agree with the opinion that dumping syndrome often develops against a predetermined background in patients with neurovegetative dystonia and a labile neuropsychic status. From this position, it is not surprising that somewhat smoothed clinical symptoms of dumping syndrome can also occur in healthy individuals. young age with rapid evacuation of food chyme from the stomach and an inadequate response of the pteroreceptor apparatus of the small intestine, leading to a short-term overexcitation of the autonomic nervous system.

Early dumping syndrome is often provoked by a large meal, the use of sugar, cakes, chocolate, less often - milk and fat. In patients during or immediately after eating, there is a sharp weakness, a feeling of fullness in the epigastrium, nausea, dizziness, palpitations, perspiration. The skin is hyperemic or, on the contrary, becomes pale, the pupils narrow, tachycardia occurs, less often - bradycardia and tachypnea. Blood pressure moderately increases or, conversely, decreases. Dumping attack lasts 1-2 hours. Late dumping syndrome has similar, but less clearly defined clinical manifestations, often accompanied by bradycardia.

In the treatment of patients with dumping syndrome, the dominant importance is given to the regimen and nature of nutrition. The diet of patients who have undergone gastric resection should be mechanically and chemically sparing only during the first 3-4 months, then it gradually expands and approaches the usual. It is important to note that diet therapy is essential not only for treatment, but also for the prevention of the development of dumping syndrome. The diet should be strictly individualized, but in all cases easily digestible carbohydrates are completely excluded. Food should be varied, high-calorie, high in protein (140-170 g), fat (up to 100 g), and vitamins. All dishes are prepared boiled, stewed or steamed. Frequent, fractional (6-8 times a day) nutrition often stops the manifestations and even prevents the development of seizures, but it is not always practically feasible. Hot and cold foods should be avoided, as they are quickly evacuated; should eat slowly, chewing food thoroughly. It is recommended to take liquid and solid food to reduce the possibility of formation of hyperosmotic (hyper-osmolar) solutions. Patients with severe dumping attacks are advised to eat lying down. Often, patients with dumping syndrome are better able to tolerate coarse, mechanically unprocessed food, especially 1-2 years after the operation. It is advisable to acidify products, for this purpose use a solution of citric acid (on the tip of a table knife in /z-/z a glass of water). It must be taken into account that such patients are especially intolerant of sugar, jams, sweet compotes, egg yolks, semolina, rice porridge, lard, milk, apples. Many recommend that patients regularly keep a food diary.

Taking into account that post-resection dumping syndrome often occurs in individuals with certain manifestations of neurovegetative dystonia, which largely determines the specific clinical symptoms of each attack (dumping attack), the importance of therapy becomes clear. ssda-tive and tranquilizers. Small doses are used phenobarbital(0.02-0.03 g 3 times a day), benzo-diazepine derivatives, infusion of valerian, motherwort. In cases where the dumping attack resembles a sympathetic-adrenal crisis, it is advisable to prescribe an rh-blocker pyrroxan(0.015 g 3 times a day before meals), as well as reserpine(0.25 mg 2 times a day) and carefully oktadine (ismeline, isobarine) in an individually selected dose. The last two drugs have not only a sympatholytic, but also an antiserotonin effect, and serotonin, released in excess by the mucous membrane of the small intestine and entering the blood, is given a certain importance in the pathogenesis of dumping syndrome. The course of treatment is 1.5-2 months; taking the considered drugs is contraindicated in patients with hypotension. According to T. N. Mordvinkina and V. A. Samoilova (1985), against the background of taking reserpine, dumping attacks proceeded less severely and for a longer time. Suggested for therapeutic purposes to use long-term use prodectine(1 tablet 3 times a day), taking into account its antikinin effect. Worthy of note in this respect peritol(4 mg 3 times a day for / g hour before meals), as endowed with anti-serotonin and anti-histamine action. In order to slow down the evacuation of food chyme into the small intestine, one can resort to prescribing non-selective anticholinergics(extract belladonna, atropine, metacin. platifillin at normal doses). They can be combined with myotropic antispasmodics (papaverine, no-shpa, halidor). Patients with late dumping syndrome at the height of hypoglycemia are recommended by some authors to prescribe sympathomimetics(0.1% solution adrenaline or 5% solution ephedrine 1 ml), if necessary, again, but this is unrealistic. More acceptable is the appointment of ephedrine orally at 0.025-0.05 g or izadrin 0.005-0.01 g under the tongue 20-30 minutes before the expected manifestations of the syndrome.

In general, the effectiveness of pharmacotherapy in patients with dumping syndrome should be assessed with extreme restraint. The range of drugs used here is limited, and therefore reasonable dietary recommendations are more useful.

Chronic afferent loop syndrome is divided into functional, arising as a result of hypotension, dyskinesia of the duodenum, afferent loop, sphincter of Oddi and gallbladder, and mechanical, caused by an obstacle in the afferent loop (kinks, strictures, adhesions). Patients with this pathology note a feeling of fullness in the epigastrium that occurs after eating, often accompanied by flatulence. There is regurgitation of bile or food mixed with bile, aggravated in a bent position. In more severe cases, recurrent profuse vomiting of bile occurs. Patients complain of painful, almost constant nausea, which increases after taking sweets, milk and fatty foods. The diagnosis is finally established after X-ray examination. Treatment is most often surgical, however, with initial manifestations, it can be prescribed. cerucal orally or parenterally at the usual dosage. With severe flatulence, which is one of the symptoms of the "syndrome of bacterial colonization of the small intestine", short repeated courses are indicated. antibiotic therapy.

Post-gastroresection dystrophy usually occurs in a longer period after surgery and is, in fact, one of the variants of the "impaired digestion syndrome". Disorders of intestinal digestion and absorption in such patients are caused by impaired secretion and motility of the stump of the stomach and intestines, secretion of bile and pancreatic juice, changes in the microflora of the small intestine, inflammatory-dystrophic changes in its mucosa, sometimes reaching a degree of deep atrophy. At the same time, progressive weight loss, diarrhea with steatorrhea, polyhypovitaminosis, anemia, hypoproteinemia, disorders of electrolyte and vitamin metabolism develop. Treatment is symptomatic and is carried out in accordance with the principles of treatment of impaired digestion of any other etiology (see Chapter 5). In connection with the development of significant disorders of some functions of the gastrointestinal tract associated with surgical removal stomach or part of it is usually recommended enzyme therapy. However, it should be noted that one should not place unnecessary hopes on it. In conditions of throwing alkaline intestinal contents into the stomach stump and accelerated emptying, hydrochloric acid and pepsin are hardly able to show their effect. The administration of pancreatic enzymes makes more sense, but their effect seems to be modest.

The treatment of peptic ulcers of the anastomosis and gastritis of the stomach stump is no different from that of exacerbation of peptic ulcer or the usual forms of chronic gastritis. The literature describes post-resection pancreatitis, in the genesis of which surgical trauma, hypotension and duodenostasis are important. They are treated according to the same rules as pancreatitis in general.

Iron deficiency anemia can develop both after total gastrectomy and after resection of the stomach in various modifications, and more often it occurs as a complication of the last surgical intervention. Discussing the pathogenesis of this type of anemia, one should take into account a slight decrease in the content of iron in the diet, an increase in its losses with feces and the absence of an increase in its absorption from food that is adequate to reduce reserves [Ryss E. S., 1972]. Achlorhydria does not play a significant role in the formation of anemia. Iron deficiency anemia occurs 1-3 years after surgery.

Msgaloblast 1H (.sk; 1st B^-difficile anemia refers to rare and late (after 5 years) complications of gastric resection. In its development, atrophic gastritis of the stomach stump is of primary importance, leading to disruption of the production of internal factor and a decrease in the absorption of vitamin Bia. Agastri separation - "ecKiix aiiCMKi"! on iron-is B,.-deficient is conditional, since in such patients there is a simultaneous deficiency of these hematopoietic substances, and in some patients there is a lack of folic acid, protein and some trace elements (cobalt, copper). In other words, anemia that develops in patients who have undergone gastric resection is always polyvalent, of mixed origin, and requires complex therapy. general rules designed for the treatment similar forms anemia. However, such patients often have intolerance to iron preparations when they are administered orally, which forces them to resort to parenteral administration of the appropriate drugs. Among them, the most noteworthy ferrum lsk, which is administered every other day or daily intramuscularly at 2-4 ml or intravenously at 5 ml; course of treatment - 15-20 days. Maintenance therapy with iron preparations in these patients is carried out "on demand". After the course of treatment, more often inpatient, patients with post-resection disorders are subject to dispensary observation, and 1-2 times a year they undergo the necessary examination, diet is corrected, and medication is prescribed according to indications or for preventive purposes. Patients can be deregistered no earlier than 3 years after the operation in the absence of any post-resection disorders during this period; good general condition and well-being [Vasilenko V. X., Grebenev A. L., 1981].

Assessing the results of treatment of post-gastroresection disorders in a more general form, one should not be overly optimistic. Although severe forms of these disorders are not so common, even with their moderate severity, it is far from always possible to provide satisfactory treatment results. Sometimes it is difficult to explain why, with similar postoperative anatomical changes, some patients have almost no complaints, while others have severe and resistant to conservative treatment of painful phenomena, and then one has to resort to reconstructive operations.

Prostate cancer can be treated in many ways, such as chemotherapy, estrogen administration, and so on. But with the greatest success it passes with the help of a surgical operation called radical prostatectomy.

Its advantages in the complete disposal of this disease when carried out at an early stage of tumor formation and a minimum of complications in recovery period compared to other cancer treatments.

The operation consists in extracting the prostate gland and, if necessary, the affected surrounding tissues. Immediately after prostate cancer surgery, the patient is transferred to the intensive care unit or intensive care unit. The attending physician will also be there.

Within a few hours, after the prostate cancer surgery, he will monitor the patient's condition. At this time, the doctor will not only monitor how the operated person regains consciousness after anesthesia, but also, under his guidance, the patient will be given all the necessary therapeutic measures. Blood and urine tests will also be collected to monitor the patient's condition and, if necessary, additional data collection will be carried out, including ECG, pressure control, and so on.

In the absence of complications after surgery, after a day, the man is transferred to urology department. The postoperative period after removal of prostate cancer in a hospital includes:

• Requirement to take prescribed antibiotics
• Taking analgesics
• Compliance with the diet prescribed by the doctor (usually after three days they are allowed to return to the usual way of eating)
• Removal of insurance drainage according to indications - normal in two days
• Removal of sutures - in cases without complications on the eighth day
• Healing check urethra and removal of the urinary catheter. This usually happens on the ninth day, after which the patient is discharged home.

Postoperative period after removal of prostate cancer at home:

• Monitor prostate-specific antigen (PSA) levels every trimester for the first two years to monitor the return of the disease.
• Restriction of power loads for a period of three months.
• A lot of reviews on the forums have been written about the benefits of walking, which relieve pain in the legs caused by blood clots in the postoperative period for prostate cancer.
• Kegel method to restore the function of urination.
• Long-term use of inhibitor tablets in low doses for the speedy restoration of potency.

The postoperative period for prostate cancer lasts one year, during which most patients manage to fully return to their normal lifestyle.

Life expectancy after removal of prostate cancer and possible relapses

Life expectancy after removal of prostate cancer is quite high and survival during the first five years is on average:

• First stage - 92%
• Second stage - 81%
• Third stage - 41%
• Fourth stage - 15%

Unfortunately, sometimes prostate cancer recurs after treatment.

Postoperative rehabilitation for prostate cancer not without reason includes the systematic determination of the level of prostate-specific antigen. By monitoring its level and noticing the increased number of antigens, we can confidently speak about the recurrence of prostate cancer (prostate cancer), since this is its main symptom. In medicine, this is called "biochemical recurrence of prostate cancer."

WE ADVISE! Weak potency, a flaccid penis, the absence of a long-term erection is not a sentence for a man's sexual life, but a signal that the body needs help and male strength is weakening. There is a large number of drugs that help a man get a stable erection for sex, but all have their drawbacks and contraindications, especially if a man is already 30-40 years old. help not only to get an erection HERE AND NOW, but act as prevention and accumulation male power, allowing a man to remain sexually active for many years!

The impact on a recurrent tumor, depending on the result of the study, is carried out using:

• Brachytherapy (irradiation in which radiation therapy localized in a specific diseased organ and affects only local cells).
• Haif method.
• Hormone therapy.
• radiation therapy.
• Chemotherapy.
• Radical prostatectomy (in the event that it has not been previously performed).

The prognosis for recurrent prostate cancer depends on many contributory factors, but the average mortality after relapse in the first five years is 4% and 15% within 15 years.

Let's compare the cost of surgery (as well as examination, tests and accommodation) on the prostate in different countries:

• Germany - 13000-24000 euros.
• South Korea - 18,000 euros.
• Turkey - 10800 euros.
• Israel - 5500-12000 euros.
• Russia (FGU "Treatment and Rehabilitation Center of Roszdrav") - 110,500 rubles (only the cost of the operation itself).

It should be noted that there are many positive reviews about such clinics as Hadassah in Israel and Dortmund in Germany.

How are the effects of prostate cancer on a man's life after surgery?

The consequences of prostate cancer in the postoperative period are expressed as follows:

• Pain in the lower abdomen when walking.
• Thrombus formation in the legs.
• Possible stagnation of lymph in the legs, which causes their swelling.
• Urinary incontinence after removal of prostate cancer, which resolves after an average of four to six months, is especially facilitated by exercises to strengthen the muscles of the pelvic floor.
• Periodic constipation.
• Erectile disfunction.

The consequences of prostate cancer somewhat correct the habitual lifestyle. For example, a bath after prostate cancer surgery is contraindicated for men, and those who care about their health should not only follow all the procedures prescribed by the doctor, but also start walking and observe the daily routine - good rest and proper nutrition help you recover faster.

It should be noted the study of the Swiss doctor Malt Reiken, who established the relationship between smoking and recurrence of prostate cancer, probably smokers should give up this addiction.

The first month and a half should refrain from sexual intercourse. In the future, if such a function is preserved, on the contrary, doctors recommend sexual intercourse twice a week. If there is no sexual partner, then masturbation is recommended after prostate cancer surgery. This is due to the normalization hormonal background and pelvic floor muscle training.

Operations on the stomach change its shape and function. The most noticeable changes are observed after resection of the stomach and vagotomy with pyloroplasty, which destroys the pylorus and its functions.

Syndromes caused by morphological changes include small stomach syndrome, ulcer recurrence, afferent loop syndrome, reflux esophagitis and reflux gastritis.

To the syndromes caused by postoperative functional disorders, include dumping syndrome (early and late), diarrhea, anemia, malabsorption, metabolic disorders. The latter are mainly associated with a violation of the hydrolysis of food ingredients, insufficient absorption of fats and vitamins in small intestine(malabsorption syndrome).

Disorders that occur in patients after resection of the stomach are associated with: 1) the loss of the reservoir function of the stomach due to the removal of a significant part of it; 2) with rapid evacuation of the contents of the stump into the duodenum or jejunum due to the removal of the pylorus; 3) with the exclusion of the passage of food through the duodenum and a decrease in its participation in neurohumoral regulation digestion (with resection of the stomach according to the Billroth-P method); 4) with functional and metabolic disorders.

The more extensive the resection of the stomach, the greater the risk of post-resection disorders.

Vagotomy in combination with antrum resection does not actually differ from resection without vagotomy, since when the lesser curvature is mobilized, the branches of the vagus are inevitably crossed, the distal part of the stomach and the pylorus are removed, as in hemigastrectomy. An anatomically correct vagotomy with antrum resection allows only to save a large part of the stomach, its reservoir function, and to prevent the development of small stomach syndrome. Only technically correctly performed selective proximal vagotomy without destruction of the pylorus, i.e. without pyloroplasty and other stomach-draining operations, is accompanied by a minimum number of post-vagotomy syndromes, which are usually easily treated conservatively and only in a few cases of ulcer recurrence require repeated surgery.

Dumping syndrome (early dumping syndrome) is a complex of symptoms of hemodynamic disturbances and neurovegetative disorders in response to the rapid entry of gastric contents into the small intestine.

Etiology and pathogenesis. The main reason for the development of the dumping reaction is the lack of receptive relaxation of the remaining upper part of the stomach, i.e., the ability of its stump or vagotomized stomach to expand when new portions of food arrive. In this regard, the pressure in the stomach after eating increases, its contents quickly enter in a significant amount into the jejunum or duodenum. This causes inadequate irritation of the receptors, an increase in the osmolarity of the intestinal contents. To achieve osmotic balance, extracellular fluid moves into the intestinal lumen. In response to stretching of the intestinal walls, biologically active substances (VIP-vasoactive polypeptide, kinins, histamine, serotonin, etc.) are released from the cells of the mucous membrane. As a result, vasodilation occurs throughout the body, the volume of circulating plasma decreases, and motor activity of the intestine increases. A decrease in the volume of circulating plasma by 15-20% is a decisive factor in the occurrence of vasomotor symptoms: weakness, dizziness, palpitations, arterial pressure lability. Due to hypovolemia and hypotension, the sympathetic-adrenal system is activated, which is manifested by pallor. skin, increased heart rate, increased blood pressure. An early dumping reaction develops against the background of a rapidly rising blood glucose level. Increased motility of the small intestine may be the cause intestinal colic, diarrhea.

Due to a violation of the synchronous intake of food, pancreatic juice, bile into the small intestine, a decrease in the content of enzymes in the pancreatic juice, an accelerated passage of chyme through the small intestine, the digestion of fats, proteins, carbohydrates is disturbed, their absorption and absorption of vitamins are reduced. As a result of food malabsorption, weight loss progresses, beriberi, anemia and other metabolic disorders develop, which to some extent reduce the quality of life of patients.

After vagotomy with pyloroplasty, dumping syndrome develops much less frequently than after gastric resection, mostly mild, less often medium degree severity, which is easily cured by conservative methods. Dumping syndrome occurs mainly in cases where the width of the hole during pyloroplasty or gastroduodenostomy according to Zhabula is more than 2-3 cm. After selective proximal vagotomy without destruction of the pylorus, i.e. without pyloroplasty, dumping syndrome and diarrhea, as a rule, do not occur .

Clinical picture and diagnosis. Patients usually complain of weakness, sweating, dizziness. In more severe cases, there may be fainting, "hot flashes" all over the body, palpitations, sometimes pains in the region of the heart. All these phenomena develop 10-15 minutes after a meal, especially after sweet, dairy, liquid foods (tea, milk, compote, etc.). Along with these symptoms, there is a feeling of heaviness and fullness in the epigastric region, nausea, scanty vomiting, rumbling and colicky pain in the abdomen, and diarrhea. Due to the pronounced muscle weakness patients after eating are forced to take a horizontal position.

Diagnosis is based on the characteristic symptoms of a dumping reaction that occurs after eating. During an objective examination during the dumping reaction, an increase in heart rate, fluctuations in blood pressure, and a drop in BCC are noted.

At x-ray examination rapid emptying of the operated stomach is detected (in patients after resection according to Billroth-P, evacuation is often carried out according to the “failure” type), an accelerated passage of contrast through the small intestine, dystonic and dyskinetic disorders (Fig. 11.19) are noted.

There are three degrees of severity of the dumping syndrome.

I- mild degree. There is a dumping reaction to the intake of sweet, dairy foods, accompanied by an increase in heart rate by 15 beats per 1 min. It usually lasts 15-30 minutes. Body weight is normal. Employability is preserved.

II - average degree. Dumping reaction to the intake of any food is combined with an increase in heart rate by 30 beats per 1 min. Arterial pressure is labile with a tendency to increase systolic. At the height of the dumping reaction, patients are forced to lie down. The duration of the reaction is from 45 minutes to 1 hour. Deficit of body weight up to 10 kg. The ability to work is reduced, some patients are forced to change their profession.

Rice. 11.19. X-ray of the stump of the stomach and jejunum. Evacuation of barium according to the "failure" type. Barium reflux into the afferent bowel loop.

1 - stomach stump; 2 - anastomosis; 3 - outlet loop of the jejunum; 4 - leading loop of the jejunum; 5 - duodenal stump.

III - severe degree. Due to severe weakness, patients are forced to eat lying down and be in a horizontal position from 30 minutes to 3 hours. Severe tachycardia develops, there is an increase in systolic and a decrease in diastolic pressure. Sometimes there is bradycardia, hypotension, collapse, neuropsychiatric disorders. The duration of the reaction is from 30 minutes to 3 hours. The body weight deficit exceeds 10 kg. Employability is lost. Dumping syndrome often coexists with other syndromes.

Treatment. Conservative treatment is used for mild to moderate severity of the dumping syndrome. It is based on diet therapy: frequent high-calorie meals in small portions (5-6 times a day), full vitamin composition food, vitamin replacement therapy mainly with group B drugs, restriction of carbohydrates and fluids. All dishes are steamed or boiled. Food is recommended to be taken warm. Hot and cold foods should be avoided. Slowdown in the evacuation of contents from the stomach and a decrease in the peristalsis of the jejunum are achieved by prescribing coordinates (cisapride). For the treatment of dumping syndrome, octreotide, a synthetic analogue of somatostatin (subcutaneously), is successfully used. A prospective randomized study showed that subcutaneous administration of this drug 30 minutes before a meal alleviates dumping syndrome and allows most patients to lead a normal life. Along with diet therapy, substitution therapy is used, for which hydrochloric acid with pepsin, pancreatin, panzinorm, festal, abomin, multivitamins with microelements are prescribed. Treatment psychopathological syndromes carried out in consultation with a psychiatrist.

Surgical treatment is used for severe dumping syndrome (III degree) and the ineffectiveness of conservative treatment for dumping syndrome II degree. The most common reconstructive operation is the reconversion of Billroth-P to Billroth-I or Billroth-N with gastrojejunal anastomosis on the Roux-enabled loop (Fig. 11.20). Gastrojejunoduodenoplasty is also used (see Fig. 11.13, e). A small intestinal graft connecting the stomach stump with the duodenum provides partial evacuation of the contents of the stomach stump, slowing down the rate of its entry into the intestine. In the duodenum

Rice. 11.20. Stages of reconstructive operations with the formation of a gastrojejunal anastomosis on the Roux-enabled loop.

A - resection of the zhelutska according to the Hofmeister-Finsterer; B - resection of the stomach according to Billroth-I; B - vagotomy in combination with pyloroplasty; G - resection of the stomach with gastrojejunal anastomosis on the loop turned off according to Roux; d - duodenum; p - leading loop; o - outlet loop.

food is mixed with pancreatic juice and bile, the osmolarity of the contents of the duodenum is equalized with the osmolarity of the plasma, and all food ingredients are hydrolyzed in the jejunum.

Hypoglycemic syndrome (late dumping syndrome) develops 2-3 hours after a meal. Pathogenesis is associated with excessive excretion

Rice. 11.21. Afferent loop syndrome. a - stenosis of the adductor loop; b - stenosis of the efferent loop.

administration of immunoreactive insulin during an early dumping reaction. As a result of hyperinsulinemia, there is a decrease in blood glucose levels to subnormal (0.4-0.5 g / l) indicators.

Clinical picture and diagnosis. Characterized by an acutely developing feeling of weakness, dizziness, a sharp feeling of hunger, sucking pain in the epigastric region, trembling, palpitations, lowering blood pressure, sometimes bradycardia, pallor of the skin, sweat. Possible loss of consciousness. These symptoms disappear quickly after eating a small amount of food, especially rich in carbohydrates. Symptoms of hypoglycemia can occur with long breaks between meals, after exercise.

To prevent pronounced manifestations of the hypoglycemic syndrome, patients try to eat more often, carry sugar, cookies, bread with them and take them when the first signs of hypoglycemia occur.

Treatment. The constant combination of hypoglycemic syndrome with dumping syndrome is due to their pathogenetic commonality. The leading suffering is the dumping syndrome, the elimination of which should be directed medical measures. To normalize the motor-evacuation function upper divisions digestive tract, one of the following drugs is prescribed: metoclopramide (intramuscularly or orally), cisapride, sulpiride.

Adductor loop syndrome. It can develop after resection of the stomach according to the Billroth-I method, especially in the Hofmeister-Finsterer modification (Fig. 11.21). This operation often creates favorable conditions to get food from the stump of the stomach into a short leading loop, i.e. into the duodenum. With stagnation of the contents in the duodenum and an increase in pressure in it in the early postoperative period, its stump may fail. In the late period, cholecystitis, cholangitis, pancreatitis, intestinal dysbacteriosis, cirrhosis of the liver may develop. Reflux of the contents of the afferent loop into the stump of the stomach causes biliary reflux gastritis and reflux esophagitis. When the afferent loop syndrome is combined with dumping syndrome and pancreatic insufficiency, malnutrition syndromes may appear, the water-electrolyte balance and the acid-base state may be disturbed.

Clinical picture and diagnosis. Patients are concerned about pain in the epigastric region and in the right hypochondrium after eating (especially fatty). The pains are dull, sometimes cramping, radiating under right shoulder blade, their intensity usually increases at the end of the day. This is followed by profuse vomiting of bile due to the sudden emptying of the contents of the stretched afferent loop into the stomach stump. After vomiting, relief usually occurs. The severity of the syndrome is determined by the frequency of vomiting of bile and the abundance of vomit, in which an admixture of bile is noticeable.

With concomitant pancreatitis, the pain is girdle. In the epigastric region, it is sometimes possible to palpate the adductor loop stretched with contents in the form of an elastic formation that disappears after vomiting.

An x-ray examination on an empty stomach in the stump of the stomach determines the liquid that has entered its lumen due to reflux from the afferent loop. The contrast agent injected into the stomach stump quickly enters the afferent loop and stays in it for a long time. If there is no contrast agent in the afferent loop, then this may be a sign of overflow with its contents, an increase in pressure in it, or a kink in the gastrointestinal anastomosis.

Treatment. The most adequate method of treatment in the early postoperative periods may be endoscopic drainage of the afferent loop with a nasointestinal probe for decompression and washing it. The bacterial flora, which quickly appears in the stagnant content of the afferent loop, is suppressed with the use of local and systemic antibiotic therapy. Assign prokinetics that normalize the motility of the stomach and duodenum (coordinax, metoclopramide cholestyramine). Given the presence of reflux gastritis, it is advisable to prescribe sucralfate, antacids (phosphalugel, almagel, maalox, vikalin). Surgical treatment is indicated for severe forms of afferent loop syndrome with frequent and profuse bilious vomiting. During the operation, the anatomical conditions that contribute to the entry and stagnation of the contents in the afferent loop are eliminated. The most reasonable operation is the reconstruction of the anastomosis according to the Hofmeister-Finsterer and the anastomosis on the Roux-enabled loop of the jejunum or Billroth-1.

Reflux gastritis. It develops due to the reflux of bile acids, lysolecithin and pancreatic juice, which are in the duodenal contents, into the stomach stump.

These substances destroy the muco-bicarbonate barrier, damage the gastric mucosa and cause biliary (alkaline) reflux gastritis. The causes of pronounced duodenogastric reflux can be resection of the stomach according to Billroth-P and Billroth-1, less often vagotomy with pyloroplasty, gastroenterostomy, chronic obstruction of the duodenum (mechanical or functional).

Clinical picture and diagnosis. The main symptoms of reflux gastritis are epigastric pain, regurgitation and vomiting, and weight loss. The pain intensifies after eating, it is dull, sometimes burning. Frequent vomiting brings no relief. Patients are concerned about the feeling of bitterness in the mouth. Accession of reflux esophagitis is accompanied by heartburn, dysphagia. As the disease progresses, hypo- and achlorhydria, anemia, and weight loss develop.

Repeated exposure of bile and intestinal contents to the mucous membrane of the operated stomach, especially in the area of ​​the anastomosis, can cause erosive gastritis, and subsequently lead to atrophic changes in the mucous membrane with intestinal metaplasia and dysplasia of the gastric epithelium. Erosive gastritis accompanied by blood loss and contributes to the development hypochromic anemia. In chronic atrophic gastritis, the number of parietal cells that produce gastromucoprotein decreases ( internal factor Castle), and there is a tendency to a decrease in the content of vitamin B 12 in the blood, followed by the development of pernicious anemia.

Patients with duodeno- or jejunogastric reflux 15-25 years after surgery may develop gastric stump cancer with a probability of 3-6 times higher compared with non-operated patients of the same age group. Duodenogastric reflux can be detected by x-ray. At endoscopy, bile is found in the operated stomach, hyperemia and swelling of the mucous membrane, however, a small amount of bile in the stomach does not give grounds for the diagnosis of refluxgastritis. Radioisotope scintigraphy and mucosal biopsy are more reliable and informative. At histological examination biopsy specimens detect changes characteristic of gastritis and determine the type of disease.

Treatment. Conservative treatment includes diet therapy and drug therapy. Usually prescribed cholestyramine, sucralfate (venter), antacids containing magnesium and aluminum hydroxides that bind bile acids; drugs that normalize the motility of the stomach and duodenum (metoclopramide, coordinax).

Surgical treatment is indicated for significant severity of symptoms and a significant duration of the disease, as well as in the case of complications such as bleeding from erosions and the occurrence of microspherocytic anemia.

The operation is carried out in order to divert duodenal contents from the operated stomach. Reconstructive surgery with the formation of a Roux-en-Y gastrojejunal anastomosis is considered the most effective. The length of the efferent part of the jejunal loop should be at least 40 cm. Gastrojejunoduodenoplasty (interposition of the small bowel graft between the stomach stump and the duodenal stump) is less reliable. This method is not widely used.

Dysphagia is observed relatively rarely after vagotomy in the immediate postoperative period, expressed in mild degree and passes quickly. It is caused by denervation of the distal esophagus, periesophageal inflammation, postoperative esophagitis. For treatment, prokinetics are used - motilium, cisapride (coordinax), aluminum containing antacids (almagel, phosphalugel, maalox).

Gastrostasis occurs in some patients after truncal vagotomy, especially with inadequate pyloroplasty. The main symptoms are nausea, regurgitation, vomiting, Blunt pain or heaviness in the upper abdomen. X-ray examination reveals long delay contrast in the stomach. For treatment, permanent nasogastric aspiration of the contents of the stomach, enteral tube feeding, prokinetics (coordinax) are recommended. If pyloroplasty is adequate, then with conservative treatment, the symptoms of gastrostasis disappear as gastric motility is restored.

Diarrhea is a consequence of mainly stem vagotomy in combination with stomach-draining operations. After resection of the stomach, it is less common. The main factors contributing to the occurrence of diarrhea are a decrease in the production of hydrochloric acid, a change in the motility of the digestive tract, an accelerated passage of chyme through the intestines, a decrease in the exocrine function of the pancreas, an imbalance of gastrointestinal hormones, morphological changes intestinal mucosa (eunit), impaired metabolism of bile acids, changes intestinal microflora. The frequency of stools, the suddenness of their appearance, the relationship with food intake are the criteria for distinguishing three degrees of diarrhea severity.

With a mild degree, loose stools occur from 1 time per month to 2 times a week, or occasionally after taking certain foods. With an average degree, loose stools appear from 2 times a week to 5 times a day. In severe cases, watery stools occur more than 5 times a day, suddenly, sometimes immediately after eating any food. Diarrhea is usually accompanied by a progressive deterioration of the patient's condition.

Treatment. It is recommended to exclude milk and other products that provoke a dumping reaction from the diet. Include foods in your diet causing delay chair. Used to normalize the intestinal microflora antibacterial agents, bifidumbacterin and its analogues. It is advisable to prescribe agents that adsorb bile acids (cholestyramine). Imodium quickly has a positive effect - an antidiarrheal agent that reduces the motility of the gastrointestinal tract.

Metabolic disorders develop more often after extensive distal resection of the stomach or gastrectomy due to the removal of a significant part of the parietal cells of the stomach that secrete the Castle factor. It is necessary for the binding of vitamin B | 2 and absorption processes in the ileum. However, some authors believe that vitamin B12 deficiency and megaloblastic anemia are not associated with impaired production of gastromucoprotein by parietal cells, but with malabsorption in the small intestine (malabsorption syndrome), abundant growth bacteria or with autoimmune gastritis. A number of patients develop iron deficiency anemia, vitamin B12 deficiency. With malabsorption, the absorption of many food ingredients is disturbed, and steatorrhea often occurs. This leads to a sharp weight loss and even cachexia, which affects the quality of life and behavioral reactions of patients.

Treatment. It is usually recommended to eat high-calorie foods in small portions several times a day. Many patients want to eat, as usual, three times a day. Due to the decrease in the volume of the stomach and the lack of receptive relaxation of its stump during eating, they have an early feeling of fullness, they stop eating and do not receive the required amount of calories. Patients must be taught to eat right, prescribe vitamin B 12, iron preparations (tardiferon, iron gluconate, ferronal, etc.). In severe cases, inpatient treatment is indicated to correct metabolic disorders.

Ulcer recurrence. After gastric surgery for peptic ulcer (resection or vagotomy), ulcer recurrence occurs with greater or lesser frequency (Fig. 11.22). The reasons for recurrence after resection of the stomach may be an insufficient decrease in the production of hydrochloric acid due to economical resection or the leaving of a part of the mucous membrane of the antrum above the duodenal stump. In connection with the shutdown of the function of the antrum that regulates acid production, the remaining gastrin-producing cells continue to secrete gastrin and maintain

Rice. 11.22. Causes of ulcer recurrence after surgery.

1 - economical resection of the stomach; 2 - leaving the area of ​​the antrum above the duodenum; 3 - incomplete vagotomy; 4 - narrowing of the gastroduodenostoma; 5 - Zollinger-Ellison syndrome; 6 - primary hyperparathyroidism (adenoma of the parathyroid glands).

a sufficiently high level of hydrochloric acid release in the stomach stump.

Ulcer recurrence after vagotomy (10-15%) is usually associated with incomplete or inadequate vagotomy. Narrowing of the outlet in pyloroplasty according to Heineke-Mikulich or gastroduodenostoma performed according to Zhabula, causing stagnation of the contents in the stomach, can also cause relapse.

Ulcer recurrence may occur due to extragastric factors such as gastrinoma (Zollinger-Ellison syndrome), hyperparathyroidism, multiple endocrine neoplasia - MEN-1.

Zollinger-Ellison syndrome includes a triad of symptoms: 1) primary peptic ulcer, localized mainly in the duodenum, often recurrent, despite adequate medical and standard surgery; 2) pronounced hypersecretion of hydrochloric acid due to excessive release of gastrin; 3) the presence of gastrinoma - a neuroendocrine tumor of the pancreas that secretes gastrin. The presence of Zollinger-Ellison syndrome can be suspected by the aggressive course of peptic ulcer, frequent relapses and complications (bleeding, history of perforation), low treatment efficiency, and recurrence of ulcers after standard stomach surgery. An important criterion for differential diagnosis is to determine the concentration of gastrin in the blood and the production of hydrochloric acid. In patients with Zollinger-Ellison syndrome, basal secretion of hydrochloric acid exceeds 15 mmol / h, and in patients who have previously undergone gastric surgery aimed at reducing acidity, no more than 5 mmol / h. In more difficult cases it is recommended to carry out special load tests with intravenous administration secretin, calcium gluconate, etc. (see "Tumors of the pancreas").

After resection of the stomach according to Billroth-P, ulcer recurrence is observed in 2-3% of cases. The ulcer most often occurs in the outlet loop of the jejunum (ulcus pepticum jejuni). Very rarely, as a result of penetration of the ulcer into the transverse colon, a fistula appears between the stomach, jejunum and transverse colon (fistula gastrojejunocolica). Recurrent ulcers after vagotomy are usually localized in the duodenum, less often in the stomach.

Clinical picture and diagnosis. Typical symptoms of ulcer recurrence are pain, vomiting, bleeding (massive or hidden), anemia, and weight loss. With a gastrointestinal fistula, diarrhea, vomiting mixed with feces, and a sharp weight loss are added to these symptoms, since food, getting from the operated stomach directly into the large intestine, is not absorbed. Most informative methods diagnostics are endoscopy and X-ray examination.

Treatment. In case of ulcer recurrence after vagotomy, the use of one antisecretory drug (omeprazole, ranitidine, famotidine, sucralfate) and two antibiotics for the eradication of Helicobacter pylori infection (triplex scheme) gives a good effect. It is noted that marginal ulcers, located at the site of the gastrojejunal junction, are poorly amenable to drug treatment. In the absence of the effect of drug treatment or in the event of life-threatening complications, reconstructive surgery is indicated. The purpose of the operation is to eliminate the cause of the recurrence of the ulcer.

Operation methods. If an antrum section with preserved mucous membrane over the duodenal stump is not removed during resection of the stomach, its removal is indicated if, due to circumstances, there is no need for another type reconstructive surgery. In case of recurrence of an ulcer after resection according to Billroth-P, it is advisable to perform a stem vagotomy or a higher resection of the stomach with removal of the ulcer. A good effect is given by stem vagotomy with reconstruction of the Hofmeister-Finsterer anastomosis into an anastomosis according to Roux. Antrum resection in combination with truncal vagotomy and Roux-en-Y gastrojejunal anastomosis is indicated for ulcer recurrence after gastric resection and after selective proximal vagotomy.

The frequency of pathological syndromes after gastric surgery is the main criterion for the effectiveness of the applied operational methods peptic ulcer treatment. In most cases, the results of gastric surgery are usually evaluated according to the Vizick criteria.

I. Pathological symptoms no.

II. There are mild symptoms of dysfunction that do not affect normal life.

III. There are symptoms of moderate severity that do not disrupt the normal life and work capacity of the patient, but require adequate treatment.

IV. Recurrence of an ulcer or other symptoms that cause disability.

The results of the operation, which meet the criteria of Visik I and II, are assessed as excellent and good. Satisfactory and poor results are graded as Visic III and IV. With this method, the quality of life is assessed by the patient himself. Complications that are mild in their symptoms are often not taken into account by the patient, since they seem not so significant compared to the severity of the symptoms of the disease before surgery. The Vizick criteria are not sensitive enough. In one study, the author compared the results of gastric surgery with the results of hernioplasty according to these criteria. According to the Vizick criteria, both groups of patients had the same number of good and excellent results. This is due to the low specificity of the Vizick criteria and the significant incidence of dyspeptic disorders in the population. Some authors try to improve the Visik scale with their additional criteria. In this regard, it becomes impossible to compare one method of operation with another.

More acceptable can be considered the Johnson scale, which reflects each pathological postoperative syndrome and assesses its severity according to a five-point system. The scale for determining the quality of life adopted by the European Association of Gastroenterologists can be considered more perfect. It takes into account not only the severity of post-resection syndromes, but also changes in the quality of life of the operated patients in a broad aspect. The quality of life is assessed not only by the patient, but also by family members, doctors, experts of the commission on medical and social expertise. Ability to work, disability group, changes in social and family life, sociability in society, psychological aspects of life and relationships are taken into account. The quality of life is determined by the effectiveness of the performed surgical intervention. From a wide variety of operations, one should choose the one that can provide the patient high quality life, and not the one that pleases the surgeon.