Long-Term Consequences of Total Gastrectomy: Quality of Life, Nutritional Status, Bacterial Overgrowth and Adaptive Changes in Esophagojejunostomic Mucosa

OBJECTIVES

The aim of the study was to evaluate long-term quality of life and adaptive changes in the mucosa of the proximal section of the small intestine used for esophagojejunostomy reconstruction in stomach cancer patients after total gastrectomy.

MATERIAL AND METHODS

Thirty-one patients who had undergone stomach cancer-related total gastrectomy were included in the study, which spanned a period of 48 to 127 months (79.6 months on the average) after the surgery. The analysis included: a) evaluation of selected biochemical parameters; b) microbiological evaluation of esophagojejunostomic area; c) evaluation of adaptive changes in esophagojejunostomic mucosa using light and electron microscopy; d) quality of life evaluation with a Troidl questionnaire.

RESULTS

Quality of life was subjectively rated as good or very good by almost all subjects. The analyzed biochemical parameters were within the range of normal values in all the subjects with the exception of mild abnormalities in alkaline phosphatase and vitamin B12 levels in some patients. Microbiological examination of mucosal specimens from below the esophagojejunostomy revealed significant bacterial flora overgrowth in all the patients, with streptococci being the most abundant species. Light and electron microscopy examination of the epithelium confirmed it was normal and characteristic of a healthy small intestine.

CONCLUSIONS

Long-term quality of life in patients after complete stomach resection is considered good or very good, irrespective of the reconstruction method used, and the esophagojejunostomic mucosa of the reconstructed area is normal and typical for a healthy small intestine.

Severe Ataxia, Myelopathy, and Peripheral Neuropathy Due to Acquired Copper Deficiency in a Patient With History of Gastrectomy

BACKGROUND

In animal studies, copper absorption has been demonstrated to occur in the proximal gut via duodenal enterocytes. Acquired copper deficiency is known as "swayback" in ruminant animals and Menkes' disease in humans. Copper is an essential micronutrient necessary for the hematologic and neurologic systems. Acquired copper deficiency in humans has been described, causing a syndrome similar to the subacute combined degeneration of vitamin B(12) deficiency.

METHODS

This is a single case report. Our patient developed a neurologic constellation of ataxia, myelopathy, and peripheral neuropathy similar to vitamin B(12) deficiency many years after gastrectomy for severe peptic ulcer disease. The patient was maintained for decades with enteral feedings via jejunostomy that provided the recommended dietary allowance (RDA) for copper.

RESULTS

Copper deficiency was suspected, identified, and treated. Over 3 months of follow-up, serum copper levels increased from 4 microg/dL to 20 microg/dL (70-150 microg/dL), and ceruloplasmin increased from 6 mg/dL to 8 mg/dL (14-58 mg/dL). During this short time of follow-up, the patient has had no further progression of his neurologic symptoms.

CONCLUSIONS

Ataxia and myelopathy secondary to acquired copper deficiency are rare complications of major gastric resection. This is quite similar to the syndrome of vitamin B(12) deficiency. Vitamin B(12) repletion does not improve symptoms. Bariatric procedures such as gastric bypass surgery result in a similar functional anatomy of the proximal gut and may place more patients at increased risk. Early recognition and therapy with oral or parenteral copper may lead to a decrease in both neurologic and hematologic consequences.

Jejunal pouch reconstruction but not preservation of duodenal passage after total gastrectomy reduces plasma cholecystokinin and pancreatic polypeptide long term in pigs

AIM

The long-term effects of reconstructions of the gastrointestinal tract after gastrectomy on plasma levels of gastrointestinal hormones that contribute to food intake controls were evaluated.

MATERIALS AND METHODS

Domestic pigs were randomly assigned to sham-surgery or total gastrectomy followed by reconstruction with oesophagojejunostomy on a Roux-en-Y loop (OJRY), jejunal interposition between the oesophagus and the duodenum (OJD), or an oesophagojejunostomy with a jejunal pouch reservoir (J-pouch) on a Roux-en-Y loop. Plasma levels of peptides were analysed by radioimmunoassay (RIA).

RESULTS

Ten weeks after surgery, levels of cholecystokinin (CCK) and pancreatic polypeptide (PP) were significantly lowered (79.6% and 67.0%, respectively) in animals with a J-pouch, but not in sham-operated animals or animals with OJRY or OJD, as compared to preoperative levels. The levels of neuropeptide Y (NPY) and peptide YY (PYY) remained unchanged, irrespective of the mode of reconstruction.

CONCLUSION

J-pouch, but not preservation of duodenal passage after total gastrectomy, lowers levels of CCK and PP, peptides that reduce food intake.

Total gastrectomy causes a sustained, long-term elevation of somatostatin in plasma, independent of the mode of reconstruction in pigs

AIM

The long-term effects of gastrectomy and various reconstructions of the gastrointestinal tract on fasting plasma levels of gastrointestinal hormones known to contribute to the control of gastrointestinal motor function were evaluated in pigs.

MATERIALS AND METHODS

Domestic pigs were randomly selected to sham surgery or total gastrectomy (TG) followed by reconstruction with oesophago-jejunostomy on a Roux-en-Y loop (OJRY), jejunal interposition between the oesophagus and the duodenum (OJD), or an oesophagojejunostomy with a proximal jejunal pouch reservoir (J-pouch) on a Roux-en-Y loop. Blood was collected just before surgery and ten weeks later and peptide levels were analysed by radioimmunoassay.

RESULTS

Somatostatin levels were sustained at a high level after TG, regardless of the mode of reconstruction, but were significantly lower in sham-operated animals. Levels of vasoactive intestinal peptide (VIP), neurotensin and motilin were unchanged.

CONCLUSION

TG by itself leads to high levels of somatostatin long term, however, somatostatin, motilin, neurotensin and VIP are unaffected by the mode of reconstruction.

Post-gastrectomy anemia: evaluation of 72 cases with post-gastrectomy anemia

Anemia is common in patients following gastrectomy. The purpose of this study was to document causes of anemias developing during the post-gastrectomy period and to determine the importance of complete blood count parameters on types of anemia. A total of 72 patients (23 women and 49 men) who had previously undergone gastrectomy in the past and who were admitted for the evaluation of anemia were enrolled in study. The patients who were evaluated and treated for anemia in the post-gastrectomy period were excluded. Iron deficiency anemia was present in 68 (94.4%) of 72 gastrectomized patients with anemia. Deficiencies of vitamin B12 and folate were present in 57 (79.2%) and in three patients, respectively. The most common cause of anemia was the combination of iron and vitamin B12 deficiencies. Iron deficiency was present in the majority of patients, followed by vitamin B12 deficiency in frequency. In all combinations of iron deficiency, the values of mean cell hemoglobin and mean cell hemoglobin concentration were either normal or low. In cases who had low white blood cell and platelet counts vitamin B12 deficiency was frequent, while in cases who had high numbers of white cells or platelets iron deficiency was more frequent. In conclusion, gastrectomized patients should be followed for anemia and treated appropriately based on the cause of anemia.

Immunologic changes to autologous transfusion after operational trauma in malignant tumor patients: neopterin and interleukin-2

OBJECTIVE

To estimate the impact of autologous transfusion on the status of perioperative immune activation in malignant tumor patients. The Serum Neopterin and Interleukin-2 (IL-2) were measured.

METHODS

Sixty patients undergoing elective radical resection for malignant stomach tumor were enrolled in the prospective study and assigned to the following groups: (1) Group A received autologous transfusion. (2) Group H received allogeneic transfusion. The perioperative course (Before induction of anesthesia, after operation and 5 d after operation) of Neopterin and IL-2 was compared.

RESULTS

In group A, Serum Neopterin was significantly lower than baseline after operation and IL-2 had no significant changes. In group H, both Serum Neopterin and IL-2 were significantly lower than baseline after operation and 5 d after operation. Compared with group A, Serum Neopterin was significantly lower than baseline after operation and 5 d after operation and IL-2 was significantly lower than baseline 5 d after operation.

CONCLUSION

Autologous transfusion decreased the perioperative immune suppression in malignant stomach tumor patients.

Enhanced levels of biochemical markers for cobalamin deficiency in totally gastrectomized rats: uncoupling of the enhancement from the severity of spongy vacuolation in spinal cord

The totally gastrectomized (TGX) rat is a new experimental model for studying the pathogenesis of cobalamin (Cbl)-deficient myelopathy, i.e., subacute combined degeneration, total gastrectomy (TG) serving as a surgical paradigm of human pernicious anemia. We determined the serum levels of some biochemical indicators of Cbl deficiency in TGX rats at 2 to 10 months after TG. Methylmalonic acid (MMA) rose within 2 months and progressively increased thereafter until the end of the investigation period. 2-Methylcitric acid (MCA) rose significantly by 6 months and showed a further increment 4 months later. Homocysteine was only clearly elevated much later than the serum MMA, i.e., 10 months after the operation. The concentrations of MMA, MCA, and cystathionine were increased in kidney, liver, and spinal cord (SC) of TGX rats at 10 months. Chronic treatment of TGX rats with Cbl greatly decreased the serum levels of all the metabolic indicators of Cbl deficiency. Chronic peroral administration of the antibiotic lincomycin to TGX rats in an attempt to suppress the enteric flora markedly decreased serum MMA levels. Only Cbl, however, given either for the first 2 months after TG or for the third and fourth postoperative months (i.e., after SC abnormalities had already appeared) significantly decreased the severity of spongy vacuolation in SC white matter, although not completely preventing or repairing the neuropathological damage. Therefore, neither the early impairment in TGX rats of the Cbl-dependent methylmalonyl-coenzyme A mutase reaction nor the more delayed impairment of the Cbl-dependent methionine synthase step, as reflected by changes in serum metabolite levels, seems to be causally related to the TG-induced spongy vacuolation in SC white matter.

Serum erythropoietin and erythroid activity in vitamin B12 deficiency

We studied erythropoiesis in 31 patients with vitamin B12 deficiency by measuring serum erythropoietin (s-Epo), serum transferrin receptor (s-TfR, taken as an index of total erythroid activity), reticulocyte count, and the reticulocyte maturation index (RMI). s-Epo and s-TfR were measured with commercial immunoassays, whereas reticulocyte count and RMI were determined by flow cytometry. s-Epo (123 +/- 196 U/L) and s-TfR (4.1 +/- 2 mg/L) levels were increased in patients with vitamin B12 deficiency. The absolute reticulocyte counts were decreased (29 +/- 18 x 10(9)/L) with a relative increase in the most immature fractions (RMI: 29.6 +/- 18%). A significant negative relationship was found between s-Epo and Hb level (r = -0.65, p < 0.0001). On the average, however, s-Epo was inappropriately low for the degree of anemia, since the observed/predicted (O/P) s-Epo ratio was 0.80 +/- 0.28 in vitamin B12 deficiency vs 1.00 +/- 0.16 in a group of patients with iron deficiency anemia. It is concluded that at least a portion of patients with vitamin B12 deficiency have serum erythropoietin levels that are inappropriately low for the degree of anemia.

Bone disorders following total gastrectomy

Bone disorders following gastrectomy were studied by measuring absolute and relative bone mineral density of the Wards triangle, serum 1,25-(OH)2-D, alkaline phosphatase, and total serum calcium. The subjects were 20 males who had undergone total gastrectomy not more than three months previously (group A1). Seventeen of these patients were reviewed three years later (group A2). Absolute and relative bone density were significantly lower in group A2 than in A1 (0.52 +/- 0.011 g/cm2 versus 0.6 +/- 0.014 g/cm2, P < 0.01 and 85.5 +/- 1.4% age-matched control versus 95 +/- 1.3%, P < 0.01). 1,25-(OH)2-D was significantly lower in group A2 than in group A1 (14.3 +/- 0.97 pg/ml versus 20.6 +/- 1.02 pg/ml, P < 0.01). There was no difference in alkaline phosphatase and calcium serum concentration. The mean weight loss was 6.26 +/- 0.57% over the follow-up period, and weight loss correlated with absolute and relative bone density (r = -0.74, P < 0.01). There was a positive correlation between 1,25-(OH)2-D and absolute or relative bone density (r = 0.67, r = 0.62 and P < 0.01). These data suggest that bone density decrease has already occurred three years after total gastrectomy and is positively correlated to 1,25-(OH)2-D deficiency. As no differences in serum alkaline phosphatase and serum calcium concentration were found, these factors are of little value for the early detection of postgastrectomy bone disorders, whereas weight loss is a valuable screening parameter.

[The differential assessment of the state of lipid peroxidation and of the antioxidant system in patients in the late period after gastric resection]

Studied after stomach resection for ulcer disease in 161 patients were lipid peroxidation (LPO), antioxidant system (AOS) and related parameters characterizing metabolism of carbon (Lactat), protein (piruvat) and fat (fat acids, lipoproteins), an indicator of the dystrophic change degree (acid phosphatase). Revealed in these patients was syndrome of peroxidation, which leads to disturbances of protein, carbon and fat metabolism, destruction of cell membranes. Increased, "normal", weakened LPO was identified in 67.7%, 9.94%, 22.36% of the patients respectively. In patients with an increased LPO statistically significant activation of AOS was established, lactate having increased more than twice, pyruvate remaining unchanged; the level of fat acids and lipoproteins almost doubled. In such a situation it is reasonable to use preparations which activate aerobic glycolysis, and antioxidants of a direct, mild degree, action. In group II patients with more prominent increase in the acid phosphatase activity preference should be given to membrane-stabilizing preparations. In patients with a decreased level of LPO considerable increase in lactate and acid phosphatase was noted. It is recommended that preparations promoting normalization of carbon and lipid metabolism, enhancement of redox processes in the respiratory chain should be included into complex therapy as should be stabilizers of membranes of cell organelles, with biogenic stimulators to follow.

[Biochemical indicators of the nutritional status of the body in various diseases of the digestive system]

In 45 patients with chronic digestive tract diseases (gastric and/or duodenal peptic ulcer, cholecystolithiasis, conditions after gastrectomy and cholecystectomy) the biochemical parameters serving as indicators of the nutritional status of the organism (Hb, Bc, Fe, Ca, alkaline phosphatase) were determined. In the group with postgastrectomy syndrome the serum calcium level was decreased. The other parameters were normal in all groups of patients.

[Intestinal osteopathy following partial gastric resection]

26 years after a partial gastric resection (Billroth II) for recurrent gastric ulcer a 62-year-old man developed severe intestinal osteopathy. For three years he had increasing pain in the lower back and hip with a noticeable waddling gait. Serum concentration of calcium (2.0 mmol/l) and 25-hydroxy-vitamin D3 (38 mmol/l) were reduced, those of alkaline phosphatase (572 U/l) and parathormone (532 pg/ml) increased. Radiology demonstrated Looser's zones in the ribs and iliac crest. Osteodensitometry showed obviously diminished bone density. Iliac crest biopsy revealed signs of osteomalacia and secondary hyperparathyroidism. Within three months of starting oral vitamin D3 and calcium the symptoms had definitely receded and serum concentrations of calcium and alkaline phosphatase had become normal (2.4 mmol/l and 156 U/l, respectively). Osteopathic symptoms are often the expression of an abnormal calcium/phosphate metabolism. The cause often lies in the gastrointestinal tract; not rarely it is a late complication of a gastrojejunostomy.

Emptying of the gastric substitute after total gastrectomy. Jejunal interposition versus Roux-y esophagojejunostomy

Emptying of the gastric substitute and small bowel transit time of a 99mTc-labeled solid test meal were measured in 20 tumor-free patients 13 to 63 (median, 35) months after total gastrectomy with Roux-y (n = 11) and jejunal interposition (n = 9) reconstruction. The emptying half-times ranged from 2 minutes to greater than 20 minutes. Rapid emptying was associated with dumping symptoms (p less than 0.03) and shorter orocoecal transit-time (p less than 0.05). Serum glucose concentrations rose more quickly in jejunal interposition, but the areas under the curve were identical in both groups. The median insulin-to-glucose ratio (areas under the curve) during the 20 minutes after the meal was 11.4 in jejunal interposition and 7.1 in Roux-y esophagojejunostomy (NS). Interposition cases had regained a significantly higher percentage (89%) of their premorbid weight than patients with Roux-y (78%; p less than 0.05). The weight/height2 ratio was above the 50th centile in 45% of interpositions, but below the 50th centile in all patients after the Roux-y mode of reconstruction (p less than 0.05). It is concluded that the emptying velocity of the gastric substitute has no impact on postoperative weight gain. The authors contend that the concept of a gastric substitute pouch is not supported by the findings of this study.

[Late complications in patients having undergone a gastric resection]

A total of 37 patients who had undergone partial gastrectomy for duodenal or gastric ulcers, were investigated. The postoperative periods ranged from 5 to 28 years. All the patients were subjected to comprehensive clinical and neurologic examinations. The content of vitamin B12 and folic acid in the blood serum was studied by radioimmunoassay in 29 gastrectomized patients, hematological parameters (hemoglobin, serum iron, red blood cell morphology, proteinogram) were estimated in 19 patients. The mean content of vitamin B12 in the blood serum of patients was lower than in normal subjects. The mean level of folic acid in the blood of patients was also lower than in the control, however, this difference was insignificant. Nine patients had subnormal content of vitamin B12, eight of them showed manifest neurologic complications, such as myelopathy and polyneuropathy. Only 3 patients had subnormal content of folic acid in the blood serum. Weakly pronounced anemic syndrome was detected only in 2 out of 19 patients. The role of vitamin B12 deficiency in the development of neurologic symptoms has been considered.

Serum pepsinogens I and II and gastric mucosal histology after partial gastrectomy

We determined the effect of postgastrectomy gastritis on serum pepsinogen I and pepsinogen II concentrations in 108 subjects with subtotal gastric resection. Eleven had normal remnant mucosa, 22 had superficial gastritis, and 75 had atrophic gastritis. In the subjects with superficial gastritis, serum pepsinogen I and II concentrations were significantly higher than in those with normal remnant mucosa, but the ratio of pepsinogen I to II did not differ from normal. In atrophic gastritis, serum pepsinogen I concentrations fell with increasing severity of mucosal damage, but pepsinogen II was persistently raised. Consequently, the ratio of pepsinogen I to II in subjects with atrophic gastritis was significantly lower than in those with superficial gastritis or normal remnant mucosa. Discriminant function analysis revealed that the ratio of pepsinogen I to II, in combination with the absolute level of pepsinogen II, had a sensitivity of 80%, a specificity of 73%, and a positive predictive value of 87% for atrophic gastritis in this population. We propose that the parallel increase in serum pepsinogen I and II concentrations in postgastrectomy superficial gastritis is because of an increased rate of endocrine release of both zymogens from the fundic glands, and that the dichotomy in pepsinogen I and II concentrations in postgastrectomy atrophic gastritis results from the loss of fundic glands, which produce both zymogens, and the appearance of metaplastic pyloric glands, which produce only pepsinogen II.

[Determination of serum vitamin B12 in hematologic diseases]

By means of a test set of the Isocommerz (GDR) determinations of vitamin B12 in the serum were carried out according to the principle of the competitive protein binding. The normal values lie between 200 and 1,000 pg/ml serum. Clearly decreased levels of vitamin B12 are found in the pernicious anaemia, in other megaloblastic anaemias and in disturbances of the resorption after resection of the stomach. Increased values can be stated in the untreated chronic myelosis and in the blast episode. Under Busulphan-therapy a significant decrease of the values of vitamin B12 develops. The method seems to be practically important for the well-timed recognition of deficiency conditions of vitamin B12 in beginning pernicious anaemia, in disturbances of intestinal resorption after resection of the stomach and for the observation of the course of the chronic myelosis.

Retained gastric antrum syndrome diagnosed by [99mTc] pertechnetate scintiphotography in man: hormonal and radioisotopic study of two cases

Retained-antrum syndrome is a rare condition, occurring in Billroth II gastrectomised patients, in which an ulcer recurs associated with high levels of circulating gastrin. Some gastrin tests are useful to differentiate a retained antrum from a gastrinoma, but a firm diagnosis is sometimes very difficult. We have studied two cases of retained-antrum syndrome both by gastrin tests and by [99mTc] pertechnetate scintiphotography. By this method a prominent area of activity was observed on the anatomic site of the duodenal stump bottom. It appeared after 20 or 30 min and lasted for the 2 hr of observation. After surgical resection, no area of activity was observed at the scintiphotographic followup. No false positive was observed out of the more than 30 subjects studied. Scintiphotography by pertechnetate seems able to demonstrate the presence and the size of retained gastric antrum in B II gastrectomised patients with recurrent ulcer.

Electrophysiological findings in gastrectomized patients with low serum B12

Thirty-eight patients with vitamin B12 deficiency after gastric surgery for a benign peptic ulcer were examined electrophysiologically. Thirteen (34 per cent) had electromyographical signs of peripheral nerve involvement and the amplitude of the sensory potentials of the median nerve at wrist (16 patients) was diminished, whereas sensory and motor conduction velocities were normal. Six patients had clinical signs of polyneuropathy. The electrophysiological findings are compatible with slight loss of myelinated nerve fibres. None of the patients had clinical or electromyographical signs of myopathy.

[Agastric dystrophy after gastrectomy]

A follow-up of 9 patients was performed 5-11 years subsequent to total gastrectomy. Biochemical findings were normal. Compared to a normal control group vitamin A absorption indicative of fat assimilation was unaltered. Subjects regained preoperative weight and presented no signs of malnutrition. Eight patients suffered seriously from reflux. Five patients showed dumping symptoms. Endoscopic specimens from jejunal mucosa were found to be normal. It seems that postoperative complaints described above may be prevented by reasonable operative measures.

[Milk intolerance, lactose intolerance and lactase deficiency in partial resection of the stomach]

Of 40 patients with a partial gastrectomy (Billroth-II) 10 developed a milk intolerance and 11 had a lactase deficiency, the latter in 4 cases appearing together with a decrease in other disaccharidases. Only 2 of the 11 lactase-deficient patients complained of milk intolerance. The Ethanol lactose tolerance test (ELTT) was performed in 21 patients and was found to be abnormal in 6. Whereas cases of abnormal ELTT usually (4 of 6 cases) showed a lactase deficiency, only 2 patients with milk intolerance showed an abnormal ELTT and lactase deficiency. Milk intolerance can therefore only exceptionally be explained by lactase deficiency, and lack of lactase in the upper jejunum usually does not produce intolerance symptoms. Moreover, in comparable determinations from the afferent and efferent jejunal loop no differences in enzyme activities could be observed.

[Gastrin in internal medicine]

A pathophysiological role of gastrin has been established only in the Zollinger-Ellison-Syndrome. Hypergastrinemia may be found in cases with prenicious anemia, atrophic gastritis and after all forms of vagotomy; furthermore in the excluded antrum syndrome, the short bowel syndrome, in renal insufficiency, pyloric stenoses and after oral or parenteral administration of calcium. The role of gastrin in the pathogenesis of duodenal ulcer is unknown.

Diagnostic value of the serum folate assay

The diagnostic value of the serum folate assay has been assessed in 90 patients, each of whom had a macrocytic anaemia and a low serum vitamin B(12) level. Twenty-nine (32%) patients were found to have anaemia due primarily to folate deficiency. The cause of the low serum vitamin B(12) levels is uncertain in the 22 (25%) patients with normal or borderline vitamin B(12) absorption. The effect of folic acid therapy was studied in four of these patients, and in each case the serum vitamin B(12) rose slowly to a normal level. The serum folate was low in only four (7.5%) of the 54 patients with pernicious anaemia, and the levels rose to normal on treatment with vitamin B(12) alone. A high serum folate occurred in eight (15%) pernicious anaemia patients. A normal serum folate indicated the diagnosis of pernicious anaemia or megaloblastic anaemia following partial gastrectomy. However, a normal serum folate and a very low vitamin B(12) level was found in two patients with idiopathic steatorrhoea. It is concluded that the serum folate assay is a valuable routine test in patients who have a macrocytic anaemia and low serum vitamin B(12). A low folate level makes the diagnosis of pernicious anaemia unlikely and is a strong indication for full investigation of small intestinal function.

Pathophysiology of post-gastrectomy hypoglycaemia

The blood glucose and plasma insulin response to oral glucose and slow intravenous infusion of glucose was determined in seven patients who had undergone partial gastrectomy or gastroenterostomy. Similar studies were conducted in normal subjects; in these experiments oral glucose administration was replaced by infusion of glucose direct into the jejunum in order to simulate the rapid gastric emptying which occurs after gastric surgery.Peak insulin levels were much higher after oral or intrajejunal glucose, though peak blood glucose levels were higher after intravenous glucose. Despite the high insulin levels occurring with oral administration the late fall in blood glucose below fasting levels was not significantly greater after oral or intrajejunal glucose than after intravenous administration of the sugar. This does not support the concept that hyperinsulinaemia alone is responsible for reactive hypoglycaemia.