The following video demonstrates the medical management of total gastrectomy with esophagojejunostomy.
These are the two different types of esophago jejunostomies. This is a simple Roux-en-Y esophagojejunostomy. It has a short blind loop and a patent loop of jejunum.
We will now see the endoscopic view of a simple Roux-en-Y esophagojejunostomy in a 73 year old female patient who underwent total gastrectomy for the management of gastric adenocarcinoma.
The scope is introduced into the esophagus. One can see the esophago-jejunal anastomosis with the blind loop on the left and the patent loop on the right. Initial attempt was made to explore the blind loop followed by exploring the patent loop of jejunum. Here the endoscope is pushed through the patent loop followed by its withdrawal.
Total gastrectomy is indicated in the management of patients with gastric cancer, gastric sarcoma and gastric lymphoma. The procedure of total gastrectomy can be done either by laparotomy or by laparoscopy. Upto 3% of people may develop life threatening complications and around 20% may develop other serious complications.
All the complications arising as a result of total gastrectomy can be grouped as Post-gastrectomy syndrome.
The basic functions of the stomach are storage of the food and digestion of the food. As a result of the loss of these two basic functions, patients after total gastrectomy exhibit two major types of disturbances. Nutritional Intolerance which is due to loss of the storage function of the stomach and Nutritional deficiency due to loss of the digestive capacity. Nutritional intolerance may present either as Dumping syndrome or Fat maldigestion.
We will now look in detail about the Dumping syndrome which is a result of the loss of gastric reservoir resulting in the rapid emptying of hyper osmolar contents into the small bowel causing fluid shifts. Depending on the time of the onset of symptoms, dumping syndrome can be classified as either early-onset type or the late-onset type. Early-onset manifests within 15-30 minutes after a meal. This is due to the hyperosmolarity of food entering the small bowel leading to fluid shifts into the small bowel lumen resulting in its rapid distension and an increase in the frequency of its contractions. Late-onset dumping syndrome occurs 2-3 hours after a meal and is due to reactive hypoglycemia which is a result of hyperglycemia and subsequent hyperinsulinemia. Patients present with Post prandial weakness, flushing, dizziness and sweating as a result of the fluid shifts and hypoglycemia.
Management of the patients with dumping syndrome includes counseling the patients about eating smaller meals at frequent intervals to prevent the hypoglycemia, to limit the fluid intake along with the meal and to eat food rich in proteins and fibers and also to avoid foods with high carbohydrates as they exacerbate both the early and late onset types.
Fat maldigestion is a result of the faster transit time, decreased enzyme production and larger food particles entering the small bowel preventing the proper mixing of enzymes leading to reduced digestion of ingested fats. The management of these patients include supplementing them with pancreatic enzymes and advising them to take a low fat diet.
Nutritional deficiencies can manifest either as Anemia or metabolic bone disease. Anemia can be either megaloblastic or microcytic. Megaloblastic anemia is due to deficiency of Vitamin b12 as a result of absent intrinsic factor requires for its absorption and a deficiency of folic acid due to impaired absorption and digestion. Oral or parenteral supplementation of B12 and 5 mg of folic acid is given to prevent megaloblastic anemia. Microcytic anemia is due to inadequate iron absorption as a result of loss of gastric acidity. 200 mg of elemental iron daily is prescribed along with advising the patient to eat iron-containing foods and take vitamin C supplements which have been shown to enhance iron absorption.
Metabolic bone disease is due to lack of calcium and Vitamin D because of altered digestion and absorption. Patients manifest with fractures from osteoporosis, osteopenia and osteomalacia. The management of these patients includes regular monitoring of the Vitamin D levels and also the bone mineral density by DEXA scans and prescribing 500 mg of calcium TID and 800IU of Vit D daily.
Chandra S. Dasari, MD, MD Anderson Cancer Center
Gottumukkala S. Raju, MD, MD Anderson Cancer Center