Surgical Treatment of the Postgastrectomy Dumping Syndrome

Roberto Miranda, MD, Gainesville, Florida

Bruce Steffes, MD, Gainesville, Florida

James Patrick O’Leary, MD, Gainesville, Florida

Edward Roy Woodward, MD, Gainesville, Florida

The so-called dumping syndrome is one of the most unpleasant complications of gastric surgery. The

common denominator of all cases is the ablation or bypass of the pyloric mechanism with the surgical creation of a relatively large sphincterless stoma into

the small bowel. This permits the rapid, uncontrolled

passage of food and fluids into the duodenum or je- junum, triggering the whole complex of neurohu-

moral modifications characteristic of this disease. Although the word dumping was first used by Mix

[I] in 1922, the syndrome was already known to the pioneers of gastric surgery in the latter part of the 19th century. Since that time a great deal of inves-

tigative effort has been expended in an effort to elucidate the pathophysiology of this syndrome. This has allowed a better understanding of the entire

syndrome and the development of more meaningful treatment modalities. Although much progress has

been achieved in the treatment of this entity, there remains a sizable population of patients who fail to

respond to conservative therapy. The present review attempts to illustrate this problem and reports our

most recent experience with surgical treatment of the postgastrectomy dumping syndrome.

Material and Methods

From 1972 to 1977, fifteen patients with the early post-

gastrectomy dumping syndrome were treated surgically at the University of Florida. Three of them had classic dumping symptoms and the remaining 12 had dumping associated with alkaline reflux gastritis. All of these pa- tients represent failures of conservative management.

From the Department of Surgery, University of Florida, College of Medicine, James Hillis Miller Health Center, Gainesville, Florida.

Reprint requests should be addressed to Roberto Miranda, MD, Department of Surgery, Box J-266, James Hillis Miller Health Center, Gainesville, Florida 32610.

Presented at the 20th Annual Meeting of the Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 22-23, 1979.

Five patients were treated with 10 cm antiperistaltic jejunal segment interposed between the gastric remnant and the Roux limb. The remaining 10 patients underwent a routine 45 cm Roux-en-Y gastrojejunostomy. Thirteen patients (86 percent) have been followed up for longer than 6 months.

Vagotomy and drainage was the initial operation in 10 of the patients in this series, followed by Billroth I in 4

patients and Billroth II in 1. Eleven women and 4 men, aged 25 to 65 years, comprised this group.

Results

Three of the five patients who had a reversed je-

junal segment interposed between the gastric rem- nant and the Roux limb ultimately required complete resection of the reversed segment. Each of these three

patients developed intractable symptoms of gastric retention. After resection of the reversed segment, all of them did well and are now asymptomatic. A fourth patient has intermittent gastric retention

managed by short-term nasogastric suction. The fifth patient has chronic gastric retention but declines

further surgery. One of the remaining 10 patients who underwent

simple Roux-en-Y duodenal diversion had surgery elsewhere for gastric outlet obstruction and was lost to follow-up. Two others underwent subsequent re- vision of the gastrojejunal stoma for anatomic ob- struction. All of the remaining nine patients are now asymptomatic and gaining weight.

After simple Roux-en-Y gastrojejunostomy, de- layed gastric motility was evident in 6 patients in the early postoperative period. This was treated with bethanechol subcutaneously and orally. In three patients the need for bethanechol persisted past 6 weeks but less than 6 months. All patients were

continued on an antidumping diet in the postoper-

ative period with liberalization allowed according to

individual tolerance.

40 The American Journal of Surgery

Postgastrectomy Dumping Syndrome

Comments

The incidence of the postgastrectomy dumping syndrome is quite high. Jordan et al [2], in a series of I 4 1 gastrectomies for duodenal ulcer, reported a 46

percent incidence of the dumping syndrome. Muir

[:I] reported d p g urn in in 75 percent of 124 patients.

In a series of 666 treated patients, Harvey et al [4] found that 13 percent of their patients suffered long-term consequences of the syndrome. Hastings et al Ifi], in a report on 343 patients, showed a 66

percent incidence of dumping symptoms with the problem persisting for over 2 years in 20 percent.

Fortunately, a sizable number of these patients

may be adequately controlled with special diet. De- sp. te all therapeutic efforts, however, a certain per- centage of the patients remain severely symptomatic

for, the rest of their lives. The surgical treatment of the postgastrectomy

dumping syndrome has evolved with the acquisition of knowledge of its pathophysiology. Originally, the size of the anastomosis and the size of the residual gastric reservoir were considered important [6-a]. As

a consequence, conversion of a Billroth II into a Hi Ilrot h I or conversion of a gastrojejunostomy into

a tiagotomy and pyloroplasty was proposed as a treatment method. This met with limited success.

For patients with small gastric remnants, various jejunal pouches were proposed, again with minimal su,:‘cess [6,Y,I0].

The latest development in the treatment of the postgastrectomy dumping syndrome has been the in1 erposition of a 10 cm antiperistaltic jejunal seg- ment between the gastric remnant and the intestine

to delay gastric emptying. The concept of reversal of small bowel segments

WES first proposed by Nicoladoni [II] in 1887, but Kirstein [ 221 was the first to publish experimental

work on the subject. Mall, the great anatomist of .Johns Hopkins, and Halsted [13] concluded from experimental studies that reversal of intestines was uniformly fatal. With this, the subject remained in oblivion for more than 5 decades, until Hammer et al [ ~41 were able to demonstrate experimentally that the reversal of intestinal loops was beneficial to dogs with the short gut syndrome. They applied this pr lnciple to patients with short gut with good success. I+.sed on that, Poth [ 15,161 proposed this technique for the treatment of the postgastrectomy dumping sy.?drome.

Although many authors report favorable results with the use of antiperistaltic jejunal segments for t,reatment of the dumping syndrome [17-291, our ex;)eriencfA with the reversed jejunal segment has

been quite disappointing. On the basis of the present

review of our experience with this technique, we no

longer use the antiperistaltic jejunal segment for treatment of the postgastrectomy dumping syn-

drome. It has been a rather fortuitous observation that

most of our patients who underwent Roux-en-Y

gastrojejunostomy, for whatever reason, experienced delayed gastric emptying. We have been using Roux-en-Y duodenal diversion extensively for the

treatment of alkaline reflux gastritis. Some patients have alkaline reflux gastritis and concomitant dumping syndrome. We have been pleasantly sur-

prised to (observe that, with the Roux-en--Y gastro- jejunostomy, many patients become free not only

from bilious vomiting but also from the unpleasant manifestations of the dumping syndrome. Precise

measurements of gastric and Roux limh emptying are

required in the laboratory and future patients to better understand this phenomenon.

It is possible that the bypass of the duodenal pacemaker may influence negatively the peristaltic activity of the small bowel in some way not yet fully

elucidated. It is known that with transection, slow wave behavior (basic electrical rhythm) albove that level is not affected, but the frequency dist,ally falls

to the level of the intrinsic frequency of the segment

at the level of the cut [20]. Preliminary studies seem to indicatle that the patients who develop gastric re- tention with Roux-en-Y probably already have a

deficiency of the motor function oft he stomach and small bowel before surgery.

In conclusion, if we consider only t.he early post- prandial dumping syndrome, the results with Roux-en-Y gastrojejunostomy have heen superior in

our hands to the use of reversed jejunal segments. We now view this as the first revisional surgery to be

considered in patients in whom dietary management of this complication has failed.

Summary

Fifteen patients were treated surgically for dumping Isyndrome at the University of Florida be- tween 1972 and 1977. Five of them had a reversed

jejunal segment interposed between the stomach and the Roux limb and 10 had simple 45 cm Roux-en-Y gastrojejunostomy. The reversed segment has been, in our experience, a uniform disappointment. Straight. Roux-en-Y duodenal diversion! with the exception of temporary delay in gastric emptying in a few cases, has proved successful in treating the postgastrectomy dumping syndrome.

Vo ume 139, January 1980 41

Miranda et al

References

1. Mix CL. Dumping following gastrojejunostomy. Surg Clin North Am 1922; 2:617.

2. Jordan GL Jr, Bolton BF, DeBakey ME. Experience with gas- trectomy at a veterans hospital. JAMA 1956: 161:1605.

3. Muir A. Postgastrectomy syndromes. Br J Surg 1949; 37: 165.

4. Harvey DH, St. John FB, Volk H. Peptic ulcer: late follow-up results after partial gastrectomy: analysis of failure. Ann Surg 1953; 138:680.

6. Hastings N, Halsted JA, Woodward ER, Gesster M, Hiscock EA. Subtotal gastric resection for benign gastric ulcer. Arch Surg 1958; 76:74.

6. Woodward ER, Hastings N. Surgical treatment of the postgas- trectomy dumping syndrome. Surg Gynecol Obstet 1960; 111:439.

7. Dragstedt LR. The present status of vagotomy. Illinois Med J 1954; 106:175.

8. Zollinger RM, Williams R. Considerations in surgical treatment for duodenal ulcer. JAMA 1956; 160:367.

9. Longmire WP, Beal JL. Construction of a substitute gastric reservoir following total gastrectomy. Ann Surg 1952; 135:673.

10. Lawrence W Jr, Kim M, lsaacs M, Randall HT. Gastric reservoir construction for severe disability after subtotal gastrectomy. Surg Gynecol Obstet 1964; 119:1219.

11. Nicoladoni C. An idea for an enteroplasty. Wiener Med Press 1887; 50128.

12. Kirstein A. Experimentelles zur pathologie des ileus. Deutsch Med Wschr 1889; 15:lOOO.

13. Mall E, Halsted WS. Reversal of the intestine. Johns Hopkins Hosp Rep 1896; 1:93.

14. Hammer JR, Seay PH, Johnson RL, Hill EJ, Prust FH, Campbell RT. The effect of antiperistaltic bowel segments on intestinal emptying time. Arch Surg 1959; 79:537.

1.5. Path EJ. The dumping syndrome and its surgical management. Am Surg 1957; 23:1097.

16. Poth EJ. Treatment of dumping syndrome by the use of anti- peristaltic segment of jejunum. In: Ellison EH, Freisen SR, Mulholland JH, eds. Current Surgical Management III. Phil- adelphia: WB Saunders, 1965383.

17. Jordan GL Jr, Angel RT, Mcllhaney JS, Willms RK. Treatment of the postgastrectomy dumping syndrome with a reversed jejunal segment interposed between the gastric remnant of the jejunum. Am J Surg 1963; 106:45 1.

18. Sawyers JL, Herrington L Jr. Superiority of antiperistaltic jejunal segments in management of severe dumping syndrome. Ann Surg 1973; 178:311.

19. Stemmer EA, Jones A, Pearson SC, Connolly JE. Antiperistaltic segments of jejunum in the treatment of the dumping syn- drome. Arch Surg 1969; 98:396.

20. Christensen J: The physiology of gastrointestinal transit. Med Clin North Am 1974; 58:1165.

Discussion

M. Michael Eisenberg (Minneapolis, MN): At the risk of offending dear and old friends, I feel I can comment on this paper because I am sure some of the patients operated on were mine from the late 1960s. The authors had 15 pa- tients, 10 of whom had severe dumping after vagotomy and drainage. You may remember from Dr. Dragstedt’s earliest work that a significant number of patients who had va- gotomy alone without a drainage procedure got along rather well, so it is apparent that not every patient who has a vagotomy needs a drainage procedure. When we see a patient with vagotomy and drainage who dumps, I think

it is reasonable to assume that without drainage the patient might have done very well.

If a patient with vagotomy, drainage, and gastroenter- ostomy or pyloroplasty dumps, the easiest way to eliminate the dumping is to take down the gastroenterostomy,

leaving the vagotomy alone. Or, as Ed Stemmer reported from the Long Beach Veterans Administration Hospital

many years ago (and we have also done this), one can simply reverse a pyloroplasty. It is not a difficult operation. Simply make the incision in the axis of the old suture line, find the ends of the sphincter and reapproximate them. We

have done that in three patients with pyloroplasty and severe dumping, with really superb results.

If the patient has reflux, both of these alterations in the drainage procedure will also help alleviate the reflux. If the

patient has severe dumping after a resective procedure, then we agree that a Roux-en-Y is the simplest and most effective way to handle both the dumping and the bile re- flux, although I must add that, particularly in women who have a combination of dumping and reflux, the Roux-en-Y conversion in our hands is only about 50 percent effective. One should be absolutely certain that what one is operating on is in fact directly related to the hookup, rather than to other ancillary problems.

Herzl Ragins (New Rochelle, NY): In the patients with vagotomy and drainage, where did you interpose the re- verse segment? With vagotomy and gastroenterostomy, did you use a reverse segment?

Dr. Allison (Iowa City, IA): I have a question about the authors’ studies and a comment related to Dr. Eisenberg’s comment. In the patients with vagotomy and drainage whom you studied, did you see any relation between dumping and incomplete vagotomy, as opposed to patients with complete vagotomy? In a patient who has had a va-

gotomy and drainage procedure and dumps, is it worth- while to examine the completeness of the vagotomy and

complete it if it is incomplete?

David Fromm (Syracuse, NY): I wonder if your results could be explained by patients altering their dietary habits postoperatively to decrease or avoid the symptoms of dumping. My question is: Have you given these patients a standard osmotic load pre- and postoperatively? The bulk of evidence indicates that dumping syndrome oc- curring after a Billroth II is initiated by an osmotic load

presented to the jejunum. Thus, I cannot think of a sound physiologic reason why Roux-en-Y gastric drainage should alter the symptoms of dumping other than by delaying gastric emptying. I do not believe, however, that the latter is an expected result of the Roux-en-Y drainage procedure

per se.

Terence Kennedy (Belfast, Northern Ireland): I agree with Dr. Eisenberg that the best treatment for dumping in patients with vagotomy and drainage is to eliminate the drainage. But when resection has been performed, I believe that the operation described, a Roux loop reversing 10 cm at the end of the loop, is very good.

42 The American Journal of Surgery

Postgastrectomy Dumping Syndrome

hly t~~prrience is quite contrary to yours, and I want to

put it c,n record that these patients can in fact do very well.

\Yh\: my six patients did well and yours did badly, I do not

know. as we each reversed the same length.

John I>. Sawyers (Nashville, TN): Dr. Miranda was vcr:; kind 111 send I)r. Herrington and me a copy of his nla!lusc,ript. Wr certainly agree with him that dumping is

rtsl; ted IO thy integrity of the pylorus as a true sphincter.

\Vr ha\,? l’c~r~ncl that ahout 25 percent of our patients are

sulljecl to the dumping syndrome after any type of gastric r~s140n or surgery that destroys the pylorus as a true ,l,hinctrr. Onlv ahout 1 percent of these patients require

ii rc medial procedure.

I would like to show you t,he results that Dr. Herrington an( 1 have obtained comparing various operations for

dumping. The isuperistaltic segment interposed between the gait ric I)ouc.h and duodenum yielded satisfactory re-

5~11 s ill onl> about 20 percent of patients. I( St-ems 10 me that placing a Roux-en-Y procedure up

to the gastric, pouch. as Dr. Miranda and his associates have

X~~(Jc;l~ed. k physiologically similar to an kpxktakic segment interposed between the gastric pouch and the

dlrcdenum. -I’his acts very much like the walkway one sees 111 the airport: Onts gets on and is rapidly carried to the other t~nci t)i the terminal.

The tlo~~t,lc-limt) gastric pouch has been effective only

iti l)atienfs with a small gastric reservoir. As Dr. Kennedy tol(l you. 1 tw twst rrlsults have been with a reverse segment nbt ut IO cw long between the gastric pouch and duo- drr-tm;. In !1.4 percent of the patients with an antiperistaltic begmen!. +~tisf’actory results were obtained.

.l’hr pro(4urt~ we prefer to use for dumping is the ‘lntiperist att ic, irgment. We were concerned that reflux

gastritis might develop, but that occurred in only one pa- (lent. 1n patients with reflux gastritis and dumping we I)rPt'er t hr ti IO 10 rm reverse segment at the end of the ROIIX !imt).

I)r. t’atric,k O’Leary, who was formerly with Dr. Wood- wa1.d illId who rcsc,entty joined our Department of Surgery at Va~ltlerbilt ! ‘nivrrsity, postulates that the delay in

em )t\-ing may be due to t,he position of the small bowel inttbstinal pacemaker which gives off both iso- and anti- l)erist;lltic, \va\~+. If the Roux limb is cut off at a certain

point, t htxrc, may be a strong preponderance of antiperi- -i:lltic wavt’s which result in slow gastric emptying. This

ik the onlv t~xplanation I have for the remarkable results that I)r. Miranda reports in his group of patients with d~~~l~J~lrlg trcaled by k)UX-en-\; gastrojejunostomy.

I Lv(,uld like to ask 1)r. Miranda if Roux-en-Y gastroje-

jilnostomy IS now the preferred method of reestablishing g:~sl rolntc~htinal c,ontinuity after gastric resection. If’ they

tire cclrrec.1. the Roux-en-Y procedure should prevent 1jos1 gaq1 rpc1 only problems of both dumping and reflux gait ril I\.

John Sonneland (Spokane, WA): Dr. Miranda, I would

like to focus on the size of the gastrojejunostomy. Surgeons

from Columbia Physicians and Surgeons Hospital, as well

as from Athens and Copenhagen, have suggested that dumping may be prevented by creating a small stoma be- tween the stomach and small intestine. either duodenum or jejunum. Would this be a factor in the results you have achieved’? B’hat kind of stomas did you have at the time

of surgery, and what did you create after you did the

Roux-en-Y limh?

Richard P. Saik (San Diego, CA): In San IXego we have

many more patients who do not have an operation than who do. I am interested in your selective criteria for oper- ation. In San Diego we have used noninvasice vascular techniques As you well know, our problem is differen-

tiating the subjective symptoms from the real findings. I

recommend that method if that becomes H problem. We have noted that the fingertip strain gauge. measuring

fingertip vascular dilatation, is a good way to c)trject,ivety quantify and perhaps even select patients who might best

benefit from surgery. We use a standardized osmotic load

much like Dr. Fromm suggests. Have you clone anything like that in terms of your criteria for select ion”

Roberto Miranda (closing): In answer to Dr. Ragins,

we had a series of pyloroplasty patients who had an inter-

posed segment between the stomach and durdenum, a revised Henle loop. We did not have good results with those patients. About 50 percent developed alkaline reflux gas- tritis; thus ‘we just exchanged dumping for alkaline reflux,

so we never used that any more. We used straight Roux- en-Y. We had only one patient with vagotomy aild enter- ostomy, and we took down the gastroenterostclmy.

Dr. Allison, in regard to incomplete vagcltomy and

dumping. we usually try to make a decision based on gastric analysis. If achlorhydria exists, we have no reason to sus- pect an inccjmplete vagotomy. However. it' high acidtty is

still present, obviously the vagotomy must be c’om- pleted.

In answer to Dr. Fromm, we do nut have preoperative or postoperative studies on osmotic load. (‘urrently at the University of Florida studies are being conducted in that direction, with a promising outlook. Postoperatively we put

these patients on an antidumping diet. with small feedings and a low intake of liquids and carboh\drates.

Dr. Sonneland, we did not, try to make hmatl stomas with our Roux-en-Y. We simply used a two I;iyer endto-end

anastomosis between the stomach and jejunum. ‘l’heoret- ically, a small 1.2 or 2 cm lumen would be ef’f’ective. but

then you have the danger of creating a stent,siL;. Dr. Saik, no we have not used the criteria for <election

you suggest. Our patient selection is based on t linical cri- teria and a long history of symptoms not responsive to medical management. More objective criteria are desir- able.

Volume 139. January 1980 43