Nutritional Consequences of Surgical Resection of the Gastrointestinal Tract for Cancer'

Home , Colectomy, Vagotomy

(CANCER RESEARCH 37, 2379-2386, July 1977] Nutritional Consequences of Surgical Resection of the Gastrointestinal Tract for Cancer'

Walter Lawrence, Jr.2 Division of Surgical Oncology and Cancer Center, Medical College of Virginia (Virginia Commonwealth University), Richmond, Virginia 23298

Summary the preoperative deficiency if nutritional intake has been hampered by these intake problems. The nutritional sequelae of major resection of the â€œhollow Since the nutritional sequelae of the resection of anatom organsâ€•of the gastrointestinal tract for cancer are re ical structures in the head and neck are on a mechanical viewed. Radical surgery of the head and neck region may rather than a metabolic basis, the clinical solutions are lead to significant nutritional problems due to the mechani likewise mechanical ones. For short-term nutritional main cal effects of surgery that limit normal methods for nutri tenance, both before and after operation, the patient can be tional intake, but these problems can be overcome by tube fed by a nasopharyngeal or nasogastric tube. A frequent feeding. Resection of the thoracic esophagus or stomach lack of emphasis on preoperative nutritional support is cer for cancer may produce varied forms of malabsorption, tainly a partial explanation for the postoperative wound particularly of ingested fat, but the reduction of caloric problems that often plague the postoperative period. Ade intake that often will accompany these procedures plays the quate alimentation can be accomplished for both the re primary role in each instance where malnutrition is pro placement of preexisting nutritional defects, and postoper duced by the operation. These nutritional difficulties are ative maintenance, by using appropriately prepared high corrected by assuring adequate caloric intake and reducing calorie liquid diets. For patients requiring long-term tube the symptoms that inhibit this. Small bowel resection rarely feeding due to permanent intake disability or protracted produces nutritional problems unless the resection is mas reconstructive procedures in the post-resection interval, a sive, a situation wherein malabsorption becomes a major cervical tube esophagostomy is often preferable to the na problem in nutritional management. Fortunately, massive sal tube. This procedure is easily accomplished either at the small bowel resection is rarely indicated for the treatment of completion of the resection or at a later time. cancer. Radical colon surgery of any extent is well tolerated from the nutritional standpoint. An understanding of the Resection of Cancer of the Thoracic Esophagus causes of malnutrition in patients undergoing surgical re section of the gastrointestinal tract for cancer should lead Careful appraisal of patients undergoing total or partial resection of the thoracic esophagus for cancer led to the to effective management of any problems that do occur. observation that patients had varying degrees of clinical steatorrhea and diarrhea following these procedures. De The most common form of cancer in the United States is tailed metabolic studies of a series of patients by Shils and cancer of the gastrointestinal tract, and surgical resection Gilat (66) led to clear-cut evidence of laboratory steatorrhea is, currently, the primary approach to patient management. in all patients when quantitative stool fat excretion meas Since the gastrointestinal tube is our major source of nutri urements were made (Table 2) but carbohydrate, nitrogen, ents under normal circumstances, a nutritional impact re vitamin B12,and electrolyte absorption measurements were suIting from these operative manipulations is not unex virtually normal. These and other studies (52, 54, 64) dem pected. This report is not meant to be an exhaustive review onstrated data similar to those obtained in patients sub of the literature on this subject, but an attempt will be made jected to truncal vagotomy and a gastric drainage proce to summarize observations that have been made from a dure, although the effect on fat absorption was generally clinical perspective. These nutritional sequelae of resection greater in patients undergoing thoracic esophageal resec are summarized in Table 1. tion. These reports are convincing in regard to the major Resectionof Head and Neck Cancer role played by vagotomy in the production of the observed malabsorption and the diarrhea, but the mechanisms are not completely clear. Radical resection of cancer arising from the oral cavity Attempts to correct both this mild diarrhea and malab and pharynx is often required in subjects who present with sorption after esophagectomy by feeding pancreatic and preexisting nutritional difficulties. Prior to resection, there biliary supplements or the use of a gluten-free diet were are varying degrees of disability from restrictions in both unsuccessful. The substitution of medium-chain triglycer mastication and deglutition. Surgical resection of these ides for the longer-chain fatty acids did reduce fecal fat cancers often produces the same disabilities or increases excretion in patients with malabsorption (64). Another po tential solution to this metabolic defect observed in some I Presented at the Conference on Nutrition and Cancer Therapy, Novem bar 29 to December 1, 1976, Key Biscayne, Fla. patients after partial or total resection of the thoracic 2 American Cancer Society Professor of Clinical Oncology. esophagus might well be preservation of the vagus innerva

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Downloaded from cancerres.aacrjournals.org on October 1, 2021. © 1977 American Association for Cancer Research. w.Lawrence,Jr. Table 1 extent of resection is usually greater than that performed for resectionOrgansNutritionalconsequences of â€˜â€˜radical'â€˜ benign disease, and the nutritional problems observed after sequeliaeOralresectedNutritional gastric resection generally increase proportionately with feedingsThoraciccavity and pharynxDependency on tube the extent of the resection that is performed. Malabsorption.There is an extensiveliterature docu esophagusGastric stasis (secondary to vagot menting absorptive defects following gastrectomy, particu omy) larly total gastrectomy. Absorption of one of the major Fat malabsorption Gastrostomy feedings in patients with nutrients, carbohydrate, is not quantitatively impaired by reconstructionStomachDumping out gastrectomy, and an increase in fecal excretion of the nitro gen, as a measure of protein malabsorption, is responsible syndrome for little if any nutritional impairment in the gastrectomized Fat absorption patient (17, 45, 61 , 74). The primary defect in absorption anemiaSmall intestineDuodenumPancreatobiliary that may play some role in chronic difficulties with weight deficiency with fat maintenance and nutrition in the postgastrectomy patient is malabsorptionJejunumDecrease impairment of fat absorption (8, 38, 45, 50, 56, 62, 67, 70, in efficiency of absorption 74). Associated problems in absorption of iron and vitamins (general)ileumVitamin may occur also. B2 and bile salt malabsorp tionMassive Fat Absorption(Chart 1). There are 2 aspectsof the (>75%)Fat malabsorption and diarrhea; vi steatorrhea problem that must be kept in mind from a prac tamin B12malabsorption; gastric hy tical clinical standpoint. The 1st is the relatively poor corre persecretionColon lation noted between the ability of the patient to maintain body weight after gastrectomy and the degree of steator (total or subtotal)Water and electrolyte loss rhea that has been observed on metabolic balance studies (38, 45, 58). Although these quantitative laboratory studies Table 2 demonstrate minor degrees of steatorrhea after partial gas Fat malabsorption after esophagectomy (distal or near total) trectomy, many patients,afterpartialresection,have fat Metabolic study of 7(66)].Range patients [from Shils and Gilat excretion levels in the normal range (73). Mean values for of fat absorp fat absorption after total gastrectomy (approximately 80% of (%)Before tion (%) Mean ingested fat) are well below the normal range (92 to 100%), 92-98 96 but there is much variation between individual patients, and After 65-84 74 these data bear little relationship to weight maintenance (38, 45) (Chart 2). The 2nd factor that should be appreciated tion, if this were feasible. When the resection is for cancer, is that the degree of steatorrhea noted in these gastrointes however, this approach is untenable, as the resection must tinal patients is mild, compared with that noted after mas include the vagus nerves, for obvious anatomical reasons. sive small bowel resection, and that of patients with sprue To put the nutritional problem of esophagectomy in per like syndromes or who are subjected to major pancreatic spective, it should be stressed that the degree of postopera resection. Although the steatorrhea observed after total tive nutritional disability observed is quite limited and is of gastrectomy is of great interest from both the etiological greater physiological interest than of practical importance. and physiological standpoints, the role of this steatorrhea in The fecal fat losses that may occur can be easily compen nutritional disability after gastrectomy appears to be a rela sated for by a modest increase in caloric intake and/or the tively minor one. exchange of medium-chain triglycerides for long-chain fatty acids inthe diet. .. 32- / GastrectomyforCancer . I 7 28- ... 7/ Nutritional disability is more frequently observed after S â€¢ 7

either partial or total gastrectomy for cancer than after - /y=-z2Ã·.21x S , r=0.76 @ esophagectomy. This impairment includes some metabolic . 7 C 7 defects due to malabsorption, as well as a host of symptom ./ 20 . problems that may limit total intake. The normal function of .. 7 the stomach is to serve as a reservoir to receive and retain @ 16 /: food, alter the food to some degree by digestive processes, /S and slowly discharge the altered nutriments into the small I S@/ @. @312 S f@S intestine at a rate that is the most efficient for the digestive La. â€¢/s @@ and absorptive functions of the gut. It is not surprising that 8 @â€¢ 8 major mechanical alterations in the size of the stomach, or its emptying function, may have a major effect on nutritional 4 @@p3.O+aO2x @ capabilities of the patient. The limited number of patients /S @S S [email protected] @ L1â€•1@I I I III I@i 1 1 I I I I who have nutritional problems following gastrectomy is Co 20 40 60 80 100 120 140 160 180 probably even more surprising. Resection of the stomach FAT INTAKE(g/day) for cancer may require partial or total resection, but the Chart 1. Fat absorption after total gastrectomy [from Lawrence et a!. (45)1.

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100 normal in patients after extensive gastrectomy (45, 61, 74), V S . -@ â€” â€” !_@ _ this malabsorption proved to be less striking than that noted .0 ---,.@ - @90 to S for fat. Whether the increase in nitrogen requirement for .0 â€˜4 S equilibrium in totally gastrectomized patients, compared ;@ 80 S with normal patients, is due only to diminution of intestinal V S absorption of nitrogen, or to some unexplained increase in : @Â° metabolic requirements, was evaluated by comparisons of C S fecal nitrogen excretion at several levels of nitrogen intake. @ 60 S S These metabolic data revealed no increase in nitrogen ex U

S cretion in postgastrectomy patients that could not be attrib 0. 50 uted to the small excess of fecal nitrogen alone (45). This

@ III I I ,@_j appears to rule out any increased metabolic requirements -25 -20 -15 -10 -5 0 +5 +10 +15 +20 for nitrogen in this group of patients. Since the absorptive Per cent Change From Pre-operative Weight defect is relatively small, a slight increase in protein intake Chart 2. Relationship between fat absorption (as percentage of intake) can easily offset any defect in absorption that does occur. and body weight after total gastrectomy [from Lawrence at al (45)]. CaloricIntake.The relativelyminordefectsin absorption described have proved of great interest to investigators. Data on factors affecting steatorrhea in the gastrecto However, it is clear from a number of observations that a mized patient are of some interest from the standpoint of limitation of total caloric intake after gastrectomy is the both the etiology of this defect in absorption and its possible major reason for observed instances of nutritional depletion correction. One mechanism might be a decrease in diges tive enzymes normally initiated by gastric acid. In this re normalr@ge. gard, it is of interest that hydrochloric acid supplements prior to meals in totally gastrectomized patients produced a significant improvement in the measured fat absorption in a these same patients (70). This effect of hydrochloric acid IaJ might be interpreted as a secretin stimulus prior to the arrival of food stuff in the small bowel, thereby alleviating U) 4 the â€œpancreaticocibalasynchronyâ€•that is produced by the I- anatomical loss of the stomach. A decrease in fat absorp a U tion that has been observed with an increase in carbohy In U drate intake in the diet of the gastrectomized patient (70) z correlates well with this concept of insufficient pancreatic U and biliary secretion in these patients (Chart 3). Hypertonic U

glucose feedings in dogs also suppress pancreatic secre U tion (41). It is difficult to correlate the degree of the steator Q. rhea with bowel hypermotility, but the increase in fecal fat during high carbohydrate intake suggests a significant role for motility, since this dietary alteration does increase â€œin testinal hurry.â€• CARBOHYDRATEINTAKE(g/day) Chart 3. Effect of carbohydrate ingestion on fat absorption after total A study of factors that do not effect fat absorption in the gastrectomy [from Vanamee et al. (70)]. gastrectomized patient are of practical importance in clini cal management. Dietary adjuvants such as pancreatin, a 100 U Tween 80, and lipase failed to show a significant affect on 0 .90 â€” normal

steatorrhea (63), nor did variations in anatomic reconstruc 0 @â€” U) tion of the intestinal tract after total gastric resection (8). On 0 @-@-@-70-60-LEGEND@_@e@___ the other hand, all of the measurable fecal fat losses after 80-S. gastrectomy could be easily balanced by a small increase in 0 U I- fat intake due to the interesting observation that the per U) centage absorption of fat remains constant over a wide U range of intake (58, 62) (Chart 4). These observations sup z I- port the concept that difficulty in maintenance of body z - @. @ U oâ€”â€”oBuerger& Konjetzny weight and malnutrition after gastrectomy is due to fat U 5â€”s Rekers ci ci U absorptionto onlya minimal degree.Other factorsaffecting 0. Authors50-.400 6â€”6 total intake are of greater importance. ProteinAbsorptionandMetabolism(Chart5). Sinceopti -S mal nutrition and maintenance of lean tissue mass are par I,â€”â€”-â€” @@@ tially governed by absorption of protein, as well as the 40 80 1 . 160 FATINTAKE(g/day) utilization of this foodstuff, the metabolism of nitrogen in Chart 4. Fat absorption (as percentage of intake) in relation to level of gastrectomized patients is of great interest. Although the dietary fat in individual patients after total gastrectomy. Three series of data fecal excretion of nitrogen is at a slightly higher level than summarized by W. Lawrence, Jr., et a!. (45).

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7 S sorbed after gastrectomy, but deficiency of these vitamins can be prevented by oral supplements (2). 6 Postprandial Symptoms and Nutrition. Postprandial S symptoms after radical gastrectomy undoubtedly play the major role in malnutrition by producing a self-limited intake

@ . S S y'1.2+O.O83x of foodstuff (9, 18, 58). Despite some variation in their manifestations, the most frequent symptom complaints are

@ .S 5SISâ€¢ @,.____â€”@ S usually described as â€œdumpingsyndromeâ€•(12,26). It is now @ S4@'@@ S generally accepted that this group of symptoms is the se 2>@/j7.S@ S quel to the loss of pyloric function, although a more exten sive resection of the stomach is more often the offender @@ 1 Normal @ ..â€” _â€˜_â€˜_S [email protected]@0.O67x than limited gastric resection. The incidence of this disturb [email protected] @ (I I !@ I l_ I _I@ I _I_ I 1 _I_ I ing problem varies somewhat, depending on the interest of 4 8 12 16 20 24 28 32 the observer, since so much of the symptomatology is sub Ditary Nitrogenintake 9 /doy jective. After subtotal gastric resection, these dumping Chart 5. Relationship between nitrogen intake and fecal nitrogen after symptoms in the early postprandial period probably occur total gastrectomy [from Lawrence at al. (45)]. in 10 to 25% of patients, and the incidence is greater than this after total gastrectomy. Less common postgastrectomy and poor weight maintenance (7, 38, 45, 58). This is sup symptoms affecting dietary intake are the so-called â€œaffer ported by the metabolic data presented, the poor correla ent loop syndromeâ€•(35)and reflux gastritis. tion between the absorption data and weight maintenance The symptoms of the dumping syndrome include epigas in patients, careful dietary histories in gastrectomized pa tric fullness, hyperperistalsis, borborygmi, and cramps with tients who do have nutritional difficulties, and the excellent occasional nausea, vomiting, or diarrhea. Many of these correlation between the state of nutrition and the presence symptoms are adequately described by the term, intestinal or absence of disturbing postprandial symptoms that limit hurry. In addition of these abdominal complaints, a more intake. striking series of postprandial symptoms suggesting sym Other MetabolicDeficienciesAssociatedwith Gastrec pathetic discharge are also observed. These include un tomy. Some vitamin and mineral deficiencies may result pleasant warmth, tachycardia, sweating, weakness, and from radical gastrectomy for cancer. These include malab dizziness, and are accompanied by electrocardiographic sorption of iron, vitamin B,2, and calcium. The stores of findings and measurable alterations in cardiac output and vitamin B,2 are slowly depleted after total gastrectomy, but regional blood flows (49, 50, 60). All of these early symp the development of megaloblastic anemia is delayed due to toms are most marked approximately 15 mm after ingestion the large store normally present in the liver that delays the of foodstuff in the symptomatic gastrectomized patient. appearance of the clinical effects of vitamin B,2 deficiency This complex of symptoms can occur with all degrees of (22). This delay in development of megaloblastic anemia severity, and symptoms in some patients are elicited only by may extend from 6 months to 4 years, and both the anemia an abnormal challenge with hypertonic foodstuff. Others and the typical neurological symptoms respond effectively experience disabling symptoms with most of their normal to parenteral vitamin B12administration. Probably all pa meals. This individual susceptibility can even be detected in tients surviving total gastrectomy for more than 2 years the patient who has not had a gastrectomy by instilling test should receive prophylactic B12.It is of interest that folic meals of hypertonic foodstuff into the small intestine acid deficiency has been identified as a cause of megalo through an intestinal tube (29). There is a relatively close blasticanemiaaftergastrectomyinsome reportsfromGreat correlation between postgastrectomy malnutrition and the Britian (11, 48). Folic acid alone will prevent the anemia severity of these symptoms, since reducing total dietary resulting from vitamin B12deficiency after gastrectomy as intake is one solution the patient finds effective for control well, but it will not control the neurological problems from ling these unpleasant symptoms. insufficient vitamin B,2 (48). In these patients, the intake of For many years, various mechanical explanations were iron is often low, and this compounds the mild defect of iron given for these symptoms, but none were well substanti absorption. Absorption of iron may be impaired after gas ated. Machella (47) established the fact that a large volume trectomy, although the presence of acid and the presence shift into the bowel occurred after intraluminal introduction of the duodenum are not essential to iron absorption (7, 21, of a hyperosmolar meal (Chart 6). This observation corre 27, 68, 71). Iron deficiency anemia has been demonstrated lates quite well with the fact that it is a uniform observation to be a problem in approximately 50% of patients undergo in gastrectomized patients that high-carbohydrate meals, ing total gastrectomy, but it is easily overcome by increased which are more likely to become hyperosmolar, intensify intake. symptoms (36, 46, 51). It has been shown experimentally Inadequate absorption of vitamin D after gastrectomy due that this large shift of fluid into the gut occurring 15 to 30 mm to steatorrhea may contribute to osteomalacia at a later time after ingestion of test meals is associated with a water loss in some patients (13, 16) but the metabolism of calcium, from the plasma as well as electrocardiogram and cardiac phosphorus, magnesium, and potassium generally does not output alterations and a redistribution of blood flow (43, 44, differ from that of normal persons (62). Other vitamins, 50, 60). This redistribution affects the renal blood flow, the particularly vitamins B and A, may be less efficiently ab digital blood flow, and flow in the intestinal circuit (28, 49).

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FOOD, vitamin B12,are also important in the dietary management of CARBOHYDRATES these patients. In spite of dietary measures, some patients continue to have disabling postprandial symptoms after radical gastrec tomy and thereby suffer secondary nutritional deficiencies. Remedial operations have been designed to counteract these symptoms by either creating a reservoir to substitute for the missing stomach (25, 33, 42, 75) or transposing intestinal segments with or without a restriction to outflow to retard the rapid intestinal transit of foodstuff that serves TPLASMAVOUJME VOLUME to accentuate the offending symptomatology (3, 4, 23, 24, REDCELLMASS REDCELLMASS 57). There is a wide range of such procedures that have proved applicable to a number of differing anatomical situa

E.CG. CHANGES tions present after radical subtotal gastrectomy or total SYMPATHETIC STIMULATION SWEATING gastrectomy (25, 59). These procedures are of some value in (FROM PRESSORECEPTORS) ABDOMINAL DISTENTION (DECREASED CARDIAC OUTPUT) TACHYCARDIA well-selected patients that are not suitably managed CORONARY INSUFFICIENCY WEAKNESS SYNCOPE by the dietary means described. These anatomical alterations are particularly relevant to the patient who has had total gas Chart 6. The â€œdumpingsyndromeâ€•after gastrectomy. trectomy, but experience in recent years with the construc tion of a substitute pouch at the time of primary resection Subsequent investigations support the release of a humoral has markedly reduced need for these secondary operations. agent or agents in response to the hyperosmolar meals, and It is impossible to construct a substitute stomach after this appears to be a reasonable explanation for both the gastrectomy that equals the function of the original organ, autonomic symptomatology and these experimental findings but these methods frequently can produce a functional (28, 34). It has been suggested that the primary humoral system that allows symptoms to be controlled adequately by agent producing these associated symptoms and physio the dietary alterations described. Body weight is usually logical changes is serotonin (41, 32, 53), and some relief of stabilized at a level that is lower than the preoperative the symptoms has been achieved by pharmacological weight, but the overall nutritional status is satisfactory in means on this basis (34). Although the release of other most patients. vasoactive polypeptides from small bowel mucosa undoubt edly occurs in response to the hyperosmolar challenge, the practical means for dealing with this symptom problem are IntestinalResectionfor Cancer dietary alterations and the attention to methods of recon struction after gastrectomy that will minimize these physio In contrast to the more proximal portions of the gut, logical responses. From the nutritional standpoint, the key major resection of the intestinal tract distal to the pylorus is to maintaining adequate nutritional state after gastrectomy more often required for noncancerous disorders, but the is the diminution of this symptom complex in those patients nutritional sequelae of intestinal resection are directly re who are the most susceptible. lated to the extent of resection in each instance. Management of MalnutritionObserved after Gastrec Small Intestine. The effect of small-bowelresectionis tomy. Since these accumulated data demonstrate that the related to the individual functions of the various segments, control of postprandial symptoms after gastrectomy is the as indicated in Table 1. The nutritional sequelae of duo major factor in adequate weight maintenance, dietary alter denal resection relate more to the anatomical alteration of ations to minimize symptoms have proven to be the primary the pancreatic and biliary secretions than to the mechanical therapeutic approach (1, 58, 60). A high-protein, high-fat, and absorptive functions of the duodenum itself (for a de low-carbohydrate, frequent-feeding diet has achieved this tailed discussion, see Ref. 65). Clinical studies in normal objective in most patients by eliminating the primary symp subjects and those with ablation of portions of the jejunum tom challenge (the high-carbohydrate insult to the small indicate that all of the various nutrients, with the exception bowel), by reducing the sudden influx of food stuff in large of vitamin B12,are most efficiently absorbed in this segment quantity into the small bowel (by using small frequent feed of the intestine, but the reserve absorptive capacity of the ings), and by providing adequate calories in as small a ileum can accommodate for any functional change pro volume as possible (high-fat diet). Not only is there higher duced by loss of the more proximal bowel (5, 6, 15, 69, 76). caloric value in fat/g of food stuff, but both protein and fat The distal ileum is responsible for absorption of vitamin B,2 have the additional advantage of slower enzymatic break and conjugated bowel salts, as well as serving as a back-up down in the bowel than carbohydrate, thereby avoiding the absorptive site for the nutrients normally absorbed in the rapid development of a hyperosmolar solution in the bowel jejunum (Chart 7). The adaptability of various segments of lumen. Other measures include reclining after meals and the small intestine to increase their absorptive capabilities the maintenance of a normal blood volume, since the de prevents major clinical problems after small bowel resec scribed postprandial shifts in blood flow are more sympto tion, except for those patients who have massive bowel matic in patients with contracted blood volumes. An in resection in the range of 75% of the total small bowel. The crease in iron intake and vitamin supplements, particularly fecal fat losses can be much greater in this circumstance

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BILE require resection of more than 2 ft of ileum and ileocecal valve, there may be a measurable increase in fecal fat, but this can be controlled quite easily with a high-protein low Glucose PANCREATIC ENZYMES fat diet (37, 55). Vitamin B,2 supplements are required to Iron correct the deficiency in this vitamin that is produced by FolicAcid , resection of this bowel segment. Resection up to 8 ft of the DUODENUMâ€˜ @ Pyridoxane. 40 jejunum fails to interfere with the absorption of glucose, fat, â€˜JEJUNUM Riboflavin 40 protein, folic acid, vitamin B,2, or other vitamins, but resec AscorbicAcid tion of both the jejunum and ileum is accompanied by an i@ Fat increase in absorptive problems from the standpoint of all

@â€˜Protein nutrients, with the severity of these problems depending on

â€”--â€”â€”â€” I.,â€”â€”â€” the extent of the resection. Calcium supplements and vi tamin D may be required, also, with these more extensive â€˜4- ILIUM .4 small bowel resections, with their resulting fecal losses. The

â€˜4- diarrhea and the increased fecal calcium, magnesium, and â€˜a other electrolyte losses occurring in some patients with â€˜4- massive resection may be reduced by reducing the intake of VitaminBa â€˜4- long-chain fatty acids in the diet. Medium-chain triglycer

â€˜4- ides have proven to be a useful approach but, when used in significant amounts, the development of ketosis may lead to the need for supplementary sodium bicarbonate. It is often â€˜4- necessary to supplement the p.o. feedings with i.v. hyperal imentation in the early postoperative period to avoid cach Chart7. Sitesof normalabsorptionfrom the smallintestine. exia at this critical stage. Another approach to the diminu tion of diarrhea in patients with massive bowel resection is S the administration of cholestyramine (30), since this will chelate the increased volume of bile salts reaching the large bowel secondary to their reduced absorption after resection of the terminal ileum. The nutritional management of the patient with massive SMALLBOWEL RESECTION small-bowel resection can be quite challenging for the clini cian but, fortunately, this is an uncommon problem for

S patients undergoing gastrointestinal surgery for cancer.

S S Blind-LoopSyndrome.Thereare a numberof conditions following surgery of the small intestine for cancer which S may give rise to this symptom complex. These include blind .S loops of the small bowel resulting from atypical intestinal @@ S@.,... @_ ,@ ,@. @-@â€¢ -@ â€” f@TAL GASTRECTOMY anastomosis, stricture of the intestine, or other mechanical reasons for blind-pouch formation, all of which have in common intestinal stasis and subsequent intraluminal in ---.- T i ,NORMAL fection. This symptom complex is characterized by diar 100 150 200 FAT INTAKE- (g/day) rhea, steatorrhea, anemia, loss of weight, and multiple vi Chart 8. Fecal fat loss after massive small bowel resection, compared with tamin deficiencies (1, 14, 39). The actual frequency of this loss after total gastrectomy. blind-loop syndrome is uncommon, since the surgeon carrying out a small-bowel resection ordinarily avoids any than after gastrectomy (Chart 8). Even then, there are exten form of short circuit or blind-pouch formation, but identifi sive experimental and clinical data to support the phenome cation of these phenomena in the affected patient is usually non of progressive adaptation to decreased absorptive Ca delayed. The diagnosis is often suspected from the hemato pacity produced by major bowel resection (10, 72, 75). logical aspects of the problem, particularly vitamin B,2defi Another clinical feature of extensive small bowel resec ciency, but there may be steatorrhea and symptoms of other tion that has a major impact of nutrition is the observation vitamin deficiencies as well. This phenomenon has engen that some patients will have persistent gastric hypersecre dered much interest from the standpoint of mechanism, but tion as a result of massive resection (20, 40). This intensifies it is clear that the principal c@useis the abnormal bacterial the diarrhea that is frequently present after major resections growth that occurs in these unusual anatomical situations. due to decreased absorptive capacities of the remaining Treatment obviously requires appropriate antibiotic therapy small intestine, and this hypersecretion may require vagot and subsequent operative correction of the underlying me omy and pyloroplasty for clinical management. chanical cause of the stasis in the small bowel. Since most massive small bowel resections are required Surgical Correction of Nutritional Deficiencies after in patients for either vascular problems or for trauma, nutri MassiveSmall BowelResection.A mechanicalapproach tional sequelae in patients undergoing small bowel surgery to the management of patients with massive small bowel for cancer are a relative rarity. In those patients who do resection is the operative transposition of a short antiperi

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Downloaded from cancerres.aacrjournals.org on October 1, 2021. © 1977 American Association for Cancer Research. Nutrition and Gastrointestinal Surgery staltic segment of bowel to replace the function of the 15. Dowllng, A. H. Compensatory Changes in Intestinal Absorption. Brit. Med. Bull.,23:275-278,1967. absent ileocecal valve. This is not generally utilized early in 16. Eddy, R. L. Metabolic Bone Disease after Gastrectomy. Am. J. Med., 50: the clinical course after resection, due to the marked adap 442-449, 1971. tation that may occur in some patients and concern regard 17. Everson, T. C. Nutrition following Total Gastrectomy with Particular Reference to Fat and Protein Assimilation. Surg. Gynecol. Obstet. ing the possible loss of absorptive surface by operation in a (lnt. Abst. Surg.), 95: 209-230, 1952. patient who already has a reduced intestinal length. This is 18. Everson, T. C., Hutchings, V. z., Eisen, J. , and Witanowski, M. F. A an approach that is used after several months in unusual Comparative Evaluation of the Dumping Syndrome after Partial Gastrec tomy and after Vagotomy with Gastroenterostomy. Ann. Surg., 145: 182- circumstances in which the ileocecal valve has been re 186, 1957. sected along with extensive, small bowel resection, and 19. Everson, T. C., Hutchings, V. Z., Eisen, J. , and Witanowski, M. F. A Comparative Evaluation of Changes in Weight after Partial Gastrectomy clinical nutritional management is incapable of dealing with and after Vagotomy with Gastroenterostomy. Ann. Surg. , 145: 223-229, the problem (76). 1957. 20. Frederick, P. L., Sizer, J. S., and Osborne, M. P. Relation of Massive Bowel Resection to Gastric Secretion. N. Eng. J. Med., 272: 509-514, Colon 1965. 21. Geokas, M. C., and McKenna, R. D. Iron-Deficiency Anemia after Partial Gastrectomy. Can. Med. Assoc. J., 96: 411-417, 1967. Operations for cancer requiring resection of the ileocecal 22. Harvey, J. C. The Vitamin B,, Deficiency State Engendered by Total valve, ileum, and right colon rarely produce nutritional defi Gastrectomy. Surgery, 40: 977-989, 1956. 23. Hendenstedt, 5., and Heijkenskjold, F. Secondary Jejunal Transposition ciency, unless the extent of ileal resection is large, and this for Severe Dumping following Billroth I Partial Gastrectomy. Acta Chir. is not the usual circumstance for patients with colon can Scand., 121: 262-273, 1961. 24. Henley, F. A. Gastrectomy with Replacement. Brit. J. Surg., 40: 118-128, cer. Major resection of the left colon is well tolerated also, 1952. even with extensive resection, and nutritional deficiencies 25. Herrington, J. L. , Jr. Remedial Operations for Postgastrectomy Syn do not occur as a result of the resection itself. However, dromes. Current Problems in Surgery. Chicago: Yearbook Medical Pub lishers, 1970. subtotal resection of the colon may produce significant 26. Hertz, A. F. The Cause and Treatment of Certain Unfavorable After water and electrolyte loss due to diarrhea if the ileum is Effects of Gastroenterostomy. Ann. Surg., 58: 466â€”472,1913. anastomosed to the proximal rectum. A similar situation 27. Hines, J. 0. , Hoffbrand, A. V., and Mollin, D. L. The Hematologic Compli cations following Partial Gastrectomy. A Study of 292 Patients. Am. J. occurs in the patient with total colectomy that requires an Med.,43:555-569,1967. ileostomy, as this may be followed by large water and elec 28. Hinshaw, D. B., Joergenson, E. J., Davis, H. A., and Stafford, C. E. trolyte losses in the early postoperative period. Fortunately, Peripheral Blood Flow and Blood Volume Studies in the Dumping Syn drome. A. M. A. Arch. Surg. , 74: 686-693, 1957. these fluid losses decrease quite rapidly soon after surgical 29. Hinshaw, D. B., Joergenson, E. J., and Stafford, C. E. Preoperative resection in both circumstances, and these patients fail to Dumping Studies in Peptic Ulcer Patients. Arch. Surg. , 80: 738-742, 1960. develop nutritional problems of clinical significance. 30. Hofmann, A. F., and Poley, J. R. Cholestyramine Treatment of Diarrhea Associated with heal Resection. N. EngI. J. Med., 281: 397-402, 1969. 31. Hudock, J. J. , Khentigan, A. , Vanamme, P., and Lawrence, W., Jr. The References Effect of Seratonin and Serotonin Antagonists on External Pancreatic Secretion in Dogs. J. Surg. Res., 3: 307-312, 1963. 1. Abbott, W. E., Krieger, H., Levey, S., and Bradshaw, B. The Etiology and 32. Hudock, J. J., Vanamee, P., and Lawrence, W., Jr. The Effect of Methyl Management of the Dumping Syndrome following a Gastroenterostomy Dopa upon Pancreatic Secretory Response to Intrajejunal Hypertonic or Subtotal Gastrectomy. Gastroenterology, 39: 12-27, 1960. Glucose Solution. Surgery, 60: 443-448, 1966. 2. Abels, J. C., Gorham, A. T., Pack, G. T., and Rhodes, C. P. Metabolic 33. Hunt, C. J. Construction of Food Pouch from Segment of Jejunum as Studies in Patients with Cancer of the Gastrointestinal Tract: I. Plasma Substitute for Stomach in Total Gastrectomy. A. M. A. Arch. Surg., 64: Vitamin A Levels in Patients with Malignant Neoplastic Disease, Particu 601-608, 1952. larly in the Gastrointestinal Tract. J. Clin. Invest., 20: 749â€”764,1941. 34. Johnson, L. P., Sloop, R. D., Jesseph, J. E., and Harkins, H. N. Serotonin 3. Amdrup, E. Surgical Treatment of Postgastrectomy Symptoms. Follow Antagonists in Experimental and Clinical â€œDumping.â€•Ann.Surg., 156: up Examinations of Patients Treated by Constriction of the Gastrojejunal 537-549, 1962. Stoma. Acta Chir. Scand., 120: 155â€”158,1960. 35. Jordan, G. L., Jr. Afferent Loop Syndrome. Surgery, 38: 1027-1035, 4. Beal, J. M., Briggs, J. D., and Longmire, W. P., Jr. Use of a Jejunal 1955. Segment to Replace a Stomach following Total Gastrectomy. Am. J. 36. Jordan, G. 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Gastric blastic Anemia after Total Gastrectomy. Brit. Med. J., 1: 158â€”161,1951. Reservoir Construction for Severe Disability after Subtotal Gastrectomy. 12. Custer, M. D., Butt, L. H. A., and Waugh, J. M. The So-called â€˜Dumping Surg. Gynecol. Obstet.,119: 1219-1232, 1964. Syndromeâ€•afterSubtotal Gastrectomy. Ann. Surg., 123: 410-418, 1946. 43. Lawrence, W. , Jr. , and Mathews, D. H. A Study in Water Shifts on 13. Deller, D. J., Begley, M. D., Edwards, R. G., and Addison, M. Metabolic Experimental Dumping Syndrome. Surg. Forum, 10: 180-185, 1959. Effects of Partial Gastrectomy with Special Reference to Calcium and 44. Lawrence, W., Jr., and Randall, H. T. Postgastrectomy Dumping Syn Folic Acid. Gut, 5: 218-225, 1964. drome: Role of Acute Blood Volume Change. In: E. H. Ellison etal. (eds), 14. Donaldson, R. M. , Jr. Studies of the Pathogenesis of Steatorrhea in the Current Surgical Management, Vol. 3, pp. 363-369. Philadelphia: W. B. Blind Loop Syndrome. J. Clin. 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2386 CANCER RESEARCH VOL. 37

Walter Lawrence, Jr.

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