The early postprandial dumping syndrome: prevention and treatment

The early postprandial dumping syndrome can be prevented or minimized by the appropriate selection of the operative procedure to fit the patient and the peptic ulcer problem he presents, and by proper attention to diet in the early postoperative period. When it does occur, the syndrome usually responds favorably to dietary management and tends to spontaneously regress in severity with time. For these reasons further surgery is seldom required for the early postprandial dumping syndrome. In the patient who fails to improve with diet therapy and time and has disabling symptoms often accompanied by progressive malnutrition, revisional surgery should be undertaken. It is the objective of the surgeon to alter the reconstruction in such a way that emptying from the stomach or gastric remnant is delayed. Therefore, the upper small intestine dose not receive a large, rapidly introduced hyperosmolar bolus to initiate the release of humoral substances causing the syndrome. All revisions utilized are potentially ulcerogenic and if vagotomy has not been a part of the original procedure, it should routinely be performed at the time of revision. Patients who have primarily has a Billroth II gastrectomy will frequently improve markedly with simple conversion to a Billroth I reconstruction. This is particularly true when the residual stomach is moderately large (i.e., after antrectomy) and when the gastrojejunal stoma is larger in diameter than the normal jejunum. Under such circumstances approximately 80 per cent of patients will improve sufficiently so that a more complex procedure need not be utilized at once. Under all other conditions we prefer a 10 cm. segment of reversed jejunum anastomosed proximally to the gastric stump and distally to a 40 cm. isoperistaltic Roux-en-Y jejunal limb. This procedure is so successful that one can justify its use as first recourse even in the anatomically favorable Billroth II patient. It should be pointed out emphatically that an isoperistaltic jejunal interposition (Henley loop) has little or no effect on the early postprandial dumping syndrome and should not be considered. Plicated loops of intestine to recreate a gastric reservoir frequently fail to empty satisfactorily and the incidence of satisfactory results is too low to consider their utilization in surgical treatment of the dumping syndrome.