Download Dumping Syndrome after Fundoplication Systemic comparison of

Dumping Syndrome after Fundoplication
Systemic comparison of complete (Nissen)
versus partial wrap (Thal/Toupet)
H. Ahmed , U. Rolle, H. Till
Department of Pediatric Surgery
Leipzig University Hospitals/Germany
Department of Pediatric surgery
Benha University Hospitals/Egypt
Introduction
 Dumping syndrome or “rapid gastric emptying” is a group of
symptoms most likely to develop after gastric surgery, as gastric
resection, gastric bypass, and antireflux procedures.
 Dumping syndrome (DS) after fundoplication seems to be a
clinical underestimated problem in the paediatric age group.
 The incidence of post-fundoplication dumping syndrome estimated
to be up to 30% in children who undergo fundoplication.
 DS occurs because of rapid transport (dumping) of large amounts
of osmotically active solids and liquids into the duodenum.
 DS presents with non-specific symptoms
and frequency.
* abdominal cramps
* retching
* paleness
* diaphoresis
 Early dumping:
 Late dumping:
30-60 min
90-240 min
with variable severity
* postprandial nausea
* tachycardia
* lethargy
* watery diarrhea
The stomach Functions
* Proximal stomach (fundus and body)
● reservoir (storage of food)
● secretion of acid, pepsin and intrinsic factor
* Distal stomach (antrum and pylorus)
● mixing the food into fine particles (chyme)
● propulsion of food into the intestine
The stomach as a reservoir
● The fasting stomach has: *resting volume of 50 ml
*intragastric pressure of 5-6 mm Hg.
● The stomach maintains a low pressure by maintaining a low wall tension
by the following mechanisms;
* Compliance gastric smooth muscle has a low
resting tone even when it is stretched
* Receptive relaxation distension of the gastric wall
causes vaso-vagal feedback
which reduces the tone of
the stomach muscle.
The stomach as a mixer
● The stomach mixes food with digestive juices, churning
it around and only allowing small amounts of fully mixed
food (chyme) out of the pylorus at a time.
● The pylorus contracts and the sphincter closes as the
waves arrive, allowing only small volumes (about 3 ml
per minute) into the doudenum.
● The gastric emptying takes 3-4 hours, liquids come first
and fats last.
Normal gastric emptying
Hanimann et al., Z Kinderchir 43; 315-8, 1988
Types of Fundoplications
A- complete wrap;
► Nissen(360) fundoplication (NFP)
► Nissen-Rossetti modification
B- Partial wrap;
► Anterior (180) fundoplication (THAL)
► Posterior (270) fundoplication (TOUPET)
Dumping syndrome after fundoplication
Hanimann et al., Z Kinderchir 43; 315-8, 1988
Material and Methods
 Systematic literature review
 Pubmed; Cochrane; Embase
 Key words: dumping syndrome (DS) and
fundoplication
 Evaluation of relevant publications
 Technique of fundoplication
 Appearance and definition of DS
 Evaluation of gastric motility (Pre-/postoperative)
 Associated factors
Esophageal atresia, neurological status, gastric
surgery
Results
 43 publications were found
Pubmed:
Cochrane:
Embase:
n=43
0
0
 34 publications were rated as relevant
1 prospective study
14 retrospective studies
4 cohort reports
12 case reports
3 reviews
Results
 Nissens fundoplication (20 publications)
Incidence of DS 5-30%
Onset 2 weeks – 12 months postoperatively
Usually moderate symptoms
OGGT only in 2 studies
 Thal fundoplication (1 publication)
No DS
 Toupet fundoplication (1 publication)
Incidence of DS 18%
Results
 Performed investigations (in all studies)
 Laboratory studies
 Contrast studies
 Endoscopy
 pH-Monitoring
 Motility studies
 No motility studies were performed
 Treatment
 Nutritional rehabilitation was achieved by dietary manipulations
 Others e.g Acarbose
Results
 Associated factors
Pyloroplasty , accelerates gastric emptying after NFP.
Gastrostomy, probably a predisposing factor rather than a
cause
Neurologically impaired children, might have DS
Esophageal atresia, associated with high incidence of DS.
Discussion
● Nissen fundoplication (NFP) is the most widely used anti-reflux
procedure, however an anterior and posterior partial fundoplications
(Thal/Toupet) are also used.
● Fundoplication accelerates the gastric emptying time by reducing the
gastric volume and disturbing the vagally mediated postprandial
receptive relaxation due to the higher possibility of inadvertent
damage of the vagal nerve.
● DS is the direct result of alterations in the storage function of the
stomach and/or the pyloric emptying mechanism.
● The available literature suggests that complete (Nissen) fundoplication
might have a higher incidence of dumping syndrome in comparison to
partial (Thal/Toupet) fundoplication.
Conclusion
● Fundoplication is the most common cause of dumping
syndrome (DS) in children.
● Pyloroplasty and gastrostomy should not be performed
simultaneously with the NFP, but only in patients with
proven delayed gastric emptying by scintigraphgy after
anti-reflux surgery.
● DS seems to occur more frequently after complete
(Nissen), than after partial fundoplication (Thal/Toupet).
● However, the available data do not allow to conclude,
which form of fundoplication is more prone to induce DS,
the point that needs further study and evaluation in the
future.
Invitation to participate in a multicenter
prospective study of Dumping Syndrome
after Fundoplication
Thank
you