What Is Post-Gastrectomy Syndrome?

Following surgery to remove the stomach (gastrectomy), some patients have several symptoms that make up what is collectively known as post-gastrectomy syndrome (PGS).

What is the stomach?

When you eat food, it needs to be digested fully before the nutrients can be absorbed. Once the food is swallowed it passes down a tube known as the oesophagus and into the stomach. The stomach is a bag of tissue and muscle. It expands as it fills with food. It is part of the digestive system that helps store, digest and move food along. The stomach contains acid which digests food. Once the food has been digested it moves into the next part of the digestive tract, the small intestine.

What can go wrong with the stomach?

Common conditions affecting the stomach:

• Heartburn and acid reflux - when the stomach acid is too high or if there are structural problems that result in acid leaving the stomach (acid reflux) people experience symptoms of heartburn and indigestion.
• Stomach inflammation and ulcers - if there is damage to the layer of the stomach that protects it from acid, the acid can damage and inflame (gastritis) the stomach wall, leading to ulceration. This can be caused by a bacterial infection (H.pylori) or as a result of long-term or high-dose use of certain drugs like aspirin and ibuprofen.
• Stomach (gastric) cancer and non-cancerous tumours - these can grow in the stomach wall.

What is a gastrectomy?

A gastrectomy is the removal of all or part of the stomach. There are several different types of gastrectomy:

• Total - removal of all of the stomach
• Partial - lower half of the stomach removed. The procedures vary depending on the amount and part of the stomach that needs to be removed.
• Sleeve - usually the left side only (often for weight loss)
• Oesophagogastrectomy - the top of the stomach is removed along with part of the oesophagus.

A gastrectomy is performed either via a cut in your abdomen (open) or several smaller cuts (laparoscopic/keyhole). Keyhole surgery usually results in fewer complications than open surgery.  If cancer is present, the lymph nodes may be removed to prevent the cancer from spreading anywhere else in the body. Part of the small intestine may be reconstructed at the same time.

When is a gastrectomy required?

There are a number of different conditions that may require a surgical gastrectomy:

• Most commonly for removal of stomach (gastric) cancer
• To remove non-cancerous tumours
• For life-threatening obesity (weight loss surgery) - the stomach is made smaller to make the person feel full faster.
• Stomach ulcers (now more commonly treated with antibiotics and other drugs).

What is post-gastrectomy syndrome?

Post-gastrectomy syndrome (PGS) is a collection of symptoms that occur as a result of partial or complete removal of the stomach (gastrectomy). After removing part or all of the stomach, food  cannot be digested as well as it w could be before the operation. This is because the food  is not exposed to the acid or the churning of the stomach.

One of the main functions of the stomach is to store food so that it is released into the small intestine in small, manageable quantities. A consequence of removing the stomach is that large amounts of undigested food can move into the small intestine faster than it can be absorbed. This is known as dumping syndrome.

In dumping syndrome the large amounts of food in the small intestine cause swelling and uncomfortable symptoms. Dumping syndrome symptoms will occur during or after a meal (early dumping syndrome) or a few hours after a meal (late dumping syndrome).

If the intestine is remodelled the new intestine attachments can become blocked in what is known as afferent or efferent loop syndrome, depending on the blockage location. This can lead to a build-up of digestive fluids that can cause uncomfortable symptoms. Hernias, ulcers, leaks or infections can also occur at sites of attachment.

The stomach secretes a protein called intrinsic factor which helps to absorb a specific vitamin (vitamin B₁₂) from food. If a large amount of the stomach is removed, the cells that produce this protein will also be removed and the patient may become deficient in vitamin B₁₂ which causes anaemia. There can also be deficiencies in other nutrients such as iron and fat-soluble vitamins.

How is post-gastrectomy syndrome diagnosed?

A diagnosis of PGS will be made by a doctor based on your symptoms and how long you have had them. A doctor may also examine your abdomen as part of the investigation and check your general health.

What are the symptoms of post-gastrectomy syndrome?

The following symptoms are associated with post-gastrectomy syndrome; in many cases, symptoms will arise after eating food:

• Abdominal pain
• Acid reflux
• Diarrhoea
• Nausea and vomiting
• Dizziness
• Weight loss

Diagnostic tests

If a doctor suspects post-gastrectomy syndrome they may decide to image your abdomen with a CT scan to look for problems such as an obstruction. A gastric emptying study may be performed where you are given a meal to eat and the speed of movement of the food through the digestive tract is measured. You may also be given a sugary drink to investigate how well this is processed and absorbed by your intestines. A doctor may request a blood test to check whether you are deficient in vitamins or other nutrients.

How does post-gastrectomy syndrome impact quality of life?

A person's quality of life can be reduced if they have post-gastrectomy syndrome.¹ The extent to which a person’s quality of life is impaired will depend on the severity of the symptoms. Many patients are more tired for a few months after a gastrectomy as their body recovers. It is very common  for patients to lose weight after the operation and their appetite may not be as large as it previously was. Eating meals may be less enjoyable if they have to restrict their diet and consuming multiple smaller meals may be more time-consuming.²

If the patient’s symptoms are severe, they may have difficulty working.² Long-term pain may also affect  a person’s mood and some people may feel depressed. Symptoms may also impair  a person’s ability to socialise as they used to which could lead to isolation. It has been found that patients who have a partial gastrectomy have fewer symptoms and a better quality of life than patients who have a complete gastrectomy.¹

What is the treatment for post-gastrectomy syndrome?

Diet modification

One of the main treatments for PGS is for patients to modify their diets so their digestive systems are able to deal with the food. It is often useful for patients with PGS to work with a dietician to optimise their diets to minimise symptoms. There are a few general dietary tips that are recommended:³

• Avoid foods containing lots of sugar
• Increase foods rich in fibre and protein
• Take vitamin supplements if deficient
• Eat fewer smaller meals more often
• Eat meals slowly
• Delay taking drinks at least 30 minutes after eating
• Rest for around 30 minutes after eating

Medications

If dietary modifications fail to  alleviate symptoms there are a few medications that may be prescribed:^3,4

• Octreotide/ Sandostatin
• Pectin
• Guar gum
• Glucomannan
• Acarbose

Vitamin B₁₂ injections and calcium and vitamin D tablets for deficiencies. Surgery may be required in a small minority of cases.⁴

How to reduce your risk of post-gastrectomy syndrome?

Modifiable risk factors

One way to reduce your risk of PGS is to reduce your risk of having to have a gastrectomy. There are a few modifiable lifestyle changes that will reduce your chances of getting stomach disease:⁵

• Lose weight if you are overweight
• Diet - eat a healthy, balanced diet and reduce salt intake
• Reduce alcohol consumption - alcohol can damage the stomach lining and reduce the amount of acid produced which can result in inflammation (gastritis) and eventually stomach cancer.
• Screening for bacterial (H.pylori) infection with early treatment
• Do not take certain anti-acids longer than required⁶
• Reduce smoking
• Exercise regularly

Non-modifiable risk factors

Unfortunately, there are some risk factors that are not modifiable:

• Age - older patients are more likely to have symptoms and to take longer to recover after surgery.
• Type of surgery - patients who have a total gastrectomy are more likely to have symptoms than those who have a partial gastrectomy.
• Family history of stomach cancer or ulcers - this will predispose someone to  have these diseases which may require surgery.

Summary

Following surgery on the stomach (gastrectomy) some people have symptoms that are collectively known as post-gastrectomy syndrome (PGS). These symptoms are a result of having a smaller or absent stomach following surgery, and the digestive system is therefore unable to digest and absorb the food as effectively as before the surgery. The most common reasons for having a gastrectomy are to treat stomach cancer, stomach ulcers and life-threatening obesity. There are different types of gastrectomy procedures such as total (removal of all the stomach) and partial (removal of part of the stomach).

Dumping syndrome is one of the post-gastrectomy syndromes where large amounts of undigested food are ‘dumped’ into the small intestine, leading to symptoms. PGS is diagnosed by a doctor based on symptoms such as abdominal pain, diarrhoea, nausea, dizziness and weight loss. A doctor may order tests such as a CT or blood test to make a diagnosis. PGS can impact a patient’s quality of life if symptoms are severe. Patients may have difficulty working and socialising and might find dietary changes make eating less enjoyable.

The treatment of PGS is to be careful about what you eat, such as reducing sugar and increasing protein intake. It is also advisable to eat smaller meals more often and to eat slowly. There are certain medications such as Octreotide and Pectin which may be prescribed if symptoms are still present after dietary modifications. To reduce your risk of PGS it is recommended that you lose weight and, if necessary, reduce alcohol intake to recommended guidelines, stop smoking and exercise regularly. If you are concerned about your symptoms, please speak to your local healthcare provider for advice and support.