今日の臨床サポート

胃切除後症候群

著者: 野村幸世 東京大学 消化管外科学

監修: 上村直実 国立国際医療研究センター 国府台病院

著者校正/監修レビュー済:2021/06/30
患者向け説明資料

概要・推奨   

  1. 胃切除後症候群とは胃癌などの胃切除後に起こる合併症である。
  1. 食事療法にてコントロールできない重症のダンピング症候群の患者には、適用外ではあるがサンドスタチンによる治療が勧められる(推奨度2)。
  1. 適用外ではあるがグルコバイは後期ダンピング症状の改善に有効である(推奨度2)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要と
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 胃切除術後の貧血患者では半数以上にビタミンB12欠乏があり、メチコバール 1日1,500μgの経口投与が必要である(推奨度1)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま
  1. 胃切除後長期経過した例で、進行性の痙性・運動失調・ニューロパチーが生じたときは、ビタミンB12欠乏と同時に銅の欠乏を疑う(推奨度2)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
野村幸世 : 特に申告事項無し[2021年]
監修:上村直実 : 未申告[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 胃切除後症候群とは、胃癌などの胃切除後に起こる合併症で、食後30分以内に発症する早期胃切除後症候群と、食後2~4時間後に発症する後期胃切除後症候群がある。
  1. 胃切除(胃全摘、幽門側胃切除、噴門側胃切除、胃部分切除を含む)の既往があることが診断の前提となる。
  1. 食後症候群、消化吸収障害、手術操作に関連する障害、その他の障害に大別される。
 
胃切除後障害

出典

img1:  著者提供
 
 
 
  1. 食後症候群は、胃手術後長期を経過してはじめて現れることはまれである。消化吸収障害、その他の障害はむしろ胃手術後長期を経過して現れることが多い。
  1. 術後長期に経過した人ではすでに平衡状態になっており、治療を要しない病態と、治療を要する病態とがある。
  1. 疾患の頻度は胃切除を受けた人のなかでは高く、部分切除よりも大きく胃切除を受けた人では何らかの障害を有する場合がほとんどである。
問診・診察のポイント  
  1. 胃切除を受けたのがいつのことか、術式、何に対する手術か、悪性疾患であればそのステージを確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: R J Loffeld
雑誌名: Can J Gastroenterol. 2000 Sep;14(8):681-4.
Abstract/Text Little is known about the long term occurrence and prevalence of upper abdominal complaints after previous partial gastrectomy. Therefore, a retrospective, uncontrolled, cross-sectional, descriptive, clinical, endoscopic study was done. A questionnaire was mailed to patients who had undergone partial gastrectomy and been sent for upper gastrointestinal endoscopy. Eight questions were scored on a five-point Likert scale, and a symptom score was calculated. During the five-year study period, 189 patients (137 men, 52 women) were identified as having had a partial gastrectomy--143 (76%) received the Billroth II operation and 46 (24%) received the Billroth I operation. The questionnaire was mailed to 124 patients, of whom 79 (64%) responded. Eighty-eight per cent of patients had undergone surgery more than 15 years earlier. Fifty-nine patients (75%) suffered from upper abdominal symptoms. Regurgitation of food, retrosternal heartburn and bile reflux occurred significantly more often in patients who underwent the Billroth II operation. The mean symptom score of patients who underwent Billroth I resection was significantly lower (4.5 [SD 3.6]) than that of patients who underwent Billroth II resection (7.1 [SD 4.4])(P=0.04). One or more symptoms indicative of dumping were found in 70% of patients who underwent Billroth II resection and in 59% of patients who underwent Billroth I resection (not significant). Many patients who had undergone a partial gastrectomy developed upper abdominal symptoms during long term follow-up that were not specifically linked to dumping.

PMID 11185533  Can J Gastroenterol. 2000 Sep;14(8):681-4.
著者: C C Wu, C Y Chen, T C Wu, T J Iiu, P K P'eng
雑誌名: Hepatogastroenterology. 1995 Nov-Dec;42(6):867-72.
Abstract/Text BACKGROUND/AIMS: The complications of cholelithiasis and cholecystitis after gastrectomy for gastric carcinoma were reviewed.
PATIENTS AND METHODS: Between 1983 and 1988, 474 patients with a normal gallbladder received gastrectomy for gastric cancer.
RESULTS: Among the 288 patients who underwent radical gastrectomy with systematic lymphadenectomy (RG), 9 (3.1%) were suffering from acute postoperative acalculous cholecystitis, and 2 of them died. None of the 186 patients treated with simple gastrectomy (SG) developed this complication (RG vs. SG, p <0.05). The long-term prognosis of RG is better than that of SG. However, as of July 1993, of among the 463 patients with a normal gallbladder who survived the operation, 85 of the 281 patients who underwent RG and 9 of the 182 patients who underwent SG had gallstones (RG vs. SG, P<0.001). Of the cases complicated by postgastrectomy cholelithiasis, the mean interval between gastrectomy and gallstone formation was shorter in the RG patients (31.4 +/- 20.9 months) than in the SG patients (48.0 +/- 12.8 months) (P<0.05). Following gallstone formation, there was a higher rate of acute biliary symptoms in patients who underwent RG.
CONCLUSIONS: Early cholecystectomy should be performed in patients who received an RG with gallstone formation. Moreover, it would be better to include a policy of prophylactic cholecystectomy in the procedures of RG, even if the gallbladder is normal, in order to prevent the complications of acute cholecystitis and cholelithiasis.

PMID 8847037  Hepatogastroenterology. 1995 Nov-Dec;42(6):867-72.
著者: Calin I Prodan, Sylvia S Bottomley, Andrea S Vincent, Linda D Cowan, Beverley Greenwood-Van Meerveld, Neil R Holland, Stuart E Lind
雑誌名: Am J Med Sci. 2009 Apr;337(4):256-8. doi: 10.1097/MAJ.0b013e31818ad0ff.
Abstract/Text BACKGROUND: : Acquired copper deficiency in adults leads to hematological and neurological manifestations that mimic vitamin B12 deficiency. A significant number of patients with copper deficiency syndrome have a history of gastric surgery, often remote. We sought to determine whether copper deficiency is present in a population of individuals with longstanding partial gastric resection.
METHODS: : Serum copper, ceruloplasmin, and zinc levels were determined in 20 patients with a history of partial gastric resection and 50 controls, randomly selected from the Oklahoma City Veterans Affairs Medical Center electronic database.
RESULTS: : Hypocupremia and symptoms of copper deficiency were detected in patients with partial gastric resection in contrast to controls (3/20 versus 0/50, P = 0.02). Serum copper and ceruloplasmin levels were significantly lower in individuals with partial gastric resection than in controls (P = 0.04 and P = 0.001, respectively). The mean interval between gastric surgery and testing was 20.7 years.
CONCLUSIONS: : Our results indicate that a significant number of individuals with longstanding history of partial gastric resection have undiagnosed hypocupremia. Screening for copper deficiency after gastric surgery may prevent the development of hematological and neurological complications in these patients.

PMID 19365170  Am J Med Sci. 2009 Apr;337(4):256-8. doi: 10.1097/MAJ.0・・・
著者: James E Speicher, Richard C Thirlby, Joseph Burggraaf, Christopher Kelly, Sarah Levasseur
雑誌名: J Gastrointest Surg. 2009 May;13(5):874-80. doi: 10.1007/s11605-009-0821-y. Epub 2009 Feb 18.
Abstract/Text INTRODUCTION: Postsurgical gastric atony occurs infrequently after gastric surgery. However, the symptoms are disabling and refractory to medical management. The only effective treatment is completion gastrectomy. A few studies have examined in detail the long-term results of this radical procedure.
METHODS: From 1988 through 2007, 44 patients (84% female, 16% male) underwent near-total or total completion gastrectomies for refractory postsurgical gastric atony. The average age was 52 (range 32-72). Gastric atony was documented using radionuclide solid food emptying studies. Charts were reviewed retrospectively to identify preoperative symptoms and long-term postoperative function, and the patients were contacted by phone to evaluate their current level of function.
RESULTS: Of the original 44 patients, 66% (n = 29) were evaluated postoperatively at a mean of 5.6 + 4.5 years (range 0.5-15.0 years). Fourteen patients (32%) had died, and seven (16%) were lost to follow-up. Most common presenting symptoms were abdominal pain (98%), vomiting (98%), nausea (77%), diet limitation (75%), heartburn (64%), and weight loss (59%, average = 19% of BW). Postoperative complications occurred in 36% (n = 16), most commonly bowel obstruction (11%), anastomotic stricture (9%), and anastomotic leak (7%), and there was one perioperative death. At last follow-up, there were significant improvements in abdominal pain (97% to 59%, p < 0.001), vomiting (97% to 31%, p < 0.001), nausea (86% to 45%, p < 0.001), and diet limited to liquids or nothing at all (57% to 7%, p < 0.001). Some symptoms were more common postoperatively, including early satiety (24% to 89%, p < 0.001), and postprandial fullness (10% to 72%, p < 0.001). Average BMI at the time of surgery and at last follow-up were 23 and 21, respectively. Osteoporosis was diagnosed pre- and postoperatively in 17% and 67% of patients, respectively (p < 0.001). Seventy-eight percent of patients stated that they were in better health after surgery, while 17% were neutral, and 6% stated that they were worse off. Mean satisfaction with surgery was 4.7 (1-5 Likert scale).
CONCLUSION: Completion gastrectomies in this patient population resulted in significant improvements in abdominal pain, vomiting, nausea, and severe diet limitations. Most patients, however, have significant ongoing gastrointestinal complaints, and the incidence of osteoporosis is high. Patient satisfaction is high; about 78% of patients believed their health status is improved. We believe these data support the selective use of completion gastrectomies in patients with severe postsurgical gastroparesis.

PMID 19224297  J Gastrointest Surg. 2009 May;13(5):874-80. doi: 10.100・・・
著者: Cengìz Beyan, Esìn Beyan, Kürşat Kaptan, Ahmet Ifran, Alì Ihsan Uzar
雑誌名: Hematology. 2007 Feb;12(1):81-4. doi: 10.1080/10245330600938554.
Abstract/Text Anemia is common in patients following gastrectomy. The purpose of this study was to document causes of anemias developing during the post-gastrectomy period and to determine the importance of complete blood count parameters on types of anemia. A total of 72 patients (23 women and 49 men) who had previously undergone gastrectomy in the past and who were admitted for the evaluation of anemia were enrolled in study. The patients who were evaluated and treated for anemia in the post-gastrectomy period were excluded. Iron deficiency anemia was present in 68 (94.4%) of 72 gastrectomized patients with anemia. Deficiencies of vitamin B12 and folate were present in 57 (79.2%) and in three patients, respectively. The most common cause of anemia was the combination of iron and vitamin B12 deficiencies. Iron deficiency was present in the majority of patients, followed by vitamin B12 deficiency in frequency. In all combinations of iron deficiency, the values of mean cell hemoglobin and mean cell hemoglobin concentration were either normal or low. In cases who had low white blood cell and platelet counts vitamin B12 deficiency was frequent, while in cases who had high numbers of white cells or platelets iron deficiency was more frequent. In conclusion, gastrectomized patients should be followed for anemia and treated appropriately based on the cause of anemia.

PMID 17364998  Hematology. 2007 Feb;12(1):81-4. doi: 10.1080/102453306・・・
著者: Emmanuel Andrès, Abrar-Ahmad Zulfiqar, Khalid Serraj, Thomas Vogel, Georges Kaltenbach
雑誌名: J Clin Med. 2018 Sep 26;7(10). doi: 10.3390/jcm7100304. Epub 2018 Sep 26.
Abstract/Text The objective of this review is to provide an update on the effectiveness of oral and nasal vitamin B12 (cobalamin) treatment in gastrointestinal (GI) disorders. Relevant articles were identified by PubMed and Google Scholar systematic search, from January 2010 and June 2018, and through hand search of relevant reference articles. Additional studies were obtained from references of identified studies, the Cochrane Library and the ISI Web of Knowledge. Data gleaned from reference textbooks and international meetings were also used, as was information gleaned from commercial sites on the web and data from CARE B12 research group. For oral vitamin B12 treatment, 4 randomized controlled trials (vs. intramuscular), 4 narrative and 4 systematic reviews, and 13 prospective studies fulfilled our inclusion criteria. These studies concerned patients with vitamin B12 deficiency related to: food-cobalamin malabsorption (n = 6), Biermer's disease (n = 3), veganism or vegetarianism (n = 1), total gastrectomy after Roux-en-Y gastric bypass (n = 2) and Crohn's disease (n = 1). Four prospective studies include patients with vitamin B12 deficiency related to the aforementioned etiologies, except veganism or vegetarianism. The systematic present review documents that oral vitamin B12 replacement, at a daily dose of 1000 μg (1 mg), was adequate to normalize serum vitamin B12 levels and cure main clinical manifestations related to vitamin B12 deficiency, in GI disorders, and thus, with safety profile. For nasal vitamin B12 treatment, only one preliminary study was available. We conclude that oral vitamin B12 is an effective alternative to intramuscular vitamin B12 (except in patients presenting with severe neurological manifestations). Oral vitamin B12 treatment avoids the discomfort, contraindication (in patients with anticoagulation), and cost of monthly injections.

PMID 30261596  J Clin Med. 2018 Sep 26;7(10). doi: 10.3390/jcm7100304.・・・
著者: T T Zittel, B Zeeb, G W Maier, G W Kaiser, M Zwirner, H Liebich, M Starlinger, H D Becker
雑誌名: Am J Surg. 1997 Oct;174(4):431-8.
Abstract/Text BACKGROUND: Studies indicate that gastrectomy might alter calcium and bone metabolism, resulting in bone disorders. No data are currently available on the prevalence of bone disorders after gastrectomy.
METHODS: Sixty gastrectomy patients were investigated for serum parameters of calcium and bone metabolism 5 to 20 years postoperatively and compared to an age- and sex-matched healthy control population. Forty patients agreed to a radiological investigation of the spine by anterior-posterior and lateral radiographs of the thoracic and lumbar spine and by computed tomography (CT) osteodensitometry.
RESULTS: Serum calcium and 25-(OH)-vitamin D were decreased in gastrectomized patients, while parathyroid hormone and 1,25-(OH)2-vitamin D were increased. Serum parameters of calcium metabolism were altered in as many as 68% of patients. We found 31 vertebral fractures in 13 patients, 30 grade 2 vertebral deformities in 18 patients, and osteopenia in 15 patients, corresponding to a prevalence of 33%, 45%, and 37% in gastrectomized patients, respectively. The overall rate of gastrectomy patients having vertebral fractures and/or osteopenia was 55%. The risk of having a vertebral deformity was increased by more than sixfold after gastrectomy. Our study is the first report evaluating vertebral deformities in gastrectomized patients, and the largest series of gastrectomized patients investigated by CT osteodensitometry.
CONCLUSION: We found a high prevalence of bone disorders in gastrectomized patients, possibly resulting from disorders in calcium metabolism. Postgastrectomy bone disease might derive from a calcium deficit, which increases calcium release from bone and impairs calcification of newly build bone matrix.

PMID 9337169  Am J Surg. 1997 Oct;174(4):431-8.
著者: Z Nihei, K Kojima, W Ichikawa, R Hirayama, Y Mishima
雑誌名: Surg Today. 1996;26(2):95-100.
Abstract/Text Recent advances in the modalities of quantitatively assessing bone mineral content have resulted in an increasing awareness of metabolic bone disease as a late complication following gastrectomy. In this study, 98 postgastrectomy patients were examined by quantitative computed tomography (QCT). The bone mineral density index (BMDI), defined as 100 x (measured bone mineral density divided by that of age- and sex-matched controls), was used to evaluate the actual effect of gastrectomy on bone disorders. The BMDI values following gastrectomy were 80.4 +/- 27.3, with no significant difference between men and women, or between total and distal gastrectomy. Moreover, no significant differences were observed between the BMDI values within 6 months, being 92.6 +/- 37.3, and those 6 months to 1 year post gastrectomy, being 79.6 +/- 31.2; however, a significant and sharp decrease to 70.5 +/- 36.0 was evident after 1-2 years. The regression coefficient of the BMDI measured within 2 years postoperatively was lower than that measured after 2 years. These findings suggest that the influence of gastrectomy on bone metabolism is induced within 2 years, after which the bone mineral content decreases in accordance with physiological nature. Thus, we conclude that the treatment for bone disease resulting from gastrectomy would only be effective if initiated within a short period after surgery.

PMID 8919278  Surg Today. 1996;26(2):95-100.
著者: S G Fisher, F Davis, R Nelson, L Weber, J Goldberg, W Haenszel
雑誌名: J Natl Cancer Inst. 1993 Aug 18;85(16):1303-10.
Abstract/Text BACKGROUND: For the past 40 years, investigators have suggested that there exists an increased risk of stomach cancer following gastric surgery for benign disease. Recent cohort studies have consistently identified an increased risk of stomach cancer beginning 20 years or more following gastric surgery. Validation of this association and elucidation of risk factors related to gastric cancer have been complicated by variability in study designs.
PURPOSE: This cohort study was designed to investigate the risk of stomach cancer following gastric surgery and to identify patient and treatment characteristics that may alter this risk.
METHODS: Medical admission records of 17077 male military veterans hospitalized during 1970-1971 in U.S. Department of Veterans Affairs (VA) hospitals were examined. From this initial cohort, 1094 patients who died within the 1st year following gastric surgery were excluded. Data analysis was performed on the final cohort consisting of 15,983 patients divided into the following two groups: 1) an exposed group (gastric surgery group) that included 7609 patients receiving gastric surgery for a documented benign disorder and 2) an unexposed group (comparison group) that included 8374 male patients randomly selected from all other hospitalized male patients in the patient database. The comparison group was matched to the gastric surgery group by age (within 10 years), race, hospital, and year of admission. Mortality follow-up utilized the following three sources to identify vital status: 1) the VA Patient Treatment File (1970-1988), 2) the VA Beneficiary Identification Record Linkage System (1970-1989), and 3) the National Death Index (1979-1988). Death certificates were obtained for 99% of the deceased patients. Analyses included estimations of risk using standardized rate ratios (SRRs) and proportional hazards techniques.
RESULTS: A statistically significant increase in risk of stomach cancer was demonstrated among males during the 20 years following gastric surgery (SRR = 1.9; 95% confidence interval [CI] = 1.3-2.4; P = .0001). The risk of developing gastric cancer was greatest during the 2nd to 5th postoperative years (SRR = 2.8; 95% CI = 1.6-4.5; P < .01) and during years 11-15 (SRR = 2.5; 95% CI = 1.2-4.8; P < .01). Also, the risk of developing gastric cancer was greatest among those treated by gastrectomy for any type of ulcer (SRR = 2.6; 95% CI = 1.2-4.9; P < .01) and those having any type of gastric surgery when the primary diagnosis was gastric ulcer (SRR = 2.9, 95% CI = 1.4-5.3; P < .01).
CONCLUSIONS: This study confirms that men undergoing gastrectomy for benign disease and men receiving any gastric surgery for gastric ulcer are at increased risk for developing gastric cancer. Unlike earlier studies, we find that the increased risk is not delayed for 20 years.

PMID 8340942  J Natl Cancer Inst. 1993 Aug 18;85(16):1303-10.
著者: W L Hasler, H C Soudah, C Owyang
雑誌名: J Pharmacol Exp Ther. 1996 Jun;277(3):1359-65.
Abstract/Text Octreotide reduces abdominal and vasomotor symptoms in dumping syndrome by unknown mechanisms. Effects of octreotide (50 microgram) on symptoms, hemodynamic parameters and plasma glucose and insulin levels after glucose meals were tested in double-blind, placebo-controlled, crossover fashion in eight patients with dumping syndrome. Gastric scintigraphy tested whether octreotide reduces symptoms by slowing gastric emptying. Octreotide reduced diarrhea, lightheadedness and palpitations after 75 g of glucose, compared with placebo (P < .001). Orthostatic pulse increases after glucose decreased from 36 +/- 6 beats/min after placebo to 9 +/- 5 beats/min after octreotide (P < .05), and standing blood pressure decreases after glucose were abolished (P < .05), but octreotide had no effect on increase in hematocrit or plasma osmolarity after glucose. Late hypoglycemia was prevented by octreotide, and peak fed insulin levels were reduced from 87 +/- 15 to 26 +/- 9 microU/ml after octreotide (P < .05). Times to maximal plasma glucose levels after meals were prolonged from 28 +/- 4 to 78 +/- 6 min after octreotide (P < .05). Octreotide had no effect on gastric emptying of liquids or solids. In conclusion, amelioration of dumping symptoms by octreotide is associated with reduced orthostasis, which is not a consequence of prevention of hemoconcentration. Prevention of late hypoglycemia may be due to blunted insulin release. Octreotide does not reverse rapid gastric emptying, indicating a limited role for this purported mechanism of action.

PMID 8667198  J Pharmacol Exp Ther. 1996 Jun;277(3):1359-65.
著者: J L Gray, H T Debas, S J Mulvihill
雑誌名: Arch Surg. 1991 Oct;126(10):1231-5; discussion 1235-6.
Abstract/Text Octreotide acetate is a long-acting analogue of the naturally occurring inhibitory gastrointestinal peptide, somatostatin. We tested the efficacy of octreotide in controlling the symptoms of dumping syndrome in response to a provocative meal in a randomized, double-blinded, crossover trial in nine severely affected patients. Pretreatment with octreotide acetate (100 micrograms injected subcutaneously) reduced postprandial dumping symptoms from a mean +/- SEM score of 15.7 +/- 1.6 (placebo treatment day) to 4.6 +/- 1.7. With placebo treatment, all nine patients became symptomatic in response to the meal, whereas with octreotide treatment, symptoms occurred in only two of nine patients. Similarly, all placebo-treated patients showed a postprandial increase in pulse rate to a mean +/- SEM of 105 +/- 6 beats per minute, whereas only one of nine octreotide-treated patients showed an increase in pulse rate (mean +/- SEM, 80 +/- 3 beats per minute). These differences were also statistically significant. While no significant changes were observed in postprandial hematocrit values or osmolality between placebo and octreotide treatments, octreotide prevented hypoglycemia in four affected patients and significantly inhibited insulin release. We conclude that octreotide is a useful tool in the treatment of patients with severe, refractory dumping syndrome.

PMID 1929823  Arch Surg. 1991 Oct;126(10):1231-5; discussion 1235-6.
著者: W O Richards, R Geer, T M O'Dorisio, T Robarts, K L Parish, D Rice, G Woltering, N N Abumrad
雑誌名: J Surg Res. 1990 Dec;49(6):483-7.
Abstract/Text The long acting somatostatin analogue octreotide acetate has been effective in the treatment of early dumping syndrome. We hypothesized that this may be related to its effects on inhibiting gastric emptying and delaying intestinal transit. To study the effect of octreotide acetate on intestinal motility in patients we carried out a randomized, double-blinded study using a subcutaneous injection of either octreotide acetate (100 micrograms) or placebo given 20 min prior to ingestion of a high carbohydrate "dumping" meal in six patients with known severe dumping syndrome. Prior to each study a multilumen polyethylene tube was inserted into the efferent limb to study small intestinal contractions using low compliance pneumo-hydraulic water-perfused manometry. Octreotide acetate prevented dumping symptoms in all six patients and induced the appearance of migrating myoelectric complexes (MMC) characteristic of interdigestive motility. After ingestion of the dumping meal the postprandial "fed" motility pattern lasted for 141 +/- 9 min while after octreotide acetate the fed motility lasted for 29 +/- 5 min (P less than 0.03). The vigor of the fed motility pattern as measured by the motility index (MI = loge (sum of amplitudes X No. of contractions + 1] was lower after octreotide acetate than after placebo (15.1 +/- 0.1 vs 13.4 +/- 0.2, P less than 0.03). The induction of fasting MMC motility pattern and reduction in the duration and vigor of fed motility may explain the symptomatic relief these patients obtained with octreotide acetate. It is not known whether the induction of the MMC is a direct effect of octreotide acetate or secondary to the concomitant inhibition of peptide release (neurotensin, insulin, glucagon, pancreatic polypeptide) that has been demonstrated in earlier studies.

PMID 2263084  J Surg Res. 1990 Dec;49(6):483-7.
著者: R J Geer, W O Richards, T M O'Dorisio, E O Woltering, S Williams, D Rice, N N Abumrad
雑誌名: Ann Surg. 1990 Dec;212(6):678-87.
Abstract/Text The present study evaluates the acute and chronic use of a long-acting somatostatin analog, octreotide acetate, in the treatment of patients with severe postgastrectomy dumping syndrome. In the acute phase, 10 patients with severe dumping were studied over 2 consecutive days before and for 3 hours after the ingestion of a 'dumping breakfast' in a randomized double-blind fashion. On one day octreotide (100 micrograms) was given subcutaneously 30 minutes before the test meal and on the other day an equal volume of vehicle was injected. An additional group of six postgastrectomy patients without dumping were studied in a similar fashion and these acted as controls. During placebo treatment the test meal resulted in an immediate increase (p less than 0.01) in the pulse rate and in plasma levels of glucose, glucagon, pancreatic polypeptide, neurotensin, and insulin. Similar changes were seen in the control group with respect to placebo; however glucagon and neurotensin (p less than 0.05) did not show the same magnitude of increase as seen with placebo. Treatment with octreotide acetate prevented the development of both vasomotor and gastrointestinal symptoms and completely ablated all of the above responses in plasma peptides. These changes were associated with complete ablation of diarrhea (p less than 0.001). Pretreatment with octreotide acetate completely suppressed the rise in plasma insulin response to the meal and this ablated the late hypoglycemia of dumping. Treatment with octreotide acetate resulted in delayed gastric emptying and transit time (578 +/- 244 minutes) versus 76 +/- 23 minutes with placebo and 125 +/- 36 minutes in controls (p less than 0.05). Chronic daily treatment with octreotide acetate resulted in minimal side effects. These patients demonstrated a stable fasting plasma glucose, normal liver function tests, and an average weight gain of 11% during a 12-month period. In addition most patients were able to resume employment. The long-acting somatostatin analog, octreotide acetate, is highly effective in preventing the development of symptoms of severe dumping syndrome, both vasomotor and gastrointestinal.

PMID 2256759  Ann Surg. 1990 Dec;212(6):678-87.
著者: Z Tulassay, T Tulassay, R Gupta, G Cierny
雑誌名: Br J Surg. 1989 Dec;76(12):1294-5.
Abstract/Text The effect of long acting somatostatin analogue, SMS 201-995, on postprandial dumping syndrome was studied in eight patients with Billroth II gastric resection. Each patient was subjected to two oral glucose challenges with 75 g glucose. One challenge was premedicated with 50 micrograms SMS 201-995 subcutaneously 15 min before the oral intake of glucose, the other with placebo. With placebo all patients experienced the subjective symptoms of the early dumping syndrome with significant (P less than 0.001) increases (mean (s.d.)) in pulse rate (from 66 (8) to 102 (10) beats/min), in packed cell volume (from 0.36 (0.05) to 0.43 (0.1) l/l) and in the plasma levels of vasoactive intestinal polypeptide (from 3.0 (0.5) to 10.2 (1.8) pmol/l). During the somatostatin study the subjective symptoms and the changes in the various parameters were not detected. In the control study seven patients showed postprandial hypoglycemia. In these patients significant elevations (P less than 0.001) in the insulin level (from 10 (0.9) to 40 (9.1) microE/ml) and gastric inhibitory peptide (GIP) concentration (from 100 (13) to 220 (41) ng/l) were seen, compared with the initial values. During the application of SMS 201-995 hypoglycaemia did not develop and plasma insulin and GIP concentrations remained unchanged. These results indicate that the long acting somatostatin analogue alleviates the symptoms of early and late postprandial dumping syndromes.

PMID 2691013  Br J Surg. 1989 Dec;76(12):1294-5.
著者: J N Primrose, D Johnston
雑誌名: Br J Surg. 1989 Feb;76(2):140-4.
Abstract/Text The dumping syndrome, which may follow partial gastrectomy or truncal vagotomy and drainage, may be refractory to treatment. The aim of this study was to determine the effect of the somatostatin analogue, SMS 201-995 (octreotide), on dumping provoked by hypertonic glucose. Ten patients with symptoms and signs of dumping were studied. After a dumping provocation test with placebo, all patients developed severe symptoms: seven patients had early dumping, two had both early and late dumping and one had late dumping alone. With either 50 or 100 micrograms SMS 201-995, the symptoms of early dumping were much reduced in all patients, and those of late dumping were completely abolished. The packed cell volume, pulse and systolic blood pressure changes of early dumping were significantly reduced by SMS 201-995 and the fall in blood glucose in patients with late dumping was abolished. SMS 201-995 may be a useful treatment for early and late dumping.

PMID 2702445  Br J Surg. 1989 Feb;76(2):140-4.
著者: W P Hopman, R G Wolberink, C B Lamers, J H Van Tongeren
雑誌名: Ann Surg. 1988 Feb;207(2):155-9.
Abstract/Text In six patients suffering from severe early dumping and six patients with late dumping after peptic ulcer surgery, the effect of the somatostatin analogue SMS 201-995 was compared with placebo. In early dumpers subcutaneous administration of 50 micrograms SMS 201-995 prior to meal ingestion induced a strong improvement of dumping symptoms as reflected by a decrease of the Sigstad dumping score from 12 +/- 2 during placebo to 5 +/- 2 (p less than 0.05). Furthermore, the postprandial increase of pulse rate was abolished; maximum pulse rate decreased from 85 +/- 7 beats/min to 67 +/- 7 beats/min (p less than 0.05). SMS 201-995 did not significantly affect postprandial changes in packed cell volume. In late dumpers 50 micrograms SMS 201-995 reduced peak plasma insulin after oral glucose from 173 +/- 16 mU/L during placebo to 35 +/- 9 mU/L during SMS 201-995 (p less than 0.05) and increased individual plasma glucose nadirs from 1.9 +/- 0.3 mmol/L to 7.5 +/- 3.3 mmol/L (p less than 0.01). Both in early and late dumpers SMS 201-995 improved postprandial expiratory breath hydrogen excretion indicating slowing of gastrointestinal hurry. SMS 201-995 is a powerful therapeutic agent for the management of patients suffering from the dumping syndrome after gastric surgery.

PMID 2893592  Ann Surg. 1988 Feb;207(2):155-9.
著者: Jan Tack, Joris Arts, Philip Caenepeel, Dominiek De Wulf, Raf Bisschops
雑誌名: Nat Rev Gastroenterol Hepatol. 2009 Oct;6(10):583-90. doi: 10.1038/nrgastro.2009.148. Epub 2009 Sep 1.
Abstract/Text Dumping syndrome is a frequent complication of esophageal, gastric or bariatric surgery. Rapid gastric emptying, with the delivery to the small intestine of a significant proportion of solid food as large particles that are difficult to digest, is a key event in the pathogenesis of this syndrome. This occurrence causes a shift of fluid from the intravascular component to the intestinal lumen, which results in cardiovascular symptoms, release of several gastrointestinal and pancreatic hormones and late postprandial hypoglycemia. Early dumping symptoms comprise both gastrointestinal and vasomotor symptoms. Late dumping symptoms are the result of reactive hypoglycemia. Besides the assessment of clinical alertness and endoscopic or radiological imaging, a modified oral glucose tolerance test might help to establish a diagnosis. The first step in treating dumping syndrome is the introduction of dietary measures. Acarbose can be added to these measures for patients with hypoglycemia, whereas several studies advocate guar gum or pectin to slow gastric emptying. Somatostatin analogs are the most effective medical therapy for dumping syndrome, and a slow-release preparation is the treatment of choice. In patients with treatment-refractory dumping syndrome, surgical reintervention or continuous enteral feeding can be considered, but the outcomes of such approaches are variable.

PMID 19724252  Nat Rev Gastroenterol Hepatol. 2009 Oct;6(10):583-90. d・・・
著者: Mitsuhiro Yamada, Takashi Ohrui, Masanori Asada, Kota Ishizawa, Satoru Ebihara, Hiroyuki Arai, Hidetada Sasaki
雑誌名: J Am Geriatr Soc. 2005 Feb;53(2):358-9. doi: 10.1111/j.1532-5415.2005.53126_8.x.
Abstract/Text
PMID 15673372  J Am Geriatr Soc. 2005 Feb;53(2):358-9. doi: 10.1111/j.・・・
著者: A Imhof, M Schneemann, A Schaffner, M Brändle
雑誌名: Swiss Med Wkly. 2001 Feb 10;131(5-6):81-3. doi: 2001/05/smw-09667.
Abstract/Text Reactive hypoglycaemia is a rare disease which occurs postprandially in everyday life involving blood glucose levels below 2.5 to 2.8 mmol/l. We report on a 66-year-old patient who developed symptomatic reactive hypoglycaemia due to late dumping syndrome 10 years after oesophagectomy with cervical anastomosis. A 75 g sucrose load revealed a plasma glucose level of 9.4 mmol/l after one hour, followed by symptomatic hypoglycaemia with a plasma glucose level of 1.8 mmol/l after three hours. Concomitantly, high concentrations of insulin (3216 pmol/l at a glucose level of 9.4 mmol/l and 335 pmol/l at a glucose level of 1.8 mmol/l) and glucagon-like peptide 1 (GLP-1) (375 pmol/l at a glucose level of 9.4 mmol/l and 85 pmol/l at a glucose level of 1.8 mmol/l) were measured. While the patient was under treatment with acarbose, another sucrose load did not provoke symptomatic hypoglycaemia (plasma glucose nadir of 4.6 mmol/l after two hours). Insulin and GLP-1 levels increased much less, to peak levels of 375 pmol/l and 75 pmol/l respectively, after one hour when plasma glucose was 6.8 mmol/l. We conclude that in patients with reactive hypoglycaemia due to gastrointestinal surgery, acarbose decreases rapid glucose absorption associated with hyperglycaemia and GLP-1 secretion, and thus diminishes excessive insulin release. Acarbose is therefore a successful treatment modality for reactive hypoglycaemia due to late dumping syndrome.

PMID 11383230  Swiss Med Wkly. 2001 Feb 10;131(5-6):81-3. doi: 2001/05・・・
著者: T Hasegawa, M Yoneda, K Nakamura, K Ohnishi, H Harada, T Kyouda, Y Yoshida, I Makino
雑誌名: J Gastroenterol Hepatol. 1998 Dec;13(12):1201-6.
Abstract/Text Dumping syndrome commonly occurs after gastrectomy. The late dumping, which is one of the dumping syndromes, is due to postprandial hypoglycaemia caused by an excessive insulin secretion after a sharp rise in plasma glucose. Several treatments, including operation, dietary fibre and somatostatin, have been attempted to relieve dumping symptoms. These treatments take effect through modulation of plasma insulin and glucose levels, but their efficacy is still under consideration. Alpha-glucosidase inhibitor attenuates the postprandial increase of plasma glucose levels and is widely used for treatment of non-insulin-dependent diabetes mellitus (NIDDM). The acute effect of alpha-glucosidase inhibitor on late dumping syndrome has been reported by some studies with test meals. The purpose of this study was to evaluate a long-term effect of alpha-glucosidase inhibitor treatment with ordinary meals in late dumping patients with NIDDM because administration of alpha-glucosidase inhibitor is only ethically allowed for diabetic patients in Japan. Six late dumping patients with NIDDM were orally administered alpha-glucosidase inhibitor, acarbose (50 or 100 mg), three times a day before each meal for 1 month. Diurnal changes of plasma glucose, insulin and pancreatic glucagon levels were compared before and after the alpha-glucosidase inhibitor treatment. All patients had late dumping-related symptoms, such as weakness, palpitation and dizziness before the induction of alpha-glucosidase inhibitor treatment. Patients suffered from a rapid fall in plasma glucose levels from hyperglycaemia at the same time as dumping symptoms. These late dumping-related symptoms disappeared and a rapid change of plasma glucose and insulin levels were attenuated after the alpha-glucosidase inhibitor treatment. These data suggest a long-term therapeutic efficacy of alpha-glucosidase inhibitor for late dumping patients.

PMID 9918426  J Gastroenterol Hepatol. 1998 Dec;13(12):1201-6.
著者: D D Ng, R J Ferry, A Kelly, S A Weinzimer, C A Stanley, L E Katz
雑誌名: J Pediatr. 2001 Dec;139(6):877-9. doi: 10.1067/mpd.2001.119169.
Abstract/Text Dumping syndrome and postprandial hypoglycemia have been reported after Nissen fundoplication. The physiopathologic mechanisms are poorly understood and a variety of therapies have failed to control the hypoglycemia in these patients. We report a series of 6 infants with postprandial hypoglycemia after Nissen fundoplication who were treated successfully with acarbose.

PMID 11743518  J Pediatr. 2001 Dec;139(6):877-9. doi: 10.1067/mpd.2001・・・

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