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Biliary Diversion: A New Method to Prevent Enterogastric Reflux and Reverse the Roux Stasis Syndrome

Biliary Diversion: A New Method to Prevent Enterogastric Reflux and Reverse the Roux Stasis Syndrome Abstract Objective: To design an operation to prevent enterogastric reflux of bile that will not interfere with gastric or proximal intestinal motility and that will be applicable in patients with primary alkaline reflux gastritis, various prior ulcer operations, and previous corrective operations for enterogastric reflux. Design: A nonrandomized, prospective review of 27 patients with enterogastric reflux operated on between 1991 and 1995. Setting: A midwestern medical school and 400-bed tertiary referral center, adult hospital. Patients: Twenty-seven patients with symptoms compatible with enterogastric reflux, primary or secondary to ulcer operations, or with Roux-en-Y limb stasis following attempts to correct alkaline reflux gastritis. Interventions: An operation designed to reestablish gastroduodenal continuity by converting previous procedures such as Billroth II gastrectomy and Roux-en-Y gastrojejunostomy to a Billroth I gastroduodenostomy, and by diverting bile away from the stomach by end-to-side choledochojejunostomy by means of a Roux-en-Y limb of 35 to 40 cm. Main Outcome Measures: Resolution of the preoperative symptoms of pain, nausea, and bilious vomiting in patients with enterogastric reflux, and elimination of the Roux stasis syndrome as well as prevention of future enterogastric reflux in patients undergoing conversion from Roux-en-Y to Billroth I. Serial evaluation of gastric emptying after conversion to a Billroth I configuration to determine whether dysmotility is improved or eliminated. Results: Symptoms were completely resolved in 22 of the 26 surviving patients, with follow-up of 6 months to 4 years. None of the 26 patients have had any bilious vomiting postoperatively. Roux-en-Y stasis has been corrected when due to a mechanical problem (eg, strictures, marginal ulcers), although thus far normal gastric emptying has not been observed in all of these multiply surgically treated patients. Conclusions: Enterogastric reflux is common following most ulcer operations. Attempted correction of this problem may result in other difficulties, including delayed emptying due to Roux-en-Y stasis. The fact that most patients with enterogastric reflux are female suggests that this condition is related to disordered motility; therefore, vagal interruption and major gastric resections should be carefully considered to avoid future disabling problems.Arch Surg. 1997;132:245-249 References 1. Wölfler A. Gastro-Enterostomie . Centralbl Chir . 1881;8:705-720. 2. Mathias JR, Fernandez A, Sninsky CA. Clench MH, Davis RH. Nausea, vomiting and abdominal pain after the Roux-en-Y anastomosis: motility of the jejunal limb . Gastroenterology . 1985;88:101-107.Crossref 3. Stiegmann G, Goff JS. An alternative to Roux-en-Y for treatment of bile reflux gastritis . Surg Gynecol Obstet . 1988;166:69-70. 4. Tu BN, Sarr MG. Kelly KA. Early results with the uncut Roux reconstruction after gastrectomy: limitations of the stapling technique . Am J Surg . 1995:170: 262-264.Crossref 5. Kauer WKH, Peters JH, DeMeester TR, Ireland AP, Bremmner CG, Hagen JA. Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone . Ann Surg . 1995;180:648-653. 6. Braun H. Uëber Gastro-enterostomie und gleichzeitung ausgefuhrte Entero-Anastomose . Arch Klin Chir . 1893;45:361-364. 7. Roux C. De las gastro-enterostomie: etude basée sur les operations pratiquées du 21 Juin 1888 au 1 Septembre 1886 . Rev Gynecol Chir Abdom . 1897; 1:95-98. 8. Henley FA. Gastrectomy with replacement . Br J Surg . 1952;40:118-128.Crossref 9. Aranow JS. Matthews JB, Garcia-Aguilar J, Novak G, Silen W. Isoperistaltic jejunal interposition for intractable postgastrectomy alkaline reflux gastritis . J Am Coll Surg . 1995;180:648-653. 10. Tu BN, Kelly KA. Elimination of the Roux stasis syndrome using a type of 'uncut Roux' limb . Am J Surg . 1995;170:381-386.Crossref 11. Sawchuck A, Canal D, Grosfeld JL, et al. Electrical pacing of the Roux limb resolves delayed gastric emptying . J Surg Res . 1987;42:635-641.Crossref 12. Morrison P, Meidema BW, Kohler L, Kelly KA. Electrical dysrhythmias in the Roux jejunal limb: cause and treatment . Am J Surg . 1990;160:252-256.Crossref 13. Hinder RA, Esser J. DeMeester TR. Management of gastric emptying disorders following the Roux-en-Y procedure . Surgery . 1988;104:765-772. 14. Gustavsson S, Ilstrup D, Morrision P, Kelly RA. Roux-Y stasis syndrome after gastrectomy . Am J Surg . 1988;155:490-494.Crossref 15. McAlhany JC Jr, Hanover TM, Taylor SM, Sticca RP, Ashmore JD Jr. Long-term follow-up of patients with Roux-en-Y gastrojejunostomy for gastric disease . Ann Surg . 1994;219:451-457.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Biliary Diversion: A New Method to Prevent Enterogastric Reflux and Reverse the Roux Stasis Syndrome

Archives of Surgery , Volume 132 (3) – Mar 1, 1997

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Publisher
American Medical Association
Copyright
Copyright © 1997 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1997.01430270031005
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective: To design an operation to prevent enterogastric reflux of bile that will not interfere with gastric or proximal intestinal motility and that will be applicable in patients with primary alkaline reflux gastritis, various prior ulcer operations, and previous corrective operations for enterogastric reflux. Design: A nonrandomized, prospective review of 27 patients with enterogastric reflux operated on between 1991 and 1995. Setting: A midwestern medical school and 400-bed tertiary referral center, adult hospital. Patients: Twenty-seven patients with symptoms compatible with enterogastric reflux, primary or secondary to ulcer operations, or with Roux-en-Y limb stasis following attempts to correct alkaline reflux gastritis. Interventions: An operation designed to reestablish gastroduodenal continuity by converting previous procedures such as Billroth II gastrectomy and Roux-en-Y gastrojejunostomy to a Billroth I gastroduodenostomy, and by diverting bile away from the stomach by end-to-side choledochojejunostomy by means of a Roux-en-Y limb of 35 to 40 cm. Main Outcome Measures: Resolution of the preoperative symptoms of pain, nausea, and bilious vomiting in patients with enterogastric reflux, and elimination of the Roux stasis syndrome as well as prevention of future enterogastric reflux in patients undergoing conversion from Roux-en-Y to Billroth I. Serial evaluation of gastric emptying after conversion to a Billroth I configuration to determine whether dysmotility is improved or eliminated. Results: Symptoms were completely resolved in 22 of the 26 surviving patients, with follow-up of 6 months to 4 years. None of the 26 patients have had any bilious vomiting postoperatively. Roux-en-Y stasis has been corrected when due to a mechanical problem (eg, strictures, marginal ulcers), although thus far normal gastric emptying has not been observed in all of these multiply surgically treated patients. Conclusions: Enterogastric reflux is common following most ulcer operations. Attempted correction of this problem may result in other difficulties, including delayed emptying due to Roux-en-Y stasis. The fact that most patients with enterogastric reflux are female suggests that this condition is related to disordered motility; therefore, vagal interruption and major gastric resections should be carefully considered to avoid future disabling problems.Arch Surg. 1997;132:245-249 References 1. Wölfler A. Gastro-Enterostomie . Centralbl Chir . 1881;8:705-720. 2. Mathias JR, Fernandez A, Sninsky CA. Clench MH, Davis RH. Nausea, vomiting and abdominal pain after the Roux-en-Y anastomosis: motility of the jejunal limb . Gastroenterology . 1985;88:101-107.Crossref 3. Stiegmann G, Goff JS. An alternative to Roux-en-Y for treatment of bile reflux gastritis . Surg Gynecol Obstet . 1988;166:69-70. 4. Tu BN, Sarr MG. Kelly KA. Early results with the uncut Roux reconstruction after gastrectomy: limitations of the stapling technique . Am J Surg . 1995:170: 262-264.Crossref 5. Kauer WKH, Peters JH, DeMeester TR, Ireland AP, Bremmner CG, Hagen JA. Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone . Ann Surg . 1995;180:648-653. 6. Braun H. Uëber Gastro-enterostomie und gleichzeitung ausgefuhrte Entero-Anastomose . Arch Klin Chir . 1893;45:361-364. 7. Roux C. De las gastro-enterostomie: etude basée sur les operations pratiquées du 21 Juin 1888 au 1 Septembre 1886 . Rev Gynecol Chir Abdom . 1897; 1:95-98. 8. Henley FA. Gastrectomy with replacement . Br J Surg . 1952;40:118-128.Crossref 9. Aranow JS. Matthews JB, Garcia-Aguilar J, Novak G, Silen W. Isoperistaltic jejunal interposition for intractable postgastrectomy alkaline reflux gastritis . J Am Coll Surg . 1995;180:648-653. 10. Tu BN, Kelly KA. Elimination of the Roux stasis syndrome using a type of 'uncut Roux' limb . Am J Surg . 1995;170:381-386.Crossref 11. Sawchuck A, Canal D, Grosfeld JL, et al. Electrical pacing of the Roux limb resolves delayed gastric emptying . J Surg Res . 1987;42:635-641.Crossref 12. Morrison P, Meidema BW, Kohler L, Kelly KA. Electrical dysrhythmias in the Roux jejunal limb: cause and treatment . Am J Surg . 1990;160:252-256.Crossref 13. Hinder RA, Esser J. DeMeester TR. Management of gastric emptying disorders following the Roux-en-Y procedure . Surgery . 1988;104:765-772. 14. Gustavsson S, Ilstrup D, Morrision P, Kelly RA. Roux-Y stasis syndrome after gastrectomy . Am J Surg . 1988;155:490-494.Crossref 15. McAlhany JC Jr, Hanover TM, Taylor SM, Sticca RP, Ashmore JD Jr. Long-term follow-up of patients with Roux-en-Y gastrojejunostomy for gastric disease . Ann Surg . 1994;219:451-457.Crossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Mar 1, 1997

References