Surgical management of postvagotomy syndrome

The purpose of the present report is to demonstrate the results of conservative surgical treatment in twelve patients with postvagotomy syndrome (PVS). The reconstructive operation performed in each case depended on the preexisting drainage procedure. Out of eight patients who had undergone vagotomy and gastrojejunostomy (GJ) four suffered from bile reflux and vomiting, four from dumping (DU) and four had diarrhea. All underwent closure of GJ and two of them duodenoplasty for coexisting duodenal stenosis. The results were very good (Visick grade I and II) in all patients except for one complete failure. Out of four patients who had undergone vagotomy and pyloroplasty, three had DU, two diarrhea and two bile reflux and vomiting. Pyloric reconstruction was performed in all subjects. Symptoms were relieved in all cases. In one patient radioisotopic control showed mild G/O and D/G reflux. Conservative surgical operations give satisfactory results in the treatment of PVS. Furthermore they have lower morbidity and mortality than radical surgery.

Surgical management of severe intractable postvagotomy diarrhoea

Experience with the surgical management of 23 patients with postvagotomy diarrhoea is outlined. The most common pre-operative abnormalities are rapid gastric emptying (14/23) and fast small bowel transit (23/23). Three patients were found to have steatorrhoea due to organic disease. Peptic ulcer surgery performed at a young age (means = 29 years, range 21-37) appears to be the only identifiable risk factor. The results of medical treatment with bile salt binding agents were disappointing in the long term. In 10 out of 13 patients treated with antiperistaltic segments, the procedure had to be reversed because of episodes of severe postprandial colic, intestinal obstruction and bacterial overgrowth. A good result with relief of the explosive diarrhoea was obtained by the distal onlay reversed ileal graft in six out of seven patients. This procedure creates a passive non-propulsive segment, and has no undesirable sequelae. It should be considered in those patients in whom the diarrhoea is not controlled by conservative measures.

Pyloric reconstruction

Fourteen patients with persistent and severe postcibal symptoms following vagotomy and pyloroplasty for duodenal ulcer had the pylorus reconstructed. A dumping provocation test was useful in patient selection and evaluation of results. When assessed between 6 months and 3 years after operation, nine patients had an excellent or good result and three were improved. Surgical technique is relatively simple and the operation should be considered and practised more often than it seems to be from documented experience.

Effect of metoclopramide on gastric stasis after reversed jejunal loop for postvagotomy diarrhea

The effect of metoclopramide on gastric emptying in a patient with an antiperistaltic jejunal loop interposed between the stomach and duodenum because of postvagotomy dumping symdrome is studied. Solid particle emptying by 99mTc-labeled chicken liver revealed profound gastric stasis with resultant bezoar formation. Orally administered metoclopramide resulted in correction of the gastric emptying rate and dramatic symptomatic relief. The possible use of metoclopramide in patients with stasis following surgical intervention to correct postvagotomy dumping is suggested.

Reversed ileal segment for treatment of ileostomy dysfunction. Clinical application

Persistent, profuse ileostomy diarrhea developed gradually in a patient over a 12-hour period after proctocolectomy for ulcerative colitis. There was no evidence of ileostomy stenosis or dilation of the ileum proximal to the stoma. He was successfully treated with a reverse ileal segment of 10 cm, and gained 14 to 18 kg. ileostomy output became semisolid and decreased from 1,000 to 2,000 ml/day to 600 ml/day. The transit time changed from 12 minutes to 2 1/2 hours. Antiperistaltic segments of intestine prolong transit time and allow for greater absorption. While most patients with ileostomies are not troubled by severe diarrhea, the small proportion who are may be candidates for a reversed ileal segment.

Revision of intestinal bypass procedures

The results of jejunoileal bypass have been satisfactory in 80 per cent of the patients. In the remaining 20 per cent, one or more problems eventually may require revision of the bypass. These problems fall into four categories: inadequate weight loss; excessive weight loss; persistent uncontrollable diarrhea or associated severe anorectal problems, or both, and severe unmanageable electrolyte and metabolic imbalance with or without liver failure. In our series, 108 patients were observed for one to five years, and ten patients required revision, one revision for every 12 bypass operations performed. The preoperative evaluation and management and the options available to the surgeon in correcting the abnormalities are evaluated. The results of ten patients who underwent revision of the bypass and the rationale for the revision are outlined. Criteria for an ideal operation have not as yet been attained.

Surgical treatment of late postgastrectomy syndromes

An analysis of the experience at the University of California Hospital, San Francisco, with the diagnosis and treatment of fifty-nine postgastrectomy syndromes shows that stomal obstruction (sixteen patients), the most common syndrome, was best treated by total reconstruction rather than stomal revision. Disappointment with the results of other procedures for the dumping syndrome (50 per cent improvement) has convinced us of the need to adopt the use of reversed jejunal interposition for surgical treatment of this condition. Because a precise etiologic diagnosis of bilious vomiting is often elusive, the preferred procedure is isoperistaltic jejunal interposition, since it eliminates the afferent loop and prevents bile from entering the stomach. All five patients with malabsorption were improved by conversion from BII to BI. Four of five patients with diarrhea were improved by various procedures (not including a reversed segment of intestine in the midjejunum). Three patients with reflux alkaline gastritis were improved by Roux-en-Y gastrojejunostomy or isoperistaltic jejunal interposition. Either is effective. Thus, in our experience if an unquestionable diagnosis of stomal obstruction, malabsorption, or reflux alkaline gastritis can be established, there is ample justification for an optimistic outlook regarding surgical therapy.

A new operation for the dumping syndrome and post-vagotomy diarrhea

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Subcutaneous lateral internal anal sphincterotomy for anal fissure

This paper describes a method of lateral internal sphincterotomy for anal fissure entirely by palpation, a technique which gives results similar to those performed under direct vision, and is superior to posterior sphincterotomy and stretching of the sphincter. It has been employed in patients with episodic and chronic diarrhoea with equally satisfactory results. Lateral sphincterotomy preserves the external anal sphincter and it is suggested that this is the main reason for the low incidence of defects of anal continence as compared with other procedures.