Delayed gastric emptying of liquids and solids following Roux-en-Y biliary diversion

Intestinal transit of food after total gastrectomy and Roux-Y esophagojejunostomy

We examined small bowel transit of solid food in 10 patients 3 to 30 months after total gastrectomy and Roux-Y esophagojejunostomy and compared the transit pattern with that in five control subjects. All persons ate a test meal consisting of 213 g of beef stew mixed with 30 g of chicken liver which was labeled with 1 mCi of technetium 99m sulfur colloid, and they stood in front of a gamma scintillation camera and were studied for 6 to 10 hours. Solid food passed rapidly from the esophagus through the Roux-Y limb and became uniformly distributed throughout a long segment of the small intestine. Mouth-to-colon transit time was 223 +/- 18 minutes in the control subjects and 298 +/- 37 minutes in the patients with gastrectomy. Small bowel transit of the head of the meal was 187 +/- 19 minutes in the control subjects and 293 +/- 37 minutes in the patients (p less than 0.02). Transit time of the tail of the meal was 175 +/- 26 minutes in the control subjects and 396 +/- 28 minutes in the patients (p less than 0.001). After total gastrectomy and Roux-Y esophagojejunostomy, the proximal jejunum does not act as a reservoir; transit of food through the small intestine is slower than in control subjects, and because the proximal jejunum empties rapidly during eating, a meal of normal size can be consumed. These findings do not support the idea that an artificial gastric reservoir is important after total gastrectomy.

Alkaline reflux gastritis and the effect of biliary diversion on gastric emptying of solid food

We prospectively studied 15 consecutive patients treated for alkaline reflux gastritis to determine the gastric motility pattern associated with this disease and the effects of Roux-Y gastrojejunostomy on gastric emptying. Eleven patients had previous antrectomies (the Billroth I procedure in 4 and the Billroth II procedure in 7), and 4 had previous cholecystectomies. Gastric emptying was measured before and after Roux-Y reconstruction by computer analysis of data from a scintillation camera using technetium 99m tagged chicken liver mixed with beef stew. Gastric emptying was also measured in another 10 patients who had previous Roux-Y gastrojejunostomies and were thought from clinical findings to have gastroparesis. In the patients with alkaline gastritis, before surgery gastric emptying was normal in 25 percent, rapid in 45 percent, and delayed in 30 percent. After Roux-Y reconstruction, the rate of gastric emptying increased in 25 percent of patients, decreased in 45 percent, and did not change in 30 percent. Gastric bezoars developed in half of the patients whose gastric emptying decreased after surgery. There were no technical features of the operations nor mechanical abnormalities of the reconstructions that characterized the patients whose gastric emptying slowed postoperatively. Forty percent of the patients studied only after Roux-Y reconstruction had rapid gastric emptying, 30 percent had normal gastric emptying, and 30 percent had delayed gastric emptying. These data show that patients with alkaline reflux gastritis do not have a single pattern of gastric emptying, and Roux-Y reconstruction has no consistent effect on gastric emptying.

Experience with vagotomy--antrectomy and Roux-en-Y gastrojejunostomy in surgical treatment of duodenal, gastric, and stomal ulcers

Gastroduodenostomy (Billroth I) is our reconstruction of choice following gastric resection for gastroduodenal ulcer. Dissatisfaction with a Billroth II anastomosis has led us in recent years to employ a Roux-en-Y diversion in selected cases, particularly those in which the pathologic state of the pyloroduodenal canal would render a Billroth I anastomosis unsafe. During the past 7 years, truncal vagotomy-antrectomy and Roux-en-Y (VARY) has been carried out in 50 selected patients: duodenal ulcer (DU) 13 patients, gastric ulcer (GU) 11 patients, and stomal ulcer (SU) 26 patients. Fourteen patients (28%) developed postoperative complications, of which nine (18%) were of major degree and five (10%) of a lesser degree. No hospital death occurred among the 50 patients. Five patients (10%) developed postoperative delayed gastric emptying and two of the five required revision of the Roux. Forty-five patients had no clinical problems with delayed emptying. Overall results showed a Visick grading of I in 72%, Visick II in 24%, and Visick III in 4%. Further analysis revealed that of the 13 patients with DU who had VARY, 62% were Visick I, 30% Visick II, and 8% Visick III. The 11 GU patients with VARY were graded Visick I 73% and Visick II 27%. Of 26 patients with SU who underwent VARY, 77% were Visick I, 19% Visick II, and 4% Visick III. Mild to moderate dumping took place in 8% of the 50 patients, mild diarrhea 10%, weight loss 10%, and no patient experienced alkaline reflux gastritis. Long-range postoperative gastric emptying studies among nine patients using a radionuclide revealed varying patterns of emptying. Overall clinical results have been satisfactory and we are continuing to use VARY in selected cases, particularly those in which a Billroth I reconstruction appears contraindicated.

[Ulcer risk in the Roux-Y stomach. An animal experiment study]

The ulcer risk of the Roux-Y anastomosis following gastric resection was analyzed experimentally in 82 rats. After 1/3 gastric resection a Roux-Y gastrojejunostomy with jejunal loops of 3, 6, 9 and 15 cm was performed. 10 months postoperatively a follow-up was performed consisting of endoscopy, measurement of pH-values, analysis of gastric secretion and serum gastrin, gastric emptying tests and histamine stimulation. Endoscopically there was a high rate of stomal ulceration related to the length of the jejunal loop. In long Roux-Y loops (9 and 15 cm), that means under reflux-free conditions, ulcer incidence ranged from 72% to 92%. In short loops with reflux-exposed stomachs the frequency of ulceration was only 9%. With additional histamine stimulation there were stomal ulcers in 100% of the reflux-free animals, but only in 60% of the rats with short Roux-Y loops. In spite of resection acidity was high (pH 1.8) in reflux-free stomachs. Only the volume of gastric secretion and the amount of acid-output was reduced. Gastric acid secretion unbuffered by duodenal content is discussed as the major factor in the etiology of stomal ulcer in reflux-free stomachs. So the Roux-Y anastomosis following gastric resection is a modification of the Mann-Williamson experiment. Therefore reflux-free operations are heavily ulcer prone.

Alterations in gastrointestinal emptying of 99m-technetium-labeled solids following sequential antrectomy, truncal vagotomy and Roux-Y gastroenterostomy

Recent reviews have documented significant delayed gastric emptying following Roux-Y biliary diversion for alkaline gastritis. This study establishes the use of radionuclide imaging in the experimental model and evaluates the following: (1) gastric emptying following antrectomy with and without vagal denervation; (2) the effect of Roux-Y diversion on gastric and upper gastrointestinal emptying using animals as their own controls; and (3) the role of truncal vagotomy in the "Roux-Y delayed emptying syndrome." Upper gastrointestinal emptying was evaluated in 8 dogs using the radionuclide technetium 99 labeled egg white method with continuous visualization by gamma camera. Eight dogs underwent B-II antrectomy without vagotomy and were divided into two groups. Four underwent vagotomy, re-evaluation, and Roux-Y diversion. Four underwent Roux-Y diversion first, re-evaluation, then truncal vagotomy. Control dogs retained 65% +/- 4% (SEM) and 45% +/- 6% of ingested food at 2 and 4 hours, respectively. Following antrectomy only, rapid gastric emptying of radionuclide solid is observed with 35% +/- 7%, 16% +/- 4% and 7% +/- 4% retention and 2, 3, and 4 hours, respectively. Roux-Y antrectomy without vagotomy results in similar rapid gastric emptying. Truncal vagotomy following B-II antrectomy delays gastric emptying compared to antrectomy only. Truncal vagotomy and Roux diversion results in varied patterns of gastrointestinal emptying. Significant gastric retention and gastric and Roux limb retention are observed in 25% of trials. Significant Roux limb retention is observed in 45% of the group. Prior to vagotomy there is no retention or altered transit in the Roux limb. In general, no delay in gastrointestinal emptying is observed in the absence of vagal denervation. These data corroborate our clinical experience in observing both Roux and gastric retention following radionuclide evaluation in Roux-Y patients.

[Ulcer risk caused by reflux prevention? Results of jejunal interposition]

The results of isoperistaltic jejunal interposition in reconstructive ulcer surgery are demonstrated on the basis of 62 patients, operated one and a half to nine years ago. The operations had been done because of dumping, reflux gastritis and afferent loop syndrome. Now 38 (65.5%) of the followed-up patients had a Visick I or II grading, 16 (27.5%) were Visick III. The endoscopical gastric mucosal biopsy showed normal mucosa as well as superficial gastritis or atrophic gastritis in different patients. By comparison with the preoperative biopsies no protective effect of the bile diversion on the gastric mucosa could be demonstrated. On the contrary 12 of 58 patients (20.5%) developed stomal ulcerations, which were often asymptomatic, mostly superficial and in 8 cases had to be operated in the meantime. The gastric acidity analysis showed a low gastric output with low pH values (pH 2.7--3.4). The incidence of stomal ulceration in jejunal interposition seemed to correlate with the reflux preventive effect. The longer the segment and the better the reflux preventive effect were, the higher was the ulcer risk. The parallelity of reflux preventive ulcer surgery and the ulcer provocation by the Mann-Williamson experiment is demonstrated. Therefore reflux preventive surgery should be used very carefully and in reconstructive procedures only. Using the jejunal interposition the segment should not be longer than 12--15 cm and a vagotomy has always to be added.

Diagnosis and treatment of gastric emptying disorders. Clinical usefulness of radionuclide measurements of gastric emptying

We studied 53 patients with severe gastrointestinal symptoms thought to be due to a gastric motility disorder. Sixty-six percent had had a previous operation on the stomach, and 21 percent had insulin-dependent diabetes mellitus. Based on clinical, radiographic, and endoscopic findings, 48 patients were thought to have gastroparesis, 3 were thought to have dumping, and 2 had no diagnosis. Measurement of gastric emptying of solids showed that gastric emptying was normal in 12 patients, rapid in 15 patients, and slow in 26 patients. Further evaluation showed that half of the patients with normal gastric emptying, and one third of those with rapid gastric emptying had other diseases of the gastrointestinal tract that responded well to surgery. Of those patients with dumping, diet modification was effective in 40 percent, and half of those who did not respond to dietary manipulations did well after reoperation. Nineteen patients with delayed gastric emptying were treated with metoclopramide. Sixty percent of those without previous gastric surgery responded, whereas only 25 percent of those with previous gastric surgery had good results. The rate of gastric emptying improved following reoperation in 9 (90 percent) of 10 patients with delayed gastric emptying (4 who had not responded to metoclopramide). Gastric emptying was measured again in 15 patients after treatment. The changes after treatment paralleled the clinical response. These studies indicate that gastroparesis cannot be reliably diagnosed on the basis of clinical findings and standard tests. Gastric emptying studies are essential to diagnose and treat patients thought to have gastric motility disorders, and to evaluate the results of therapy.