Gastric emptying after Roux-Y and Billroth-I gastrectomy depends on viscosity of meal and contractile patterns of small intestine in dogs

Gastrojejunostomy without partial gastrectomy to manage duodenal stenosis in a dog

A nine-year-old female Rottweiler with a history of repeated gastrointestinal ulcerations and three previous surgical interventions related to gastrointestinal ulceration presented with symptoms of anorexia and intermittent vomiting. Benign gastric outflow obstruction was diagnosed in the proximal duodenal area. The initial surgical plan was to perform a pylorectomy with gastroduodenostomy (Billroth I procedure), but owing to substantial scar tissue and adhesions in the area a palliative gastrojejunostomy was performed. This procedure provided a bypass for the gastric contents into the proximal jejunum via the new stoma, yet still allowed bile and pancreatic secretions to flow normally via the patent duodenum. The gastrojejunostomy technique was successful in the surgical management of this case, which involved proximal duodenal stricture in the absence of neoplasia. Regular telephonic followup over the next 12 months confirmed that the patient was doing well.

Risk factors for cholangitis following pancreaticoduodenectomy

AIM: To summarize the diagnosis and treatment for cholangitis following pancreaticoduodenectomy (CFPD) and analyze the related risk factors.

METHODS: The clinical data of 99 cases who underwent pancreaticoduodenectomy (PD) from January 2004 to August 2007 were retrospectively analyzed and 26 of them experienced CFPD. Single-factor analysis was performed on the related risk factors, and the statistic significant difference was re-introduced by non-conditional logistic regression model for multivariate analysis.

RESULTS: The occurrence of CFPD was 26.3% (26/99). Cholangitis was well managed with the treatment of putting catheter in intrahepatic bile duct for continuous low-pressure perfusion and administration of antibiotics and cholagogic drugs. Multi-factor logistic regression analysis showed that there were significant differences in preoperative bile duct diameter, postoperative input loop obstruction and preoperative biliary drainage in CFPD (OR = 0.241, 10.335, 0.102, all P < 0.05). In comparison with PD patients without complications, the duration of hospitalization for the CFPD patients also showed statistically significant difference (Z = -2.947, P < 0.05).

CONCLUSION: The bile duct diameter less than 1.5 cm before operation and postoperative input loop obstruction are the independent risk factors for CFPD occurrence. The preoperative biliary drainage could reduce CFPD occurrence. In comparison with PD patients without complication, the duration of hospitalization for the CFPD patients is remarkably prolonged.

Motility in the Roux-Y limb after distal gastrectomy: relation to the length of the limb and the afferent duodenojejunal segment--an experimental study

Following gastrectomy, the longer is a Roux-Y limb constructed to restore digestive continuity the higher the frequency of postoperative symptoms. The aim of this experimental study was to test how the level of the jejunal transection and the length of the Roux limb affect the motility of the constructed limb and in particular the onset and the propagation of activity fronts (AFs). Three months after a distal Roux-en-Y gastrectomy, electromyographic tracings were recorded in six groups of rats grouped according to the level of the transection (20 or 40 cm from the pylorus) and the length of the limb (10, 20 or 30 cm). Animals in which a simple laparotomy or laparotomy + jejunal transection was performed, served as controls. During the interdigestive period, all animals had AFs in the limb which were independent from those recorded in the duodenum. In the limb, the mean time interval between two AFs was shorter (P < 0.01) and more irregular than in controls. An increase in limb length was associated with a lower incidence of completely propagated AFs (P < 0.05) and a higher incidence of irregularly propagated AFs (P < 0.01). When propagation of the AFs was analysed both in the limb and in the jejunum distal to the anastomosis, propagation abnormalities were more frequent. Below the gastrojejunal anastomosis, for an intestinal length of either 20 or 30 cm, the frequency of abnormal AFs was not different when this length was either only a limb or a limb with the 10 cm of distal jejunum below the jejuno-jejunal anastomosis. Interruption of AFs by a meal was irregular in the limb and more rarely observed in the 30-cm than in 10-cm limbs (P < 0.05). Interruption of AFs was shorter than in controls (P < 0.01). In the duodenum and the jejunum proximal to the limb, the interval between AFs was higher than in controls and in the Roux-Y limbs (P < 0.001). Intraluminal concentrations of bacterial strains were not different in the different types of limb while lactobacillus concentrations and pooled concentrations of bacteria were higher than in controls (P < 0.05). No relationship was found between the incidence of myoelectric abnormalities and intraluminal bacterial concentrations. Increasing the length of a Roux-Y limb resulted in more frequent disturbances in AFs in the limb but had no significant consequence on the overall rate of abnormal AFs in the jejunum distal to the transection. Motor response to food intake was also reduced. Motor changes were not related to intraluminal bacterial concentrations.

Esvaziamento gástrico e jejunal proximal em ratos submetidos ou não à gastrectomia parcial com reconstrução do trânsito intestinal em Y de Roux ou a Billroth II

Estudou-se os efeitos da reconstrução gastrojejunal em Y de ROUX (YR) ou a BILLROTH II (BII) no esvaziamento gástrico (EG) e jejunal proximal de líquido nutriente. Constitui-se quatro grupos de dez ratos Wistar machos: simulado (grupo I), antrectomia em YR (grupo II), gastrectomia subtotal em YR (grupo III) e antrectomia a BII (grupo IV). O EG e jejunal proximal foram avaliados no sétimo dia de pós-operatório, 60 minutos após a introdução gástrica de ovo cru mexido marcado com Tc99m. Após esse tempo, retirou-se separadamente o estômago, intestino proximal e restante do intestino, seguindo-se da quantificação do radioisótopo presente em cada segmento, numa câmara de ionização. O EG foi mais rápido nos animais gastrectomizados do que naqueles sem gastrectomia (α < 0,05). O EG no grupo antrectomia em YR foi mais lento do que no grupo gastrectomia subtotal em YR (α < 0,05), mas não apresentou diferença significante com relação ao grupo antrectomia a BII. O esvaziamento da alça de ROUX (grupos TI e III) não mostrou diferença significante em relação ao da alça eferente de igual comprimento (grupo IV). Concluiu-se que o EG de liquido nutriente foi semelhante na antrectomia em YR ou a BII e que nas reconstruções em YR, foi mais rápido na gastrectomia subtotal do que na antrectomia.

[Stomach emptying after stomach resection with and without retention of duodenal passage]

On domestic pigs 2/3 gastrectomies with retention and elimination of the duodenal passage were carried out. Postprandial gastric emptying was measured scintigraphically for 4 h and compared with a control group (laparotomy only). For the semi-solid, 99mTc-labeled test meal delayed gastric emptying after elimination of the duodenal passage by Roux reconstruction could not be shown. There was no difference in gastric emptying between B-I and Roux-en-Y partial gastrectomy. Also alteration of the length of the jejunum loop from 40 to 20 cm after Roux-en-Y reconstruction had no influence on gastric emptying. Roux reconstruction (40 cm loop) in combination with truncal vagotomy led to a non-uniform gastric emptying, but there was a statistically proven acceleration compared with B-I resection. After 240 min the mean residual intragastric activity of the control group (n = 5) was 47.8%, 78.9% after B-I resection (n = 5), 59% after Roux reconstruction with 40 cm jejunal loop (n = 5), 38.1% after Roux reconstruction with 20 cm jejunal loop (n = 5) and 20.9% after Roux-en-Y (40 cm loop) with truncal vagotomy (n = 4).

[Increased bile acid retention in biliodigestive Roux-Y anastomosis in animal experiment]

In an experimental study on 65 rats the influence of different Roux-Y biliary anastomoses on the enterohepatic bile acid circulation was investigated. Long (10 cm) and short (3 cm) isoperistaltic and long (10 cm) anisoperistaltic Roux-Y loops were studied and compared to sham-operated controls. 75-SeHCAT a y-labeled synthetic bile acid was used for assessment of enterohepatic circulation. Hepatic excretion and enteric bile flow was investigated by 99m-Tc-HIDA. Intestinal transit time was evaluated by 51-Cr-EDTA an inert marker of intestinal contents. Animals with biliary anastomoses showed an increased retention of the synthetic bile acid 75-SeHCAT compared to the controls. Highest retention values were found in animals with anisoperistaltic loops (t1/2 = 98.6 h). Isoperistaltic loops showed uniform values independently of the length of the Roux-limb (t1/2 = 59.8 h resp. 59.3 h). Differences to the controls (t1/2 = 42.6 h) were highly significant (p less than 0.001). In the 99m-Tc-HIDA hepatic excretion into the connected small bowel was normal in all groups. But in rats with biliary anastomoses a marked stasis of the 99m-Tc-HIDA in the Roux-Y loop was apparent. Bowel transit time tested by 51-Cr-EDTA showed comparable results in all groups without significant differences. The results demonstrate an increased bile acid retention in Roux-Y biliary anastomoses. An alteration of the enterohepatic circulation due to stasis in the Roux-Y limb seems to be the underlying mechanism.

Bile acid retention after Roux-en-Y biliary reconstruction demonstrated by tauro-23-(75Se)selena-25-homocholic acid. An experimental animal study

In this study of 65 laboratory rats the influence of biliary Roux-en-Y anastomosis on the enterohepatic circulation was investigated. Three different types of Roux-en-Y limbs were studied and compared with sham-operated controls. To collect information about the influence of the length and motility of the Roux limb, 10-cm and 3-cm isoperistaltic Roux segments and 10-cm anisoperistaltic Roux limbs were investigated. 75SeHCAT, a tau-labelled synthetic bile acid, was used for assessment of enterohepatic circulation. Intestinal transit time was evaluated by measuring the decrease of whole-body counts of 51Cr-labelled ethylenediamintetraacetic acid (EDTA), an inert marker of intraluminal contents. 99mTc-labelled dimethyl-iminodiacetic acid (HIDA) was used to detect possible alterations of bile flow. 75SeHCAT results showed marked retention of bile acids in all Roux-en-Y animals compared with controls. Results of short and long Roux limbs did not differ significantly from each other (t1/2 10 cm, 59.8 h; 3 cm, 59.3 h; control, 42.6 h; p less than or equal to 0.001). The anisoperistaltic Roux limbs showed prolonged retention even when compared with isoperistaltic limbs (t1/2 98.6 h; p less than or equal to 0.001). 51Cr-EDTA results did not show significant differences between all groups. 99mTc-HIDA showed undelayed excretion in all animals but increase of radioactivity at the site of the Roux-en-Y enteroanastomosis, indicating marked stasis in the biliodigestive Roux limb. The results demonstrate the impact of biliary Roux-en-Y anastomosis on bile acid retention due to stasis in the defunctioning jejunal segment.

Gastrointestinal motility and gastric emptying after Billroth II gastrectomy in dogs

This study was undertaken to compare the effects of subtotal Billroth II gastrectomy on gastric emptying and gastrointestinal motility with previously published results in intact dogs and in dogs with subtotal Roux-Y gastrectomy. Extraluminal strain gauge transducers were used to study gastrointestinal motility after Billroth II gastrectomy in four conscious dogs. Gastric emptying was measured radiographically. In Billroth II dogs gastric emptying of low-viscosity meals was biphasic with an initial rapid emptying. The addition of nutrients to low-viscosity meals delayed gastric emptying accompanied with reduction in gastric and jejunal motility. Similar to that in Roux-Y dogs, gastric emptying of noncaloric medium-viscosity meals was delayed because of segmenting motor patterns of the jejunal loops, in contrast to the propulsive jejunal motor pattern in intact dogs. Nutrients added to medium-viscosity meals did not change the jejunal motor pattern; gastric emptying was delayed compared with intact dogs. Results show that meal viscosity and jejunal motor pattern influence gastric emptying after Billroth II gastrectomy.

The use of complex carbohydrates in barley groats for determination of the mouth-to-caecum transit time

Lactulose is often used as a substrate to estimate the mouth-to-caecum transit time (MCTT), but because of osmotic effects the outcome depends on the dose consumed. In this study, barley groats, a complex carbohydrate (CH) that produces a clear breath hydrogen response after consumption, were used. Eight volunteers consumed the same dose of softened barley groats (1.0 g CH/kg body weight) three times. Ten volunteers ate three different doses (0.75, 1.0, and 1.5 g CH/kg body weight). Breath samples were collected every 30 or 60 min for at least 12.5 h and analysed for hydrogen. To study the effect of the particle size of the barley groats or the addition of fat on the MCTT, 11 volunteers consumed barley groats (1.0 g CH/kg body weight) with cream cheese (0.25 g fat/kg body weight) and 5 volunteers ate crushed barley groats (particles of +/- 1 mm, 1.0 g CH/kg body weight). After consumption of 1.0 g CH/kg body weight a mean MCTT of 8.4 +/- 0.4 h was found. After consumption of the high dose, a mean MCTT of 9.0 +/- 0.5 h was found, and after the low dose, 8.5 +/- 0.6 h. Addition of fat resulted in a significantly increased MCTT, presumably caused by retarded stomach emptying (9.2 +/- 0.6 h versus 8.1 +/- 0.5 h in controls). Particle size did not significantly affect the MCTT (7.2 +/- 0.5 h at 1 mm versus 7.8 +/- 0.6 h at normal particle size).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of various prokinetic agents on post Roux-en-Y gastric emptying. Experimental and clinical observations

The effect of various prokinetic drugs was assessed in animals with Roux-en-Y gastrojejunostomy. The agents tested were (1) bethanechol 2.5 mg subcutaneously at 0 min and 30 min postprandially (pp); (2) metoclopramide 20 mg intravenous bolus at 0 min pp; (3) a combination of 1 and 2; (4) oxytocin 5 mg intramuscularly at 0 min and 240 min pp; (5) motilin at 100 ng/kg/hr; or (6) 300 ng/kg/hr continuous intravenous infusion from 0 to 270 min pp. Only bethanechol administration resulted in significantly less gastric retention (65 +/- 6% vs 32 +/- 5% retention at 5 hr). (P less than 0.002). The animal results with parenteral bethanechol were confirmed in humans with chronic delayed gastric emptying following Roux-en-Y gastrojejunostomy, with a decrease in gastric retention on radionuclide scan from 78.5 +/- 5% to 26 +/- 12% at 2 hr pp (P less than 0.01). Initially all patients responded with symptomatic improvement. However, subsequently 3/6 (50%) of patients required total or near total gastrectomy for recurrent symptoms of gastric stasis. Nevertheless, 2/6 (33%) of patients have no further evidence of gastric stasis, and a trial of bethanechol is recommended prior to considering further gastrectomy in patients with the Roux-stasis syndrome.

Canine motility and gastric emptying after subtotal gastrectomy

The aim of the present study was to elucidate factors influencing gastric emptying in dogs after a two-thirds distal gastrectomy with either Roux-Y or Billroth I reconstruction. The effects of a medium-viscosity nutrient meal on gastrointestinal motility and gastric emptying were investigated. Motility was recorded with long-term implanted extraluminal strain gauge force transducers; gastric emptying was measured radiographically. Gastric emptying after Roux-Y gastrectomy was almost linear and not different from that in intact control dogs. In contrast to Roux-Y gastrectomy, emptying after Billroth I gastrectomy was initially accelerated and followed by a slow emptying phase. During the initial period, the segmenting activity of the Roux-Y limb significantly differed from the propulsive contractile pattern of the duodenum after Billroth I reconstruction. Force and frequency of gastrointestinal contractions were equivalent after both reconstruction procedures. Results indicate that after subtotal gastrectomy, the intestinal contractile patterns are important determinants of gastric emptying. They are the main causes for the different emptying patterns of viscous nutrient meals.

Effects of nutrients on gastrointestinal motility and gastric emptying after Billroth-I gastrectomy in dogs

We wanted to clarify the way in which nutrients influence gastrointestinal motility and gastric emptying following distal gastrectomy with Billroth-I gastroduodenostomy. Four gastrectomized dogs were equipped with extraluminal strain gauge transducers. Gastric emptying was measured radiographically. Four intact dogs were used as controls for emptying studies. Following gastrectomy, gastric emptying of both acaloric and nutrient meals was rapid in the initial period of the experiments. Gastric outflow was supported by propagating duodenal contractions. Compared with control dogs, the early emptying of nutrient meals was accelerated. In the following period, nutrients markedly slowed gastric emptying compared with acaloric meals due to a segmenting contractile pattern of the duodenum and a significant diminution of gastrointestinal motility. Results suggest that after Billroth-I gastrectomy (1) the control of gastric emptying by nutrients acts too late to slow the initial enhanced gastric outflow, and (2) the duodenal contractile patterns influence gastric emptying.

Clinical and radionuclide evaluation of Roux-Y diversion for postgastrectomy dumping

From 1973 to 1986, 22 patients underwent Roux-Y gastrojejunostomy for the early postgastrectomy dumping syndrome. In the early years, five patients underwent Roux-Y conversion with the addition of a 10 cm antiperistaltic jejunal segment interposed between the Roux-Y limb and the stomach. Within 4 years, all five patients had the jejunal segment removed due to severe symptoms of gastric retention. These patients underwent reconstruction to create Roux-Y limb only and joined the pool of 17 patients who underwent Roux-Y diversion only for the dumping syndrome. Overall, 19 of 22 patients (86 percent) had almost complete resolution of their dumping symptoms on long-term follow-up. Three patients showed no improvement, two with severe gastric retention and one with recurrent dumping symptoms. Overall, 5 of 22 patients (23 percent) had moderate to severe early and late postoperative gastric retention necessitating medical treatment in three and subsequent near-total gastrectomy in two. Although other procedures such as pyloric reconstruction or the addition of isoperistaltic or antiperistaltic jejunal interpositions have been reported to be equally successful in delaying gastric emptying and resolving dumping symptoms, we have preferred Roux-Y diversion for the treatment of combined alkaline reflux gastritis and dumping or the pure early vasomotor postgastrectomy dumping syndrome. As reported, we have abandoned the use of an antiperistaltic jejunal segment interposed between the stomach and the Roux-Y limb due to the high rate of postoperative gastric retention.

[Recurrent gastroduodenal ulcer: controversies in primary and secondary interventions]

Today controversial points of view in ulcer surgery are related to operative tactics. In principal resective and non-resective procedures and the type of anastomosis are discussed. Physiopathological criteria for decision are the effects on acid reduction, motility, intestinal acid exposure and entero-gastric reflux. Therapeutic security and the frequency of side effects are determined by these parameters. Postpyloric ulcer remains the domain of vagotomy. Gastric ulcers should be resected or treated by a combined procedure. In reconstructing the gastrointestinal tract the dualism of residual acid and postresectional reflux must be taken into account.

Effects of nutrients on gastrointestinal motility and gastric emptying after distal gastrectomy with Roux-Y gastrojejunostomy in dogs

The aim of the study was to clarify whether nutrients are still capable of slowing gastric emptying following Roux-Y gastrectomy, as in normal dogs. Gastrointestinal motility and gastric emptying of acaloric and nutritive meals with different viscosities were measured in normal dogs and after a two-thirds Roux-Y gastrectomy. In gastrectomized dogs low-viscosity nutritive meals emptied unduly rapidly in an initial phase, although the frequency and spread of contractions, ie, the propulsive activity of the jejunal Roux limb were diminished. A slow emptying rate during the following period was due to a long-lasting inhibition of gastric and jejunal motility. Medium-viscosity nutritive meals emptied in gastrectomized dogs as slowly as in normal animals, but this effect was primarily caused by the meal viscosity and only secondarily by the nutrients. It is concluded that following Roux-Y gastrectomy a regulation of gastric emptying is preserved; however, the onset of an effective control is delayed, resulting in a rapid initial emptying of low-viscosity meals.