Measurement of duodenogastric reflux with 99mTc-HIDA in duodenal ulcer patients

Complications of gastric bypass: avoiding the Roux-en-O configuration

BACKGROUND

Atypical complications of gastric bypass surgery include the Roux-en-O configuration: an improper connection of the bilio-pancreatic limb to the gastric pouch.

METHODS

Four cases of Roux-en-O, which occurred at institutions not affiliated with the authors, were reviewed for issues related to causation and patient outcomes.

RESULTS

One case was diagnosed intraoperatively (patient 1), while the time of diagnosis in the remaining three patients was postoperative days 2, 52, and 230 (patients 2-4). The delay resulted in two computed tomography scans, two endoscopies, and four contrast studies per patient. These patients presented with protracted biliary emesis and a clinical picture of bowel obstruction. Irrespective of time to diagnosis, all patients endured significant postoperative sequelae-numerous surgeries (n=10, 3, 1, and 3, respectively) and increased length of stay (97, 86, 49, and 125 days, respectively). Patients 2 and 3 were diagnosed by repeat laparotomy, and patient 4 was diagnosed by HIDA scan.

CONCLUSIONS

Nevertheless, surgery remains the most effective means by which to diagnose the problem, as well as correct the complication. Maneuvers that should be employed to prevent this rare complication include keeping the bilio-pancreatic limb short, identifying the ligament of Treitz and marking the Roux limb shortly after jejunal transection.

Duodenogastric bile reflux before and after selective proximal vagotomy with and without pyloroplasty

Duodenogastric bile reflux was determined by nasogastric aspiration in 60 patients with prepyloric, pyloric, or duodenal ulcer before and after selective proximal vagotomy (SPV) or SPV and pyloroplasty (PP). All patients underwent two aspiration tests before and 3 months, 1 year, and 3 years after operation. The highest 1-h output of bile acids was recorded, and 100 mumol x h-1 or more was considered a positive reflux test. Sixteen patients (27%) had positive tests before operation; seven of them had previously been cholecystectomized. Forty-four patients (73%) had negative tests preoperatively; one had been cholecystectomized. Of 43 non-reflux patients without previous cholecystectomy 21 were randomized to SPV and 22 to SPV + PP. Sixteen patients (76%) remained negative after SPV, and 19 of 22 (86%) after SPV + PP. The incidence of negative bile reflux before and after SPV or SPV + PP did not differ. Cholecystectomized patients had a high incidence of bile reflux before (seven of eight) and after (six of eight) SPV or SPV + PP. It is concluded that neither SPV nor PP causes bile reflux.