Postoperative results of distal partial gastrectomy, selective vagotomy plus antrectomy, and selective proximal vagotomy for duodenal ulcers

Reflux esophagitis in patients with partial gastrectomy and Billroth I or II reconstruction

BACKGROUND

Data on the occurrence of reflux esophagitis and Barrett's esophagus in patients with Billroth I or II resection is sparse. For this reason a cross-sectional study was done in order to assess reflux disease in Billroth resection.

METHODS

Consecutive patients were included in the study. Coincidental pathology (hiatus hernia, ulcer, esophagitis, and cancer) was noted.

RESULTS

Over a period of 12 years, 370 consecutive patients with a partial gastrectomy were seen (268 Billroth II, 102 Billroth I) and three groups of patients were identified. Group 1 included 64 patients (17%) with a hiatus hernia; group 2, 16 patients (4%) with reflux esophagitis; and group 3, 290 patients (78%) with only a Billroth resection. Reflux disease occurred significantly more often in men than in women (7.5% vs. 2%, p<0.05). There was no difference in type of resection or in the presence of reflux esophagitis. Four patients had an esophageal cancer (only one adenocarcinoma).

CONCLUSION

Only a minority of patients with partial gastrectomy has signs of esophagitis in the long term.

Postgastrectomy syndromes

Anatomic and physiological changes introduced by gastric surgery result in postgastrectomy syndromes in approximately 20% of patients. Most of these disorders are caused by operation-induced abnormalities in the motor functions of the stomach, including disturbances in the gastric reservoir function, the mechanical-digestive function, and the transporting function. Division of the vagal innervation to the stomach and ablation or bypass of the pylorus are the most significant factors contributing to postgastrectomy syndromes. Either rapid or slow emptying may result, depending on the relative importance of lack of a compliant gastric reservoir, loss of an effective contractile force, and loss of controlling factors that slow or speed gastric emptying and result in duodenal-gastric reflux. Clearly defining which syndrome is present in a given patient is critical to developing a rational treatment plan. In syndromes with slow gastric emptying, bilious vomiting, or alkaline reflux gastritis, the use of endoscopy is essential to rule out mechanical causes of the syndrome. Contrast radiography and scintigraphic gastric emptying studies are useful to document rapid or delayed gastric emptying. Postgastrectomy syndromes often abate with time. Conservative measures, including medical, dietary, and behavioral therapy, should be given at least a 1-year trial. If these nonoperative measures fail, surgical therapy is recommended. The Roux-en-Y gastrojejunostomy is useful for patients with dumping, because it slows gastric emptying and the transit of chyme through the Roux limb. The same operation helps patients with alkaline reflux gastritis, because it diverts pancreaticobiliary secretions away from the gastric remnant. Near-total gastrectomy, which reduces the size of a flaccid gastric reservoir, can be used to treat delayed gastric emptying. This operation should be combined with the Roux procedure to prevent postoperative reflux gastritis and esophagitis. Newer techniques, such as gastrointestinal pacing and the uncut Roux operation, may improve the treatment of the postgastrectomy syndromes in the future.