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Migrating contractions of the afferent and Roux limbs show peristaltic movement independently of each other in conscious dogs after Roux-en-Y reconstruction after distal gastrectomy. Surg Today 2020; 51:391-396. [PMID: 32926235 DOI: 10.1007/s00595-020-02139-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/20/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE The Roux-en-Y (RY) procedure is used frequently for surgical reconstruction after gastrectomy. However, a minority of patients suffer a serious motility disorder of the Roux and afferent limb postoperatively. We conducted this study to clarify the association between the motility and peristaltic direction of two limbs in conscious dogs. METHODS We performed distal gastrectomy on five dogs and implanted seven force transducers on the serosal surfaces of the remnant gastric body and afferent and Roux limbs. We then analyzed the electric signals from these force transducers. RESULTS Migrating contractions were observed in the two limbs, but not in the gastric remnant body. Migrating contractions in the forward direction propagated independently from the most proximal side in each limb. There was no propagation of contraction across the jejunojejunostomy between the two limbs. CONCLUSIONS Each proximal part of the Roux and afferent limbs has an independent motility pacemaker in conscious dogs after gastrectomy with RY reconstruction.
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Wang THH, Angeli TR, Beban G, Du P, Bianco F, Gibbons SJ, Windsor JA, Cheng LK, O’Grady G. Slow-wave coupling across a gastroduodenal anastomosis as a mechanism for postsurgical gastric dysfunction: evidence for a "gastrointestinal aberrant pathway". Am J Physiol Gastrointest Liver Physiol 2019; 317:G141-G146. [PMID: 31169993 PMCID: PMC6734376 DOI: 10.1152/ajpgi.00002.2019] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Postsurgical gastric dysfunction is common, but the mechanisms are varied and poorly understood. The pylorus normally acts as an electrical barrier isolating gastric and intestinal slow waves. In this report, we present an aberrant electrical conduction pathway arising between the stomach and small intestine, following pyloric excision and surgical anastomosis, as a novel disease mechanism. A patient was referred with postsurgical gastroparesis following antrectomy, gastroduodenostomy, and vagotomy for peptic ulceration. Scintigraphy confirmed markedly abnormal 4-h gastric retention. Symptoms included nausea, vomiting, postprandial distress, and reflux. Intraoperative, high-resolution electrical mapping was performed across the anastomosis immediately before revision gastrectomy, and the resected anastomosis underwent immunohistochemistry for interstitial cells of Cajal. Mapping revealed continuous, stable abnormal retrograde slow-wave propagation through the anastomosis, with slow conduction occurring at the scar (4.0 ± 0.1 cycles/min; 2.5 ± 0.6 mm/s; 0.26 ± 0.15 mV). Stable abnormal retrograde propagation continued into the gastric corpus with tachygastria (3.9 ± 0.2 cycles/min; 1.6 ± 0.5 mm/s; 0.19 ± 0.12 mV). Histology confirmed ingrowth of atypical ICC through the scar, defining an aberrant pathway enabling transanastomotic electrical conduction. In conclusion, a "gastrointestinal aberrant pathway" is presented as a novel proposed cause of postsurgical gastric dysfunction. The importance of aberrant anastomotic conduction in acute and long-term surgical recovery warrants further investigation.NEW & NOTEWORTHY High-resolution gastric electrical mapping was performed during revisional surgery in a patient with severe gastric dysfunction following antrectomy and gastroduodenostomy. The results revealed continuous propagation of slow waves from the duodenum to the stomach, through the old anastomotic scar, and resulting in retrograde-propagating tachygastria. Histology showed atypical interstitial cells of Cajal growth through the anastomotic scar. Based on these results, we propose a "gastrointestinal aberrant pathway" as a mechanism for postsurgical gastric dysfunction.
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Affiliation(s)
- Tim H.-H. Wang
- 1Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Timothy R. Angeli
- 2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Grant Beban
- 3Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Peng Du
- 2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Francesca Bianco
- 4Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota,5Departments of Medical and Surgical Sciences (DIMEC) and Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Simon J. Gibbons
- 4Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota
| | - John A. Windsor
- 1Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Leo K. Cheng
- 2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand,6Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Gregory O’Grady
- 1Department of Surgery, University of Auckland, Auckland, New Zealand,2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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Abstract
Postgastrectomy syndromes result from altered form and function of the stomach. Gastrectomy disrupts reservoir capacity, mechanical digestion and gastric emptying. Early recognition of symptoms with prompt evaluation and treatment is essential. Many syndromes resolve with minimal intervention or dietary modifications. Re-operation is not common but often warranted for afferent and efferent loop syndromes and bile reflux gastritis. Preoperative nutritional assessment and treatment of common vitamin and mineral deficiencies after gastrectomy can reduce the incidence of chronic complications. An integrated team approach to risk assessment, patient education, and postoperative management is critical to optimal care of patients with gastric cancer.
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Abstract
A 31-year-old woman who had successfully undergone bariatric surgery (gastric bypass with Roux-en-Y anastamosis) three years earlier presented with complaints of acute epigastric abdominal pain, nausea, and vomiting. Computed tomography (CT) showed small bowel intussusception, and the patient was taken to the operating room. A mass the size and shape of a football was found; the mass consisted of the proximal limb of the Roux-en-Y intussuscepted in a retrograde manner. The bowel was gently reduced, deemed viable, and the Roux-en-Y anastamosis was revised with resection of the lead point. We urge the surgeon to be highly suspicious of acute bowel obstruction in the post-bariatric surgery population and believe that CT is essential in evaluating these patients. We further recommend resection of the lead point to avoid repeat bouts of intussusception from the same focal etiology.
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Nel JJ, du Plessis CJ, Coetzee GL. Gastrojejunostomy without partial gastrectomy to manage duodenal stenosis in a dog. J S Afr Vet Assoc 2015; 86:1285. [PMID: 26824343 PMCID: PMC6138148 DOI: 10.4102/jsava.v86i1.1285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 06/05/2015] [Accepted: 07/20/2015] [Indexed: 11/02/2022] Open
Abstract
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.
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Affiliation(s)
- Johannes J Nel
- Department of Companion Animal Clinical Studies, University of Pretoria.
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Kim TG, Hur H, Ahn CW, Xuan Y, Cho YK, Han SU. Efficacy of Roux-en-Y Reconstruction Using Two Circular Staplers after Subtotal Gastrectomy: Results from a Pilot Study Comparing with Billroth-I Reconstruction. J Gastric Cancer 2011; 11:219-24. [PMID: 22324013 PMCID: PMC3273692 DOI: 10.5230/jgc.2011.11.4.219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Revised: 10/11/2011] [Accepted: 10/12/2011] [Indexed: 01/11/2023] Open
Abstract
Purpose The Roux en Y method has rarely been performed due to longer operation time and high risk of complication, despite several merits including prevention of bile reflux. We conducted a retrospective review of the result of Roux en Y reconstruction using two circular staplers after subtotal gastrectomy. Materials and Methods From December 2008 to May 2009, a total of 26 patients underwent Roux en Y reconstruction using two circular staplers after subtotal gastrectomy, and seventy-two patients underwent Billroth-I reconstruction. Roux en Y anastomosis was performed using two circular staplers without hand sewing anastomosis. We compared clinicopathologic features and surgical outcomes between the two groups. All patients underwent gastrofiberscopy between six and twelve months after surgery to compare the bile reflux. Results No significant differences in clinicopathologic findings were observed between the two groups, except for the rate of minimal invasive surgery (P=0.004) and cancer stage (P=0.002). No differences in the rate of morbidity (P=0.353) and admission duration (P=0.391) were observed between the two groups. Gastrofiberscopic findings showed a significant reduction of bile reflux in the remnant stomach in the Roux en Y group (P=0.019). Conclusions When compared with Billroth-I reconstruction, Roux en Y reconstruction using the double stapler technique was found to reduce bile reflux in the remnant stomach without increasing postoperative morbidity. Based on these results, we planned to begin a randomized controlled clinical trial for comparison of Roux en Y reconstruction using this method with Billroth-I anastomosis.
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Affiliation(s)
- Tae Gyun Kim
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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Tack J, Arts J, Caenepeel P, De Wulf D, Bisschops R. Pathophysiology, diagnosis and management of postoperative dumping syndrome. Nat Rev Gastroenterol Hepatol 2009; 6:583-90. [PMID: 19724252 DOI: 10.1038/nrgastro.2009.148] [Citation(s) in RCA: 217] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Dumping syndrome is a frequent complication of esophageal, gastric or bariatric surgery. Rapid gastric emptying, with the delivery to the small intestine of a significant proportion of solid food as large particles that are difficult to digest, is a key event in the pathogenesis of this syndrome. This occurrence causes a shift of fluid from the intravascular component to the intestinal lumen, which results in cardiovascular symptoms, release of several gastrointestinal and pancreatic hormones and late postprandial hypoglycemia. Early dumping symptoms comprise both gastrointestinal and vasomotor symptoms. Late dumping symptoms are the result of reactive hypoglycemia. Besides the assessment of clinical alertness and endoscopic or radiological imaging, a modified oral glucose tolerance test might help to establish a diagnosis. The first step in treating dumping syndrome is the introduction of dietary measures. Acarbose can be added to these measures for patients with hypoglycemia, whereas several studies advocate guar gum or pectin to slow gastric emptying. Somatostatin analogs are the most effective medical therapy for dumping syndrome, and a slow-release preparation is the treatment of choice. In patients with treatment-refractory dumping syndrome, surgical reintervention or continuous enteral feeding can be considered, but the outcomes of such approaches are variable.
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Affiliation(s)
- Jan Tack
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium.
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Retrograde intussusception after Roux-en-Y gastric bypass for morbid obesity. Obes Surg 2008; 19:381-4. [PMID: 19067088 DOI: 10.1007/s11695-008-9775-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Accepted: 11/19/2008] [Indexed: 10/21/2022]
Abstract
Intussusception after Roux-en-Y gastric bypass procedure (RYGBP) is a rare complication that typically presents late after open or laparoscopic procedures with intermittent partial or complete bowel obstruction. It may be antegrade (peristaltic) or retrograde (antiperistaltic) and usually the common channel is affected. We describe an unusual case of retrograde intussusception that occurred 2 years after a laparoscopic RYGBP in which the proximal common channel had invaginated into the distal anastomotic site and the distal Roux limb.
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Chaiyasate K, Jacobs M, Brooks SE, del Rosario G, Andrus L, Kestenberg W, Mittal V. The uncut Roux-en-Y with jejunal pouch: a new reconstruction technique for total gastrectomy. Surgery 2007; 142:33-9. [PMID: 17629998 DOI: 10.1016/j.surg.2007.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2006] [Revised: 03/01/2007] [Accepted: 03/03/2007] [Indexed: 01/01/2023]
Abstract
BACKGROUND Roux Stasis Syndrome is a well-known complication after Roux-en-Y reconstruction. It has been hypothesized that reconstruction with an uncut Roux limb and jejunal pouch after total gastrectomy would preserve unidirectional intestinal myoelectrical activity, improve postoperative weight gain and nutritional parameters, and diminish Roux Stasis Syndrome in canines. METHODS A total gastrectomy was performed, and 2 methods were used for reconstruction: Roux-en-Y esophagojejunostomy (RY) was performed on 5 canines (control), and the uncut Roux-en-Y with a jejunal pouch (URYJP) was performed on 5 other canines (experimental). The canines were monitored for 10 weeks postoperatively. Serial weight and nutritional parameters were measured. Emptying profiles and motility studies were performed in the fasting and postprandial states. RESULTS Ten weeks after operation, the URYJP group had significantly improved nutritional parameters, including weight, total protein, albumin, hemoglobin, serum total iron binding capacity, and serum IgA, IgG, and IgM. The emptying times for both groups were similar, with an increase of disordered propagation of the jejunal pacesetter potential in the RY group. The aboral propagation occurred more frequently in the URYJP group during fasting and after feeding (98% +/- 1% vs 39% +/- 16%; P = .02, and 99% +/- 1% vs 43% +/- 18%; P = .03). The sites of luminal occlusions were intact in the URYJP group at 10 weeks. CONCLUSIONS The combination of jejunal pouch and uncut Roux limb improved overall nutritional parameters when compared with the traditional Roux-en-Y, while preserving aboral propagation of jejunal pacesetter potentials.
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Affiliation(s)
- Kongkrit Chaiyasate
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, MI 48075, USA.
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Mabrut JY, Collard JM, Baulieux J. Le reflux biliaire duodéno-gastrique et gastro-œsophagien. ACTA ACUST UNITED AC 2006; 143:355-65. [PMID: 17285081 DOI: 10.1016/s0021-7697(06)73717-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This study reviews current data regarding duodenogastric and gastroesophageal bile reflux-pathophysiology, clinical presentation, methods of diagnosis (namely, 24-hour intraluminal bile monitoring) and therapeutic management. Duodenogastric reflux (DGR) consists of retrograde passage of alkaline duodenal contents into the stomach; it may occur due to antroduodenal motility disorder (primary DGR) or may arise following surgical alteration of gastoduodenal anatomy or because of biliary pathology (secondary DGR). Pathologic DGR may generate symptoms of epigastric pain, nausea, and bilious vomiting. In patients with concomitant gastroesophageal reflux, the backwash of duodenal content into the lower esophagus can cause mixed (alkaline and acid) reflux esophagitis, and lead, in turn, to esophageal mucosal damage such as Barrett's metaplasia and adenocarcinoma. The treatment of DGR is difficult, non-specific, and relatively ineffective in controlling symptoms. Proton pump inhibitors decrease the upstream effects of DGR on the esophagus by decreasing the volume of secretions; promotility agents diminish gastric exposure to duodenal secretions by improving gastric emptying. In patients with severe reflux resistant to medical therapy, a duodenal diversion operation such as the duodenal switch procedure may be indicated.
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Affiliation(s)
- J Y Mabrut
- Service de Chirurgie Générale, Digestive et de Transplantation Hépatique, Hôpital de la Croix-Rousse - Lyon.
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Goverman J, Greenwald M, Gellman L, Gadaleta D. Antiperistaltic (Retrograde) Intussusception after Roux-en-Y Gastric Bypass. Am Surg 2004. [DOI: 10.1177/000313480407000116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Adult intussusception has been described after various types of gastrointestinal surgery. In some instances there may be intussusception of the jejunum into the stomach via a gastrointestinal stoma, a rare complication known as jejunogastric intussusception (JGI). We present a retrospective review of two cases of retrograde intussusception occurring years after open Roux- en-Y gastric bypass (RYGB) for morbid obesity. To our knowledge there have been no documented reports of JGI occurring after RYGB and only scattered reports of JGI after Roux-en-Y reconstruction in general. Two reports of intussusception following RYGB were identified in the English literature and comprised three patients, only one of whom suffered a retrograde intussusception. As the number of RYGB procedures continues to rise, we will likely see more of this entity; and it is therefore crucial that surgeons consider acute and chronic intussusception as a cause of abdominal pain in patients who have undergone RYGB.
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Affiliation(s)
- Jeremy Goverman
- From the Department of Surgery, North Shore Long Island Jewish Health Care System, North Shore University Hospital, Manhasset, New York
| | - Marc Greenwald
- From the Department of Surgery, North Shore Long Island Jewish Health Care System, North Shore University Hospital, Manhasset, New York
| | - Larry Gellman
- From the Department of Surgery, North Shore Long Island Jewish Health Care System, North Shore University Hospital, Manhasset, New York
| | - Dominick Gadaleta
- From the Department of Surgery, North Shore Long Island Jewish Health Care System, North Shore University Hospital, Manhasset, New York
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Forstner-Barthell AW, Murr MM, Nitecki S, Camilleri M, Prather CM, Kelly KA, Sarr MG. Near-total completion gastrectomy for severe postvagotomy gastric stasis: analysis of early and long-term results in 62 patients. J Gastrointest Surg 1999; 3:15-21, discussion 21-3. [PMID: 10457319 DOI: 10.1016/s1091-255x(99)80003-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aim of this study was to evaluate results of completion gastrectomy for severe postgastrectomy gastric stasis. A total of 51 women and 11 men underwent completion gastrectomy for gastric stasis between 1985 and 1996; follow-up was complete in 98% at 5.4 +/- 5 years. All patients had modified Visick scores preoperatively of grade III (37%) or IV (63%). Presentation included combinations of nausea, vomiting, postprandial pain, chronic abdominal pain, and chronic narcotic use. All had undergone prior vagotomy and had a median of four previous gastric operations. Hospital mortality was zero. Complications occurred in 25 patients (40%) and included the following: narcotic withdrawal syndrome (18%), ileus (10%), wound infection (5%), intestinal obstruction (2%), and anastomotic leak (5%). All or most symptoms were relieved in 43% (Visick grade I or II), but 57% of the patients remained in Visick grade III or IV. Nausea, vomiting, and postprandial pain were reduced from 93% to 50%, 79% to 30%, and 58% to 30%, respectively (P<0.05), but chronic pain, diarrhea, and dumping syndrome were not significantly affected. Univariate analysis revealed no preoperative characteristic to be predictive of good outcome. Logistic regression analysis suggested that the combination of nausea, need for total parenteral nutrition, and retained food in the stomach predicted a poor outcome (P<0.05). Completion gastrectomy is successful in 43% of patients. The combination of nausea, need for total parenteral nutrition, and retained food at endoscopy are negative prognostic factors.
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Takahashi M, Tu BL, Leombruni E, Kelly KA. Use of an ileal Roux limb to prevent the Roux stasis syndrome. J Gastrointest Surg 1997; 1:545-53. [PMID: 9834390 DOI: 10.1016/s1091-255x(97)80071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aim of this study was to determine whether the use of an ileal Roux limb, rather than a jejunal Roux limb, would prevent the Roux stasis syndrome that can occur after Roux gastrectomy. An ileal Roux limb was constructed in eight dogs and anastomosed to the gastric remnant after distal hemigastrectomy. Flow of chyme through the jejunum was preserved via an ileojejunostomy and a jejunoileostomy. Six dogs with distal gastrectomy and a conventional Roux gastrojejunostomy served as a control group. Chronic enteric recording electrodes and intraluminal, open-tipped pressure catheters were implanted in all dogs. After recovery, the electrical activity and motility of the Roux limbs and the rates of gastric emptying of liquids and solids were measured. Dogs with a Roux gastroileostomy had a slower frequency of pacesetter potentials in the Roux limb, a greater Roux motility index, and a faster rate of gastric emptying of liquids and solids than did dogs with a Roux gastrojejunostomy. Stomal ulcers, however, developed in seven of the eight ileal Roux limbs but in none of the jejunal Roux limbs. It was concluded that Roux gastroileostomy does ameliorate the Roux stasis syndrome, but there is a greater risk of stomal ulceration in the limb.
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Affiliation(s)
- M Takahashi
- Department of Surgery, Mayo Clinic Scottsdale, Scottsdale, AZ 85259, USA
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Garani FJ, Novo NF, Juliano Y, Fagundes DJ. 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. Acta Cir Bras 1997. [DOI: 10.1590/s0102-86501997000100008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Cheng G, Hocking MP, Vogel SB, Sninsky CA. The effect of Roux-en-Y diversion on gastric and Roux-limb emptying in a rodent model. Am J Surg 1995; 169:618-21. [PMID: 7771628 DOI: 10.1016/s0002-9610(99)80233-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The "Roux stasis syndrome" is characterized by symptoms of upper gut stasis following Roux-en-Y gastrojejunostomy (RG). Whether symptoms result from delayed gastric emptying, altered Roux-limb transit, or both has never been settled, partly because of the difficulty of measuring Roux-limb transit. The aim of this study was to develop a model to simultaneously quantitate Roux-limb transit and gastric emptying. METHODS Rats underwent vagotomy and antrectomy with RG or Billroth II reconstruction (B-II). Gastrointestinal transit of a solid meal (Technetium-99m sulfur colloid-labelled egg white) was assessed 0.5, 1, and 1.5 hours postprandial (pp). Transit of a liquid marker (Na51-CrO4 injected through an efferent-limb catheter) was measured at 25 minutes pp. RESULTS Solid gastric emptying was slower in RG than in B-II rats at 60 and 90 minutes pp. More of the solid meal and of the liquid marker was retained in the Roux limb than the efferent limb of the B-II at all time points (P < 0.05). CONCLUSIONS In a rodent model, Roux-en-Y gastrojejunostomy is associated with delayed gastric emptying and slowed efferent-limb transit of solids and liquids.
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Affiliation(s)
- G Cheng
- Department of Surgery, University of Florida College of Medicine, Gainesville, USA
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Van der Mijle HC, Kleibeuker JH, Limburg AJ, Beekhuis H, Lamers CB, van Schilfgaarde R. Role of vagal dysfunction in motility and transit disorders of jejunal Roux limb after Roux-en-Y gastrojejunostomy. Dig Dis Sci 1994; 39:827-33. [PMID: 8149849 DOI: 10.1007/bf02087430] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
After a Roux-en-Y gastrojejunostomy patients frequently complain about abdominal pain, fullness, nausea and vomiting, ie, the Roux-en-Y syndrome. Stasis in the Roux limb due to disordered motility is known to be a cause of these complaints. The aim of the present study was to determine whether vagal denervation contributes to the development of motility disturbances and stasis in the Roux limb. Forty-seven patients with a Roux-en-Y gastrojejunostomy after partial gastrectomy were studied. A truncal vagotomy had been performed in 26 of these 47 patients. Transit through the Roux limb was evaluated by radionuclide studies, motility in the Roux limb was studied by manometry, and vagal function was tested by measuring the pancreatic polypeptide response to an insulin-induced hypoglycemia (PP test). On the basis of the PP test patients were classified as having (1) normal, (2) moderately impaired, and (3) severely impaired vagal function. The PP test showed that two of the 26 patients subjected to vagotomy had a moderately impaired vagal function, the other 24 all had a severely impaired vagal function. In the patients not subjected to a vagotomy, vagal function was disturbed in 11 of the 21 patients. Motility disturbances were not observed more frequently in patients with either moderately or severely impaired vagal function than in patients with normal vagal function. Stasis in the Roux limb was seen even more frequently in patients with a normal vagal function than in patients with a severely impaired vagal function.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H C Van der Mijle
- Department of Surgery, University Hospital, Groningen, The Netherlands
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Mason RJ, Bremner CC. Gastric emptying and acid-output patterns following a suprapapillary duodenojejunostomy reconstruction with differing lengths of the afferent limb in the baboon. Am J Surg 1994; 167:322-6. [PMID: 8160906 DOI: 10.1016/0002-9610(94)90209-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The importance of afferent limb draining biliopancreatic secretions in Roux-en-Y type reconstructions has never been evaluated experimentally. The effects of the suprapapillary Roux-en-Y duodenojejunostomy operation using a constant duodenal and afferent limb length but a varying afferent limb length was assessed in three groups of five baboons. Gastric emptying, which was assessed preoperatively and postoperatively, was not changed in the baboons with a 12.5-cm-long afferent limb, was significantly delayed in the baboons with a 25-cm-long limb, and was significantly increased in the baboons with a 37.5-cm-long limb. Gastric acid control remained unchanged postoperatively.
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Affiliation(s)
- R J Mason
- Department of Surgery, University of the Witwatersrand Medical School, Parktown, South Africa
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19
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Schippers E, Schumpelick V. [Motility disorders in the blind loop after Roux-en-y reconstruction. Electromyography studies in the animal experiment]. LANGENBECKS ARCHIV FUR CHIRURGIE 1994; 379:99-104. [PMID: 8196436 DOI: 10.1007/bf00195871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Disturbances of intestinal motility, bacterial overgrowth and pancreocibal asynchrony are frequent findings in patients after Roux-en-y reconstruction (RYR). In dogs (n = 6) electromyographic recording of motility after partial gastrectomy with Roux-en-y reconstruction revealed no significant differences from controls in the Roux limb. However, changes in intestinal motility were extensively in the blind loop. The electromyographic pattern was characterized by an extreme loss of activity in the fasted and postprandial state. The activity front of the migrating motility complex occurred only in 25% of the fasting studies and was not correlated in time with motility patterns of connected small intestine. Food intake led to a significant increase in the motility index in the Roux limb (60.2 +/- 10.5), but not in the blind ending loop (27.8 +/- 4.1). Pharmacological stimulation of the hypomotile blind loop with cisapride is successful: increase of the motility index to 111.2 +/- 16.5. It might be useful in the treatment of symptomatic patients after RYR.
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Affiliation(s)
- E Schippers
- Chirurgische Klinik, Klinikum der RWTH, Aachen
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20
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Abstract
The stomach has two distinct physiologic motor areas: the proximal stomach and the distal stomach. The proximal stomach, with its slow, sustained contractions, has a key role in regulating intragastric pressure and gastric emptying of liquids, while the distal stomach, with its peristaltic contractions, has a major role in mixing, trituration, and emptying of solids. Diseases and operations that disturb the motility of these two areas can result in unique adverse motor sequelae. For example, operations that impair proximal gastric motility, such as proximal gastric resection, may cause rapid gastric emptying of liquids and subsequent dumping and diarrhea. In contrast, operations that impair distal gastric contractions, such as truncal vagotomy, may cause slow gastric emptying of solids and chronic gastric atony. Knowledge of the physiology of the stomach in health and of the pathophysiology with disease and after operation provides a basis for the successful treatment and prevention of these disorders.
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Affiliation(s)
- J J Cullen
- Department of Surgery, Mayo Clinic Postgraduate School of Medicine, Rochester, Minnesota
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21
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Woodward A, Sillin LF, Bortoff A. Migrating myoelectric complex and jejunal slow-wave propagation after Roux gastrectomy in dogs. Dig Dis Sci 1993; 38:1073-8. [PMID: 8508702 DOI: 10.1007/bf01295723] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Roux-en-Y gastrectomy is associated with a high incidence of symptoms of gastric stasis. Retrograde propagation of jejunal electrical slow waves and spike bursts has been implicated in the Roux Y stasis syndrome. Since the fasted state may persist after feeding, this study examined the extent of retrograde slow-wave propagation in the fasted state, particularly during aboral migration of phase III. Six dogs underwent Roux gastrectomy and placement of bipolar electrodes along the Roux limb. Four normal dogs with electrodes acted as controls. Thirty-five migrating myoelectric complexes were recorded in Roux dogs and 13 in controls. In Roux dogs, the incidences of retrograde propagation of slow waves during the migrating myoelectric complex were phase I 56 +/- 13%, phase II 60 +/- 12% and phase III 58 +/- 14% (not significant). For controls, the incidences were 0%, 0%, and 1%, respectively (P < 0.006 versus Roux dogs). In the Roux limb, retrograde propagation of slow waves, and hence spike bursts, occurs even during aboral migration of phase III. This abnormality may contribute to the Roux Y stasis syndrome.
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Affiliation(s)
- A Woodward
- Department of Surgery, VAMC, Syracuse, New York
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22
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Coelho JC, Clemente L, Matias JE, Campos AC, Wiederkehr JC. Gastrointestinal motility of patients with Roux-en-Y reconstruction. World J Surg 1992; 16:1111-5; discussion 1115-6. [PMID: 1455881 DOI: 10.1007/bf02067071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The electromyographic activity of the gastrointestinal tract was studied in 28 patients undergoing gastric, biliary, and pancreatic operations with reconstruction of the gastrointestinal tract with a Roux-en-Y limb. The Roux-en-Y limb was constructed 1 to 5 years before the study in 8 patients (chronic Roux-en-Y) and at the operation in which the electrodes were implanted in 20 patients (recent Roux-en-Y). All four phases of the migrating motor complex (MMC) were identified in the gastrointestinal tract, including in the Roux-en-Y limb. The duration of the MMC was 82.4 +/- 22.3 min in the patients with chronic Roux-en-Y and 89.0 +/- 25.1 min in the patients with recent Roux-en-Y. Food ingestion converted the MMC to the fed pattern in the entire gastrointestinal tract, including the Roux-en-Y limb in 16 (76.2%) of 21 recordings of the patients with chronic Roux-en-Y and in 27 (84.4%) of 32 recordings of the patients with recent Roux-en-Y. The duration of the fed pattern was 170 +/- 34 min in the patients with chronic Roux-en-Y and 154 +/- 26 min in the patients with recent Roux-en-Y. The findings of this study indicate that the electromyographic activity of the Roux-en-Y limb is normal during both fasting and fed states, even many years after the construction of the Roux-en-Y.
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Affiliation(s)
- J C Coelho
- Department of Surgery, Federal University of Parana, Curitiba, Brazil
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23
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Abstract
The duodenal switch operation is a new form of pancreaticobiliary diversion with superior physiologic consequences compared with the Roux-en-Y procedure. The new technique has been extensively tested in the laboratory and found to be nonulcerogenic and to be less disruptive of foregut physiology than the Roux-en-Y procedure. The duodenal switch has been used in more than 40 patients with confirmed duodenogastric reflux and has proved to be well tolerated and successful in long-term follow-up.
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Affiliation(s)
- R A Hinder
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
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24
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Abstract
Improved technology has expanded the study and understanding of gastrointestinal motility. Although no clear cause and effect relation has been demonstrated, altered motility has been found in association with a variety of nonsurgical and postoperative settings. As this relation is better defined, perhaps patients who are at risk to develop complications of surgery can be better identified so that treatment can be tailored toward their specific defect. Technological advances can also be expected to provide new and more effective interventions in this expanding field.
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Affiliation(s)
- G E Summers
- Department of Surgery, University of Florida College of Medicine, Gainesville
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25
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Hocking MP, Carlson RG, Vogel SB. Does selective vagotomy prevent delayed gastric emptying and altered myoelectric activity following Roux-en-Y gastrojejunostomy? Am J Surg 1992; 163:32-5; discussion 35-6. [PMID: 1733372 DOI: 10.1016/0002-9610(92)90249-q] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Delayed gastric emptying occurs frequently following Roux-en-Y gastrojejunostomy. The role of vagal denervation in the etiology of this "Roux-stasis syndrome" is controversial. This study evaluates the effect of selective vagotomy on gastric emptying and motility following Roux-en-Y. Four dogs underwent control gastric emptying studies. The animals then underwent selective vagotomy, antrectomy, and Billroth II gastrojejunostomy, with placement of serosal electrodes. Gastric emptying was assessed with simultaneous myoelectric recordings, and the animals were converted to Roux-en-Y, followed by repeat studies. Gastric emptying was unchanged following selective vagotomy, antrectomy, and Billroth II gastrojejunostomy (T 1/2: 132 +/- 18 min [SEM] versus 118 +/- 14 min control) but was markedly delayed following Roux-en-Y diversion (T 1/2: 286 +/- 44 min; p less than 0.01). All animals went into the fed pattern following Billroth II gastrojejunostomy (migrating myoelectric complex [MMC] interval: 326 +/- 6 min postprandial versus 92 +/- 5 min fasting; p less than 0.01), but no fed pattern was recognized in three of four animals following Roux-en-Y diversion (MMC interval: 68 +/- 12 min postprandial versus 62 +/- 1.5 min fasting; p = NS). In a canine model, selective vagotomy does not prevent delayed gastric emptying or myoelectric alterations following Roux-en-Y.
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Affiliation(s)
- M P Hocking
- Department of Surgery, University of Florida College of Medicine, Gainesville
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26
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Walgenbach S, Junginger T, Eissner D, Hahn K, Schicketanz KH, Schrezenmeir J. [Stomach emptying after stomach resection with and without retention of duodenal passage]. LANGENBECKS ARCHIV FUR CHIRURGIE 1991; 376:222-7. [PMID: 1943409 DOI: 10.1007/bf00186816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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).
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Affiliation(s)
- S Walgenbach
- Klinik und Poliklinik für Allgemein- und Abdominalchirurgie, Johannes-Gutenberg-Universität, Mainz, BRD
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27
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Treatment of severe peptic esophageal stricture with Roux-en-Y partial gastrectomy, vagotomy, and endoscopic dilation. J Thorac Cardiovasc Surg 1991. [DOI: 10.1016/s0022-5223(19)36695-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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28
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Abstract
The various operations performed for the treatment of peptic ulcer disease can lead to a variety of iatrogenic disorders collectively referred to as the "postgastrectomy syndromes." Although the etiology of most of these disorders remains unclear, loss of vagal innervation and bypass, ablation, or destruction of the pylorus clearly are involved in the pathogenesis of most, if not all, of these disorders. Unfortunately, there often is also a poorly understood psychological element involved in the pathogenesis. Of all ulcer operations, proximal gastric vagotomy results in the fewest physiologic abnormalities and the mildest postoperative symptoms. The continued popularity of this operation should effect a marked reduction in the incidence of disabling postgastrectomy syndromes. Fortunately, symptoms severe enough to necessitate remedial operation are uncommon, and conservative medical management is always indicated and usually suffices. When disabling symptoms are refractory, a thorough evaluation of the patient and an accurate classification of the syndrome are essential to guarantee a satisfactory result from surgical intervention. Although numerous surgical procedures have been developed to deal with the different syndromes, with varied results, the Roux-en-Y procedure has emerged as the operation of choice for most, if not all, postgastrectomy syndromes. However, the Roux-en-Y procedure has not been universally successful, and this operation can itself lead to the recently recognized postgastrectomy state of Roux-en-Y stasis syndrome. Prevention therefore remains the best form of therapy, and remedial operation should not be undertaken until adequate time has elapsed since the original operation and all forms of conservative treatment have failed.
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Affiliation(s)
- R Delcore
- Department of Surgery, University of Kansas Medical Center, Kansas City
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29
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Carlson RG, Hocking MP, Courington KR, Sninsky CA, Vogel SB. Erythromycin enhances delayed gastric emptying in dogs after Roux-Y antrectomy. Am J Surg 1991; 161:31-4; discussion 34-5. [PMID: 1987856 DOI: 10.1016/0002-9610(91)90357-j] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Delayed gastric emptying occurs in up to 50% of patients after truncal vagotomy and Roux-Y antrectomy and is often resistant to nonsurgical therapy. This study evaluates the effect of erythromycin, metoclopramide, and motilin on delayed gastric emptying in four dogs after Roux-Y antrectomy. Solid food gastric emptying was measured using a radionuclide technique. Study groups were: (1) saline control; (2) erythromycin 1 mg/kg intravenously over 1 hour; (3) erythromycin 3 mg/kg by mouth 45 minutes prior to feeding; (4) metoclopramide 0.6 mg/kg intravenously over 1 hour; and (5) motilin 500 ng/kg intravenously over 1 hour. After Roux-Y antrectomy, saline control dogs had 73% +/- 5% (SEM) gastric retention at 2 hours. After intravenous and oral erythromycin, gastric emptying improved at 2 hours to 27% +/- 6% and 39% +/- 5% (p less than 0.01 compared with control). Erythromycin intravenously and by mouth improved gastric emptying compared with metoclopramide (64% +/- 8%, p less than 0.05). Motilin enhanced gastric emptying to a similar degree as erythromycin, with a 2-hour gastric retention of 37% +/- 4% (NS). Erythromycin improved gastric emptying in dogs with severe Roux-Y gastroparesis and may have clinical application.
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Affiliation(s)
- R G Carlson
- Department of Surgery, University of Florida College of Medicine, Gainesville
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30
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Harrison WD, Hocking MP, Vogel SB. Gastric emptying and myoelectric activity following Roux-en-Y gastrojejunostomy. J Surg Res 1990; 49:385-9. [PMID: 2246882 DOI: 10.1016/0022-4804(90)90184-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The purpose of this study was to compare gastric emptying and Roux myoelectric activity in a canine model. Four dogs underwent truncal vagotomy, antrectomy, and 40 cm Roux-en-Y gastrojejunostomy, with placement of serosal electrodes. Following recovery, gastric emptying was determined scintigraphically with a radiolabeled solid meal, and fasting and fed small-bowel myoelectric activity was obtained. Gastric emptying was markedly slowed compared to control unoperated animals (202 +/- 91 versus 46 +/- 12 min; P less than 0.05). Slow wave frequency declined in the Roux limb compared to the duodenum (14.2 +/- 0.4 versus 18.0 +/- .06 counts per minute; P less than 0.01). No gradient in slow wave frequency was observed in the Roux limb, although one animal was noted to have reversed propagation of slow waves in the proximal Roux limb. Migrating myoelectric complexes (MMCs) were coordinated between the Roux limb and jejunum distal to the enteroenterostomy, but not with the duodenum. Periodicity of the MMCs was different in the Roux limb and duodenum (98.6 +/- 6.3 versus 138 +/- 17.5 min; P less than 0.05). None of the animals converted to the fed myoelectric pattern with a 272 kcal meal (MMC periodicity in the Roux limb = 99 +/- 10 min postprandially, P = N.S.). These quantitative and qualitative alterations in myoelectric activity may contribute to the observed delay in gastric emptying following Roux-en-Y gastrojejunostomy.
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Affiliation(s)
- W D Harrison
- Department of Surgery, University of Florida College of Medicine, Gainesville 32610
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31
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Morrison P, Miedema BW, Kohler L, Kelly KA. Electrical dysrhythmias in the Roux jejunal limb: cause and treatment. Am J Surg 1990; 160:252-6. [PMID: 2393051 DOI: 10.1016/s0002-9610(06)80017-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Electrical dysrhythmias in the Roux limb after Roux gastrojejunostomy are associated with upper gut stasis of food. The aim of this study was to determine the cause of the dysrhythmias and whether they could be eliminated with pacing. A set of four dogs (Group A) underwent three sequential operations: placement of jejunal electrodes at sites corresponding to the Roux limb; construction of a Roux limb without vagotomy, gastrectomy, or gastrojejunostomy; and transthoracic truncal vagotomy. A second set of five dogs (Group B) underwent truncal vagotomy, distal gastrectomy, and Roux gastrojejunostomy with recording electrodes placed on the Roux limb and a pacing electrode situated at the proximal end of the limb. Electrical recordings were obtained on four separate occasions after each operation. In Group A dogs, orad and disordered propagation of jejunal pacesetter potentials occurred in the Roux limb 56 +/- 5% of the time after limb construction but never before construction. The pattern was not changed with vagotomy. In Group B dogs, electrical dysrhythmias in the Roux limb also occurred and were corrected with electrical pacing. We concluded that electrical dysrhythmias in the canine Roux limb are secondary to the jejunal transection done during Roux limb construction, and are not due to gastrectomy, gastroenterostomy, or vagotomy. The dysrhythmias can be corrected with pacing.
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Affiliation(s)
- P Morrison
- Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905
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32
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Haglund UH, Jansson RL, Lindhagen JG, Lundell LR, Svartholm EG, Olbe LC. Primary Roux-Y gastrojejunostomy versus gastroduodenostomy after antrectomy and selective vagotomy. Am J Surg 1990; 159:546-9. [PMID: 2190476 DOI: 10.1016/s0002-9610(06)80062-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
One hundred twenty-one patients with prepyloric ulcer disease entered a randomized clinical trial comparing gastroduodenostomy with Roux-Y gastrojejunostomy after antrectomy and selective gastric vagotomy. The postoperative course and morbidity were quite similar in the two study groups, as was the postoperative infectious complication rate. Forty-four of the patients with a Billroth I reconstruction and 52 of those with a Roux-Y reconstruction were followed up with a clinical assessment at least 6 months after the operation. The postgastrectomy symptoms were quite frequent, but did not differ between the two study groups. Seventy-five percent of the patients with a Billroth I gastroduodenostomy had symptoms corresponding to Visick grades 1 and 2, compared with 81% of those with Roux-Y reconstruction. Although the latter procedure was very effective in preventing bile reflux to the gastric remnant, no difference was observed in the gastric emptying rate after the two operations.
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Affiliation(s)
- U H Haglund
- Department of Surgery, General Hospital, Malmö, Sweden
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33
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Ehrlein HJ, Wulschke S, Thoma G, Schumpelick V. Gastrointestinal motility and gastric emptying after Billroth II gastrectomy in dogs. Dig Dis Sci 1989; 34:1199-210. [PMID: 2752870 DOI: 10.1007/bf01537268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- H J Ehrlein
- Institut für Zoophysiologie, Universität Hohenheim, Stuttgart, F.R.G
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34
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Vogel SB, Woodward ER. The surgical treatment of chronic gastric atony following Roux-Y diversion for alkaline reflux gastritis. Ann Surg 1989; 209:756-61; discussion 761-3. [PMID: 2730185 PMCID: PMC1494111 DOI: 10.1097/00000658-198906000-00013] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Symptoms of severe nausea, vomiting, abdominal pain, and frequent bezoars, as well as objective gastric retention, can occur following Roux-Y biliary diversion for alkaline reflux gastritis. Medical therapy and prokinetic drugs have proven ineffective. This review evaluates 37 patients who underwent further gastric resection from 1979 to 1987 to improve gastric emptying and resolve symptoms. Fifteen patients underwent perioperative radionuclide solid-food gastric emptying studies. Seventy-three per cent (27 of 37 patients) of the patients who underwent further gastric resection (70% to 95%) had a satisfactory postoperative response. Twenty patients were graded Visick 1 or 2 and 7 Visick-3 patients, although much improved, still had some symptoms of gastroparesis. Twenty-seven per cent (10 of 37 patients) failed to improve and underwent completion total gastrectomy. Overall, 70% of this group had almost complete resolution of their symptoms. Three of 10 patients were considered "failures" due to postprandial pain in 1 and early vasomotor dumping in 2. Of the 10 patients who failed initial revisional surgery, 7 underwent a 70% to 80% subtotal gastric resection (STG) and 3 patients underwent 85% to 95% extensive resection (EXT.G.). Of the 15 patients who underwent perioperative radionuclide evaluation, a mean two-hour gastric retention of 61.4% +/- 4% (SEM) decreased to 25% +/- 4% following further gastric resection. Eight patients were in the STG group and seven patients were in the EXT.G group. Following STG, mean two-hour gastric retention of 58.2% +/- 3.5% decreased to 38% +/- 3% (p less than 0.05). In seven patients who underwent EXT.G, mean two-hour retention of 65% +/- 4% decreased to 10% +/- 2.5% (p less than 0.005). EXT.G resulted in normal gastric emptying and few late failures. In post-Roux-Y patients with symptoms of gastroparesis and documented gastric retention, EXT.G normalizes gastric emptying and restores a better quality of life. Total gastrectomy should be reserved for those patients who are failed by more extensive resection.
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Affiliation(s)
- S B Vogel
- Department of Surgery, University of Florida, College of Medicine, Gainesville 32610
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35
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Haglund U, Fork FT, Högström H, Lilja B. Esophageal and jejunal motor function after total gastrectomy and Roux-Y esophagojejunostomy. Am J Surg 1989; 157:308-11. [PMID: 2919735 DOI: 10.1016/0002-9610(89)90557-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Emptying and peristaltic activity of the esophagus and proximal jejunum were studied using scintigraphy and fluoroscopy documented on videotape in 11 patients after total gastrectomy and Roux-Y loop reconstruction. Impaired esophageal motor function, as judged by both methods, was seen in five patients who were all 50 years of age or older. This was in contrast to the findings in a group of healthy control subjects, all over 50 years of age, in whom esophageal function appeared normal on scintigraphy in five of seven. Disturbed jejunal function, as judged by radiography, was found in eight patients, whereas the emptying rate according to scintigraphy was judged normal in all but two patients. Five of the patients complained of various adverse alimentary tract symptoms, but the scintigraphic and radiographic findings did not correlate with these symptoms.
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Affiliation(s)
- U Haglund
- Department of Surgery, Lund University, Malmö General Hospital, Sweden
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36
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Abstract
The aim of this study was to determine the clinical outcome after Roux-Y gastrectomy for chronic gastric atony. Forty patients (11 men, 29 women; age 47 +/- 12 years) presented with severe chronic gastric atony: 32 patients had postvagotomy atony, 6 had idiopathic atony, and 2 had diabetic gastroparesis. The patients underwent either extensive subtotal or near-total gastrectomy and Roux-Y gastrojejunostomy. No early postoperative mortality occurred. Among the 39 patients followed for a mean of 32 months, 31 patients (79 percent) had fewer symptoms postoperatively than preoperatively, with 26 patients (66 percent) improving at least one Visick grade postoperatively and 22 patients (56 percent) going from grades III and IV preoperatively to grades I and II postoperatively. In contrast, 13 patients (33 percent) did not improve after operation. We concluded that extensive subtotal Roux-Y gastrectomy and near-total Roux-Y gastrectomy were safe procedures that led to improvement in two-thirds of the patients with chronic gastric atony; however, one-third of patients did not have improvement.
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Affiliation(s)
- L Karlstrom
- Department of Surgery, Mayo Medical School, Rochester, Minnesota
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37
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Perniceni T, Gayet B, Fékété F. Total duodenal diversion in the treatment of complicated peptic oesophagitis. Br J Surg 1988; 75:1108-11. [PMID: 3208045 DOI: 10.1002/bjs.1800751119] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Total duodenal diversion (TDD) has been carried out in 59 patients with complicated forms of peptic oesophagitis (acquired short oesophagus, columnar lined oesophagus, previous oesophagogastric surgery, stenosis). A standard procedure (truncal vagotomy, antrectomy and gastrojejunal anatomosis using a 70 cm Roux-en-Y loop) was performed in 41 patients, and some technical adjustments were required in 18 patients previously operated on. One patient died from postoperative pulmonary embolism. Bowel movements were resumed before the fifth postoperative day in 93 per cent of patients (54/59). Early postoperative complications (gastroparesis, 5; fistula, 1; subsequent operation, 1) occurred in 12 per cent of patients. Stabilization of the oesophagitis was achieved in less than 3 months in 95 per cent of cases (55/58). There were two cases of regression of columnar lined oesophagus. A 3-h postprandial pH assessment showed that the reflux had been controlled in 92 per cent of cases (47/51). One patient who still had an acid reflux died subsequently of a perforated oesophageal ulcer. Three anastomotic ulcers occurred in eight patients who did not have vagotomy. Digestive side-effects have been observed in nine patients, but only in one case were they crippling. Our results suggest that TDD is a suitable form of treatment for complicated forms of peptic oesophagitis.
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Affiliation(s)
- T Perniceni
- Université Paris VII, Department of Digestive Surgery, Hôpital Beaujon, Clichy-Paris, France
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38
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Hocking MP, Brunson ME, Vogel SB. Effect of various prokinetic agents on post Roux-en-Y gastric emptying. Experimental and clinical observations. Dig Dis Sci 1988; 33:1282-7. [PMID: 2901940 DOI: 10.1007/bf01536681] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- M P Hocking
- Department of Surgery, University of Florida College of Medicine, Gainesville 32610
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Editorial comment. Am J Surg 1988. [DOI: 10.1016/s0002-9610(88)80066-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Bühner S, Ehrlein HJ, Thoma G, Schumpelick V. Canine motility and gastric emptying after subtotal gastrectomy. Am J Surg 1988; 156:194-200. [PMID: 3421427 DOI: 10.1016/s0002-9610(88)80065-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- S Bühner
- Institut für Zoophysiologie, Universität Hohenheim, Stuttgart, Federal Republic of Germany
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41
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Abstract
The aim of the present study was to determine which factors lead to upper gastrointestinal stasis after Roux-Y reconstruction. Among the 214 patients with Roux-Y reconstructions performed between 1961 and 1983, follow-up data were obtained for 187 (87 percent) after a mean of 6.2 years. Patients with vomiting of food but not bile, postprandial pain, and nausea were considered to have the Roux-Y stasis syndrome. The syndrome was found in 49 patients with gastrojejunostomy (30 percent of those at risk) but in only 2 patients with esophagojejunostomy (8 percent, p less than 0.05). The condition was more common in women than men (p less than 0.05), but it was equally common in patients with and without vagotomy. The mean length of the Roux-Y limb in patients with stasis was 41 cm, which was longer than the 36 cm in patients without stasis (p less than 0.001). When multiple logistic regression was used, the length of the Roux-Y limb emerged as the major risk factor (p less than 0.01). In conclusion, construction of Roux-Y limbs greater than about 40 cm in length may increase the incidence of the Roux-Y stasis syndrome.
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Affiliation(s)
- S Gustavsson
- Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905
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Vogel SB, Hocking MP, Woodward ER. Clinical and radionuclide evaluation of Roux-Y diversion for postgastrectomy dumping. Am J Surg 1988; 155:57-62. [PMID: 3341539 DOI: 10.1016/s0002-9610(88)80258-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- S B Vogel
- Department of Surgery, University of Florida, College of Medicine, Gainesville 32610
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Britton JP, Johnston D, Ward DC, Axon AT, Barker MC. Gastric emptying and clinical outcome after Roux-en-Y diversion. Br J Surg 1987; 74:900-4. [PMID: 3664221 DOI: 10.1002/bjs.1800741010] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The results of 48 Roux-en-Y (RY) diversion procedures are reported: 41 were performed as secondary procedures and 7 as part of a primary operation for peptic ulcer. There was no operative mortality, but four patients developed temporary fistulae in the postoperative period and three patients required reoperation. Good clinical results were found when RY diversion was performed as a primary procedure or when the indication for operation was peptic ulceration. The overall results, however, were poor: 24 patients (50 per cent) felt that they had not benefited and 32 patients (67 per cent) remained in Visick grades III or IV. The main cause of failure was gastric stasis, especially of solid food. Gastric emptying studies were carried out after RY diversion in 22 patients, most of whom had symptoms of stasis. Emptying of liquids was found to be normal in most patients, but emptying of solids was delayed, the median t 1/2 for solids being 160 (75-370) min compared with 67 (50-85) min in DU patients. Bilious vomiting improved significantly after RY diversion, but 18 patients (38 per cent) complained of vomiting food and 32 patients (67 per cent) experienced postprandial distress or pain. Loss of the antral mill, vagotomy of the gastric remnant and, perhaps, resistance to gastric emptying by the Roux loop itself may together explain the delay in gastric emptying of solids after RY diversion.
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Affiliation(s)
- J P Britton
- University Department of Surgery, General Infirmary, Leeds, UK
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DeMeester TR, Fuchs KH, Ball CS, Albertucci M, Smyrk TC, Marcus JN. Experimental and clinical results with proximal end-to-end duodenojejunostomy for pathologic duodenogastric reflux. Ann Surg 1987; 206:414-26. [PMID: 3662657 PMCID: PMC1493213 DOI: 10.1097/00000658-198710000-00003] [Citation(s) in RCA: 154] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Existing Roux-en-Y bile diversion procedures for duodenogastric reflux coupled with distal gastric resection or antrectomy and vagotomy have varied success due to interruption of the physiologic relationships between stomach and duodenum, the reduction of the gastric reservoir, the side effects of vagotomy, and the effect of the Roux limb on gastric emptying. A new bile diversion procedure, suprapapillary Roux-en-Y duodenojejunostomy, was studied, which eliminates the need for gastric resection to prevent jejunal ulcers by preserving duodenal inhibition of gastric acid secretion and the protective effects of duodenal secretion on the surrounding mucosa. Experimentally, the incidence of jejunal ulceration was significantly decreased by the preservation of the proximal duodenum. Clinically, bile diversion by suprapapillary Roux-en-Y duodenojejunostomy alleviates symptoms of duodenogastric reflux disease without being ulcerogenic (in the presence of normal gastric secretion) or prolonging gastric emptying.
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Affiliation(s)
- T R DeMeester
- Department of Surgery, Creighton University, School of Medicine, Omaha, NE 68131
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Sawchuk A, Canal D, Grosfeld JL, Slaughter M, Gardner G, O'Connor T, Behrman D. Electrical pacing of the Roux limb resolves delayed gastric emptying. J Surg Res 1987; 42:635-41. [PMID: 3495700 DOI: 10.1016/0022-4804(87)90007-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This study compares antegrade gastric and Roux-limb electrical pacing in the evaluation and treatment of delayed gastric emptying following vagotomy, antrectomy and Roux-Y enterostomy. Twenty-four male Sprague-Dawley rats (250 g) underwent midline laparotomy, truncal vagotomy, antrectomy, and Roux-Y jejunostomy. Pacemaker leads were implanted 1 cm apart in both the gastric fundus and proximal Roux limb. Pacing was accomplished using a 0.5 mA, 50 msec, 0.33 Hz signal and monitored by an oscilloscope. Animals were fasted for 2 hr and then gavaged with 1.0 cc of 99mTc-labeled egg white. At 1 hr rats were anesthetized. The stomach, Roux limb, small intestine, and colon were doubly ligated and excised without disturbing their contents. The total number of counts per minute per rat was determined in a gamma radiation counter, and percentage gastric emptying (GE) was evaluated. Group I controls (n = 8) retained 76 +/- 15.8% for a GE of 24%. Group II gastric paced rats (n = 8) retained 64.5 +/- 19.2% (GE 35.5%) and Group III Roux-limb paced rats (n = 8) retained 46.8% +/- 13.2 (GE 53.2%) (P less than 0.005 III vs I, P less than 0.05 III vs II). The amount of radioactive meal distal to the Roux limb was also evaluated. Group I had 15.7 +/- 16.1%, Group II (gastric paced) 20.5 +/- 19.0%, and Group III (Roux-limb paced) 37.2 +/- 11.9% (P less than 0.005 III vs I, P less than 0.05 III vs II). These data imply that Roux-en-Y limb dysmotility may contribute to delayed gastric emptying following vagotomy, antrectomy, and Roux-Y enterostomy.(ABSTRACT TRUNCATED AT 250 WORDS)
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Abstract
The most common types of postgastrectomy disorders are the dumping syndromes (early postprandial and late or hypoglycemic) and alkaline reflux gastritis. Both are caused by destruction of the pyloric mechanism. A third problem, Roux-en-Y duodenal diversion, frequently results in delayed gastric emptying.
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Ehrlein HJ, Thoma G, Keinke O, Tsiamitas C, Schumpelick V. Effects of nutrients on gastrointestinal motility and gastric emptying after distal gastrectomy with Roux-Y gastrojejunostomy in dogs. Dig Dis Sci 1987; 32:538-46. [PMID: 3568940 DOI: 10.1007/bf01296038] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Ehrlein HJ, Bühner S, Thoma G, Schemann M, Keinke O, Tsiamitas C, Schumpelick V. Gastric emptying after Roux-Y and Billroth-I gastrectomy depends on viscosity of meal and contractile patterns of small intestine in dogs. Dig Dis Sci 1987; 32:529-37. [PMID: 3568939 DOI: 10.1007/bf01296037] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The aim of the study was to examine gastrointestinal motility after distal gastrectomy and the influence of meal viscosity on gastric emptying. Gastrointestinal motility and gastric emptying of acaloric meals with different viscosities were measured in normal dogs and after a two-thirds gastrectomy with Billroth-I or Roux-Y gastroenterostomy. After distal gastrectomy, gastric emptying depended on the viscosity of the meal, as in normal dogs. Acaloric viscous meals emptied significantly faster in the Billroth-I than in the Roux-Y group due to different contractile patterns of the duodenum and jejunum. In comparison to normal dogs, gastric emptying of viscous meals was accelerated in the Billroth-I and delayed in the Roux-Y group. Several motility parameters of the stomach and intestine differed between the normal and gastrectomized dogs. Thus, after distal gastrectomy, the viscosity of the meal and the contractile patterns of the small intestine are important determinants of gastric emptying.
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Vogel SB, Hocking M. Motility in Roux-en-Y patients. Gastroenterology 1987; 92:1097-8. [PMID: 3556991 DOI: 10.1016/0016-5085(87)91003-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
In 1977, a controlled, prospective trial was initiated to test the hypothesis that excessive enterogastric (EG) reflux was responsible for a unique postgastrectomy syndrome, "alkaline reflux gastritis." Late (42 +/- 3 months) follow-up on all treated patients (N = 14; Rx = 45 cm Roux Y limb) is reported. The following parameters were assessed in symptomatic (N = 11 nonrefluxers, 15 refluxers) and asymptomatic postgastrectomy patients (N = 9): CCK-stimulated scintographically determined EG reflux (EGRI %), intragastric (IG) concentration of bile acids (BA, mM), net bile acid reflux/hr (microM), maximum acid output (mEq/hr), intragastric pH, gastric emptying of 99Tc-labeled solids (T 1/2; minutes), gastritis score (GS = 0-15), and specific symptomotology. A significant linear relationship was noted between intragastric BA concentration and the severity of histologic gastritis in the residual gastric pouch. As a group, excessive refluxers demonstrated significantly greater IG BA concentration, net BA reflux/hour, and EGRI than did either nonrefluxers or controls. Gastritis score in this group was also greater, intragastric pH higher, and maximal acid output (MAO) lower. Gastric emptying was not different between groups. Following Roux (N = 14), reflux was eliminated early and late, pH fell, MAO increased, and gastritis improved. Early marked delays in emptying occurred but normalized late and were rarely a clinical problem. Early symptomatic results were pain eliminated in 14/14, nausea in 8/14, vomiting 11/14, bilious vomiting in 14/14. Complications were one marginal ulcer (no vagotomy), two severe delays in emptying (simultaneous Roux + vagotomy). Late symptomatic results were recurrent or persistent pain in 4/14, nausea in 7/14, vomiting in 5/14. Bilious vomiting remains eliminated.
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