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After presentation of postgastrectomy syndromes the methods for demonstrating the quantity of alkaline reflux are described. In 81 patients with gastrectomy the authors compare the reconstruction methods--named after Siewert/Peiper, Hunt/Lawrence, Schreiber and Schloffer--according to their reflux characteristics. The Y-Roux anastomosis shows better results than the Schloffer method.
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The results of a 5-year follow-up of 289 consecutive, peptic ulcer patients treated by antrectomy and gastroduodenostomy, with or without vagotomy, are presented. Patients with a preoperative gastric acid secretory capacity (PAO) below 40 mmol/h were treated by antrectomy alone, while subjects with a higher PAO had a vagotomy in addition. The antrectomy was defined by lithmus indication of the corpus-antrum border and by histologic verification, including gastrin cell counting. The over all incidence of gastroscopically verified recurrent ulceration was 8.5%. In patients with ulcer location in the bulb or the pyloric/prepyloric region (juxtapyloric ulcer) and treated by antrectomy alone, the recurrence rate was 18% (n = 102), and in gastric ulcer patients it was 4% (n = 47). Altogether 14 patients with recurrent ulcer were subsequently reoperated on by vagotomy showing no further recurrence. Antrectomy combined with vagotomy was primarily performed almost exclusively in patients with juxtapyloric ulceration, in whom the recurrence rate was 2% (n = 106). According to a postoperative insulin test, the patients with recurrence after antrectomy and vagotomy were incompletely vagotomized. In patients who remained free of symptoms or signs of recurrent disease, the median reduction in gastric acid secretory capacity was about 60% after antrectomy alone and 80% after antrectomy and vagotomy. In juxtapyloric ulcer patients with recurrence after antrectomy alone there was a small median reduction in PAO one month after operation (26%) and then an increase close to the preoperative level (6% reduction). In patients with a postoperative reduction in PAO of less than 35%, there was a high probability of recurrent ulcer, about 70%. In spite of selection of patients with a comparatively low preoperative PAO (less than 40 mmol/h) for antrectomy alone, the recurrence rate was 18% in patients with juxtapyloric ulcer location. In this selected group of patients the preoperative PAO was not higher in patients with ulcer recurrence than in patients who were asymptomatic after the operation. Selecting patients with juxtapyloric ulcer for antrectomy, with or without vagotomy, on the basis of gastric acid secretory capacity therefore seems unjustified. When vagotomy was added to antrectomy and gastroduodenostomy it seemed to increase the risk of developing serious (Visick 3u and 4) postgastrectomy syndromes; 12% after antrectomy and vagotomy versus 3% after antrectomy alone. Vagotomy appeared to be associated with an increased risk of bile reflux gastritis, gastric mycosis, and milk intolerance. Dumping and diarrhoea after vagotomy often coincided with milk intolerance. Antrectomy, with or without vagotomy, did not markedly impair recorded nutritional parameters.(ABSTRACT TRUNCATED AT 400 WORDS)
The aim of this study was to compare a new type of reconstruction method (Noh's operation) with Roux-en- Y operation after subtotal gastrectomy. Noh's operation described herein includes a jejunal occlusion, an end-to-side gastrojejunostomy, a side-to-end jejunoduodenostomy, and a side-to-side jejunojejunostomy after subtotal gastrectomy. A series of 43 patients who had the new operation were compared with 47 patients with the Roux-en- Y procedure. The postgastrectomy syndromes, and the mucosal change of the remnant stomach and esophagus were evaluated after surgery. In the new operation, the Roux stasis syndrome occurred in 34.9% at 3 months, in 23.3% at 6 months, in 14.0% at 12 months, and in 11.6% at 24 months. In patients undergoing the Roux-en- Y operation, the syndrome occurred in 42.6% at 3 months, in 34.0% at 6 months, in 31.9% at 12 months, and in 29.8% at 24 months. This study shows that the new type of operation (Noh's operation) can be a good option for reconstruction after subtotal gastrectomy.
Although the diagnosis of peptic ulcer disease may be difficult in the pediatric age group, this problem is being faced increasingly by the physicians charged with the care of these children. Chronicity of symptoms has been documented in over 50 per cent of the patients demonstrating early peptic ulcers and therefore an aggressive approach to management has been advocated. Although the numbers are small, postgastrectomy syndromes of mechanical and nutritional nature appear less common in the young patient than in adults. Satisfactory growth and development are reported in nearly all series of patients followed after various gastric procedures. Both pyloroplasty and vagotomy and vagotomy and antrectomy appear to be extraordinarily well tolerated by the pediatric patient. Experimental evidence suggests that these patients should enjoy normal growth and development.
Alkaline reflux gastritis is by far most common following gastric operations, but its true incidence remains to be determined. It is a distinct postgastrectomy disorder with unique features from other postgastrectomy syndromes. Eight patients with the diagnosis of postoperative alkaline reflux gastritis are presented. Five patients had Henley jejunal loop interposition procedures and two had takedown of their gastroenterostomy and pyloroplasty. One patient had a Roux-en-Y jejunojejunostomy after a vagotomy and pyloroplasty. A Henley jejunal loop failed to relieve the symptoms in one patient and a Roux-en-Y jejunojejunostomy brought complete relief of symptoms. Six of the eight patients had esophagitis. The frequent coexistence of alkaline esophagitis and alkaline gastritis must be considered in both treatment.
The hypothesis that reflux of upper intestinal content, particularly of bile acids (BA), is responsible for a unique postgastrectomy syndrome, alkaline reflux gastritis, was tested on 28 occasions in 21 postoperative patients (14 symptomatic patients, 7 controls). Parameters evaluated: recumbent (rec.), upright, p.c. intragastric pH, {BA}, net BA reflux per hour, specific BA fractions, fasting and p.c. gastrin, maximal acid output (MAO), gastric emptying of solids by delta-scintigraphy), and the severity of nonstomal histologic gastritis, the "gastritis score," graded 0-15 by an independent senior pathologist. For the entire group, gastritis severity correlated positively with intragastric {BA} and net BA reflux per hour, both in recumbency and p.c. Five symptomatic patients demonstrated rec. and p.c. {BA} and net BA reflux per hour greater than two standard deviations from comparable mean values in control patients. They differed significantly from the remaining symptomatic patients as follows: increased intragastric {BA} and net BA reflux per hour, increased intragastric pH and decreased MAO. They also demonstrated a more severe grade of gastritis. Lithocholic acid was present in their reflux content significantly more often. Bilious vomiting was also more frequent. No other differences could be identified, either objectively or clinically, between the symptomatic groups. Four patients with excessive reflux underwent Roux-en-Y revision and restudy 6-22 months later. BA reflux was completely abolished, histologic gastritis improved, hematocrit rose, MAO increased, and gastric emptying slowed. Burning pain, bilious vomiting, and symptoms of esophageal reflux were eliminated. Vomiting and nausea were improved. Diarrhea was unchanged. The objective criteria outlined can identify symptomatic postgastrectomy patients with a greater than normal reflux and gastritis. Clinical criteria alone cannot. Revisional surgery in these patients eliminates reflux, improves gastritis, and produces symptomatic improvement. The hypothesis under consideration is strengthened but not proven.
Corrective surgical procedures for postgastrectomy syndromes are well-established in abdominal surgery. The indications for early corrective intervention are clearly defined on the basis of the patients' postoperative course. Corrections at a later date should only be considered in presence of major symptoms which did not respond to conservative therapy and following careful morphological and functional assessment of the patient. An analysis of gastric acid secretion should be carried out before and after the operation. The aim of corrective interventions is the restitution, as far as possible, of physiological conditions: prevention of rapid gastric emptying and reduction of gastric hypersecretion. Through postoperative follow-up examination of the patients over many years is essential. The case history, operation technique and outcome is presented in this review of 92 patients treated at the First Department of Surgery, University of Vienna and the findings are discussed.
Eight patients with severe postgastrectomy syndromes for predominantly bile reflux gastritis were examined by quantification of bile acids in the gastric remnant before and after a standardized liquid meal. Gastroscopy with biopsy and determination of gastric acid secretion and gastric emptying were performed. Six of the patients were also studied 3 months after Roux-en-Y transposition. Controls consisted of six completely asymptomatic partially gastrectomized patients studied 4--11 years postoperatively and six healthy students without any history of gastrointestinal disease. The healthy subjects had virtually no reflux of bile acids in the fasting state or after a meal. Both the symptomatic and asymptomatic patients had reflux in the fasting state and postprandially. The reflux of bile acids was, however, significantly greater late in the fasting period and early in the postprandial period in the symptomatic patients than in those without symptoms. The Roux-en-Y transposition eliminated the bile acid reflux and the symptoms of bile reflux gastritis but did not change the gastric emptying pattern. In patients with reflux gastritis the acid disappearance in the gastric remnant was moderate and the maximal acid output was unchanged after Roux-en-Y transposition.
PURPOSE: To test the hypothesis that the changes in ileal smooth muscle contractility accompanying postgastrectomy syndromes are agonist-specific, we investigated the effects of potassium chloride (KCl), carbachol, substance P (SP), and serotonin on ileal smooth muscle contractility after total gastrectomy in rats. METHODS: We performed total gastrectomy in ten rats and a sham operation in another ten rats as a control. All of the rats were killed and their ileums excised 4 weeks postoperatively. The concentration-response relationships for KCl, SP, and serotonin were obtained by adding each agent cumulatively to the organ bath. Morphological changes in the ileum were also examined by light microscopy. RESULTS: There was no significant difference between the responsiveness of gastrectomized and control tissues to KCl. Maximum responses (E(max)) to carbachol and SP were less in the gastrectomized ileal segments than in the control ileal segments. E(max) to serotonin was higher in the gastrectomized ileal segments than in the control ileal segments. The pD(2)value, i.e., the negative logarithm of the concentration for the half-maximal response, EC(50), for carbachol, SP, and serotonin was unchanged in the gastroctomized ileal segments and the control segments. Total gastrectomy also caused morphological changes in the ileum. CONCLUSIONS: These data indicate that the contractile response to various agents is altered after total gastrectomy and that receptor-mediated mechanisms may cause these changes.
BACKGROUND: Even though many types of reconstruction after total gastrectomy have been proposed to reduce postgastrectomy syndromes, choosing a method that would further improve the quality of life and nutrition of the gastrectomized patient is controversial. Hunt-Lawrence single pouch reconstruction seems to obtain better results compared with the more common Roux-en-Y technique, but both of these reconstructive approaches are associated with some reduction in food intake and some problems in achievement of ideal body weight. METHODS: In this prospective, randomized trial, after total gastrectomy 18 patients had reconstruction according to the Hunt-Lawrence or single pouch technique (SP group), whereas for 23 patients, the technique was modified with construction of a second pouch in the distal portion of the jejunal loop (DP group). Patients in the two groups were compared at 12 months after surgery for problems in gastrointestinal function, quality of life, improvement in body weight and nutritional parameters, serum albumin, hemoglobin level, and serum protein. RESULTS: The DP group demonstrated fewer symptom problems, better weight maintenance, and better laboratory values when compared with patients undergoing standard single jejunal pouch reconstruction. CONCLUSIONS: Reconstruction with use of a double pouch as a gastric substitute leads to better outcome assessments than with a single pouch reconstruction. Our double pouch technique has demonstrated significant improvement in quality of life and nutritional recovery in terms of functional results as well as patient satisfaction.
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