Comparison between Henley jejunal interposition and Roux-en-Y anastomosis as concerns enterogastric biliary reflux levels

Duodenum inclusion in alimentary transit for preventing or correcting nutritional deficiencies resulting from Roux-en-y gastric bypass in obesity treatment

Nutritional and metabolic complications can develop after Roux-en-Y gastric bypass (RYGB) when there is an exaggerated response to the anatomical and functional changes or when there is inadequate nutritional supplementation. Severe malnutrition is rare, but deficiencies of vitamin B12, iron, calcium and thiamin, metabolic bone disease and gallstones are common after RYGB. Shortage of vitamin B12, iron, calcium and also cholelithiasis are caused at least partially by excluding the duodenum and proximal jejunum from food transit. We designed a new procedure, with the maintenance of the duodenum and proximal jejunum in the gastrointestinal transit through interposition of jejunal loop, as a primary operation to prevent such deficiencies or as corrective surgery for severe malnutrition after RYGB with failure in responding to conservative treatment. Complicações nutricionais e metabólicas podem se desenvolver após a derivação gástrica em Y de Roux (DGYR) quando há uma resposta exagerada às mudanças anatômicas e funcionais ou quando há suplementação nutricional inadequada. A desnutrição grave é rara, mas deficiências de vitamina B12, ferro, cálcio e tiamina, doença óssea metabólica e cálculos biliares são comuns após a DGYR. Dessas deficiências mencionadas, a de vitamina B12, de ferro, de cálcio e também a colelitíase, são causadas, ao menos parcialmente, pela exclusão do duodeno e jejuno proximal. Um novo procedimento com a manutenção do duodeno e do jejuno proximal no trânsito gastrointestinal, mediante interposição de alça jejunal, foi idealizado como operação primária para prevenir essas deficiências ou como cirurgia corretiva de desnutrição grave após DGYR com falha na resposta a exaustivas tentativas de tratamento conservador.

Influence of bile reflux and Helicobacter pylori infection on gastritis in the remnant gastric mucosa after distal gastrectomy

BACKGROUND

Two main pathogenic factors, bile reflux and Helicobacter pylori infection, have been identified in the remnant stomach, but it is still unclear which factor is important in the pathogenesis of gastritis in the remnant stomach after distal gastrectomy.

METHODS

In 184 patients who had had distal gastrectomy performed using the Billroth-I procedure (B-I; n-106), Billroth-II procedure (B-II; n-36), and jejunal interposition (J-I; n-42) we examined the severity of remnant gastritis endoscopically and carried out examinations for H. pylori infection and histological examination.

RESULTS

The endoscopic severity of remnant gastritis was grade 1 or more in 101 of the 106 B-I patients (95.3%) and in all 36 B-II patients (100%). But, of the 42 J-I patients, the grade was 0 in 33 (78.6%). The endoscopic severity of remnant gastritis was significantly milder for J-I than for B-I (P < 0.001) and B-II (P < 0.001). H. pylori infection was confirmed in 59 of the 106 B-I patients (55.6%), 21 of the 36 B-II patients (58.3%), and 32 of the 42 J-I patients (76.1%). The rate of H. pylori infection was higher for J-I patients than for B-I (P < 0.05), but not for B-II patients (P = 0.1495). The severity of chronic and active inflammatory cellular infiltration tended to be inverse proportional relation with the endoscopic severity of the remnant gastritis. Furthermore, the histological inflammation and activity scores of H. pylori-positive patients were higher than those of H. pylori-negative patients, without regard to the endoscopic grade of gastritis.

CONCLUSIONS

Reconstruction techniques play an important role in the prevention of bile reflux, and we found that endoscopically more severe remnant gastritis was associated with a lower rate of H. pylori infection and with a lower degree of inflammatory cellular infiltration.

Primary bile reflux gastritis: diagnosis and surgical treatment

Bile reflux gastritis has been recognized since the first successful gastric operations and has persisted for more than a century. Diagnosis has been difficult and non-operative therapy largely ineffective. Early attempts at surgical correction resulted in stomal ulceration and it was not until the advent of flexible endoscopy and other techniques that diagnosis became more secure. Operative attempts at correction have included the Roux-en-Y procedure, the Braun enteroenterostomy, and Henley jejunal interposition. None of the procedures has been uniformly successful, and the Roux-en-Y has resulted in a disabling stasis syndrome in most patients. The diagnosis of bile reflux without previous gastric surgery has been even more elusive and seems to be associated with previous cholecystectomy. Thirty-one patients diagnosed with primary bile reflux, having typical symptoms of epigastric pain, nausea, and bilious vomiting have been treated by diverting bile flow through a Roux-en-Y choledochojejunostomy without accompanying gastric resection or vagotomy. There were no operative deaths and no long-term problems, such as anastomotic stricture. Two patients had self-limited bile leaks. Twenty-seven of the 31 patients (87%) have achieved complete relief of symptoms and have no gastrointestinal complaints. Serial gastric emptying has demonstrated no alteration in 9 of 12 patients who were normal before operation, and improvement in 12 of the 19 (63%) patients with abnormal preoperative studies.

Primary Bile Reflux Gastritis: Which Treatment is Better, Roux-en-Y or Biliary Diversion?

Primary bile reflux gastritis is an unusual and elusive problem. Postgastrectomy bile reflux has been long recognized and treated variously with Roux-en-Y gastrojejunostomy, Braun enteroenterostomy, and Henley jejunal interposition. All of these procedures have been fraught with postoperative side effects, the worst of which is stasis. A new procedure utilizing biliary diversion has been proposed to divert bile from the gastric lumen without vagotomy or gastric resection. This procedure was used for 16 patients with diagnosed bile reflux, and results were compared with those of a previous group of 21 patients who had been treated with Roux-en-Y gastrojejunostomy. The patient groups were similar in age, sex, weight, symptoms, and results of investigative studies. The earlier group all had vagotomy, antrectomy, and gastrojejunal anastomosis to a 45-cm Roux limb. The later group all had an end-to-side choledochojejunostomy to a 45-cm Roux limb, taken 45 cm from the ligament of Treitz. The patients in the bile diversion group had fewer complications and shorter hospital stays. In addition, they had few postoperative complaints, no further operations for either bile reflux or upper gastrointestinal stasis, and no long-term deaths due to gastrointestinal problems or malnutrition. Their eventual postoperative gastric emptying improved significantly when compared with the Roux-en-Y patients, suggesting that the dysmotility observed preoperatively may well have been a result of the bile injury to the stomach, rather than an underlying gastric dysmotility.

Does the Length of the Interposed Segment in the Henley Procedure Influence Duodenogastric Reflux? An Experimental Study

This study assesses duodenogastric reflux (DGR) using 99mTechnetium-diisopropyl iminodiacetic acid in unoperated dogs and in dogs 28 days after a Billroth II gastrectomy and 28 days after the Henley procedure. Fourteen mongrel dogs were divided randomly into two groups of seven each, according to the length of the interposed jejunal segment used (Group A 10 cm; Group B, 20 cm). All dogs were subjected to a Billroth II gastrectomy, followed by the Henley procedure 30 days later. In Group A, DGR was significantly lower in the preoperative period (median, 0.0%; range, 0.0–0.02%) than after gastrectomy (median, 0.13%; range, 0.08–0.70%) and the Henley procedure (median, 0.12%; range, 0.06–0.22%), but did not differ significantly after gastrectomy and jejunal interposition. In Group B, DGR was significantly higher after gastrectomy (median, 0.15%; range, 0.10–0.64%) than in the preoperative period (median, 0.00%; range, 0.00–0.09%) or than after the Henley procedure (median, 0.00%; range, 0.00–0.7%). DGR did not differ significantly between the preoperative period and after Henley procedure. After jejunal interposition, DGR was significantly higher in Group A than in Group B. The Henley procedure is effective in preventing DGR when the interposed segment is 20 cm in length.

The duodenojejunal junction and Treitz ligament in the regulation of duodenal emptying

In chronic experiments in dogs the evacuatory and absorptive duodenal functions and the level of duodenogastric reflux (DGR) in sham-operated dogs and dogs with transected Treitz ligament (TL) and resected duodenojejunal junction (DJJ) were studied. The electrophysiologic characteristics of the antrum, duodenum, and DJJ in sham-operated dogs were examined. It was shown that there is a coordination of gastric and duodenal solid carbohydrate food emptying. The process of evacuation from both organs was characterized by three closely correlated phases, phase 2 of emptying being exponential. In the TL transection and DJJ resection groups the coordination of gastric and duodenal emptying disappeared. The rate of carbohydrate solid food evacuation from the duodenum decreased, on average, by 45.5% +/- 5.5% (P < 0.05); phase 2 of duodenal emptying became unexponential, and the level of DGR considerably increased. The rate of duodenal absorption of main organic chyme components increased significantly in most of the time intervals studied. Significantly higher amplitudes of slow waves and spike potentials were recorded from the DJJ than from the duodenum. We conclude that the DJJ and TL are possible regulators of duodenal emptying. The DJJ is probably a functional sphincter that provides coordinated activity of the stomach and duodenum.

Postgastrectomy syndromes

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