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Management of Gastrointestinal Dysfunction After Gastric Surgery
Symposium on Acid-Peptic Disease
Management of Gastrointestinal Dysfunction After Gastric Surgery Martin A. Adson, M.D., and Onye E. Akwari, M.D.
Although minor disturbances in digestive function after gastric surgery are not uncommon, major disability fortunately is rare. Disabling early satiety, frequent or persistent vomiting, severe diarrhea with or without postcibal vasomotor reactions, or incapacitating pain in the absence of recurrent ulceration develops in less than 5% of patients who have undergone surgical treatment for gastric or duodenal ulcer. Most patients so affected will improve with time or will respond to medication or altered diet. Further operation must be considered for 1 or 2% of patients. When mechanical factors responsible for dysfunction can be defined, a proper remedial operation can be conceived without difficulty. However, disturbances related to abnormal gastrointestinal motility or to exaggerated vasomotor or metabolic reactions as well as to disability associated with psychiatric problems respond less predictably to mechanical alterations of existing anatomic relations. Major contributions to understanding of physiologic abnormalities have been made in recent years, and operations that restore more normal function have been developed. Reported results, however, are variable, and there is still debate about the most suitable operative procedure for certain specific disturbances. When it is realized that few patients are incapacitated by anatomic alterations that are well tolerated by more than 90% of patients who have had similar operative procedures, it is not surprising that the results of further structural revisions may be unpredictable. Also, the results of surgical treatment may be compromised by psychiatric factors. Some patients seem reluctant to live without discomfort, since they have achieved secondary gain from their disability, and drug dependency may complicate rehabilitation and interpretation of therapeutic results. Most frustrating to surgeons have been the combinations of syndromes, common to our practice, which present a therapeutic dilemma. A patient with severe dumping syndrome who also vomits frequently may respond poorly to an operative procedure which delays gastric emptying, and the Surgical Clinics of North America-VOl. 51, No.4, August 1971
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patient who had dumping and alkaline gastritis may be relieved of postcibal vasomotor reactions after interposition of an antiperistaltic jejunal segment between the stomach and the duodenum only to suffer further from the effects of reflux of bile into the stomach. Although these complicated combinations of syndromes continue to frustrate us, and in specific cases the choice of an appropriate operative procedure remains a problem, rehabilitation of many so-called gastric cripples is now possible with appropriate remedial operations.
EARLY POSTOPERATIVE GASTRIC RETENTION After gastric resection or drainage procedures with or without vagotomy, normal gastric empyting usually will resume within a few days. The return of this function, however, may be delayed for 5 to 7 days, or at times, varying degrees of gastric retention may develop after a week of apparently normal function. Minor dysfunction may go undetected or may resolve without treatment, but persistent gastric retention requires specific treatment. Stomal or efferent limb obstruction that results from technical error, an adhesive kink or twist, volvulus or internal hernia, intussusception, and other purely mechanical obstructive situations generally require reoperation. However, gastric retention is related more frequently to transient phenomena, perhaps a combination of stomal edema and gastric atony. Clinical observations indicate the possible development of a vicious circle of stomal obstruction and gastric atony correctable by gastric decompression. Early recognition followed by continuous decompression with a nasogastric tube for 24 to 48 hours (or the use of a gastrostomy tube, if this complication has been anticipated), feeding, and gastric aspirations twice daily usually will correct this complication. The tube should be removed between aspirations done before breakfast and 5 to 6 hours after the evening meal. If some degree of outlet patency is demonstrated by radiographic contrast studies, bethanechol (Urecholine) or a similar smooth muscle stimulant may hasten recovery. Parenteral administration of nutrients is advisable during this interval. This regimen may be discomforting for both patient and surgeon, but it is tolerated better than an early inappropriate operation. Skepticism about this simple concept often is expressed but frequent clinical observations have convinced us as well as our predecessors and colleagues of its validity. We seldom undertake reoperation before the 21st postoperative day unless unrelenting obstruction is demonstrated radiographically in the efferent limb or unless we are concerned about the development of intestinal ischemia or closed loop obstruction. Earlier reoperation too often discloses a normal, patent anastomosis which cannot be altered to advantage. After appropriate nonoperative treatment and delay, the surgeon will select those patients who have mechanical obstruction and will make a definitive alteration of a questionable stoma. We continue to see patients who have had inappropriate reoperations a week or 10 days after their original gastric operation. Many of these patients will respond to an appropriate program of gastric decompression, but too
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often anastomosis between afferent and efferent jejunal limbs is followed by persisting stomal obstruction or subsequent development of stomal ulcers. We have seen a few patients in whom gastric atony has had a major role in gastric retention, which first became clinically apparent 1 or 2 months after eperation. X-ray study revealed a dilated atonic stomach and a patent but slowly emptying stoma. Specific questioning revealed that some degree of gastric retention went unnoticed during early convalescence but progressed in severity. Further surgical treatment proved unnecessary for many of these patients who responded to a proper regimen of gastric decompression.
LATE POSTOPERATIVE OBSTRUCTION OF THE GASTRIC OUTLET Obstruction of the gastric outlet or efferent jejunal limb that develops close to the gastroenterostomy many months or years after operation for ulcer usually is caused by recurrent ulceration. In the absence of indications for immediate operation, assessment of gastric secretory response is mandatory for such patients. Evidence of incomplete vagotomy may alter the surgical approach, and the presence of achlorhydria may alert one to the possible existence of alkaline gastritis rather than acid peptic diathesis as the cause of stomal obstruction. Commoner manifestations of this entity will be discussed subsequently, but we have seen two patients with stomal obstruction caused by gastritis or prestomal gastric ulceration related to reflux of bile and pancreatic secretions. Because operations appropriate for this condition may be ulcerogenic, every effort should be made before operation to distinguish between acid and alkaline secretions as the cause of stomal stenosis. The same purely mechanical factors, unrelated to ulcer diathesis, that cause obstruction in the early surgical convalescence may obstruct the gastric outlet or efferent limb months or years after gastric operations. Because transient stomal complications or gastric atony rarely is a contributing factor at this time, the obstructing mechanism, or at least its location, usually can be demonstrated radiographically. Aqueous radiographic media may be used safely to advantage when obstructive mechanisms rather than mucosal detail require evaluation. However, when obstruction is associated with persistent pain or any evidence of local compromise of circulation, as may occur w,ith volvulus, closed loop obstruction of the afferent jejunal limb, retrograde intussusception, or herniations through the transverse mesocolon, prompt operation rather than meddlesome diagnostic study is indicated.
AFFERENT LOOP SYNDROME Accumulation of bile and pancreatic secretions within a partially obst-ructed afferent jejunal limb may cause sensations of epigastric fullness and pain. Increased pressure and jejunal contraction incident
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to distention of the limb may cause abrupt expulsion of secretions into the stomach with resultant vomiting and relief of distress. This concept of dysfunction is valid and a distinct clinical entity. However, unequivocal diagnosis may be difficult for several reasons: (1) varying degrees of obstruction may produce symptoms of varying severity and intermittency; (2) roentgenographic visualization or intubation of the obstructed afferent limb usually is impossible; and (3) postcibal distress and vomiting may be caused by other mechanisms that are poorly understood. Some authors 28 ,30-32 include such conditions in their consideration of afferent loop syndrome, but disorders of less certain cause are best considered separately. It seems most reasonable to consider afferent loop syndrome as a purely mechanical entity. Surgical evaluation is indicated only when there is significant disability and when preoperative evaluation gives one the perspective to deal with other possible etiologic factors, such as alkaline gastritis or small pouch syndrome, if obstruction of the afferent limb is not confirmed at operation. We have not had experience with the diagnostic maneuvers of Jordan and Dahlgren, but these provocative tests are reported to have value in resolving diagnostic uncertainty. Because the symptoms related to alkaline gastritis and to efferent loop syndrome may be similar, and because these phenomena may coexist, we have considered endoscopic examination an essential aspect of preoperative evaluation. Great reliance is placed on interpretation of the patient's description of his symptoms and we have been influenced by knowledge of the exact nature of previous operative procedures. A long, redundant afferent limb of the type more commonly used in antecolic anastomosis is more vulnerable to obstruction, but afferent limb syndromes have been documented after almost every type of gastrojejunal reconstruction subsequent to gastric resection. Although symptoms may be modified by the presence of a patent pylorus, variations of the syndrome have been described after gastroenterostomy alone. Some confusion can be avoided if symptoms that develop in the absence of an afferent limb (as with gastroduodenal anastomosis after resection or after pyloroplasty) are most properly classified and considered separately. Earlier efforts to modify discomforting retention and abrupt expulsion of bile from the afferent limb involved a variety of procedures to suspend, plicate, or shorten the prestomallimb. Failure to correct completely the precise obstructing mechanism and persistence of bile reflux into the stomach after such operations contributed to frequent therapeutic failures. Although anastomoses between afferent and efferent jejunal limbs and simple conversion to a Roux limb have theoretical disadvantages, these simple expedients may have merit when the risk of alternative revisions is increased by severe adhesive reactions or the patient's general condition. These procedures must be avoided if there is any question about stomal patency; and the anastomosis which is now denied the neutralizing effect of bile and pancreatic secretions must be protected from ulceration by vagotomy. By definition, the afferent limb syndrome should be correctable by
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elimination of the afferent limb. However, simple conversion to gastroduodenostomy is reported to give imperfect relief in some cases. It is likely that gastric sensitivity to alkaline reflux (alkaline gastritis) has had an additional role in the production of symptoms in such cases. Because alkaline reflux is common after gastroduodenostomy, interposition of an isoperistaltic jejunal segment between stomach and duodenum and vagotomy to protect the neostoma appear to be the procedures of choice. We have not had experience with the Tanner procedure26 (the construction of a circular loop in the gastric limb of a Roux limb, the socalled Roux 19). Several authors have reported success with this operation although it seems unnecessarily complex to us.
ACUTE OBSTRUCTION OF THE AFFERENT LOOP An altogether different clinical picture results from acute complete obstruction of the afferent jejunal limb. Occurring either in the early surgical convalescence or months or years after Billroth II gastrectomy, the local and systemic manifestations of closed loop obstruction predominate over symptoms of dysfunction common to the other conditions discussed. Thus, this uncommon entity deserves mention only because it shares a causal mechanism with chronic recurring afferent loop syndrome. The need for prompt operative intervention should be obvious if the surgeon is not misled by elevations of serum levels of pancreatic enzymes that may occur when bile and pancreatic duct pressures are exceeded by the pressures in the closed afferent limb. 19 • 27 Gangrenous bowel must be resected and gastrointestinal continuity reestablished; reconstruction obviously is challenging and hazardous if the duodenum related to the biliary and pancreatic ducts must be resected. 10 If the obstructed afferent limb is viable, correction of the obstructive mechanism may be possible with or without resection of portions of the redundant limb, and simple decompression by enteroanastomosis may prove satisfactory if stomal obstruction is not ignored and vagotomy is done to minimize the risk of stomal ulceration.
ALKALINE REFLUX GASTRITIS Since Du Plessis 4 • 5 and Lawson demonstrated that gastric mucosal changes (gastritis or gastric ulcer) may occur in patients and experimental animals in response to reflux of pancreatic secretions and bile into the stomach, we have come to recognize reflux alkaline gastritis as a definite clinical entity. Successful treatment of five patients by biliary diversion employing a Roux limb was reported by Van Heerden and associates from this clinic in 1969. Subsequent experience has been confirmatory and interposition of an isoperistaltic jejunal segment between stomach and duodenum also has given satisfactory results. Criteria for diagnosis include the presence of persistent epigastric pain or pain provoked by eating, total or near achlorhydria, and endo-
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scopic evidence of bile reflux and gastritis or ulcer on the gastric aspect of an anastomosis. The syndrome is seen after gastroenterostomy alone or after gastric resection and either gastroduodenal or gastrojejunal anastomoses. Treatment consists of preventing bile reflux by Roux-Y drainage or isoperistaltic jejunal interposition and protecting the anastomosis from acid peptic ulceration with vagotomy. Even in the achlorhydric patient, vagotomy is essential because the resolution of gastritis may be accompanied by regeneration of acid-producing mucosa. In addition to patients who fulfill all diagnostic criteria for alkaline gastritis whose typical severe symptoms have responded dramatically to biliary diversion, we have seen many patients whose evaluation has raised questions about less certain aspects of alkaline reflux. Regurgitation of bile into the stomach is commonly seen during endoscopic examinations in the absence of gastritis, and some patients with reflux and evidence of prestomal gastritis are asymptomatic. Whereas most patients with symptomatic alkaline gastritis are achlorhydric or nearly so, symptoms and endoscopic evidence of prestomal gastritis without anastomotic or jejunal ulceration have been observed in patients with more normal levels of gastric acidity. Whether efforts to control refluJ:< involve greater risk of subsequent acid-peptic ulcer for such patients remains uncertain. Short-term observation of a single patient having alkaline gastritis and a normal gastric secretory pattern treated by conversion to Roux-Y drainage and vagotomy is encouraging. Most frustrating to us have been patients who present with pain, achlorhydria, and endoscopic evidence of alkaline gastritis and who also have severe dumping syndrome and diarrhea. The dilemma is obvious in that one hopes to prevent reflux and still delay gastric emptying significantly.
POSTPRANDIAL DUMPING SYNDROME Vasomotor symptoms, with or without diarrhea or cramping abdominal distress, are experienced during or soon after meals by a third or more of patients who have had operations which alter pyloric function or create a new gastric outlet. Fortunately, in most cases symptoms are milk, occur only occasionally, improve with time, or respond to alterations in diet. Surgery must be considered for about 1 % of these patients, that is, those with incapacitating discomfort and malnutrition. Of all unfavorable sequelae of gastric surgery, this entity has stimulated the greatest interest, the largest variety of remedial operations, and the most controversy. Limitations of space preclude detailed review and crediting of all contributions to the evolution of surgical treatment, and current concepts can be summarized only briefly herein. The reader is encouraged to study Herrington's scholarly comprehensive review of the literature and report of his experience. Although the metabolic and physiologic changes accompanying dumping syndrome are complex, the underlying mechanical cause is
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simple-rapid gastric emptying. All remedial operations have in common the goal of simulating pyloric function and restoring to the gastric pouch its function as a reservoir. Although the size of a gastroenteric anastomosis influences the rate of gastric emptying, quantitation of stomal size for remedial operations is uncertain, carries a risk of producing obstruction, and has produced variable results. Because the incidence of dumping syndrome after gastroduodenal anastomoses is generally reported to be less than that after gastrojejunostomy, conversion of a Billroth II operation to a Billroth I operation has been tried by many authors. Borg and associates and Andreassen analyzed their experience and offered convincing evidence that conversion from gastrojejunostomy to gastroduodenostomy should be avoided for relief of dumping. A recent review of patients so treated at this clinic in earlier years has revealed generally unsatisfactory results. Whereas segments of transverse colon lack peristalsis, are susceptible to ulceration,15 and are generally agreed to be unsuitable for interposition between stomach and duodenum, good evidence now exists that interposition of jejunal segments constitutes the most appropriate remedial operation for the dumping syndrome. The relative effectiveness of isoperistaltic versus antiperistaltic segments is debatable, however, and disagreement exists concerning the proper length of jejunum to be utilized. Isoperistaltic segments of jejunum appear to be less effective in delaying gastric emptying and in restoring gastric reservoir function than are antiperistaltic segments of similar length. Although some surgeons report unsatisfactory or inconsistent results after isoperistaltic transfer,I°' 17. 18 Henley continues to employ this procedure. Hedenstedt and Lundquist prefer to use isoperistaltic segments 10 to 15 cm in length, having encountered motility disturbances and retention in 50% of patients with reversed jejunal segments 6 to 15 cm in length. Whether their unfavorable results were associated with the use of longer segments and whether differences in length attributable to variations in technique for measuring intestine in the relaxed or contracted state account for these problems cannot be determined from their report. Although most surgeons in this country report less satisfactory results with isoperistaltic segments of the length employed by Henley and Hedenstedt and Lundquist, others present evidence that long segments (25 to 30 cm or longer) may be more effective in delaying gastric emptying or providing some reservoir function. 6 ,18 Individualization regarding the use of vagotomy with isoperistaltic transfers has been recommended by some surgeons on the basis of gastric secretory studies or the type of ulcer (duodenal or gastric) primarily treated. However, it seems most reasonable to utilize vagotomy to minimize the risk of stomal ulceration whenever the gastric outlet is not exposed to alkaline secretions. 22 Herrington, Jordan, Poth, Rutledge, and others report satisfactory control of the dumping syndrome employing lO-cm antiperistaltic segments measured prior to the division and isolation of the intestinal segment. Although Stemmer and associates have had success with
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shorter (4 to 6 cm) reverse segments, they measured the intestine in the contracted state, so actually their segments may have been as long as those used by the other surgeons. Obstructive complications have not been reported by these authors when 25% or more of the stomach remains, but there is general agreement that swollen gastric pouches may be obstructed by antiperistaltic segments. As one becomes concerned that conflicting reports about the relative effectiveness of isoperistaltic and antiperistaltic segments may be due to undefinable differences in the selection of patients for treatment and minor differences in technique, the reported experience of Herrington becomes most impressive. He has had extensive experience with both operations and is specific in his descriptions of operative technique. His results with isoperistaltic jejunal transfers 10 to 20 cm in length were far from satisfactory and he reported 12 excellent and 2 good results for 14 patients having antiperistaltic interpositions 10 cm in length. Although Stemmer and associates reported similarly satisfactory results using somewhat shorter segments, Jordan attributed failure of treatment in two patients to the use of 6-cm segments and now favors the use of segments 10 cm in length. Because regurgitation of bile can be demonstrated in the gastric pouch after antiperistaltic transfer, there is less justification for vagotomy. However, good results have been reported with and without vagotomy. More complicated, ingenious arrangements of jejunal segments, which combine isoperistaltic and antiperistaltic intervals connected by enteroanastomoses between contiguous loops, and various pouch constructions have been used and favored by some authorsP· 20, 32 The reservoir function offered by these operations may be useful in the presence of minute, poorly contracting gastric pouches, but in other respects these operations seem unnecessarily complicated for the management of the dumping syndrome. Our experience with surgical treatment of dumping as an isolated entity is limited, but experience with dumping associated with other states gives us perspective in evaluating the reports of other authors, appreciation and some envy of those who report consistently excellent results, and sympathy with those who report therapeutic failures apparently related to variation in selection of patients, undefinable physiologic disturbances, or emotional factors. Most of our experience is recent and some results are equivocal. Initial enthusiasm for the use of isoperistaltic segments was stimulated by dramatic relief of severe dumping and diarrhea for a patient who had experienced a loss of 70 pounds after a Billroth II gastrectomy and vagotomy. After interposition of an isoperistaltic segment 18 cm in length between the stomach and the duodenum, the patient was completely relieved of symptoms of dumping and diarrhea and regained his normal weight. We were then attracted to the use of isoperistaltic segments in four patients who had incapacitating pain and definite evidence of severe alkaline reflux gastritis associated with disabling vasomotor and gas-
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trointestinal manifestations of dumping syndrome. Fearing persistence of alkaline reflux with antiperistaltic interposition, isoperistaltic transfers were utilized for these patients with the addition of vagotomy when the procedure had not been done before or had proved to be incomplete. The pain of alkaline gastritis has been relieved, but incomplete relief of dumping and postcibal diarrhea for these patients and several others so treated for dumping syndrome alone has impressed us with the definite limitations of isoperistaltic interposition for the management of dumping syndrome. Although we are attracted by the reported advantages of antiperistaltic segments in retarding gastric emptying and controlling vasomotor gastrointestinal symptoms of dumping as a separate entity, we remain hesitant to employ such revisions in the presence of clinically significant alkaline gastritis, and are more attracted to the use of longer isoperistaltic segments when confronted by patients with these combined disorders. We continue to be impressed by the role of undefined physiologic and possible psychologic factors in patients whose satisfactory progress is interrupted by episodes of anorexia, nausea, or vomiting in the absence of demonstrable mechanical obstruction. For some patients, the line between beneficial delay of gastric emptying and dysfunction appears to be exceedingly fine. Although the dumping syndrome is experienced by most patients during or soon after meals, a few patients will suffer vasomotor symptoms common to the dumping syndrome 2 to 4 hours after eating. This syndrome appears to be related to a reactive hypoglycemia16 that follows insulin response to initial hyperglycemia. We have had no experience with the surgical treatment of this condition. Woodward30 reports successful treatment of two patients. Delay in gastric empyting prevented early hyperglycemia as well as the late reactive hypoglycemia.
THE SMALL GASTRIC POUCH SYNDROME We have had no experience with remedial operations for the disability that may attend exceedingly small gastric remnants and have some concern about motility disturbances that develop when isoperistaltic jejunal segments are used to drain larger gastric remnants. Various ingenious loops and pouches, however, have been designed and reported to be beneficial by several authors. Study of the writings of Poth and Cleveland and Lawrence and associates as well as the review of this subject by Herrington is recommended.
POSTV AGOTOMY DIARRHEA After vagotomy some patients experience diarrhea that is distinguishable from the diarrhea that may accompany the vasomotor symptoms of dumping syndrome.7 Loose stools, often explosive in onset, may
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be unrelated to meals or may even awaken the patient. Truly disabling diarrhea of this type is rare and there is debate about its cause. Herrington, however, recognized a mechanism different from the dumping syndrome and has successfully treated nine patients with severe postvagotomy diarrhea by reversal of a 10-cm jejunal segment 50 to 100 cm from the ligament of Treitz. He pointed out the probable role of absorptive functions in the proximal portion of the jejunum and suggested that the more distal reversal pennits better mixing of ingested food with biliary and pancreatic secretions. Herrington, Poth,21 Stemmer and associates, and Madding and associates give evidence for the fact that this procedure has less or no effect on the vasomotor symptoms as compared with gastroduodenal interposition, because the proximal jejunum is still exposed to hyperosmolar content of the bowel. Herrington reported the case of one patient who was relieved of postvagotomy diarrhea by reversal of a distal segment and of persisting vasomotor dumping symptoms by interposition of another reversed segment between the stomach and the duodenum.
SUMMARY Gastric retention that follows operation for gastroduodenal ulcer is most often related to transient stomal obstruction or altered gastric motility, which will respond to a proper program of gastric decompression. In the absence of suspicion or signs of intestinal ischemia or x-ray evidence of other more specific causes of obstruction, delay and nonoperative treatment will lead to selection of those patients who truly need reoperation and will give the surgeon conviction about the need to make proper definitive alterations of questionable obstructive mechanisms when reoperation clearly becomes necessary. The term "afferent loop syndrome" is best used to describe symptoms related only to partial obstruction of the afferent jejunal limb, postcibal distress relieved by bilious vomiting. Revision of gastrointestinal continuity by interposition of an isoperistaltic jejunal segment between stomach and duodenum does away with the afferent limb, prevents reflux of bile into the stomach, and generally constitutes the most effective treatment. Alkaline gastritis may be responsible for some symptoms in afferent loop syndrome and may be the phenomenon responsible for disability occurring in the absence of demonstrable mechanical obstruction of the afferent jejunal limb erroneou~ly classified as "afferent loop syndrome" by some authors. Patients who experience constant or postcibal pain and who have endoscopic evidence of regurgitation of bile into the stomach, prestomal gastritis or gastric ulcer, and near or total achlorhydria may be relieved of their symptoms by biliary diversion utilizing a Roux limb or isoperistaltic jejunal segment interposed between stomach and duodenum. Vagotomy must be added to these procedures. Relief from vasomotor and gastrointestinal symptoms of the dumping syndrome may be obtained by operations that delay emptying of the
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stomach and restore its function as a reservoir. Interposition of isoperistaltic segments of jejunum 10 to 12 cm in length between stomach and duodenum is favored by British and Scandinavian authors, but most American surgeons consider such isoperistaltic segments to have limited effectiveness. Most surgeons in this country consider similar transfers of antiperistaltic jejunal segments 10 cm in length to be more effective in the control of dumping syndrome. Postvagotomy diarrhea, which is patternless and is not associated with postcibal dumping syndrome, is a distinct entity. Patients are reported to respond to reversal of a 10-cm jejunal segment 50 to 100 cm distal to the ligament of Treitz.
REFERENCES 1. Andreassen M: Surgical treatment of severe dumping syndrome: conversion of Billroth II into Billroth 1. Acta Chir Scand SuppI283:221-227, 1961 2. Borg I, Borgstrom SG, Haeger K: The value of the B II-B I conversion operation in the treatment of the postgastrectomy syndrome. Acta Chir Scand 134:655-659, 1968 3. Dahlgren S: The afferent loop syndrome. Acta Chir Scand Supp1327: 1-149,1964 4. Du Plessis DJ: Gastric mucosal changes after operations on the stomach. South African Med J 36:471-478, 1962 5. Du Plessis DJ: Pathogenesis of gastric ulceration. Lancet 1 :974-978,1965 6. Gerwig WH Jr, Easley GW, Mendoza CB Jr: Results following remedial operations for severe dumping syndrome. Arch Surg (Chicago) 95:631-634, 1967 7. Harkins HN, Stavney LS, Griffith CA, et al: Selective gastric vagotomy. Ann Surg 158: 448-460, 1963 8. Hedenstedt S, Lunquist G: Antiperistaltic jejunal segment in gastric surgery. Acta Chir Scand 133:545-554, 1967 9. Henley FA: Jejunal graft interposition in the correction of postgastrectomy syndromes. XXII Cong Soc Int Chir 1967 10. Herrington JL Jr: Remedial operations for post gastrectomy syndromes. Curr Probl Surg, 1970, pp 3-63 11. Jordan GL Jr: Surgical management of post gastrectomy problems. Arch Surg (Chicago) 102:251-258,1971 12. Lawrence W Jr, Kim M, Isaacs M, et al: Gastric reservoir construction for severe disability after subtotal gastrectomy. Surg Gynec Obstet 119:1219-1232, 1964 13. Lawson HH: Effect of duodenal contents on the gastric mucosa under experimental conditions. Lancet 1 :469-472, 1964 14. Madding GF, Kennedy PA, McLaughlin RT: Clinical use of anti-peristaltic bowel segments. Ann Surg 161 :601-604, 1965 15. Moroney J: Colonic replacement of the stomach. Lancet 1 :993-996, 1951 16. Muir A: Postgastrectomy syndromes. Brit J Surg 37:165-178,1949 17. Nagel CB: Clinical experiences with jejunal interposition for postgastrectomy syndrome. Calif Med 107:399-405, 1967 18. Nagel CB, Farris JM: Clinical experiences with corrective surgery for the dumping syndrome. Amer J Surg 116:229-234, 1968 19. Perry JF Jr: Post-gastrectomy proximal jejunal loop obstruction simulating acute pancreatitis. Ann Surg 140:119-121, 1954 20. Poth EJ: The dumping syndrome and its surgical treatment. Amer Surg 23:1097-1102, 1957 21. Poth EJ: Treatment of the dumping syndrome by the use of antiperistaltic segment of jejunum. In Current Surgical Management III: A Book of Alternative Viewpoints on Controversial Surgical Problems. Edited by EH Ellison, SR Friesen, JH Mulholland. Philadelphia, WB Saunders Company, 1965, pp 383-386 22. Poth EJ: Use of gastrointestinal reversal in surgical procedures. Amer J Surg 118:893899,1969 23. Poth EJ, Cleveland BR: A functional substitution pouch for the stomach (B). Arch Surg (Chicago) 83:42-52, 1961 24. Rutledge RH: Jejunal segments for the post gastrectomy syndromes. Ann Surg 169: 810-825, 1969
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25. Stemmer EA, Jones SA, Pearson SC, et al: Antiperistaltic segments of jejunum in the treatment of the dumping syndrome. Arch Surg (Chicago) 98:396-404,1969 26. Tanner NC: Disabilities which may follow the peptic ulcer operation. Proc Roy Soc Med 59:362-368, 1966 27. Thal A, Perry JF Jr: A further case of afferent loop obstruction simulating acute pancreatitis. Ann Surg 143:266-268, 1956 28. Toye DKM, Williams JA: Post-gastrectomy bile vomiting. Lancet 2:524-526,1965 29. Van Heerden JA, Priestley JT, Farrow GM, et al: Postoperative alkaline reflux gastritis: surgical implications. Amer J Surg 118:427-434, 1969 30. Woodward ER: The Postgastrectomy Syndromes. Springfield, Illinois, Charles C Thomas, Publisher, 1963 31. Woodward ER: The pathophysiology of afferent loop syndromes. SURG CLIN N AMER 46: 411-423, 1966 32. Woodward ER, Hastings N: Surgical treatment of the post gastrectomy dumping syndrome. Surg Gynec Obstet 111 :429-437, 1960
Management of Gastrointestinal Dysfunction After Gastric Surgery Martin A. Adson, M.D., and Onye E. Akwari, M.D.
Although minor disturbances in digestive function after gastric surgery are not uncommon, major disability fortunately is rare. Disabling early satiety, frequent or persistent vomiting, severe diarrhea with or without postcibal vasomotor reactions, or incapacitating pain in the absence of recurrent ulceration develops in less than 5% of patients who have undergone surgical treatment for gastric or duodenal ulcer. Most patients so affected will improve with time or will respond to medication or altered diet. Further operation must be considered for 1 or 2% of patients. When mechanical factors responsible for dysfunction can be defined, a proper remedial operation can be conceived without difficulty. However, disturbances related to abnormal gastrointestinal motility or to exaggerated vasomotor or metabolic reactions as well as to disability associated with psychiatric problems respond less predictably to mechanical alterations of existing anatomic relations. Major contributions to understanding of physiologic abnormalities have been made in recent years, and operations that restore more normal function have been developed. Reported results, however, are variable, and there is still debate about the most suitable operative procedure for certain specific disturbances. When it is realized that few patients are incapacitated by anatomic alterations that are well tolerated by more than 90% of patients who have had similar operative procedures, it is not surprising that the results of further structural revisions may be unpredictable. Also, the results of surgical treatment may be compromised by psychiatric factors. Some patients seem reluctant to live without discomfort, since they have achieved secondary gain from their disability, and drug dependency may complicate rehabilitation and interpretation of therapeutic results. Most frustrating to surgeons have been the combinations of syndromes, common to our practice, which present a therapeutic dilemma. A patient with severe dumping syndrome who also vomits frequently may respond poorly to an operative procedure which delays gastric emptying, and the Surgical Clinics of North America-VOl. 51, No.4, August 1971
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patient who had dumping and alkaline gastritis may be relieved of postcibal vasomotor reactions after interposition of an antiperistaltic jejunal segment between the stomach and the duodenum only to suffer further from the effects of reflux of bile into the stomach. Although these complicated combinations of syndromes continue to frustrate us, and in specific cases the choice of an appropriate operative procedure remains a problem, rehabilitation of many so-called gastric cripples is now possible with appropriate remedial operations.
EARLY POSTOPERATIVE GASTRIC RETENTION After gastric resection or drainage procedures with or without vagotomy, normal gastric empyting usually will resume within a few days. The return of this function, however, may be delayed for 5 to 7 days, or at times, varying degrees of gastric retention may develop after a week of apparently normal function. Minor dysfunction may go undetected or may resolve without treatment, but persistent gastric retention requires specific treatment. Stomal or efferent limb obstruction that results from technical error, an adhesive kink or twist, volvulus or internal hernia, intussusception, and other purely mechanical obstructive situations generally require reoperation. However, gastric retention is related more frequently to transient phenomena, perhaps a combination of stomal edema and gastric atony. Clinical observations indicate the possible development of a vicious circle of stomal obstruction and gastric atony correctable by gastric decompression. Early recognition followed by continuous decompression with a nasogastric tube for 24 to 48 hours (or the use of a gastrostomy tube, if this complication has been anticipated), feeding, and gastric aspirations twice daily usually will correct this complication. The tube should be removed between aspirations done before breakfast and 5 to 6 hours after the evening meal. If some degree of outlet patency is demonstrated by radiographic contrast studies, bethanechol (Urecholine) or a similar smooth muscle stimulant may hasten recovery. Parenteral administration of nutrients is advisable during this interval. This regimen may be discomforting for both patient and surgeon, but it is tolerated better than an early inappropriate operation. Skepticism about this simple concept often is expressed but frequent clinical observations have convinced us as well as our predecessors and colleagues of its validity. We seldom undertake reoperation before the 21st postoperative day unless unrelenting obstruction is demonstrated radiographically in the efferent limb or unless we are concerned about the development of intestinal ischemia or closed loop obstruction. Earlier reoperation too often discloses a normal, patent anastomosis which cannot be altered to advantage. After appropriate nonoperative treatment and delay, the surgeon will select those patients who have mechanical obstruction and will make a definitive alteration of a questionable stoma. We continue to see patients who have had inappropriate reoperations a week or 10 days after their original gastric operation. Many of these patients will respond to an appropriate program of gastric decompression, but too
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often anastomosis between afferent and efferent jejunal limbs is followed by persisting stomal obstruction or subsequent development of stomal ulcers. We have seen a few patients in whom gastric atony has had a major role in gastric retention, which first became clinically apparent 1 or 2 months after eperation. X-ray study revealed a dilated atonic stomach and a patent but slowly emptying stoma. Specific questioning revealed that some degree of gastric retention went unnoticed during early convalescence but progressed in severity. Further surgical treatment proved unnecessary for many of these patients who responded to a proper regimen of gastric decompression.
LATE POSTOPERATIVE OBSTRUCTION OF THE GASTRIC OUTLET Obstruction of the gastric outlet or efferent jejunal limb that develops close to the gastroenterostomy many months or years after operation for ulcer usually is caused by recurrent ulceration. In the absence of indications for immediate operation, assessment of gastric secretory response is mandatory for such patients. Evidence of incomplete vagotomy may alter the surgical approach, and the presence of achlorhydria may alert one to the possible existence of alkaline gastritis rather than acid peptic diathesis as the cause of stomal obstruction. Commoner manifestations of this entity will be discussed subsequently, but we have seen two patients with stomal obstruction caused by gastritis or prestomal gastric ulceration related to reflux of bile and pancreatic secretions. Because operations appropriate for this condition may be ulcerogenic, every effort should be made before operation to distinguish between acid and alkaline secretions as the cause of stomal stenosis. The same purely mechanical factors, unrelated to ulcer diathesis, that cause obstruction in the early surgical convalescence may obstruct the gastric outlet or efferent limb months or years after gastric operations. Because transient stomal complications or gastric atony rarely is a contributing factor at this time, the obstructing mechanism, or at least its location, usually can be demonstrated radiographically. Aqueous radiographic media may be used safely to advantage when obstructive mechanisms rather than mucosal detail require evaluation. However, when obstruction is associated with persistent pain or any evidence of local compromise of circulation, as may occur w,ith volvulus, closed loop obstruction of the afferent jejunal limb, retrograde intussusception, or herniations through the transverse mesocolon, prompt operation rather than meddlesome diagnostic study is indicated.
AFFERENT LOOP SYNDROME Accumulation of bile and pancreatic secretions within a partially obst-ructed afferent jejunal limb may cause sensations of epigastric fullness and pain. Increased pressure and jejunal contraction incident
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to distention of the limb may cause abrupt expulsion of secretions into the stomach with resultant vomiting and relief of distress. This concept of dysfunction is valid and a distinct clinical entity. However, unequivocal diagnosis may be difficult for several reasons: (1) varying degrees of obstruction may produce symptoms of varying severity and intermittency; (2) roentgenographic visualization or intubation of the obstructed afferent limb usually is impossible; and (3) postcibal distress and vomiting may be caused by other mechanisms that are poorly understood. Some authors 28 ,30-32 include such conditions in their consideration of afferent loop syndrome, but disorders of less certain cause are best considered separately. It seems most reasonable to consider afferent loop syndrome as a purely mechanical entity. Surgical evaluation is indicated only when there is significant disability and when preoperative evaluation gives one the perspective to deal with other possible etiologic factors, such as alkaline gastritis or small pouch syndrome, if obstruction of the afferent limb is not confirmed at operation. We have not had experience with the diagnostic maneuvers of Jordan and Dahlgren, but these provocative tests are reported to have value in resolving diagnostic uncertainty. Because the symptoms related to alkaline gastritis and to efferent loop syndrome may be similar, and because these phenomena may coexist, we have considered endoscopic examination an essential aspect of preoperative evaluation. Great reliance is placed on interpretation of the patient's description of his symptoms and we have been influenced by knowledge of the exact nature of previous operative procedures. A long, redundant afferent limb of the type more commonly used in antecolic anastomosis is more vulnerable to obstruction, but afferent limb syndromes have been documented after almost every type of gastrojejunal reconstruction subsequent to gastric resection. Although symptoms may be modified by the presence of a patent pylorus, variations of the syndrome have been described after gastroenterostomy alone. Some confusion can be avoided if symptoms that develop in the absence of an afferent limb (as with gastroduodenal anastomosis after resection or after pyloroplasty) are most properly classified and considered separately. Earlier efforts to modify discomforting retention and abrupt expulsion of bile from the afferent limb involved a variety of procedures to suspend, plicate, or shorten the prestomallimb. Failure to correct completely the precise obstructing mechanism and persistence of bile reflux into the stomach after such operations contributed to frequent therapeutic failures. Although anastomoses between afferent and efferent jejunal limbs and simple conversion to a Roux limb have theoretical disadvantages, these simple expedients may have merit when the risk of alternative revisions is increased by severe adhesive reactions or the patient's general condition. These procedures must be avoided if there is any question about stomal patency; and the anastomosis which is now denied the neutralizing effect of bile and pancreatic secretions must be protected from ulceration by vagotomy. By definition, the afferent limb syndrome should be correctable by
GASTROINTESTINAL DYSFUNCTION AFTER GASTRIC SURGERY
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elimination of the afferent limb. However, simple conversion to gastroduodenostomy is reported to give imperfect relief in some cases. It is likely that gastric sensitivity to alkaline reflux (alkaline gastritis) has had an additional role in the production of symptoms in such cases. Because alkaline reflux is common after gastroduodenostomy, interposition of an isoperistaltic jejunal segment between stomach and duodenum and vagotomy to protect the neostoma appear to be the procedures of choice. We have not had experience with the Tanner procedure26 (the construction of a circular loop in the gastric limb of a Roux limb, the socalled Roux 19). Several authors have reported success with this operation although it seems unnecessarily complex to us.
ACUTE OBSTRUCTION OF THE AFFERENT LOOP An altogether different clinical picture results from acute complete obstruction of the afferent jejunal limb. Occurring either in the early surgical convalescence or months or years after Billroth II gastrectomy, the local and systemic manifestations of closed loop obstruction predominate over symptoms of dysfunction common to the other conditions discussed. Thus, this uncommon entity deserves mention only because it shares a causal mechanism with chronic recurring afferent loop syndrome. The need for prompt operative intervention should be obvious if the surgeon is not misled by elevations of serum levels of pancreatic enzymes that may occur when bile and pancreatic duct pressures are exceeded by the pressures in the closed afferent limb. 19 • 27 Gangrenous bowel must be resected and gastrointestinal continuity reestablished; reconstruction obviously is challenging and hazardous if the duodenum related to the biliary and pancreatic ducts must be resected. 10 If the obstructed afferent limb is viable, correction of the obstructive mechanism may be possible with or without resection of portions of the redundant limb, and simple decompression by enteroanastomosis may prove satisfactory if stomal obstruction is not ignored and vagotomy is done to minimize the risk of stomal ulceration.
ALKALINE REFLUX GASTRITIS Since Du Plessis 4 • 5 and Lawson demonstrated that gastric mucosal changes (gastritis or gastric ulcer) may occur in patients and experimental animals in response to reflux of pancreatic secretions and bile into the stomach, we have come to recognize reflux alkaline gastritis as a definite clinical entity. Successful treatment of five patients by biliary diversion employing a Roux limb was reported by Van Heerden and associates from this clinic in 1969. Subsequent experience has been confirmatory and interposition of an isoperistaltic jejunal segment between stomach and duodenum also has given satisfactory results. Criteria for diagnosis include the presence of persistent epigastric pain or pain provoked by eating, total or near achlorhydria, and endo-
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scopic evidence of bile reflux and gastritis or ulcer on the gastric aspect of an anastomosis. The syndrome is seen after gastroenterostomy alone or after gastric resection and either gastroduodenal or gastrojejunal anastomoses. Treatment consists of preventing bile reflux by Roux-Y drainage or isoperistaltic jejunal interposition and protecting the anastomosis from acid peptic ulceration with vagotomy. Even in the achlorhydric patient, vagotomy is essential because the resolution of gastritis may be accompanied by regeneration of acid-producing mucosa. In addition to patients who fulfill all diagnostic criteria for alkaline gastritis whose typical severe symptoms have responded dramatically to biliary diversion, we have seen many patients whose evaluation has raised questions about less certain aspects of alkaline reflux. Regurgitation of bile into the stomach is commonly seen during endoscopic examinations in the absence of gastritis, and some patients with reflux and evidence of prestomal gastritis are asymptomatic. Whereas most patients with symptomatic alkaline gastritis are achlorhydric or nearly so, symptoms and endoscopic evidence of prestomal gastritis without anastomotic or jejunal ulceration have been observed in patients with more normal levels of gastric acidity. Whether efforts to control refluJ:< involve greater risk of subsequent acid-peptic ulcer for such patients remains uncertain. Short-term observation of a single patient having alkaline gastritis and a normal gastric secretory pattern treated by conversion to Roux-Y drainage and vagotomy is encouraging. Most frustrating to us have been patients who present with pain, achlorhydria, and endoscopic evidence of alkaline gastritis and who also have severe dumping syndrome and diarrhea. The dilemma is obvious in that one hopes to prevent reflux and still delay gastric emptying significantly.
POSTPRANDIAL DUMPING SYNDROME Vasomotor symptoms, with or without diarrhea or cramping abdominal distress, are experienced during or soon after meals by a third or more of patients who have had operations which alter pyloric function or create a new gastric outlet. Fortunately, in most cases symptoms are milk, occur only occasionally, improve with time, or respond to alterations in diet. Surgery must be considered for about 1 % of these patients, that is, those with incapacitating discomfort and malnutrition. Of all unfavorable sequelae of gastric surgery, this entity has stimulated the greatest interest, the largest variety of remedial operations, and the most controversy. Limitations of space preclude detailed review and crediting of all contributions to the evolution of surgical treatment, and current concepts can be summarized only briefly herein. The reader is encouraged to study Herrington's scholarly comprehensive review of the literature and report of his experience. Although the metabolic and physiologic changes accompanying dumping syndrome are complex, the underlying mechanical cause is
~ j'
;1 I'
II
II II
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I.·I!
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II
I
GASTROINTESTINAL DYSFUNCTION AFTER GASTRIC SURGERY
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simple-rapid gastric emptying. All remedial operations have in common the goal of simulating pyloric function and restoring to the gastric pouch its function as a reservoir. Although the size of a gastroenteric anastomosis influences the rate of gastric emptying, quantitation of stomal size for remedial operations is uncertain, carries a risk of producing obstruction, and has produced variable results. Because the incidence of dumping syndrome after gastroduodenal anastomoses is generally reported to be less than that after gastrojejunostomy, conversion of a Billroth II operation to a Billroth I operation has been tried by many authors. Borg and associates and Andreassen analyzed their experience and offered convincing evidence that conversion from gastrojejunostomy to gastroduodenostomy should be avoided for relief of dumping. A recent review of patients so treated at this clinic in earlier years has revealed generally unsatisfactory results. Whereas segments of transverse colon lack peristalsis, are susceptible to ulceration,15 and are generally agreed to be unsuitable for interposition between stomach and duodenum, good evidence now exists that interposition of jejunal segments constitutes the most appropriate remedial operation for the dumping syndrome. The relative effectiveness of isoperistaltic versus antiperistaltic segments is debatable, however, and disagreement exists concerning the proper length of jejunum to be utilized. Isoperistaltic segments of jejunum appear to be less effective in delaying gastric emptying and in restoring gastric reservoir function than are antiperistaltic segments of similar length. Although some surgeons report unsatisfactory or inconsistent results after isoperistaltic transfer,I°' 17. 18 Henley continues to employ this procedure. Hedenstedt and Lundquist prefer to use isoperistaltic segments 10 to 15 cm in length, having encountered motility disturbances and retention in 50% of patients with reversed jejunal segments 6 to 15 cm in length. Whether their unfavorable results were associated with the use of longer segments and whether differences in length attributable to variations in technique for measuring intestine in the relaxed or contracted state account for these problems cannot be determined from their report. Although most surgeons in this country report less satisfactory results with isoperistaltic segments of the length employed by Henley and Hedenstedt and Lundquist, others present evidence that long segments (25 to 30 cm or longer) may be more effective in delaying gastric emptying or providing some reservoir function. 6 ,18 Individualization regarding the use of vagotomy with isoperistaltic transfers has been recommended by some surgeons on the basis of gastric secretory studies or the type of ulcer (duodenal or gastric) primarily treated. However, it seems most reasonable to utilize vagotomy to minimize the risk of stomal ulceration whenever the gastric outlet is not exposed to alkaline secretions. 22 Herrington, Jordan, Poth, Rutledge, and others report satisfactory control of the dumping syndrome employing lO-cm antiperistaltic segments measured prior to the division and isolation of the intestinal segment. Although Stemmer and associates have had success with
922
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shorter (4 to 6 cm) reverse segments, they measured the intestine in the contracted state, so actually their segments may have been as long as those used by the other surgeons. Obstructive complications have not been reported by these authors when 25% or more of the stomach remains, but there is general agreement that swollen gastric pouches may be obstructed by antiperistaltic segments. As one becomes concerned that conflicting reports about the relative effectiveness of isoperistaltic and antiperistaltic segments may be due to undefinable differences in the selection of patients for treatment and minor differences in technique, the reported experience of Herrington becomes most impressive. He has had extensive experience with both operations and is specific in his descriptions of operative technique. His results with isoperistaltic jejunal transfers 10 to 20 cm in length were far from satisfactory and he reported 12 excellent and 2 good results for 14 patients having antiperistaltic interpositions 10 cm in length. Although Stemmer and associates reported similarly satisfactory results using somewhat shorter segments, Jordan attributed failure of treatment in two patients to the use of 6-cm segments and now favors the use of segments 10 cm in length. Because regurgitation of bile can be demonstrated in the gastric pouch after antiperistaltic transfer, there is less justification for vagotomy. However, good results have been reported with and without vagotomy. More complicated, ingenious arrangements of jejunal segments, which combine isoperistaltic and antiperistaltic intervals connected by enteroanastomoses between contiguous loops, and various pouch constructions have been used and favored by some authorsP· 20, 32 The reservoir function offered by these operations may be useful in the presence of minute, poorly contracting gastric pouches, but in other respects these operations seem unnecessarily complicated for the management of the dumping syndrome. Our experience with surgical treatment of dumping as an isolated entity is limited, but experience with dumping associated with other states gives us perspective in evaluating the reports of other authors, appreciation and some envy of those who report consistently excellent results, and sympathy with those who report therapeutic failures apparently related to variation in selection of patients, undefinable physiologic disturbances, or emotional factors. Most of our experience is recent and some results are equivocal. Initial enthusiasm for the use of isoperistaltic segments was stimulated by dramatic relief of severe dumping and diarrhea for a patient who had experienced a loss of 70 pounds after a Billroth II gastrectomy and vagotomy. After interposition of an isoperistaltic segment 18 cm in length between the stomach and the duodenum, the patient was completely relieved of symptoms of dumping and diarrhea and regained his normal weight. We were then attracted to the use of isoperistaltic segments in four patients who had incapacitating pain and definite evidence of severe alkaline reflux gastritis associated with disabling vasomotor and gas-
GASTROINTESTINAL DYSFUNCTION AFTER GASTRIC SURGERY
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trointestinal manifestations of dumping syndrome. Fearing persistence of alkaline reflux with antiperistaltic interposition, isoperistaltic transfers were utilized for these patients with the addition of vagotomy when the procedure had not been done before or had proved to be incomplete. The pain of alkaline gastritis has been relieved, but incomplete relief of dumping and postcibal diarrhea for these patients and several others so treated for dumping syndrome alone has impressed us with the definite limitations of isoperistaltic interposition for the management of dumping syndrome. Although we are attracted by the reported advantages of antiperistaltic segments in retarding gastric emptying and controlling vasomotor gastrointestinal symptoms of dumping as a separate entity, we remain hesitant to employ such revisions in the presence of clinically significant alkaline gastritis, and are more attracted to the use of longer isoperistaltic segments when confronted by patients with these combined disorders. We continue to be impressed by the role of undefined physiologic and possible psychologic factors in patients whose satisfactory progress is interrupted by episodes of anorexia, nausea, or vomiting in the absence of demonstrable mechanical obstruction. For some patients, the line between beneficial delay of gastric emptying and dysfunction appears to be exceedingly fine. Although the dumping syndrome is experienced by most patients during or soon after meals, a few patients will suffer vasomotor symptoms common to the dumping syndrome 2 to 4 hours after eating. This syndrome appears to be related to a reactive hypoglycemia16 that follows insulin response to initial hyperglycemia. We have had no experience with the surgical treatment of this condition. Woodward30 reports successful treatment of two patients. Delay in gastric empyting prevented early hyperglycemia as well as the late reactive hypoglycemia.
THE SMALL GASTRIC POUCH SYNDROME We have had no experience with remedial operations for the disability that may attend exceedingly small gastric remnants and have some concern about motility disturbances that develop when isoperistaltic jejunal segments are used to drain larger gastric remnants. Various ingenious loops and pouches, however, have been designed and reported to be beneficial by several authors. Study of the writings of Poth and Cleveland and Lawrence and associates as well as the review of this subject by Herrington is recommended.
POSTV AGOTOMY DIARRHEA After vagotomy some patients experience diarrhea that is distinguishable from the diarrhea that may accompany the vasomotor symptoms of dumping syndrome.7 Loose stools, often explosive in onset, may
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be unrelated to meals or may even awaken the patient. Truly disabling diarrhea of this type is rare and there is debate about its cause. Herrington, however, recognized a mechanism different from the dumping syndrome and has successfully treated nine patients with severe postvagotomy diarrhea by reversal of a 10-cm jejunal segment 50 to 100 cm from the ligament of Treitz. He pointed out the probable role of absorptive functions in the proximal portion of the jejunum and suggested that the more distal reversal pennits better mixing of ingested food with biliary and pancreatic secretions. Herrington, Poth,21 Stemmer and associates, and Madding and associates give evidence for the fact that this procedure has less or no effect on the vasomotor symptoms as compared with gastroduodenal interposition, because the proximal jejunum is still exposed to hyperosmolar content of the bowel. Herrington reported the case of one patient who was relieved of postvagotomy diarrhea by reversal of a distal segment and of persisting vasomotor dumping symptoms by interposition of another reversed segment between the stomach and the duodenum.
SUMMARY Gastric retention that follows operation for gastroduodenal ulcer is most often related to transient stomal obstruction or altered gastric motility, which will respond to a proper program of gastric decompression. In the absence of suspicion or signs of intestinal ischemia or x-ray evidence of other more specific causes of obstruction, delay and nonoperative treatment will lead to selection of those patients who truly need reoperation and will give the surgeon conviction about the need to make proper definitive alterations of questionable obstructive mechanisms when reoperation clearly becomes necessary. The term "afferent loop syndrome" is best used to describe symptoms related only to partial obstruction of the afferent jejunal limb, postcibal distress relieved by bilious vomiting. Revision of gastrointestinal continuity by interposition of an isoperistaltic jejunal segment between stomach and duodenum does away with the afferent limb, prevents reflux of bile into the stomach, and generally constitutes the most effective treatment. Alkaline gastritis may be responsible for some symptoms in afferent loop syndrome and may be the phenomenon responsible for disability occurring in the absence of demonstrable mechanical obstruction of the afferent jejunal limb erroneou~ly classified as "afferent loop syndrome" by some authors. Patients who experience constant or postcibal pain and who have endoscopic evidence of regurgitation of bile into the stomach, prestomal gastritis or gastric ulcer, and near or total achlorhydria may be relieved of their symptoms by biliary diversion utilizing a Roux limb or isoperistaltic jejunal segment interposed between stomach and duodenum. Vagotomy must be added to these procedures. Relief from vasomotor and gastrointestinal symptoms of the dumping syndrome may be obtained by operations that delay emptying of the
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stomach and restore its function as a reservoir. Interposition of isoperistaltic segments of jejunum 10 to 12 cm in length between stomach and duodenum is favored by British and Scandinavian authors, but most American surgeons consider such isoperistaltic segments to have limited effectiveness. Most surgeons in this country consider similar transfers of antiperistaltic jejunal segments 10 cm in length to be more effective in the control of dumping syndrome. Postvagotomy diarrhea, which is patternless and is not associated with postcibal dumping syndrome, is a distinct entity. Patients are reported to respond to reversal of a 10-cm jejunal segment 50 to 100 cm distal to the ligament of Treitz.
REFERENCES 1. Andreassen M: Surgical treatment of severe dumping syndrome: conversion of Billroth II into Billroth 1. Acta Chir Scand SuppI283:221-227, 1961 2. Borg I, Borgstrom SG, Haeger K: The value of the B II-B I conversion operation in the treatment of the postgastrectomy syndrome. Acta Chir Scand 134:655-659, 1968 3. Dahlgren S: The afferent loop syndrome. Acta Chir Scand Supp1327: 1-149,1964 4. Du Plessis DJ: Gastric mucosal changes after operations on the stomach. South African Med J 36:471-478, 1962 5. Du Plessis DJ: Pathogenesis of gastric ulceration. Lancet 1 :974-978,1965 6. Gerwig WH Jr, Easley GW, Mendoza CB Jr: Results following remedial operations for severe dumping syndrome. Arch Surg (Chicago) 95:631-634, 1967 7. Harkins HN, Stavney LS, Griffith CA, et al: Selective gastric vagotomy. Ann Surg 158: 448-460, 1963 8. Hedenstedt S, Lunquist G: Antiperistaltic jejunal segment in gastric surgery. Acta Chir Scand 133:545-554, 1967 9. Henley FA: Jejunal graft interposition in the correction of postgastrectomy syndromes. XXII Cong Soc Int Chir 1967 10. Herrington JL Jr: Remedial operations for post gastrectomy syndromes. Curr Probl Surg, 1970, pp 3-63 11. Jordan GL Jr: Surgical management of post gastrectomy problems. Arch Surg (Chicago) 102:251-258,1971 12. Lawrence W Jr, Kim M, Isaacs M, et al: Gastric reservoir construction for severe disability after subtotal gastrectomy. Surg Gynec Obstet 119:1219-1232, 1964 13. Lawson HH: Effect of duodenal contents on the gastric mucosa under experimental conditions. Lancet 1 :469-472, 1964 14. Madding GF, Kennedy PA, McLaughlin RT: Clinical use of anti-peristaltic bowel segments. Ann Surg 161 :601-604, 1965 15. Moroney J: Colonic replacement of the stomach. Lancet 1 :993-996, 1951 16. Muir A: Postgastrectomy syndromes. Brit J Surg 37:165-178,1949 17. Nagel CB: Clinical experiences with jejunal interposition for postgastrectomy syndrome. Calif Med 107:399-405, 1967 18. Nagel CB, Farris JM: Clinical experiences with corrective surgery for the dumping syndrome. Amer J Surg 116:229-234, 1968 19. Perry JF Jr: Post-gastrectomy proximal jejunal loop obstruction simulating acute pancreatitis. Ann Surg 140:119-121, 1954 20. Poth EJ: The dumping syndrome and its surgical treatment. Amer Surg 23:1097-1102, 1957 21. Poth EJ: Treatment of the dumping syndrome by the use of antiperistaltic segment of jejunum. In Current Surgical Management III: A Book of Alternative Viewpoints on Controversial Surgical Problems. Edited by EH Ellison, SR Friesen, JH Mulholland. Philadelphia, WB Saunders Company, 1965, pp 383-386 22. Poth EJ: Use of gastrointestinal reversal in surgical procedures. Amer J Surg 118:893899,1969 23. Poth EJ, Cleveland BR: A functional substitution pouch for the stomach (B). Arch Surg (Chicago) 83:42-52, 1961 24. Rutledge RH: Jejunal segments for the post gastrectomy syndromes. Ann Surg 169: 810-825, 1969
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25. Stemmer EA, Jones SA, Pearson SC, et al: Antiperistaltic segments of jejunum in the treatment of the dumping syndrome. Arch Surg (Chicago) 98:396-404,1969 26. Tanner NC: Disabilities which may follow the peptic ulcer operation. Proc Roy Soc Med 59:362-368, 1966 27. Thal A, Perry JF Jr: A further case of afferent loop obstruction simulating acute pancreatitis. Ann Surg 143:266-268, 1956 28. Toye DKM, Williams JA: Post-gastrectomy bile vomiting. Lancet 2:524-526,1965 29. Van Heerden JA, Priestley JT, Farrow GM, et al: Postoperative alkaline reflux gastritis: surgical implications. Amer J Surg 118:427-434, 1969 30. Woodward ER: The Postgastrectomy Syndromes. Springfield, Illinois, Charles C Thomas, Publisher, 1963 31. Woodward ER: The pathophysiology of afferent loop syndromes. SURG CLIN N AMER 46: 411-423, 1966 32. Woodward ER, Hastings N: Surgical treatment of the post gastrectomy dumping syndrome. Surg Gynec Obstet 111 :429-437, 1960