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Peptic ulcer disease after choledochojejunostomy
Peptic Ulcer Disease after Chokdochojejunostomy
The possible relationship between peptic ulcer disease and the anatomic rearrangement after Roux-en-Y choledochojejunostomy has been a subject of interest among surgeons for a number of years. At the UCLA Hospital, this operative procedure has been the method of choice for the treatment of benign extrahepatic biliary obstruction [I]. A review of the choledochojejunostomy series and the ensuing course of each operation was undertaken to determine the incidence of postoperative peptic ulcer. Clinical Material
From 1957 to 1970, ninetyseven choledochojejunostomies were performed for benign extrahepatic biliary obstruction. The average age of patients undergoing this procedure was forty-five years, ranging from four weeks to seventy-nine years. (Table I.) The oldest patient was a man with obstruction of the common bile duct secondary to benign stricture of the ampulla of Vater. Of the ninety-seven patients, females outnumbered males by a ratio of 2: 1. This ratio remained constant whether or not there were postoperative complications or peptic ulcer. Of the total number of patients, significant complications including peptic ulcer, cholangitis, infection, or significant abdominal pain of unknown cause developed in the postoperative period in thirty-nine. (Table II.) Peptic ulcer developed postoperatively in ten patients. Of these ulcers, nine were duodenal and one, gastric. An additional ten patients had upper abdominal pain suggestive of possible ulcer disease, but proof of this or other disease processes was never established. Cholangitis was diagnosed in fifteen patients at some time in the follow-up period. A significant number of these patients had documented attacks of chills, fever, and abdominal pain prior to choledochojejunostomy. The diagnosis of peptic ulcer in the ten patients was established either radiologically (three patients), at reoperation (five patients), or by postmortem examination (two patients). None of the patients had had demonstrable ulcer disease or sympFrom the Deoartment of Surgery, UCLA School of Medicine, Los Angeles, Celiforhia 90024. Presented et the Forty-Second Annual Meeting of the Pacific Coast Surgical Association, Mexico City, Mexico, February 14-18. 1970. l By invitation.
Volume
122. August 1971
MICHAEL
S. McARTHUR,
MD,*
WILLIAM
P. LONGMIRE,
Jr, MD,
Los Angeles, Los Angeles,
California California
toms prior to the development of extrahepatic biliary obstruction. Eight of the ten patients with demonstrated postoperative ulcer h,ad at least one bleeding episode; four of these had two episodes, and one had three. Two died as a direct result of the hemorrhage. Three patients had bleeding within the first postoperative month, one within the first year, and four within a five year followup period. Four patients required surgical intervention for ulcer complications, three for bleeding and one for perforation. For comparative purposes, thirty-nine cases of choledochoduodenostomy performed at the UCLA Hospital and the Wadsworth VA Hospital were reviewed. (Table III.) In this series, extant peptic ulcer was proved at operation in one patient who subsequently died of a second bleeding episode. Three of five patients with postoperative biliary fistul’as died during the postoperative period. Strictures occurred postoperatively in three patients. Proved cholangitis in three patients required conversion from a choledochoduodenostomy to a choledochojejunostomy. Comments
In 1951 O’Malley, Aufses, and Whipple [2] presented data on fifty-four patients who had undergone randomized repairs for biliary duct stenosis. Four had bleeding postoperatively, all of whom had had Roux-en-Y choledochojejunostomy. The experience led these investigators to speculate that diversion of the alkaline bile from the first portion of the duodenum increased a proclivity toward peptic ulceration of the duodenum with subsequent bleeding. Bowers [S], after experience with four ulcer occurrences after choledochojejunal anastomoses, stated that the incidence of duodenal ulcers was increased. He advocated routine preoperative measurements of gastric acidity as an aid to the surgeon in his selection of a repair procedure. The effect of common bile duct transplantation on gastric acid secretion in the dog was documented by Breen, Molina, and Ritchie [.4]. Their findings demonstrated an increase in gastric acid production after choledochojejunostomy. Choledochoduodenostomy and end to end anastomosis of
155
McArthur
and Longmire
TABLE I
Age Range of Ninety-Beven Patients Undergoing Choledochojejunortomy Patients
Agetv) O-10 11-20 21-30 31-40 41-50 5160 61-70 71-80
TABLE II
Male
Female
1 0 1 2 11 5 7 4
3 2 7 10 14 15 12 3
Complications of Choledochojejunostomy in Ninety-Seven Patients Complications
Number of Patients
Peptic ulcer Cholangitis Infection Abdominal pain of unknown etiology
TABLE Ill
10
Complications of Choledochoduodenostomy In Thirty-Nine Patients Complications Fistula Cholangitis Stricture Peptic ulcer
l
10 15 4
Three patients
Number of Patients 5* 3 3 1
_._-
died.
the duct did not significantly increase gastric acid secretion in this series of dogs. They postulated tihat impairment of duodenal mechanisms responsible for inhibition of gastric secretion was involved. In his experiments on dogs, Menguy [5] found that after biliary diversions to the lower ileum, hypersecretion of gastric acid occurred one to seven weeks postoperatively. He suggested that this hypersecretion was related to liver disease (fatty liver) and to diminished ability of the liver to destroy histamine absorbed from the intestine. Silen et al [6] agreed with this proposal and unvia canine Heidenhain dertook experiments pouches after obstruction of the common bile duct to document gastric secretory response. Gastric hypersecretion was demonstrated and found to parallel changes in hepatic function and microscopic alterations in the liver before and after biliary obstruction. Breen, Molina, and Ritchie [4] found that hypersecretion occurred as soon aa collections began postoperatively (five days). Only one dog in five showed a change in liver histology
156
and this was of minor degree. Studies of ulcer formation after total biliary exclusion procedures were reviewed by Kehne and Campbell [7]. Their experiments in dogs with choledochojejunostomy demonstrated a 62 per cent incidence of peptic ulcer formation. After choledochojejunostomy with histamine stimulation, the ulcer incidence was 76 per cent. Histamine was given to normal animals as a control with a resulting 40 per cent incidence of peptic ulcer. Although small bowel resection is not a routine part of Roux-en-Y choledochoj ej unostomy, Frederick, Sizer, and Osborne [8], in an interesting experimental study, demonstrated increased gastric acid secretion after small bowel resection. They proposed that some unidentified inhibitory hormone may have been removed by the proportional amounts of the resected bowel. However, they did not find abnormal liver function studies associated with the rise in acid secretion after bowel resection. In view of these experiments and case documentation by others of peptic ulcer after Rouxen-Y limbs, it is somewhat surprising that a larger percentage of the patients in our study did not demonstrate peptic ulcer disease. All patients who are to undergo biliary diversion for benign biliary tract disease should have a complete evaluation to determine peptic ulcer potential. Included would be radiographs of the upper gastrointestinal tract, special x-ray examinations when indicated, gastric acid analysis, and special secretory studies. The possibility of postoperative ulcer disease should be explained to the patient. Periodic re-evaluation and complete investigation of suggestive complaints would hopefully provide earlier diagnosis and treatment if the disease develops. In high risk patients, that is, patients with elevated gastric acidity before operation, vagotomy and pyloroplasty should be considered. Summary
The possible relationship between peptic ulcer disease and the anatomic rearrangement after Roux-en-Y choledochoj ej unostomy was studied in a series of ninety-seven patients who had undergone this procedure for the treatment of benign extrahepatic biliary obstruction. Peptic ulcer was documented in ten of thirty-nine patients in whom significant complications had developed in the postoperative period. Eight of these had at least one bleeding episode, four had two, and one had three bleeding episodes. Two patients died from the bleeding episodes. Nine of these patients had
The Amdean
Journal
of Surg~y
Peptic Ulcer after Choledochojejunostomy
duodenal ulcers, and one had a gastric ulcer. Four required surgical intervention for complications of the ulcer: three for bleeding and one for perforation. Other complications in this series included fifteen cases of cholangitis, four of infection, and ten of abdominal pain of unknown origin. For comparative purposes, a series of thirtynine patients who had undergone choledochoduodenostomy at the UCLA and Wadsworth VA Hospitals were reviewed. Of these, twelve had significant postoperative complications: five cases of fistula, three of cholangitis, three of stricture, and one of peptic ulcer. It has been speculated that the cause of peptic ulcer after choledochojejunostomy is secondary to the divergence of alkaline bile secretions from the duodenum. Others have judged that a secondary gastric hypersecretory phenomenon is primarily responsible. In view of our findings, it is believed that a complete preoperative evaluation of peptic ulcer potential is warranted, and postoperative protection of patients with a proclivity to ulcer disease is essential. In high risk patients, vagotomy and pyloroplasty should be considered. Rdi!tWKX!S
1. Trout HT, Longmire Wp: Long term follow-up of patients with congenital cystic dilatation of the common bile duct. Amer J Surg 121: 68, 1971. 2. O’Malley RD, Aufses AH Jr, Whipple AO: Benign extrehepatlc biliary tract obstruction. Ann Surg 134: 797, 1951. 3. Bowers RM: Morbid conditions following choledochojejunostomy. Ann Surg 159: 424, 1964. 4. Breen JJ, Molina E, Ritchie WP Jr: Effects of common bileduct transplantation on gastric acid secretion in the dog. Brit J Surg 55: 282, 1968. 5. Menguy RB: Mechanism of hyperseoretion in dogs with exclusion of bile or pancreatic juice from the small intestine. Surg Forum 13: 300, 1962. 6. Silen W, Hein MF, Albo RJ, Harper HA: influence of liver upon canine gastric secretion. Surgery 54: 29,1963. 7. Kehne JH, Campbell RE: Choledochojejunostomy en Roux Y: an experimental study. Arch Surg 73: 12. 1956. 8. Frederick PL, Sizer JS, Osborne MP: Relation of massive bowel resection to gastric secretion. New Eng J Med
272: 509, 1965. Discussion HARRY A. OBERHELMAN (Palo Alto, Calif) : Doctors McArthur and Longmire have presented convincing figures on the occurrence of peptic ulcer after choledochojejunostomy. For many years it was believed that
the loss of neutralization by diverting the alkaline bile secretions away from the duodenum rendered the duodenum more susceptible to peptic ulceration. More recently, secondary gastric hypersecretion has been observed in experimental animals after biliary and/or pancreatic diversion f,rom the duodenum.
Volume 122, August
1971
Doctors McArthur and Longmire have alluded to the possible mechanisms of this hypersecretion which include impairment of duodenal inhibition of gastric secretion and hepatic dysfunction. Sircus in 1968 postulated a decreased liberation of the gastric secretory inhibitor, enterogastrone, as a result of biliary diversion. Bile and pancreatic secretions have been found necessary for the liberation of enterogastrone by their role in forming a stable fat emulsion for injested fat. The difficulties in estimating the gastric or humoral phase of secretion in man pose a problem in demonstrating hypersecretion since the intestinal inhibitors primarily affect the gastrin mechanism. It may be that serum gastrin measurements may shed further light on the role of increased gastric secretion in patients with choledochojejunostomy. The present authors suggest that vagotomy and pyloroplasty be considered in high risk patients. I would concur with their suggestion provided there is evidence of prior ulcer or increased gastric secretion preoperatively. On the other hand, I prefer cholodochoduodenostomy to choledochojejunostomy in view of the low risk of ulcers as well as a belief that it is a superior reconstructive procedure. EDWARD A. STEMMER (Long Beach, Calif) : When Dr Oberhelman asked me if I would present his discussion, I thought I would summarize our own experience at the Long Beach VA Hosiptal as well. Unfortunately, I found only two patients in five years in whom choledochojejunostomy was performed for benign disease. For what it is worth, ulcers developed in neither of those patients postoperatively. I would like to ask the authors what the role of stress ulceration may be in their patients since they did not have a prior history of peptic ulcer and how it is related to biliary diversion. WILLIAM B. HUTCHINSON (Seattle, Wash:) I would like to re-emphasize the statements of Drs McArthur and Longmire regarding preoperative evaluation of peptic ulcer potential in patients with benign extrahepatic obstruction. In a recent review of 100 consecutive duodenostomies performed for a variety of reasons in patients with benign disease at the Swedish Hospital in Seattle, I found that thirty-two patients, or one third of the total, had some very serious complications. Two of eight patients who died had undergone choledochoduodenostomy, and in the other six the sphincter was involved in the procedure. In seven survivors of fistulas, one had had choledochojejunostomy. What I wish to emphasize is that in benign extrahepatic obstruction, we are dealing with a difficult problem in which no single operative correction is possible but must be individualized. Often this problem occurs in debilitated, physiologic wrecks in whom any significant, additional preoperative information and correction of defects may make it possible to win the day for the patient. The authors present a large series of Roux-Y chole-
157
McArthur and Longmire
dochojejunostomies for benign extrahepatic obstruction. I would like to ask if this procedure was preferred, as I suspect it was, and if so, why. I have some ideas as to the advantages and disadvantages of the operation, but I would like to hear their point of view. THOMAS T. WHITE (Seattle, Wash) : Ulcers were thought to occur with Roux-Y pancreaticojejunostomies. In our first seventy-five cases, two patients had ulcers. Four other patients had an exacerbation of the pre-existing ulcer. All six of these patients had cirrhosis of the liver. As far as choledochojejunostomy is concerned, we have seen three ulcers in thirty patients who had a Roux-Y; all three had cirrhosis. The patient who had postoperative bleeding was later found to have had bleeding from an ulcer previously. As Dr Hutchinson has just stated, the presence of a pre-existing ulcer should be determined before operation. Of the patients undergoing choledochoduodenostomy, thirty-three did not have ulcers postoperatively, whereas five who later had ulcers were known beforehand to have had cirrhosis and duodenal ulcer. Fistula or stricture of the anastomosis occurred in about 10 per cent after either operation and there were two cases of cholangitis in each group. CHARLESA. GRIFFITH (Seattle, Wash) : For the reasons they have presented, I agree with the authors that Roux-Y choledochojejunoatomy predisposes to peptic ulcer. On the other hand, choledochoduodenostomy does not and therefore seems preferable. However, the authors report a rather high rate of complications, other than ulcer, after choledochoduodenostomy. Their experience is in decided contrast to that of Mr Capper in Bristol, England, who has reported highly successful results and has emphasized several points of importance to the success of choledochoduodenostomy. The most important is that the common duct should be dilated. I would like to ask the authors whether they used Mr Capper’s methods in their patients with choledochoduodenostomy. In my experience the most common cause of benign biliary stricture is stenosis at the choledochoduodenal junction. This condition is often unrecognized, particularly when the common duct is not dilated and does not contain stones or biliary sludge. For choledochoduodenal stenosis, rather than either choledochojejunostomy or choledochoduodenostomy, I prefer an adequate transduodenal sphincterotomy or sphincteroplasty as described by Dr Jones and his colleagues to this Association three years ago. CAMERON R. HARRISON(Vancouver, BC, Canada) : I
158
want to ask one question of the authors, that is, whether they studied the gastric secretory levels before and after this procedure. WILEY F. BARKER(closing) : It is hard to determine the role of stress ulceration since it should be equally applicable in both groups. There were nine duodenal and one gastric ulcer in the choledochojejunostomy series, suggesting that the process is not due to stress. Doctor White, as usual, has raised some pertinent questions ; the role of liver function may be most important. Augmented hyperacidity, however, was shown without demonstrable liver dysfunction by Frederick and his co-authors, and Menguy has not been able to define exactly the etiologic source of this recognized hypersection. Doctor Griffith’s comments about the technical matters are critical. We cannot positively answer the questions about the technical details. Doctor,McArthur did not mention in his oral presentation the acid studies that have been done. Let me just describe one patient who was seen after a common duct injury which occurred during vagotomy and pyloroplasty. Basal secretion in this patient, measured before the biliary diversion, was at a rate of 0.1 basal and 4.4 mEq/L stimulated. After operation this rate had increased to 1.2 and 31.9, respectively. We have had here mentioned several different possible etiologies for the ulceration. I believe I can summarize the comments of Drs William Longmire and Morton Grossman as follows: first, the bile itself probably offers less than 20 per cent of the total neutralizing effects on gastric acidity; secondly, fat absorption is probably deficient because of the biliary diversion, and this may be the source of the resultant lessening of the output of gastric secretory inhibitors. Although we cannot be certain of the etiology, the mechanism is probably not as simple as any of those we have yet postulated. We believe, however that the observation that there is an increased incidence of ulceration is a true one. Our continued preference of choledochojejunostomy over choledochoduodenostomy, despite this apparent increased incidence of ulcer, is based on two factors. One is a complication rate in choledochoduodenostomy of about twice the magnitude of that in choledochojejunostomy. Furthermore, if a fistula does occur, it is much more difficult if it occurs in the duodenum than in the defunctionalized jejunostomy limb. We believe that careful evaluation of a patient and appropriate use of pyloroplasty and vagotomy may reduce the risk of peptic ulceration after the operation.
lho
Amorkon
Journal
of
Surgery
The possible relationship between peptic ulcer disease and the anatomic rearrangement after Roux-en-Y choledochojejunostomy has been a subject of interest among surgeons for a number of years. At the UCLA Hospital, this operative procedure has been the method of choice for the treatment of benign extrahepatic biliary obstruction [I]. A review of the choledochojejunostomy series and the ensuing course of each operation was undertaken to determine the incidence of postoperative peptic ulcer. Clinical Material
From 1957 to 1970, ninetyseven choledochojejunostomies were performed for benign extrahepatic biliary obstruction. The average age of patients undergoing this procedure was forty-five years, ranging from four weeks to seventy-nine years. (Table I.) The oldest patient was a man with obstruction of the common bile duct secondary to benign stricture of the ampulla of Vater. Of the ninety-seven patients, females outnumbered males by a ratio of 2: 1. This ratio remained constant whether or not there were postoperative complications or peptic ulcer. Of the total number of patients, significant complications including peptic ulcer, cholangitis, infection, or significant abdominal pain of unknown cause developed in the postoperative period in thirty-nine. (Table II.) Peptic ulcer developed postoperatively in ten patients. Of these ulcers, nine were duodenal and one, gastric. An additional ten patients had upper abdominal pain suggestive of possible ulcer disease, but proof of this or other disease processes was never established. Cholangitis was diagnosed in fifteen patients at some time in the follow-up period. A significant number of these patients had documented attacks of chills, fever, and abdominal pain prior to choledochojejunostomy. The diagnosis of peptic ulcer in the ten patients was established either radiologically (three patients), at reoperation (five patients), or by postmortem examination (two patients). None of the patients had had demonstrable ulcer disease or sympFrom the Deoartment of Surgery, UCLA School of Medicine, Los Angeles, Celiforhia 90024. Presented et the Forty-Second Annual Meeting of the Pacific Coast Surgical Association, Mexico City, Mexico, February 14-18. 1970. l By invitation.
Volume
122. August 1971
MICHAEL
S. McARTHUR,
MD,*
WILLIAM
P. LONGMIRE,
Jr, MD,
Los Angeles, Los Angeles,
California California
toms prior to the development of extrahepatic biliary obstruction. Eight of the ten patients with demonstrated postoperative ulcer h,ad at least one bleeding episode; four of these had two episodes, and one had three. Two died as a direct result of the hemorrhage. Three patients had bleeding within the first postoperative month, one within the first year, and four within a five year followup period. Four patients required surgical intervention for ulcer complications, three for bleeding and one for perforation. For comparative purposes, thirty-nine cases of choledochoduodenostomy performed at the UCLA Hospital and the Wadsworth VA Hospital were reviewed. (Table III.) In this series, extant peptic ulcer was proved at operation in one patient who subsequently died of a second bleeding episode. Three of five patients with postoperative biliary fistul’as died during the postoperative period. Strictures occurred postoperatively in three patients. Proved cholangitis in three patients required conversion from a choledochoduodenostomy to a choledochojejunostomy. Comments
In 1951 O’Malley, Aufses, and Whipple [2] presented data on fifty-four patients who had undergone randomized repairs for biliary duct stenosis. Four had bleeding postoperatively, all of whom had had Roux-en-Y choledochojejunostomy. The experience led these investigators to speculate that diversion of the alkaline bile from the first portion of the duodenum increased a proclivity toward peptic ulceration of the duodenum with subsequent bleeding. Bowers [S], after experience with four ulcer occurrences after choledochojejunal anastomoses, stated that the incidence of duodenal ulcers was increased. He advocated routine preoperative measurements of gastric acidity as an aid to the surgeon in his selection of a repair procedure. The effect of common bile duct transplantation on gastric acid secretion in the dog was documented by Breen, Molina, and Ritchie [.4]. Their findings demonstrated an increase in gastric acid production after choledochojejunostomy. Choledochoduodenostomy and end to end anastomosis of
155
McArthur
and Longmire
TABLE I
Age Range of Ninety-Beven Patients Undergoing Choledochojejunortomy Patients
Agetv) O-10 11-20 21-30 31-40 41-50 5160 61-70 71-80
TABLE II
Male
Female
1 0 1 2 11 5 7 4
3 2 7 10 14 15 12 3
Complications of Choledochojejunostomy in Ninety-Seven Patients Complications
Number of Patients
Peptic ulcer Cholangitis Infection Abdominal pain of unknown etiology
TABLE Ill
10
Complications of Choledochoduodenostomy In Thirty-Nine Patients Complications Fistula Cholangitis Stricture Peptic ulcer
l
10 15 4
Three patients
Number of Patients 5* 3 3 1
_._-
died.
the duct did not significantly increase gastric acid secretion in this series of dogs. They postulated tihat impairment of duodenal mechanisms responsible for inhibition of gastric secretion was involved. In his experiments on dogs, Menguy [5] found that after biliary diversions to the lower ileum, hypersecretion of gastric acid occurred one to seven weeks postoperatively. He suggested that this hypersecretion was related to liver disease (fatty liver) and to diminished ability of the liver to destroy histamine absorbed from the intestine. Silen et al [6] agreed with this proposal and unvia canine Heidenhain dertook experiments pouches after obstruction of the common bile duct to document gastric secretory response. Gastric hypersecretion was demonstrated and found to parallel changes in hepatic function and microscopic alterations in the liver before and after biliary obstruction. Breen, Molina, and Ritchie [4] found that hypersecretion occurred as soon aa collections began postoperatively (five days). Only one dog in five showed a change in liver histology
156
and this was of minor degree. Studies of ulcer formation after total biliary exclusion procedures were reviewed by Kehne and Campbell [7]. Their experiments in dogs with choledochojejunostomy demonstrated a 62 per cent incidence of peptic ulcer formation. After choledochojejunostomy with histamine stimulation, the ulcer incidence was 76 per cent. Histamine was given to normal animals as a control with a resulting 40 per cent incidence of peptic ulcer. Although small bowel resection is not a routine part of Roux-en-Y choledochoj ej unostomy, Frederick, Sizer, and Osborne [8], in an interesting experimental study, demonstrated increased gastric acid secretion after small bowel resection. They proposed that some unidentified inhibitory hormone may have been removed by the proportional amounts of the resected bowel. However, they did not find abnormal liver function studies associated with the rise in acid secretion after bowel resection. In view of these experiments and case documentation by others of peptic ulcer after Rouxen-Y limbs, it is somewhat surprising that a larger percentage of the patients in our study did not demonstrate peptic ulcer disease. All patients who are to undergo biliary diversion for benign biliary tract disease should have a complete evaluation to determine peptic ulcer potential. Included would be radiographs of the upper gastrointestinal tract, special x-ray examinations when indicated, gastric acid analysis, and special secretory studies. The possibility of postoperative ulcer disease should be explained to the patient. Periodic re-evaluation and complete investigation of suggestive complaints would hopefully provide earlier diagnosis and treatment if the disease develops. In high risk patients, that is, patients with elevated gastric acidity before operation, vagotomy and pyloroplasty should be considered. Summary
The possible relationship between peptic ulcer disease and the anatomic rearrangement after Roux-en-Y choledochoj ej unostomy was studied in a series of ninety-seven patients who had undergone this procedure for the treatment of benign extrahepatic biliary obstruction. Peptic ulcer was documented in ten of thirty-nine patients in whom significant complications had developed in the postoperative period. Eight of these had at least one bleeding episode, four had two, and one had three bleeding episodes. Two patients died from the bleeding episodes. Nine of these patients had
The Amdean
Journal
of Surg~y
Peptic Ulcer after Choledochojejunostomy
duodenal ulcers, and one had a gastric ulcer. Four required surgical intervention for complications of the ulcer: three for bleeding and one for perforation. Other complications in this series included fifteen cases of cholangitis, four of infection, and ten of abdominal pain of unknown origin. For comparative purposes, a series of thirtynine patients who had undergone choledochoduodenostomy at the UCLA and Wadsworth VA Hospitals were reviewed. Of these, twelve had significant postoperative complications: five cases of fistula, three of cholangitis, three of stricture, and one of peptic ulcer. It has been speculated that the cause of peptic ulcer after choledochojejunostomy is secondary to the divergence of alkaline bile secretions from the duodenum. Others have judged that a secondary gastric hypersecretory phenomenon is primarily responsible. In view of our findings, it is believed that a complete preoperative evaluation of peptic ulcer potential is warranted, and postoperative protection of patients with a proclivity to ulcer disease is essential. In high risk patients, vagotomy and pyloroplasty should be considered. Rdi!tWKX!S
1. Trout HT, Longmire Wp: Long term follow-up of patients with congenital cystic dilatation of the common bile duct. Amer J Surg 121: 68, 1971. 2. O’Malley RD, Aufses AH Jr, Whipple AO: Benign extrehepatlc biliary tract obstruction. Ann Surg 134: 797, 1951. 3. Bowers RM: Morbid conditions following choledochojejunostomy. Ann Surg 159: 424, 1964. 4. Breen JJ, Molina E, Ritchie WP Jr: Effects of common bileduct transplantation on gastric acid secretion in the dog. Brit J Surg 55: 282, 1968. 5. Menguy RB: Mechanism of hyperseoretion in dogs with exclusion of bile or pancreatic juice from the small intestine. Surg Forum 13: 300, 1962. 6. Silen W, Hein MF, Albo RJ, Harper HA: influence of liver upon canine gastric secretion. Surgery 54: 29,1963. 7. Kehne JH, Campbell RE: Choledochojejunostomy en Roux Y: an experimental study. Arch Surg 73: 12. 1956. 8. Frederick PL, Sizer JS, Osborne MP: Relation of massive bowel resection to gastric secretion. New Eng J Med
272: 509, 1965. Discussion HARRY A. OBERHELMAN (Palo Alto, Calif) : Doctors McArthur and Longmire have presented convincing figures on the occurrence of peptic ulcer after choledochojejunostomy. For many years it was believed that
the loss of neutralization by diverting the alkaline bile secretions away from the duodenum rendered the duodenum more susceptible to peptic ulceration. More recently, secondary gastric hypersecretion has been observed in experimental animals after biliary and/or pancreatic diversion f,rom the duodenum.
Volume 122, August
1971
Doctors McArthur and Longmire have alluded to the possible mechanisms of this hypersecretion which include impairment of duodenal inhibition of gastric secretion and hepatic dysfunction. Sircus in 1968 postulated a decreased liberation of the gastric secretory inhibitor, enterogastrone, as a result of biliary diversion. Bile and pancreatic secretions have been found necessary for the liberation of enterogastrone by their role in forming a stable fat emulsion for injested fat. The difficulties in estimating the gastric or humoral phase of secretion in man pose a problem in demonstrating hypersecretion since the intestinal inhibitors primarily affect the gastrin mechanism. It may be that serum gastrin measurements may shed further light on the role of increased gastric secretion in patients with choledochojejunostomy. The present authors suggest that vagotomy and pyloroplasty be considered in high risk patients. I would concur with their suggestion provided there is evidence of prior ulcer or increased gastric secretion preoperatively. On the other hand, I prefer cholodochoduodenostomy to choledochojejunostomy in view of the low risk of ulcers as well as a belief that it is a superior reconstructive procedure. EDWARD A. STEMMER (Long Beach, Calif) : When Dr Oberhelman asked me if I would present his discussion, I thought I would summarize our own experience at the Long Beach VA Hosiptal as well. Unfortunately, I found only two patients in five years in whom choledochojejunostomy was performed for benign disease. For what it is worth, ulcers developed in neither of those patients postoperatively. I would like to ask the authors what the role of stress ulceration may be in their patients since they did not have a prior history of peptic ulcer and how it is related to biliary diversion. WILLIAM B. HUTCHINSON (Seattle, Wash:) I would like to re-emphasize the statements of Drs McArthur and Longmire regarding preoperative evaluation of peptic ulcer potential in patients with benign extrahepatic obstruction. In a recent review of 100 consecutive duodenostomies performed for a variety of reasons in patients with benign disease at the Swedish Hospital in Seattle, I found that thirty-two patients, or one third of the total, had some very serious complications. Two of eight patients who died had undergone choledochoduodenostomy, and in the other six the sphincter was involved in the procedure. In seven survivors of fistulas, one had had choledochojejunostomy. What I wish to emphasize is that in benign extrahepatic obstruction, we are dealing with a difficult problem in which no single operative correction is possible but must be individualized. Often this problem occurs in debilitated, physiologic wrecks in whom any significant, additional preoperative information and correction of defects may make it possible to win the day for the patient. The authors present a large series of Roux-Y chole-
157
McArthur and Longmire
dochojejunostomies for benign extrahepatic obstruction. I would like to ask if this procedure was preferred, as I suspect it was, and if so, why. I have some ideas as to the advantages and disadvantages of the operation, but I would like to hear their point of view. THOMAS T. WHITE (Seattle, Wash) : Ulcers were thought to occur with Roux-Y pancreaticojejunostomies. In our first seventy-five cases, two patients had ulcers. Four other patients had an exacerbation of the pre-existing ulcer. All six of these patients had cirrhosis of the liver. As far as choledochojejunostomy is concerned, we have seen three ulcers in thirty patients who had a Roux-Y; all three had cirrhosis. The patient who had postoperative bleeding was later found to have had bleeding from an ulcer previously. As Dr Hutchinson has just stated, the presence of a pre-existing ulcer should be determined before operation. Of the patients undergoing choledochoduodenostomy, thirty-three did not have ulcers postoperatively, whereas five who later had ulcers were known beforehand to have had cirrhosis and duodenal ulcer. Fistula or stricture of the anastomosis occurred in about 10 per cent after either operation and there were two cases of cholangitis in each group. CHARLESA. GRIFFITH (Seattle, Wash) : For the reasons they have presented, I agree with the authors that Roux-Y choledochojejunoatomy predisposes to peptic ulcer. On the other hand, choledochoduodenostomy does not and therefore seems preferable. However, the authors report a rather high rate of complications, other than ulcer, after choledochoduodenostomy. Their experience is in decided contrast to that of Mr Capper in Bristol, England, who has reported highly successful results and has emphasized several points of importance to the success of choledochoduodenostomy. The most important is that the common duct should be dilated. I would like to ask the authors whether they used Mr Capper’s methods in their patients with choledochoduodenostomy. In my experience the most common cause of benign biliary stricture is stenosis at the choledochoduodenal junction. This condition is often unrecognized, particularly when the common duct is not dilated and does not contain stones or biliary sludge. For choledochoduodenal stenosis, rather than either choledochojejunostomy or choledochoduodenostomy, I prefer an adequate transduodenal sphincterotomy or sphincteroplasty as described by Dr Jones and his colleagues to this Association three years ago. CAMERON R. HARRISON(Vancouver, BC, Canada) : I
158
want to ask one question of the authors, that is, whether they studied the gastric secretory levels before and after this procedure. WILEY F. BARKER(closing) : It is hard to determine the role of stress ulceration since it should be equally applicable in both groups. There were nine duodenal and one gastric ulcer in the choledochojejunostomy series, suggesting that the process is not due to stress. Doctor White, as usual, has raised some pertinent questions ; the role of liver function may be most important. Augmented hyperacidity, however, was shown without demonstrable liver dysfunction by Frederick and his co-authors, and Menguy has not been able to define exactly the etiologic source of this recognized hypersection. Doctor Griffith’s comments about the technical matters are critical. We cannot positively answer the questions about the technical details. Doctor,McArthur did not mention in his oral presentation the acid studies that have been done. Let me just describe one patient who was seen after a common duct injury which occurred during vagotomy and pyloroplasty. Basal secretion in this patient, measured before the biliary diversion, was at a rate of 0.1 basal and 4.4 mEq/L stimulated. After operation this rate had increased to 1.2 and 31.9, respectively. We have had here mentioned several different possible etiologies for the ulceration. I believe I can summarize the comments of Drs William Longmire and Morton Grossman as follows: first, the bile itself probably offers less than 20 per cent of the total neutralizing effects on gastric acidity; secondly, fat absorption is probably deficient because of the biliary diversion, and this may be the source of the resultant lessening of the output of gastric secretory inhibitors. Although we cannot be certain of the etiology, the mechanism is probably not as simple as any of those we have yet postulated. We believe, however that the observation that there is an increased incidence of ulceration is a true one. Our continued preference of choledochojejunostomy over choledochoduodenostomy, despite this apparent increased incidence of ulcer, is based on two factors. One is a complication rate in choledochoduodenostomy of about twice the magnitude of that in choledochojejunostomy. Furthermore, if a fistula does occur, it is much more difficult if it occurs in the duodenum than in the defunctionalized jejunostomy limb. We believe that careful evaluation of a patient and appropriate use of pyloroplasty and vagotomy may reduce the risk of peptic ulceration after the operation.
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