- Email: [email protected]
Roux-Y gastrectomy for chronic gastric atony
Roux-Y Gastrectomy Lars Karlstrom,
MD,
for Chronic Gastric Atony Keith A. Kelly,
The aim of this study was to determine the clinical outcome after Roux-Y gastrectomy for chronic gastric atony. Forty patients ( 11 men, 29 women; age 47 f 12 years) presented with severe chronic gastric atony: 32 patients had postvagotomy atony, 6 had idiopathic atony, and 2 had diabetic gastropare&s. The patients underwent either extensive subtotal or near-total gastrectomy and Roux-Y gastrojejunostomy. No early postoperative mortality occurred. Among the 39 patients followed for a mean of 32 months, 31 patients (79 percent) had fewer symptoms postoperatively than preoperatively, with 26 patients (66 percent) improving at least one Visick grade postoperatively and 22 patients (56 percent) going from grades HI and IV preoperatively to grades I and II postoperatively. In contrast, 13 patients (33 percent) did not improve after operation. We concluded that extensive subtotal Roux-Y gastrectomy and near-total Roux-Y gastrectomy were safe procedures that led to improvement in two-thirds of the patients with chronic gastric atony; however, one-third of patients did not have improvement.
hronic gastric atony, an uncommon but disabling condition, may occur as a complication of truncal C vagotomy, diabetes mellitus, or in an idiopathic form [I6J. Atony results in pain, nausea, and vomiting, especially of solid food. Poor nutrition and weight loss ensue. Many patients with atony require supplemental parenteral nutrition and some need total parenteral nutrition. We wondered whether the atony could be treated successfully by extensive subtotal or near-total gastrectomy and Roux-Y gastrojejunostomy. In our view, extensive gastrectomy should eliminate the hold-up of focd in the dilated, atonic stomach and allow ingesta to pass rapidly from the esophagus into the small intestine. The Roux-Y jejunal segment should prevent reflux of small intestinal contents into the remaining proximal stomach From the Department of Surgery and the Digestive Disease Center, Mayo Medical School, Rochester, Minnesota. Requests for reprints should be addressed to Keith A. Kelly, MD, Digestive Disease Center, Mayo Clinic, 200 First Street SW, Rochester. Minnesota 55905. Suuwrted in Dart by United States Public Health Service-National Institutes of Health Grants TWO4013 and DK34988, Bethesda, Maryland; the Swedish Medical Research Council; and the Mayo Foundation, Rochester, Minnesota. Presented at the 29th Annual Meeting of the Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 17-18, 1988.
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MD, Rochester, Minnesota
and esophagus. Subtotal or near-total gastrectomy ought to be safer than total gastrectomy. This study evaluated the success of extensive Roux-Y gastrectomy in 40 patients with chronic gastric atony operated on at the two Mayo-affiliated hospitals over an 1l-year period. MATERIAL
AND METHODS
Between July 1976 and July 1987, 40 patients (29 women, 11 men) were operated on for chronic gastric atony. Preoperative, operative, and early postoperative data were collected retrospectively. The mean age of the patients was 47 f 2 years (mean f SE, range 1 to 71 years). Two were children, 1 and 5 years of age. Thirtytwo patients had postvagotomy gastric atony, 6 had idiopathic gastric atony, and 2 had severe juvenile diabetes mellitus with diabetic gastroparesis. One patient with postvagotomy gastric atony had diet-controlled diabetes mellitus, which was thought not to have contributed to the atony. Eight patients had a history of postoperative or idiopathic hypothyroidism; all were receiving thyroid replacement and were euthyroid clinically and by laboratory tests at the time of evaluation. Thirty-eight of the 40 patients had had one or more previous gastric operations. The number of previous operations per patient averaged 2.4 f 0.2 (range 0 to 7). The most frequent indication for the first previous operation was peptic ulcer disease (74 percent). Five of the ulcers were complicated by pyloric obstruction. The most frequent indication for the last operation prior to the operation for atony was gastric outlet obstruction (35 percent), followed by recurrent ulcer without obstruction, bile reflux gastritis, and gastric atony. The interval from the previous operation to the operation for gastric atony averaged 28 months, but the interval varied from 2 months to more than 8 years. As a result of previous operations, 27 of the 40 patients (67 percent) had had a truncal vagotomy with subtotal distal gastric resection. Of these, 16 had a RouxY gastrojejunostomy: 12 with antrectomy, 1 with distal hemigastrectomy, and 3 with distal three-fourths gastrectomy. The final patient status prior to the operation for atony is shown in Table I. Preoperative symptoms included postprandial pain, nausea, vomiting of food but not bile, weight loss, and bloating (Table II). All patients experienced 2 or more of the symptoms, and 29 of 40 patients (73 percent) experienced 5 or 6 of the symptoms (Figure 1). Postprandial pain was felt by 90 percent of the patients, whereas bloating, the least frequent symptom, occurred in 75 percent. Weight loss was present in 32 of the 40 patients (80 percent). The mean weight at presentation was 56 f 2 kg compared with a preillness weight of 67 f 2 kg (p
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TABLE i1 ResuHs of Roux-Y Gastrectomy for Gastric Atony In 39 Patients
TABLE I Gastric Atony: Status Immediately Before Operation Previous Oparatlons
Patients (n)
None Truncal vagctomy Alone With dralnage With gastrectomy Other
2 1 6 27’ 47
Total
40
No. of Patients With Condltion Before Operation After Operation*
* Sixteen patients hsd Roux-Y gastrojejunostomy. gastrectomy without vagotomy in one patient, Nissen fundopllcatlon In two patients, and gastrojejunostomy without vagotomy in one patient.
t BillrothII
Symptom Pain Nausea Vomitlng Weight loss Bloating
36 34 32 32 30
20 17 20 16 13
Dietary restrictions Frequent small meals Solids not tolerated
13 18
5 3
9 31
11 11 6 11
Visick grade
I
grade III and 31 patients (77 percent), grade IV using a modified Visick classification [ 71. According to this classification, patients placed in grade IV have persistent, disabling symptoms not responsive to medical therapy, whereas grade III patients have continuing symptoms requiring medical therapy. Grade II patients have occasional symptoms that sometimes require therapy, whereas grade I patients have no symptoms and require no therapy. For documentation of gastric atony, 37 patients underwent an upper gastrointestinal radiographic examination, and 39 patients were examined by gastroscopy. A dilated stomach with a widely patent stoma was usually found. One patient with a Billroth II gastrojejunostomy had an anastomotic stricture 10 mm in diameter. The stricture had been successfully dilated preoperatively without relief of symptoms. In another patient, a narrowed anastomosis was described at endoscopy, but this was not verified at operation or by postoperative examination of the resected specimen. Twenty-one patients had retained food or fluid, and 10 patients had bezoars evident on preoperative gastroscopy or on previous gastroscopy. Preoperative gastroscopy revealed bile in the stomach in seven patients, gastritis in eight patients, and minor stoma1 erosions in four patients. No obvious ulcers were present. Thirteen patients underwent a preoperative gastric emptying study using radioisotopes, according to a method described elsewhere [8]. With this method, the halflife time (TM) for emptying of solids in healthy persons is 129 minutes, with the 10 and 90 percent confidence limits being 7 1 and 198 minutes, respectively. The corresponding values for liquids are T1%43 minutes, with the 10 and 90 percent confidence limits being 33 and 75 minutes, respectively. Emptying of solid food was markedly delayed in 10 of the 13 patients, the half time for emptying being greater than 198 minutes. In 6 of the 10 patients, more than 50 percent of the solid marker remained in the stomach 4 hours after ingestion of the test meal. Three patients had normal emptying of solids. Emptying of liquids was slow (T% greater than 75 minutes) in three patients, normal in four patients, and rapid (Tl/z less than 33 minutes) in six patients. In six patients, the emptying of liquids described a biphasic pattern, with rapid initial THE AMERICAN
II Ill IV l
One patient lost to follow-up.
16 fZCI Before operation
(n = 40)
e d 5 ‘= h
0
1
2
3
Symptoms,
4
5
6
no.
Fi9ure 1. Gastric atony. Symptoms befke and after Rcux-Y gsstrectomy.
emptying and slow later emptying. In these patients, more than half of the liquid marker was emptied within the first 10 minutes. Emptying of liquids did not always correlate with emptying of solids. Preoperative gastrointestinal motility studies using pressure-sensitive transducers were performed in 15 patients [9]. One of these patients had not been previously operated on, whereas all of the others had been. Twelve patients demonstrated sporadic, irregular low-amplitude gastric contractions and absent gastric migrating motor complexes during fasting, whereas 3 patients showed a pronounced postprandial antral hypomotility. Small intestinal motility was normal in 10 of 12 patients studied. One patient had bursts of high-amplitude small-intestinal motor waves, which migrated rapidly toward the ileum during fasting. The other patient failed to show a clear-cut motor pattern on eating, and instead had nonpropagating bursts of motor activity. Further evidence against a primary small intestinal motor disorder was obtained in one of these patients and in nine others by perfusing the small intestine by way of a nasointestinal tube with a nutrient solution (Osmolyte@ or Vi-
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RESULTS No patient died during the immediate postoperative
Near-total
Subtotal
n=24
n=16
Iguro 2. Operations ueed for chronic ga.str_lFatony. Let& . . _. . . . . ... gaetrojejunoetuiny. Right, near-total gaetrectomy with Roux-Y ga-Wn@~Y.
vonex@) given at 3 ml/min for 12 to 24 hours. The patients tolerated the perfusate well without experiencing abdominal cramps, nausea, vomiting, distention, borborygmus, or diarrhea. Twenty-four patients underwent extensive subtotal gastrectomy and 16 patients underwent near-total gastrectomy. Three of the patients first underwent subtotal gastrectomy and later, near-total gastrectomy. They were included in both operative groups. The two children underwent near-total gastrectomy. At subtotal gastrectomy, 75 to 80 percent of the distal stomach was resected. At near-total gastrectomy, nearly all of the stomach was removed; only a 1 to 3-cm rim of proximal stomach was left. With both types of gastrectomy, the jejunum was divided about 20 cm distal to the ligament of .Treitz. The distal cut end of jejunum was closed and an end-to-side, usually antecolic, gastrojejunostomy was performed 2 to 3 cm distal to the closure. The proximal cut end of jejunum was then anastomosed end-to-side to the midjejunum a mean distance of 46 cm (range 12 to 60 cm) distal to the gastrojejunostomy (Figure 2). Postoperative follow-up was performed by examination of the medical records, by mailed questionnaire, and by telephone. Patients were assessed for residual or new symptoms, and the need for additional medical or surgical therapy. Their weight and overall health status according to the modified Visick classification were also determined. The postoperative data were compared with the preoperative data in the same patient using the paired t test. A control group of gastric atony patients who did not have operation and who were followed for a similar interval was not available for comparison. 46
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period. The mean length of the hospital stay was 14 f 1 days (range 6 to 41 days). Two patients underwent reoperation during this period. One patient had reoperation on the seventh postoperative day for intestinal obstruction caused by a twist at the jejunojejunostomy. A side-to-side duodenojejunostomy was performed. Her total hospital stay was 18 days. She has had an excellent postoperative result (grade 1). Another patient underwent reoperation the day after operation for subcutaneous wound bleeding that had ceased at the time of reoperation. She developed severe angina pectoris 3 days later and was transferred to the cardiac unit, where she underwent percutaneous transluminal coronary angioplasty. Thereafter, her hospital stay was uneventful, and at follow-up, she was classified grade II. No other serious complications occurred. Two patients left the hospital with a feeding jejunostomy and one patient left on home parenteral nutrition. One patient was lost to follow-up. The other 39 patients were followed for a mean interval of 32 f 5 months (range 2 to 130 months). Four patients, all with subtotal gastrectomy, died during follow-up. The two patients with diabetic gastroparesis died from nonenteric complications of severe juvenile diabetes 4 years and 6.5 years postoperatively. A third patient, operated on for postvagotomy gastric atony, died from epileptic disease 1 year postoperatively. At the time of death, she had no gastrointestinal symptoms and was gaining weight. The fourth patient, a 70-year-old woman, who had undergone seven previous gastric operations, received extensive subtotal gastrectomy at our institution for postvagotomy gastric atony. One month after dismissal, she underwent a total gastrectomy at another hospital for inability to eat. She died 2.5 years later from severe malnutrition. For each of the symptoms, namely, postprandial pain, nausea, vomiting of food, weight loss, and bloating, approximately half of the patients experienced relief of symptoms (Table II). Among the 39 patients followed, 31 patients (79 percent) had fewer symptoms after operation than before operation, and 12 patients had 0 or only 1 remaining symptom postoperatively. The mean number of symptoms was markedly reduced from 4.9 f 0.2 preoperatively to 2.7 f 0.3 postoperatively (p = 0.001). Body weight, which had decreased from 67 f 2 kg before illness to 56 f 2 kg preoperatively (p0.05 compared with preoperative weight); the Roux-Y gastrectomy prevented further weight loss. Dietary restrictions were also eased by the operation. Among 18 patients who could not tolerate solids before operation, 15 could consume them without difficulty postoperatively. Fewer patients were restricted to small, frequent meals after operation (5 patients) than before operation (13 patients). In addition, only 8 patients complained of postoperative diarrhea, compared to 14 patients with diarrhea preoperatively. Mild dumping, however, was found in four patients postoperatively versus two preoperatively. Of 31 patients classified grade IV preoperatively, 20 were improved postoperatively: 7 were improved to grade 157
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I (perfect result), 9 to grade II (good result), and four to grade III (fair result). Eleven patients remained in grade IV (poor result). Of eight patients classified grade III preoperatively, six had had improvement postoperatively: four were improved to grade I, two to grade II; two remained in grade III. Overall, 22 of 39 patients (56 percent) improved from grade III or IV to grade I or II (Table II). When improvement was defined as advancing at least one grade, two-thirds of the patients were improved (Table III). Near-total gastrectomy appeared at first glance to yield better overall results than subtotal gastrectomy (Table III). The difference was most pronounced for patients who had undergone previous operations for gastric outlet obstruction. Of nine patients with this history, eight had improvement after near-total gastrectomy, whereas only two of five had improvement after subtotal gastrectomy. Patients with previous Roux-Y gastrectomy also appeared to do better with the more extensive gastrectomy. Among 10 such patients who received near-total gastrectomy, 7 were improved, whereas among 6 such patients who received subtotal gastrectomy, only 2 were improved. When the outcomes for all patients who underwent the two operations were considered, however, no clear-cut superiority of near-total gastrectomy was present (p >0.05). The length of the Roux-Y limb did not correlate with postoperative outcome. Among six patients who had Roux-Y limbs of 40 cm or less in length, four (67 percent) had improvement by operation and two did not. Similarly, among 31 patients who had Roux-Y limb of greater than 40 cm in length, 21 (68 percent) were improved by operation and 10 were not. Overall, the mean length of the Roux-Y limb in the improved patients was 46 f 3 cm, whereas the length in the nonimproved patients was 45 f 5 cm (p >0.05). Other factors, such as age, gender, indication for previous operations, number of previous operations, and amount of time elapsed after the last previous operation, were also considered to be possible influences on operative outcome, No correlation was found between any of these factors and outcome. COMMENTS Our data support those of others, who found that extensive Roux-Y gastrectomy leads to improvement in patients with chronic gastric atony [4,10-131. Before operation, all 40 of our patients experienced 2 or more severe upper gastrointestinal symptoms, such as weight loss, nausea, vomiting, bloating, and postprandial pain. After operation, 12 of 39 patients had 0 or 1 of these symptoms, whereas the overall number of symptoms per patient was markedly reduced. The operation was performed safely and with minimal morbidity. Nonetheless, although two-thirds of our patients with gastric atony were improved by Roux-Y gastrectomy, one-third were not, and 17 of 39 patients remained in grade III (fair results) or IV (poor results) at long-term follow-up. Of the 40 patients treated, only 1 in 4 was restored to perfect health. The operations left most paTHE AMERICAN
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TABLE III Results of Roux-Y Oastrectomy
Type of Operation
Total No. of Patients
for Qartrlc
Atony’
No. of Patients Vlsick Grade Vlakk &ade Improved Not lmpw3d
Gaatrectomy Subtotal Near-total Roux limb length 540 cm >40 cm
23 16
14 (61) 12 (75)’
8 31
4 (67) 21 (66)’
g (39) 4 (25)’ 2 (33) 10 (32)’
Values In parentheses are percentages. + Value does not differ slgnlficantly from that Just above (p > 0.05). l
tients with some symptoms and left one in four patients completely disabled. We tried to identify which factors might predict success or failure after Roux-Y gastrectomy. Age, gender, indications for previous gastric operations, number of previous gastric operations, and the amount of time elapsed from the last previous operation to the operation for gastric atony did not clearly influence outcome. One factor that may have predisposed to failure, however, was a history of hypothyroidism. Among eight patients with such a history, two had subtotal gastrectomy, three had near-total gastrectomy, and three had subtotal gastrectomy and then a subsequent near-total gastrectomy. Only 4 of the 11 operations led to improvement, and the only operation that did so was near-total gastrectomy. Hypothyroidism is known to be associated with gastric atony, delayed gastric emptying, and intestinal motor dysfunction [14]. Even when treated with thyroid replacement, the motor abnormalities may persist in the remaining stomach or intestinal tract and account for the poor response to Roux-Y gastrectomy. In contrast to hypothyroidism, two patients in our series with another endocrine disorder, diabetic gastroparesis, both had improvement with subtotal Roux-Y gastrectomy. This is surprising, because diabetic gastroparesis is often only one manifestation of a widespread diabetic enteropathy [6,9,15,16]. Abnormal motility in the esophagus, small intestine, and large intestine in diabetes might be expected to continue, even though the gastroparesis had been satisfactorily resolved by Roux-Y gastrectomy. Clearly, a greater experience is needed before Roux-Y ga&ectomy can be recommended for widespread application in diabetic gastroparesis. Because few preoperative factors could be clearly identified as influencing outcome, we looked more carefully at the remedial operation itself and specifically at the extent of resection. We wondered whether a neartotal gastrectomy was more likely to improve patients than a subtotal gastrectomy. Near-total Roux-Y gastrectomy has been shown to speed gastric emptying of solids in patients with slow emptying after subtotal Roux-Y gastrectomy [ 131. Some investigators have reported that near-total or total gastrectomy with Roux-Y gastrojejunostomy improves most patients with chronic gastric atony, whereas others have written that subtotal Roux-Y gastrectomy does not [12,13,17]. We found in a previous
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study that upper gastrointestinal stasis was less common after total gastrectomy with Roux-Y gastrojejunostomy than after subtotal gastrectomy with Roux-Y gastrojejunostomy [18]. Based on these several past reports, the smaller the gastric remnant left after operation, the better the postoperative result may be. In the present study, we found that patients with chronic gastric atony did tend to do better with near-total gastrectomy than with subtotal gastrectomy, but the difference was not clear-cut (p >0.05). Thus, our data do not allow us to conclude that near-total gastrectomy is the better operation. We also wondered whether a long Roux-Y limb might have contributed to continued postoperative gastrointestinal stasis in the patients. Certainly, poor propulsive motility in the Roux-Y limb has been associated with chronic gastric stasis in some patients [I 91. The poor propulsion may be due, in part, to the appearance of ectopic pacemakers in the limb, which drive the limb in a reverse or oral direction [20]. Along these lines, a short Roux-Y limb (mean length 36 cm) was associated with less upper gastrointestinal stasis after the Roux-Y operation than a longer Roux-Y limb (mean length 40 cm) [18]. Based on these data, the creation of a Roux-Y limb of 40 cm or less in length would be reasonable for patients with chronic gastric atony, especially for those with atony after Roux-Y subtotal gastrectomy. The present study showed, however, that the mean length of the Roux-Y limb created in patients improved by Roux-Y gastrectomy was 46 f 3 cm, a length similar to the 45 f 5 cm length found in the nonimproved patients (p >0.05). Thus, removing the dilated, atonic gastric remnant seemed to be the factor that led to postoperative improvement, rather than an alteration in the length of the RouxY limb. Whether shortening the limb and resecting the atonic stomach would have improved the results over resection alone is unknown. The use of extensive Roux-Y gastrectomy in patients with chronic gastric atony may seem, at first glance, to be excessively radical. It should be emphasized, however, that the patients described in this report had nearly all failed lesser gastric revisional operations, and all were long-term gastric cripples. Perhaps a lesser procedure would be satisfactory among other patients with less severe disabilities. For example, patients with gastric retention after proximal gastric vagotomy should likely be treated with a gastric drainage operation as an initial revisionary procedure rather than with a near-total Roux-Y gastrectomy. REFERENCES 1. Kraft R, Fry WJ, DeWeese MS. Postvagotomy gastric atony. Arch Surg 1964; 88: 865-74. 2. Bergin WF, Jordan PH Jr. Gastric atony and delayed gastric emptying after vagotomy for obstructing ulcer. Am J Surg 1959; 98: 612-6. 3. Kassander P. Asymptomatic gastric retention in diabetes (gastroparesis diabeticorum). Ann Intern Med 1958; 48: 797-812. 4. Telander RL, Morgan KG, Kreulen DL, Schmalz PF, Kelly KA, Szurszewski JH. Human gastric atony with tachygastria and gastric retention. Gastroenterology 1978; 75: 497-501. 5. Ricci DA, McCallum RW. Idiopathic gastric stasis. Dig Dis 1983; 1: 79-96. 48
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6. Minami M, McCallum RW. The physiology and pathophysiology of gastric emptying in humans. Gastroenterology 1984; 86: 1592-610. 7. Visick AH. Measured radical gastrectomy: review of 505 operations for peptic ulcer. Lancet 1948; 1: 505. 8. Camilleri M, Malagelada J-R, Brown ML, Becker G, Zinsmeister AR. Relation between antral motility and gastric emptying of solids and liquids in humans. Am J Physiol 1985; 249: G580-5. 9. Malagelada J-R, Rees WDW, Mazzotta LJ, Go VLW. Gastric motor abnormalities in diabetic and postvagotomy gastroparesis. Effect of metoclopramide and bethanecol. Gastroenterology 1980; 78: 286-93. 10. Hocking MP, Vogel SB, Falasca CA, Woodward ER. Delayed gastric emptying of liquids and solids following Roux-en-Y biliary diversion. Ann Surg 198 1; 194: 494-501. 11. Shellito PC, Warshaw AL. Idiopathic intermittent gastroparesis and its surgical alleviation. Am J Surg 1984; 148: 408-12. 12. Eckhauser FE, Knol JA, Raper SA, Guice KS. Completion gastrectomy for postsurgical gastroparesis syndrome: preliminary results with 15 patients. Ann Surg 1988; 208: 345-53. 13. Hinder RA, Esser J, DeMeester TR. Management of gastric emptying disorders following the Roux-en-Y procedure. Surgery 1988; 104: 765-72. 14. Miller LJ, Gorman LA, Go VLW. Gut-thyroid interrelationships. Gastroenterology 1978; 75: 901-l 1. 15. Mandelstam P, Lieber A. Esophageal dysfunction in diabetic neuropathy. JAMA 1967; 201: 582-6. 16. Katz LA, Spiro HM. Gastrointestinal manifestations of diabetes. N Engl J Med 1966; 275: 1350-61. 17. Britton JP, Johnston D, Ward DC, Axon ATR, Barker MCJ. Gastric emptying and clinical outcome after Roux-en-Y diversion. Br J Surg 1987; 74: 900-4. 18. Gustavsson S, Ilstrup DM, Morrison P, Kelly KA. The Rouxstasis syndrome after gastrectomy. Am J Surg 1988; 155: 490-4. 19. Mathias JR, Fernandez A, Sninsky CA, Clench MH, Davis RH. Nausea, vomiting, and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb. Gastroenterology 1985; 88: 101-7. 20. Morrison PM, Kelly KA, Hocking MP. Electrical dysrhythmias in the Roux-en-Y jejunal limb and their correction by pacing (abstr). Gastroenterology 1985; 88: 1508. DISCUSSION John Sonneland
(Spokane, WA): Drs. Karlstrom and Kelly, could you give us a little information about the preoperative care of these patients, that is, about the medical measures taken before surgery, such as a trial with metoclopramide? Also, what were the endoscopic and microscopic findings in these patients? John J. Gleysteen (Birmingham, AL): I would like to direct my question toward those patients with chronic atony who had previous vagotomies. in nearly half of them, the previous operation had been for gastric outlet obstruction. We presented a study at this meeting last year [Am J Surg 1988; 155: 1991, which was conducted in dogs and which showed impaired gastric contractile activity early after repair of outlet obstruction. Contractile activity was compromised further if truncal vagotomy was part of that surgical repair, but was not changed further if proximal gastric vagotomy was used, We concluded that proximal gastric vagotomy with a drainage procedure or even with a limited resective procedure might be preferable for obstructive disease. We have had a moderate clinical experience which confirms this. My
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question is whether your experience presented today might lead you to a similar recommendation in order to prevent this postoperative cause of chronic atony?
we have also used this type of extensive gastric resection in 18 similar patients and have been equally satisfied with the outcome.
Carlos A. Pellegrini (San Francisco, CA): Could you tell us a bit about the factors that affected the outcome? You mentioned that there was no relationship between age, gender, and the type of previous operation or disease. Was there any factor in the preoperative work-up, for example, the degree of delayed gastric emptying that these patients had, that correlated with the postoperative outcome? What was the degree of gastric emptying impairment that these patients had? You mentioned that it was abnormal, but do you have a certain threshold above which you would recommend a total gastrectomy, for example, no emptying at X number of minutes or something along that line? Why did the patient who had a previous vagotomy alone have total gastrectomy as op posed to a drainage procedure?
Lars Karlstrom (closing): Drs. Sonneland and Pellegrini, in regard to your questions relating to preoperative work-up of the patients, we had no specific criteria to select the patients for total or near-total gastrectomy. The diagnosis of gastric atony was based on the clinical finding of slow gastric emptying in the absence of gastric outlet obstruction; however, we did perform gastric emptying tests in 13 of our patients and all 13 had a prolonged T% for emptying of solids but not of liquids. We also studied gastric motility in 15 of the patients. All of them had hypomotility or absent motility. In 12 of them, we also studied small intestinal motility by means of pressure transducers and found that 10 of them had normal small intestinal motility. Furthermore, we exposed 10 patients to perfusion of the small intestine with Vivonex or Osmolite; none of the patients developed symptoms during perfusion. These data further support the absence of a small intestinal motor disorder in our patients.
Paul H. Jordan, Jr. (Houston, TX): In view of the fact that there are several studies showing that gastric emptying is slowed by performing a Roux-Y gastrectomy, why do you think that the Roux-Y worked as well as it did in this situation? Is it a question of how much stomach is left? Is that what allowed you to have better results with the near-total rather than the subtotal procedure? Ronald A. Hinder (Omaha, NE): I was also wondering about the selection of patients for the procedure because so many postgastrectomy patients have motility abnormalities but they need further surgery. Is there any particular preoperative investigation that could lead us to decide on who requires reoperation? My second question is in regard to the choice of drainage of the restricted stomach. We know that the Roux-Y limb is not regarded as being the ideal form of drainage of the stomach since its motility characteristics are not ideal. Did you consider draining the extensive gastrectomy by another means to avoid potential problems? Finally I would like to add that
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Keith A. Kelly (closing): In regard to medical treatment before operation, all of these patients had been treated medically and none had responded. None of these patients had bile reflux as the primary presentation of the disorder. Dr. Gleysteen, we certainly agree that the chronic gastric atony found in these patients after truncal vagotomy is a point against truncal vagotomy and a point for proximal gastric vagotomy when treating duodenal ulcer. In regard to the Roux-Y limb, some data show that the limb itself may impede gastric emptying. On the other hand, the Roux-Y limb does prevent reflux of small intestinal content into the gastric remnant. Thus, a trade-off is present between preventing reflux and delaying emptying. The delay caused by the Roux-Y limb, however, is probably not that great. We believe that the major cause of a delay in gastric emptying in our patients was the dilated atonic gastric segment rather than the Roux-Y limb.
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MD,
for Chronic Gastric Atony Keith A. Kelly,
The aim of this study was to determine the clinical outcome after Roux-Y gastrectomy for chronic gastric atony. Forty patients ( 11 men, 29 women; age 47 f 12 years) presented with severe chronic gastric atony: 32 patients had postvagotomy atony, 6 had idiopathic atony, and 2 had diabetic gastropare&s. The patients underwent either extensive subtotal or near-total gastrectomy and Roux-Y gastrojejunostomy. No early postoperative mortality occurred. Among the 39 patients followed for a mean of 32 months, 31 patients (79 percent) had fewer symptoms postoperatively than preoperatively, with 26 patients (66 percent) improving at least one Visick grade postoperatively and 22 patients (56 percent) going from grades HI and IV preoperatively to grades I and II postoperatively. In contrast, 13 patients (33 percent) did not improve after operation. We concluded that extensive subtotal Roux-Y gastrectomy and near-total Roux-Y gastrectomy were safe procedures that led to improvement in two-thirds of the patients with chronic gastric atony; however, one-third of patients did not have improvement.
hronic gastric atony, an uncommon but disabling condition, may occur as a complication of truncal C vagotomy, diabetes mellitus, or in an idiopathic form [I6J. Atony results in pain, nausea, and vomiting, especially of solid food. Poor nutrition and weight loss ensue. Many patients with atony require supplemental parenteral nutrition and some need total parenteral nutrition. We wondered whether the atony could be treated successfully by extensive subtotal or near-total gastrectomy and Roux-Y gastrojejunostomy. In our view, extensive gastrectomy should eliminate the hold-up of focd in the dilated, atonic stomach and allow ingesta to pass rapidly from the esophagus into the small intestine. The Roux-Y jejunal segment should prevent reflux of small intestinal contents into the remaining proximal stomach From the Department of Surgery and the Digestive Disease Center, Mayo Medical School, Rochester, Minnesota. Requests for reprints should be addressed to Keith A. Kelly, MD, Digestive Disease Center, Mayo Clinic, 200 First Street SW, Rochester. Minnesota 55905. Suuwrted in Dart by United States Public Health Service-National Institutes of Health Grants TWO4013 and DK34988, Bethesda, Maryland; the Swedish Medical Research Council; and the Mayo Foundation, Rochester, Minnesota. Presented at the 29th Annual Meeting of the Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 17-18, 1988.
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MD, Rochester, Minnesota
and esophagus. Subtotal or near-total gastrectomy ought to be safer than total gastrectomy. This study evaluated the success of extensive Roux-Y gastrectomy in 40 patients with chronic gastric atony operated on at the two Mayo-affiliated hospitals over an 1l-year period. MATERIAL
AND METHODS
Between July 1976 and July 1987, 40 patients (29 women, 11 men) were operated on for chronic gastric atony. Preoperative, operative, and early postoperative data were collected retrospectively. The mean age of the patients was 47 f 2 years (mean f SE, range 1 to 71 years). Two were children, 1 and 5 years of age. Thirtytwo patients had postvagotomy gastric atony, 6 had idiopathic gastric atony, and 2 had severe juvenile diabetes mellitus with diabetic gastroparesis. One patient with postvagotomy gastric atony had diet-controlled diabetes mellitus, which was thought not to have contributed to the atony. Eight patients had a history of postoperative or idiopathic hypothyroidism; all were receiving thyroid replacement and were euthyroid clinically and by laboratory tests at the time of evaluation. Thirty-eight of the 40 patients had had one or more previous gastric operations. The number of previous operations per patient averaged 2.4 f 0.2 (range 0 to 7). The most frequent indication for the first previous operation was peptic ulcer disease (74 percent). Five of the ulcers were complicated by pyloric obstruction. The most frequent indication for the last operation prior to the operation for atony was gastric outlet obstruction (35 percent), followed by recurrent ulcer without obstruction, bile reflux gastritis, and gastric atony. The interval from the previous operation to the operation for gastric atony averaged 28 months, but the interval varied from 2 months to more than 8 years. As a result of previous operations, 27 of the 40 patients (67 percent) had had a truncal vagotomy with subtotal distal gastric resection. Of these, 16 had a RouxY gastrojejunostomy: 12 with antrectomy, 1 with distal hemigastrectomy, and 3 with distal three-fourths gastrectomy. The final patient status prior to the operation for atony is shown in Table I. Preoperative symptoms included postprandial pain, nausea, vomiting of food but not bile, weight loss, and bloating (Table II). All patients experienced 2 or more of the symptoms, and 29 of 40 patients (73 percent) experienced 5 or 6 of the symptoms (Figure 1). Postprandial pain was felt by 90 percent of the patients, whereas bloating, the least frequent symptom, occurred in 75 percent. Weight loss was present in 32 of the 40 patients (80 percent). The mean weight at presentation was 56 f 2 kg compared with a preillness weight of 67 f 2 kg (p
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TABLE i1 ResuHs of Roux-Y Gastrectomy for Gastric Atony In 39 Patients
TABLE I Gastric Atony: Status Immediately Before Operation Previous Oparatlons
Patients (n)
None Truncal vagctomy Alone With dralnage With gastrectomy Other
2 1 6 27’ 47
Total
40
No. of Patients With Condltion Before Operation After Operation*
* Sixteen patients hsd Roux-Y gastrojejunostomy. gastrectomy without vagotomy in one patient, Nissen fundopllcatlon In two patients, and gastrojejunostomy without vagotomy in one patient.
t BillrothII
Symptom Pain Nausea Vomitlng Weight loss Bloating
36 34 32 32 30
20 17 20 16 13
Dietary restrictions Frequent small meals Solids not tolerated
13 18
5 3
9 31
11 11 6 11
Visick grade
I
grade III and 31 patients (77 percent), grade IV using a modified Visick classification [ 71. According to this classification, patients placed in grade IV have persistent, disabling symptoms not responsive to medical therapy, whereas grade III patients have continuing symptoms requiring medical therapy. Grade II patients have occasional symptoms that sometimes require therapy, whereas grade I patients have no symptoms and require no therapy. For documentation of gastric atony, 37 patients underwent an upper gastrointestinal radiographic examination, and 39 patients were examined by gastroscopy. A dilated stomach with a widely patent stoma was usually found. One patient with a Billroth II gastrojejunostomy had an anastomotic stricture 10 mm in diameter. The stricture had been successfully dilated preoperatively without relief of symptoms. In another patient, a narrowed anastomosis was described at endoscopy, but this was not verified at operation or by postoperative examination of the resected specimen. Twenty-one patients had retained food or fluid, and 10 patients had bezoars evident on preoperative gastroscopy or on previous gastroscopy. Preoperative gastroscopy revealed bile in the stomach in seven patients, gastritis in eight patients, and minor stoma1 erosions in four patients. No obvious ulcers were present. Thirteen patients underwent a preoperative gastric emptying study using radioisotopes, according to a method described elsewhere [8]. With this method, the halflife time (TM) for emptying of solids in healthy persons is 129 minutes, with the 10 and 90 percent confidence limits being 7 1 and 198 minutes, respectively. The corresponding values for liquids are T1%43 minutes, with the 10 and 90 percent confidence limits being 33 and 75 minutes, respectively. Emptying of solid food was markedly delayed in 10 of the 13 patients, the half time for emptying being greater than 198 minutes. In 6 of the 10 patients, more than 50 percent of the solid marker remained in the stomach 4 hours after ingestion of the test meal. Three patients had normal emptying of solids. Emptying of liquids was slow (T% greater than 75 minutes) in three patients, normal in four patients, and rapid (Tl/z less than 33 minutes) in six patients. In six patients, the emptying of liquids described a biphasic pattern, with rapid initial THE AMERICAN
II Ill IV l
One patient lost to follow-up.
16 fZCI Before operation
(n = 40)
e d 5 ‘= h
0
1
2
3
Symptoms,
4
5
6
no.
Fi9ure 1. Gastric atony. Symptoms befke and after Rcux-Y gsstrectomy.
emptying and slow later emptying. In these patients, more than half of the liquid marker was emptied within the first 10 minutes. Emptying of liquids did not always correlate with emptying of solids. Preoperative gastrointestinal motility studies using pressure-sensitive transducers were performed in 15 patients [9]. One of these patients had not been previously operated on, whereas all of the others had been. Twelve patients demonstrated sporadic, irregular low-amplitude gastric contractions and absent gastric migrating motor complexes during fasting, whereas 3 patients showed a pronounced postprandial antral hypomotility. Small intestinal motility was normal in 10 of 12 patients studied. One patient had bursts of high-amplitude small-intestinal motor waves, which migrated rapidly toward the ileum during fasting. The other patient failed to show a clear-cut motor pattern on eating, and instead had nonpropagating bursts of motor activity. Further evidence against a primary small intestinal motor disorder was obtained in one of these patients and in nine others by perfusing the small intestine by way of a nasointestinal tube with a nutrient solution (Osmolyte@ or Vi-
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RESULTS No patient died during the immediate postoperative
Near-total
Subtotal
n=24
n=16
Iguro 2. Operations ueed for chronic ga.str_lFatony. Let& . . _. . . . . ... gaetrojejunoetuiny. Right, near-total gaetrectomy with Roux-Y ga-Wn@~Y.
vonex@) given at 3 ml/min for 12 to 24 hours. The patients tolerated the perfusate well without experiencing abdominal cramps, nausea, vomiting, distention, borborygmus, or diarrhea. Twenty-four patients underwent extensive subtotal gastrectomy and 16 patients underwent near-total gastrectomy. Three of the patients first underwent subtotal gastrectomy and later, near-total gastrectomy. They were included in both operative groups. The two children underwent near-total gastrectomy. At subtotal gastrectomy, 75 to 80 percent of the distal stomach was resected. At near-total gastrectomy, nearly all of the stomach was removed; only a 1 to 3-cm rim of proximal stomach was left. With both types of gastrectomy, the jejunum was divided about 20 cm distal to the ligament of .Treitz. The distal cut end of jejunum was closed and an end-to-side, usually antecolic, gastrojejunostomy was performed 2 to 3 cm distal to the closure. The proximal cut end of jejunum was then anastomosed end-to-side to the midjejunum a mean distance of 46 cm (range 12 to 60 cm) distal to the gastrojejunostomy (Figure 2). Postoperative follow-up was performed by examination of the medical records, by mailed questionnaire, and by telephone. Patients were assessed for residual or new symptoms, and the need for additional medical or surgical therapy. Their weight and overall health status according to the modified Visick classification were also determined. The postoperative data were compared with the preoperative data in the same patient using the paired t test. A control group of gastric atony patients who did not have operation and who were followed for a similar interval was not available for comparison. 46
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period. The mean length of the hospital stay was 14 f 1 days (range 6 to 41 days). Two patients underwent reoperation during this period. One patient had reoperation on the seventh postoperative day for intestinal obstruction caused by a twist at the jejunojejunostomy. A side-to-side duodenojejunostomy was performed. Her total hospital stay was 18 days. She has had an excellent postoperative result (grade 1). Another patient underwent reoperation the day after operation for subcutaneous wound bleeding that had ceased at the time of reoperation. She developed severe angina pectoris 3 days later and was transferred to the cardiac unit, where she underwent percutaneous transluminal coronary angioplasty. Thereafter, her hospital stay was uneventful, and at follow-up, she was classified grade II. No other serious complications occurred. Two patients left the hospital with a feeding jejunostomy and one patient left on home parenteral nutrition. One patient was lost to follow-up. The other 39 patients were followed for a mean interval of 32 f 5 months (range 2 to 130 months). Four patients, all with subtotal gastrectomy, died during follow-up. The two patients with diabetic gastroparesis died from nonenteric complications of severe juvenile diabetes 4 years and 6.5 years postoperatively. A third patient, operated on for postvagotomy gastric atony, died from epileptic disease 1 year postoperatively. At the time of death, she had no gastrointestinal symptoms and was gaining weight. The fourth patient, a 70-year-old woman, who had undergone seven previous gastric operations, received extensive subtotal gastrectomy at our institution for postvagotomy gastric atony. One month after dismissal, she underwent a total gastrectomy at another hospital for inability to eat. She died 2.5 years later from severe malnutrition. For each of the symptoms, namely, postprandial pain, nausea, vomiting of food, weight loss, and bloating, approximately half of the patients experienced relief of symptoms (Table II). Among the 39 patients followed, 31 patients (79 percent) had fewer symptoms after operation than before operation, and 12 patients had 0 or only 1 remaining symptom postoperatively. The mean number of symptoms was markedly reduced from 4.9 f 0.2 preoperatively to 2.7 f 0.3 postoperatively (p = 0.001). Body weight, which had decreased from 67 f 2 kg before illness to 56 f 2 kg preoperatively (p
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I (perfect result), 9 to grade II (good result), and four to grade III (fair result). Eleven patients remained in grade IV (poor result). Of eight patients classified grade III preoperatively, six had had improvement postoperatively: four were improved to grade I, two to grade II; two remained in grade III. Overall, 22 of 39 patients (56 percent) improved from grade III or IV to grade I or II (Table II). When improvement was defined as advancing at least one grade, two-thirds of the patients were improved (Table III). Near-total gastrectomy appeared at first glance to yield better overall results than subtotal gastrectomy (Table III). The difference was most pronounced for patients who had undergone previous operations for gastric outlet obstruction. Of nine patients with this history, eight had improvement after near-total gastrectomy, whereas only two of five had improvement after subtotal gastrectomy. Patients with previous Roux-Y gastrectomy also appeared to do better with the more extensive gastrectomy. Among 10 such patients who received near-total gastrectomy, 7 were improved, whereas among 6 such patients who received subtotal gastrectomy, only 2 were improved. When the outcomes for all patients who underwent the two operations were considered, however, no clear-cut superiority of near-total gastrectomy was present (p >0.05). The length of the Roux-Y limb did not correlate with postoperative outcome. Among six patients who had Roux-Y limbs of 40 cm or less in length, four (67 percent) had improvement by operation and two did not. Similarly, among 31 patients who had Roux-Y limb of greater than 40 cm in length, 21 (68 percent) were improved by operation and 10 were not. Overall, the mean length of the Roux-Y limb in the improved patients was 46 f 3 cm, whereas the length in the nonimproved patients was 45 f 5 cm (p >0.05). Other factors, such as age, gender, indication for previous operations, number of previous operations, and amount of time elapsed after the last previous operation, were also considered to be possible influences on operative outcome, No correlation was found between any of these factors and outcome. COMMENTS Our data support those of others, who found that extensive Roux-Y gastrectomy leads to improvement in patients with chronic gastric atony [4,10-131. Before operation, all 40 of our patients experienced 2 or more severe upper gastrointestinal symptoms, such as weight loss, nausea, vomiting, bloating, and postprandial pain. After operation, 12 of 39 patients had 0 or 1 of these symptoms, whereas the overall number of symptoms per patient was markedly reduced. The operation was performed safely and with minimal morbidity. Nonetheless, although two-thirds of our patients with gastric atony were improved by Roux-Y gastrectomy, one-third were not, and 17 of 39 patients remained in grade III (fair results) or IV (poor results) at long-term follow-up. Of the 40 patients treated, only 1 in 4 was restored to perfect health. The operations left most paTHE AMERICAN
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TABLE III Results of Roux-Y Oastrectomy
Type of Operation
Total No. of Patients
for Qartrlc
Atony’
No. of Patients Vlsick Grade Vlakk &ade Improved Not lmpw3d
Gaatrectomy Subtotal Near-total Roux limb length 540 cm >40 cm
23 16
14 (61) 12 (75)’
8 31
4 (67) 21 (66)’
g (39) 4 (25)’ 2 (33) 10 (32)’
Values In parentheses are percentages. + Value does not differ slgnlficantly from that Just above (p > 0.05). l
tients with some symptoms and left one in four patients completely disabled. We tried to identify which factors might predict success or failure after Roux-Y gastrectomy. Age, gender, indications for previous gastric operations, number of previous gastric operations, and the amount of time elapsed from the last previous operation to the operation for gastric atony did not clearly influence outcome. One factor that may have predisposed to failure, however, was a history of hypothyroidism. Among eight patients with such a history, two had subtotal gastrectomy, three had near-total gastrectomy, and three had subtotal gastrectomy and then a subsequent near-total gastrectomy. Only 4 of the 11 operations led to improvement, and the only operation that did so was near-total gastrectomy. Hypothyroidism is known to be associated with gastric atony, delayed gastric emptying, and intestinal motor dysfunction [14]. Even when treated with thyroid replacement, the motor abnormalities may persist in the remaining stomach or intestinal tract and account for the poor response to Roux-Y gastrectomy. In contrast to hypothyroidism, two patients in our series with another endocrine disorder, diabetic gastroparesis, both had improvement with subtotal Roux-Y gastrectomy. This is surprising, because diabetic gastroparesis is often only one manifestation of a widespread diabetic enteropathy [6,9,15,16]. Abnormal motility in the esophagus, small intestine, and large intestine in diabetes might be expected to continue, even though the gastroparesis had been satisfactorily resolved by Roux-Y gastrectomy. Clearly, a greater experience is needed before Roux-Y ga&ectomy can be recommended for widespread application in diabetic gastroparesis. Because few preoperative factors could be clearly identified as influencing outcome, we looked more carefully at the remedial operation itself and specifically at the extent of resection. We wondered whether a neartotal gastrectomy was more likely to improve patients than a subtotal gastrectomy. Near-total Roux-Y gastrectomy has been shown to speed gastric emptying of solids in patients with slow emptying after subtotal Roux-Y gastrectomy [ 131. Some investigators have reported that near-total or total gastrectomy with Roux-Y gastrojejunostomy improves most patients with chronic gastric atony, whereas others have written that subtotal Roux-Y gastrectomy does not [12,13,17]. We found in a previous
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study that upper gastrointestinal stasis was less common after total gastrectomy with Roux-Y gastrojejunostomy than after subtotal gastrectomy with Roux-Y gastrojejunostomy [18]. Based on these several past reports, the smaller the gastric remnant left after operation, the better the postoperative result may be. In the present study, we found that patients with chronic gastric atony did tend to do better with near-total gastrectomy than with subtotal gastrectomy, but the difference was not clear-cut (p >0.05). Thus, our data do not allow us to conclude that near-total gastrectomy is the better operation. We also wondered whether a long Roux-Y limb might have contributed to continued postoperative gastrointestinal stasis in the patients. Certainly, poor propulsive motility in the Roux-Y limb has been associated with chronic gastric stasis in some patients [I 91. The poor propulsion may be due, in part, to the appearance of ectopic pacemakers in the limb, which drive the limb in a reverse or oral direction [20]. Along these lines, a short Roux-Y limb (mean length 36 cm) was associated with less upper gastrointestinal stasis after the Roux-Y operation than a longer Roux-Y limb (mean length 40 cm) [18]. Based on these data, the creation of a Roux-Y limb of 40 cm or less in length would be reasonable for patients with chronic gastric atony, especially for those with atony after Roux-Y subtotal gastrectomy. The present study showed, however, that the mean length of the Roux-Y limb created in patients improved by Roux-Y gastrectomy was 46 f 3 cm, a length similar to the 45 f 5 cm length found in the nonimproved patients (p >0.05). Thus, removing the dilated, atonic gastric remnant seemed to be the factor that led to postoperative improvement, rather than an alteration in the length of the RouxY limb. Whether shortening the limb and resecting the atonic stomach would have improved the results over resection alone is unknown. The use of extensive Roux-Y gastrectomy in patients with chronic gastric atony may seem, at first glance, to be excessively radical. It should be emphasized, however, that the patients described in this report had nearly all failed lesser gastric revisional operations, and all were long-term gastric cripples. Perhaps a lesser procedure would be satisfactory among other patients with less severe disabilities. For example, patients with gastric retention after proximal gastric vagotomy should likely be treated with a gastric drainage operation as an initial revisionary procedure rather than with a near-total Roux-Y gastrectomy. REFERENCES 1. Kraft R, Fry WJ, DeWeese MS. Postvagotomy gastric atony. Arch Surg 1964; 88: 865-74. 2. Bergin WF, Jordan PH Jr. Gastric atony and delayed gastric emptying after vagotomy for obstructing ulcer. Am J Surg 1959; 98: 612-6. 3. Kassander P. Asymptomatic gastric retention in diabetes (gastroparesis diabeticorum). Ann Intern Med 1958; 48: 797-812. 4. Telander RL, Morgan KG, Kreulen DL, Schmalz PF, Kelly KA, Szurszewski JH. Human gastric atony with tachygastria and gastric retention. Gastroenterology 1978; 75: 497-501. 5. Ricci DA, McCallum RW. Idiopathic gastric stasis. Dig Dis 1983; 1: 79-96. 48
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6. Minami M, McCallum RW. The physiology and pathophysiology of gastric emptying in humans. Gastroenterology 1984; 86: 1592-610. 7. Visick AH. Measured radical gastrectomy: review of 505 operations for peptic ulcer. Lancet 1948; 1: 505. 8. Camilleri M, Malagelada J-R, Brown ML, Becker G, Zinsmeister AR. Relation between antral motility and gastric emptying of solids and liquids in humans. Am J Physiol 1985; 249: G580-5. 9. Malagelada J-R, Rees WDW, Mazzotta LJ, Go VLW. Gastric motor abnormalities in diabetic and postvagotomy gastroparesis. Effect of metoclopramide and bethanecol. Gastroenterology 1980; 78: 286-93. 10. Hocking MP, Vogel SB, Falasca CA, Woodward ER. Delayed gastric emptying of liquids and solids following Roux-en-Y biliary diversion. Ann Surg 198 1; 194: 494-501. 11. Shellito PC, Warshaw AL. Idiopathic intermittent gastroparesis and its surgical alleviation. Am J Surg 1984; 148: 408-12. 12. Eckhauser FE, Knol JA, Raper SA, Guice KS. Completion gastrectomy for postsurgical gastroparesis syndrome: preliminary results with 15 patients. Ann Surg 1988; 208: 345-53. 13. Hinder RA, Esser J, DeMeester TR. Management of gastric emptying disorders following the Roux-en-Y procedure. Surgery 1988; 104: 765-72. 14. Miller LJ, Gorman LA, Go VLW. Gut-thyroid interrelationships. Gastroenterology 1978; 75: 901-l 1. 15. Mandelstam P, Lieber A. Esophageal dysfunction in diabetic neuropathy. JAMA 1967; 201: 582-6. 16. Katz LA, Spiro HM. Gastrointestinal manifestations of diabetes. N Engl J Med 1966; 275: 1350-61. 17. Britton JP, Johnston D, Ward DC, Axon ATR, Barker MCJ. Gastric emptying and clinical outcome after Roux-en-Y diversion. Br J Surg 1987; 74: 900-4. 18. Gustavsson S, Ilstrup DM, Morrison P, Kelly KA. The Rouxstasis syndrome after gastrectomy. Am J Surg 1988; 155: 490-4. 19. Mathias JR, Fernandez A, Sninsky CA, Clench MH, Davis RH. Nausea, vomiting, and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb. Gastroenterology 1985; 88: 101-7. 20. Morrison PM, Kelly KA, Hocking MP. Electrical dysrhythmias in the Roux-en-Y jejunal limb and their correction by pacing (abstr). Gastroenterology 1985; 88: 1508. DISCUSSION John Sonneland
(Spokane, WA): Drs. Karlstrom and Kelly, could you give us a little information about the preoperative care of these patients, that is, about the medical measures taken before surgery, such as a trial with metoclopramide? Also, what were the endoscopic and microscopic findings in these patients? John J. Gleysteen (Birmingham, AL): I would like to direct my question toward those patients with chronic atony who had previous vagotomies. in nearly half of them, the previous operation had been for gastric outlet obstruction. We presented a study at this meeting last year [Am J Surg 1988; 155: 1991, which was conducted in dogs and which showed impaired gastric contractile activity early after repair of outlet obstruction. Contractile activity was compromised further if truncal vagotomy was part of that surgical repair, but was not changed further if proximal gastric vagotomy was used, We concluded that proximal gastric vagotomy with a drainage procedure or even with a limited resective procedure might be preferable for obstructive disease. We have had a moderate clinical experience which confirms this. My
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question is whether your experience presented today might lead you to a similar recommendation in order to prevent this postoperative cause of chronic atony?
we have also used this type of extensive gastric resection in 18 similar patients and have been equally satisfied with the outcome.
Carlos A. Pellegrini (San Francisco, CA): Could you tell us a bit about the factors that affected the outcome? You mentioned that there was no relationship between age, gender, and the type of previous operation or disease. Was there any factor in the preoperative work-up, for example, the degree of delayed gastric emptying that these patients had, that correlated with the postoperative outcome? What was the degree of gastric emptying impairment that these patients had? You mentioned that it was abnormal, but do you have a certain threshold above which you would recommend a total gastrectomy, for example, no emptying at X number of minutes or something along that line? Why did the patient who had a previous vagotomy alone have total gastrectomy as op posed to a drainage procedure?
Lars Karlstrom (closing): Drs. Sonneland and Pellegrini, in regard to your questions relating to preoperative work-up of the patients, we had no specific criteria to select the patients for total or near-total gastrectomy. The diagnosis of gastric atony was based on the clinical finding of slow gastric emptying in the absence of gastric outlet obstruction; however, we did perform gastric emptying tests in 13 of our patients and all 13 had a prolonged T% for emptying of solids but not of liquids. We also studied gastric motility in 15 of the patients. All of them had hypomotility or absent motility. In 12 of them, we also studied small intestinal motility by means of pressure transducers and found that 10 of them had normal small intestinal motility. Furthermore, we exposed 10 patients to perfusion of the small intestine with Vivonex or Osmolite; none of the patients developed symptoms during perfusion. These data further support the absence of a small intestinal motor disorder in our patients.
Paul H. Jordan, Jr. (Houston, TX): In view of the fact that there are several studies showing that gastric emptying is slowed by performing a Roux-Y gastrectomy, why do you think that the Roux-Y worked as well as it did in this situation? Is it a question of how much stomach is left? Is that what allowed you to have better results with the near-total rather than the subtotal procedure? Ronald A. Hinder (Omaha, NE): I was also wondering about the selection of patients for the procedure because so many postgastrectomy patients have motility abnormalities but they need further surgery. Is there any particular preoperative investigation that could lead us to decide on who requires reoperation? My second question is in regard to the choice of drainage of the restricted stomach. We know that the Roux-Y limb is not regarded as being the ideal form of drainage of the stomach since its motility characteristics are not ideal. Did you consider draining the extensive gastrectomy by another means to avoid potential problems? Finally I would like to add that
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Keith A. Kelly (closing): In regard to medical treatment before operation, all of these patients had been treated medically and none had responded. None of these patients had bile reflux as the primary presentation of the disorder. Dr. Gleysteen, we certainly agree that the chronic gastric atony found in these patients after truncal vagotomy is a point against truncal vagotomy and a point for proximal gastric vagotomy when treating duodenal ulcer. In regard to the Roux-Y limb, some data show that the limb itself may impede gastric emptying. On the other hand, the Roux-Y limb does prevent reflux of small intestinal content into the gastric remnant. Thus, a trade-off is present between preventing reflux and delaying emptying. The delay caused by the Roux-Y limb, however, is probably not that great. We believe that the major cause of a delay in gastric emptying in our patients was the dilated atonic gastric segment rather than the Roux-Y limb.
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