Alkaline Reflux Esophagitis after Total Gastrectomy Douglas Morrow, MD, Los Angeles, California Edward R. Passaro, Jr, MD, Los Angeles, California
As experience with total gastrectomy increased, the complications soon became apparent. Alkaline reflux esophagitis along with dumping and inability to maintain weight have emerged as the most important problems. These complications are related to the type of anatomic reconstruction after total gastrectomy. The usual procedures utilized to reestablish intestinal continuity after total gastrectomy are shown in Figure 1. The most commonly used form of reconstruction is end-to-side esophagojejunostomy with distal enteroenterostomy Loop EJEE) [I -51. Total gastrectomy is most frequently performed for gastric malignahcy. The postoperative survival time is short-approximately 10 per cent survive five years after resection [S]. Patients with gastric malignancy are often treated with adjuvant chemotherapy and radiation therapy, which lead to a confusing array of postoperative symptoms. In these patients, therefore, it is difficult to evaluate loop EJEE and other forms of alimentary tract reconstruction, such as Roux-en-Y esophagojejunostomy. The treatment of choice in patients with the Zollinger-Ellison syndrome is also total gastrectomy. Their postoperative survival time is much longer-55 per cent at five years and 42 per cent at ten years [7]. This provides an opportunity to evaluate the clinical advantages of each form of gastric reconstruction. The clinical experiences of twelve post total gastrectomy patients with Zollinger-Ellison syndrome, seven of whom had initial loop EJEE and five of whom had initial Roux-en-Y esophagojejunostomy, are compared here. Five of the seven patients with loop EJEE were later converted to Roux-en-Y esophagojejunostomy with a jejunal pouch (Roux-en-Y EJ). (Figure 2.) The five patients with severe alkaline reflux esophagitis after loop EJEE provided the impetus for this study. The significant symptomatic
From the Surgical and Medical Services, VA Wadsworth Hospital Center, and the Department of Surgery, UCLA School of Medicine, Los Angeles, California. Reprint requests should be addressed to Edward Ft. Passaro, Jr, MD, Surgical Service 691/i 12. VA Wadsworth Hospital Center, Los Angeles, California 90073. Presented at the Forty-Seventh Annual Meeting of the Pacific Coast Surgical Association, Monterey, California, February 15-18, 1976.
Volume 132, August 1976
improvement that occurred after their revision to a Roux-en-Y EJ prompted us to review the clinical course of other post total gastrectomy patients with Zollinger-Ellison syndrome. Case Reports Case I. EM, a fifty year old female, had vagotomyhemigastrectomy for a bleeding duodenal ulcer fifteen years ago. Ten years ago, she underwent 80 per cent gastric resection for a recurrent bleeding duodenal ulcer and seven
Flgure 1. Usual procedures for reestabitshing intestinal conthdty after total gastrecfomy.
LOOP
ROUX-en-
Y
Figure 2. Convedon from hwp EJEE to Roux-en-Y esophago~junostomy with a jejunai loop.
287
Morrow and Passaro
years ago total gastrectomy for the Zollinger-Ellison syndrome. Three tumors of the pancreas were excised. She was reconstructed with loop EJEE. Postoperatively, she had moderate dumping and severe alkaline reflux esophagitis manifested by dysphagia, retrosternal burning pain, eructations, and bile regurgitation. One year ago, her esophagojejunal anastomoeis was revised to Roux-en-Y EJ and the alkaline reflux esophagitis and dumping ceased. She gained 8 pounds and she has been able to work full-time postoperatively. Case II. RW, a fifty-five year old male, had vagotomypyloroplasty for duodenal ulcer disease four years ago, and biopsy of a tumor in the head of the pancreas showed an islet cell adenoma. Two years later when ulcer symptoms recurred, total gastrectomy with loop EJEE was performed. In his early postoperative course, he complained of bitter brash, eructations, and vomiting. The esophagitis did not respond to medical therapy. He became depressed and confused and lost 48 pounds. Because of his continued deterioration, his anastomoeie was converted to Roux-en-Y EJ six months after his total gastrectomy. In the two years since, he has become nearly asymptomatic. He has gained 10 pounds and has returned to work part-time. Serial endoscopies reveal no esophagitis. Case III. DS, a thirty-nine year old male, had total gastrectomy and loop EJEE four years ago. At operation a gastrinoma of the head of the pancreas and multiple liver nodules were noted. Postoperatively, he had recurrent vomiting and regurgitation of a bitter brash. A second enteroenterostomy below the first was created in an attempt to relieve symptoms of esophagi% There was no change in symptoms after this procedure. Approximately three years after total gastrectomy, the anastomosis was converted to Roux-en-Y EJ and subsequently he has been
asymptomatic. He has gained 30 pounds and has returned to work full-time. Case IV. DM, a forty-four year old female, noted the onset of continuous epigaatric pain and diarrhea two years ago. One year ago, persistent symptoms were associated with increased serum gastrin levels. At laparotomy no gastrinoma was found and vagotomy, antrectomy, and TABLE I
Bitter brash Retrosternal pain Dysphagia Eructations Vomiting Regurgitation Dumping Weight gain Working
288
Methods
Five patients with documented Zollinger-Ellison syndrome and loop EJEE after total gastrectomy presented with evidence of alkaline eeophagitis. They were interviewed by one of us and completed a standard questionnaire. After the conversions of their anastomosis to Roux-en-Y EJ, they were interviewed again and completed the same questionnaire. Seven additional patients who had total gastrectomy were also interviewed and asked to answer the standard questions. After the interview their records were reviewed to determine the type of esophagointestinal anastomosis that had been performed. Results
All five patients post total gastrectomy with loop had symptoms of severe alkaline reflux esophagitis. (Table 1.) In RW this was manifested primarily by a bitter brash, in DS by bitter brash and recurrent vomiting, in EM and DM by retrosternal burning pain, and in HB by severe retrosternal pain, vomiting, and bitter brash. All five patients described their symptoms as markedly incapacitating. After conversion to Roux-en-Y EJ, symptoms of reflux esophagitis abated. Diarrhea did not occur after loop EJEE or after conversion to Roux-en-Y EJ. Four patients comEJEE
Results of Conversion of Anastomosis after Total Gastrectomy from Loop EJEE to Roux-en-Y EJ in 5 Patients* RW
Note: *Data
distal pancreatectomy were performed. In the postoperative period, she had a penetrating gastric ulcer. Total gastrectomy with loop EJEE was performed and a gastrinoma-bearing lymph node was excised. Postoperatively, she had severe anorexia, retrosternal burning pain, regurgitation, and narcotic addiction. She lost 65 pounds. Barium and endoscopic examination revealed esophagitie and a tight eeophagojejunal stricture. Six months after total gastrectomy, the esophagojejunal anastomosis was converted to Roux-en-Y EJ. Postoperatively, her esophagitia has cleared completely. She has gained 20 pounds and works part-time.
+++/+ O/O
OS +++/o Q/Q
Q/+ +/+ +I0 Q/O Q/Q
O/Q 010 +++/o O/Q +I0
Yes No/Yes
Yes Yes/Yes
0 = absent; + = mild; ++ = moderate; presented as Loop EJEE/Roux-en-Y
EM Q/O +++/O
++/Q +I0 O/Q +I0 ++/+ Yes No/Yes
DM
HE
++/o +++/O
+++/+ +++/+
++/+ +I0 +/O 010 +++/+
++lO +/o +++/+ +/+ ++/o
Yes No/Yes
Yes No/Yes
+++ = marked. EJ.
lhoAmukulJwrnalofsurgafy
Postgastrectomy
are alkaline reflux esophagitis, secondary weight loss, and dumping [2,4,5,8]. The esophageal mucosa is very sensitive to the erosive effects of bile and pancreatic juice [I J. Both esophagoduodenostomy and loop esophagojejunostomy with or without enteroenterostomy allow free reflux into the esophagus [2,5,8,9]. Roux-en-Y esophagojejunostomy with or without a jejunal reservoir pouch is more effective in preventing alkaline reflux &d dumping [8,9]. Pearse, Radakovich, and Coghill [lo] noted in dog studies that an enteroenterostomy at the base of a loop fails to effectively divert all intestinal contents. A Roux-en-Y jejunal limb prevented reflux if it was greater than 12 inches in length. Scott and Weidner [3] showed in dogs that Roux-en-Y anastomosis with a limb of adequate length prevented drainage from an externally located jejunal fistula. All dogs in this group survived and maintained weight. By comparison, dogs with jejunal loop fistulas experienced marked drainage despite an enteroenterostomy proximal to the fistuia. All died in five to fourteen days. Nakayama [4], after comparing the clinical course in patients reconstructed with an esophagoduodenostomy, jejunal interposition, and esophagojejunostomy with enteroenterostomy (EJEE) concluded that EJEE was the least favorable. In particular, he noted a 58.6 and 33.3 per cent incidence of postoperative reflux esophagitis after esophagoduodenostomy and EJEE, respectively. Zollinger 1111has stated that “in general the Roux-en-Y type of anasto&osis has been preferred” after total gastrectomy for the ZollingerEIlison syndrome. Roux-en-Y esophagojejunostomy without a jejunal pouch has been criticized, however, since it does not provide a gastric substitute. Some authors contend that a gastric reservoir is a prerequisite for maintenance of ideal weight [2]. Our first group of five patients converted from loop EJEE to Roux-en-Y EJ
plained of mild to severe dumping prior to their conversion. Dumping improved in all four after conversion to Roux-en-Y EJ. Four patients, DS, RW, DM, HB, lost 25,45,70, and 75 pounds, respectively, after initial loop EJEE. After reconstruction with Roux-en-Y EJ, these four patients have regained between 10 and 35 pounds. The fifth patient, EM, reported a 10 pound weight gain after loop EJEE. After reconstruction, she has gained an additional 10 pounds. Two patients, EM and DS, were able to work full-time before and after conversion. Three patients, RW, DM, HB, were unable to work after loop EJEE. All three were able to work part-time shortly after conversion to Roux-en-Y EJ. In the second group of seven post total gastrectomy patients with Zollinger-Ellison syndrome interviewed, five were reconstructed with Roux-en-Y EJ and two had loop EJEE reconstruction. (Table IL) Tviro of the five Roux-en-Y patients had mild to moderate retrosternal pain, and three were pain free. Three complained of mild eructations. All denied vomiting, regurgitation or bitter brash, diarrhea, or dumping. One patient (with known residual tumor and extensive hepatic metastases) complained of initial mild to moderate weight loss which subsequently remained stable. By comparison, one of the two patients with loop EJEE has had severe alkaline relflux esophagitis, moderate dumping, and weight loss. He is unable to work. The second patient has done well with loop EJEE. He is symptom-free and is working. Comments The problems associated with total gastrectomy and subsequent reestablishment of esophagointestinal continuity are many. The primary complications following esophagoduodenostomy or loop esophagojejunostomy with or without enteroenterostomy TABLE
II
Results of Loop EJEE and Roux-en-Y EJ in 7 Patients after Total Gastrectomy Loop EJEE
,Bitter brash Retrosternal pain Dysphagia Eructations Vomiting Regurgitation Dumping Weight gain Working
Roux-en-Y EJ
WP
JW
ER
LS
CP
00
WPK
0 0 0 0 0 0 0 Yes Yes
+++ +++ 0 +-f-t ++ 0 ++ No No
0 + + + 0 0 + Yes Yes
0 ++ 0 4 0 0 0 Yes No”
0 0 ++ + 0 0 0 No Yes
0 0 0 0 0 0 0 Yes Not
0 0 0 0 0 0 0 Yes Yes
Note: 0 = absent; + = mild; ++ = moderate; *Extensive metastatic tumor. ‘f Severe coronary artery disease.
v0hm
182, m
Alkaline Reflux Esophagitis
1979
+++ = marked,
289
Morrow and Passaro
were all dramatically relieved of symptoms of alkaline reflux esophagitis. All five gained weight after
conversion. In the second group of patients, four were reconstructed with Roux-en-Y without and one with a jejunal pouch. All five patients have minimal to absent esophagitis and dumping. All are now maintaining or gaining weight. Inability to gain weight occurred in only one patient with extensive metastatic tumor. A jejunal pouch did not appear to be of importance in maintaining weight in our patients.
Esophagoduodenostomy and loop esophagojejunostomy with or without enteroenterostomy may not be the optimal reconstructive procedures after total gastrectomy because of esophagitis and dumping. More effective esophagointestinal anastomoses have been described [1,3,4,8,9,12]. We have had good success using a Roux-en-Y esophagojejunostomy with and without a jejunal pouch after total gastrectomy for the Zollinger-Ellison syndrome and agree that a jejunal pouch associated with Roux-en-Y esophagojejunostomy as described by Hunt and Lawrence is an excellent reconstructive procedure (1,131. Several reports using this type of procedure have emphasized the absence of alkaline reflux esophagitis and the ability of their patients to maintain ideal weight [1,2,8]. References 1.
2.
3.
4. 5. 6. 7.
6. 9.
10. 11. 12.
290
HuntCJ:Cancerof the stomach, with description of formatii of a food pouch in total gastrectomy. So& Med J47: 883, 1954. Long RTL: Esophagogastric SubstiMlon after total gastrectomy and distal esophagectomy for locally advanced gastric cancer. South Med J 86: 1121. 1973. Scott HW Jr. Weidner MG Jr: Total gastrectomy with Ftoux+n-Y esophagojejunostomy in treatment of gastric cancer. Am Swg 143: 862.1956. Nakayama K: Evaluation of the various operative methods for total gastrectomy. Surgqv 40: 488, 1956. Stensrud N: Late results after total gastrectomy for high gastric carcinoma. Ann Surg 150: 63, 1959. Barber KW Jr, Remine WI-f, Priestly JT, Gage RD: A critical evaluation of total gastrectorny. Arch Surg 87: 23, 1963. Fox DS, Hofman JW, Decosse JJ. Wilson SD The influence of total gastrectomy on survival in malignant Zollinger-Ellison tumors. Ann Surg 180: 558, 1974. Lawrence W Jr: Reservoir construction after total gastrectomy, an instructive case. Ann Surg 155: 191. 1962. Scott HW Jr, Gobbel WG Jr, Law DH IV: Clinkzalexperience with a jejunal pouch (Hunt-Lawrence) as a substitute stomach after total gastrectcmy. Surg Gynecd Obstet 121: 1231, 1965. Pearse HE, Radakovich M, Co@ill CL: An experimental st&y of antiperlstaitic jejunal loops. Ann Surg 129: 57, 1949. Zollinger RM: Islet tumors of the pancreas and the alimentary tract. Am JSwg 129: 102. 1974. Beal JM, Briggs JD, Longmire WP Jr: Use of jejunal segment
to replace the stomach following total gastrectomy. Am J Surg 88: 194, 1954. 13. Miae WH, Priestley JT: Late results after total gastrectomy. Swg Gynecol Obstet 94: 519, 1952.
Discussion James C. Thompson (Galveston, TX): The first successful total gastrectomy was performed by Schlatter in Switzerland in 1897 with an end-to-side anastomosis between the esophagus and a loop of proximal jejunum. With and without an enteroenterostomy, this was the standard anaetomosis for total gastrectomy until about the middle of this century. The first use of Roux-en-Y esophagojejuno&my after total gastrectomy was by Goldachwend in 1909 but it did not become popular until the mid-1950s. I was surprised that the authors said that loop esophagojejunostomy is still the most common operation. I have no data, but that is not my impression. I would certainly agree with the authors that Roux-en-Y esophagojejunostomy is vastly preferable. We have been following twelve patients who have had total gastrectomy with Roux-en-Y esophagojejunostomy for the Zollinger-Ellison syndrome. We have usually performed end-to-end anastomosis, but on four occasions we have closed off the end of the jejunum and performed an adjacent end-to-side esophagojejunostomy. Their perioperative course has been uniformly good. I suspect that gastrin is a trophic hormone for the esophagus as well as for the stomach and this may account for the excellent tissue that the surgeon has to work with when he performs esophagojejunal anastomosis for the Zollinger-Ellison syndrome. Patients with the Zollinger-Ellison syndrome are usually in good nutritional condition (in contradistinction to patients with gastric carcinoma). I would like to know if the authors are sure that none of their patients had any residual fundic mucosa that might give rise to severe symptoms of esophagi& The term alkaline reflux esophagitis is used repeatedly and I wonder if the pH was actually measured in all patients. I am sure that alkaline esophagi& is the major problem. On two occasions, however, as we were about to anastomose the distal esophagus to the jejunum I obtained a frozen section and was surprised to see that we were leaving a rim of fundic mucosa with the esophagus. I am sure this would have led to further difficulty. The lesson to learn from this paper, I believe, is that certainly for the Zollinger-Ellison syndrome the operation of choice is Roux-en-Y esophagojejunostomy. Nutritional results in these patients are excellent; we have one patient who weighs 190 pounds and another patient who weighs more than 200 pounds and both are more than two years post total gastrectomy and are employed full-time. The larger man works as a stevedore. In patients who have had total gastrectomy for gastric carcinoma, I believe there is a great deal to recommend in the creation of a residual pouch, for example, the Hunt-Lawrence pouch. I would agree with the position of the authors that it is probably superfluous in patients with the Zollinger-Ellison syndrome.
Postgastrectomy
David A. Taft (Seattle, WA): I enjoyed the paper by Doctors Morrow and Passaro very much but would have enjoyed it more if it had not included one of my own patients. Four years ago I had two young patients with Zollinger-Ellison syndrome. I had previously used the Rouxen-Y method but thought it would be nice to create a reservoir for these young patients. I performed two loop esophagoenterostomies with lower enteroenterostomy. I had to convert one of them myself, and Doctor Passaro repaired the other one. Both Doctor Passaro and I had the privilege of training under Doctor Robert M. Zollinger. I wondered at the time how I could have the courage to go against his recommendation for performing Roux-en-Y anastomosis. Certainly the Hunt-Lawrence pouch, if you are taking down a loop esophagoenterostomy, is appealing, but if you haven’t had one formed already for you to work with, I would agree with the authors that I see no reason to create one. The Roux-en-Y anastomosis is the standard procedure. Arthur N. Thomas (San Francisco, CA): The use of a Hunt-Lawrence pouch reminded me of an experience using a jejunal pouch and the need to emphasize that long-term follow-up is necessary to evaluate these cases. A forty-seven year old male with carcinoma of the cardia of the stomach was treated by 90 per cent gastrect+my with the antral remnant anastomosed to the distal esophagus. The patient had no recurrence of carcinoma but had severe alkaline esophagitis, anorexia, and a 50 pound weight loss. The patient’s alkaline reflux symptoms were constant and severe for five and a half years after subtotal gastrectomy. There was no evidence of persistent carcinoma, but the patient was miserable and desired relief. We decided to treat him by use of a Poth jejunal interposition procedure. After this, he was dramatically improved. He gained 30 pounds in weight and was then one of the more grateful patients I have had. This situation began to change eighteen months later. Postprandial abdominal cramps and bloating occurred. There was roentgenographic evidence of delayed emptying of the jejunal pouch. He required periodic readmission for nasogastric tube treatment of pouch obstruction. He lived with these symptoms for another seven years and eventually died of cirrhosis. It is interesting that all of the patients with alkaline reflux esophagitis presented by the authors also had weight loss. In patients who have reflux gastroesophagitis and
Alkaline Reflux Esophagitis
hiatal hernia, obesity is the more usual finding. I hope that Doctor Passaro will comment on whether use of the Hunt-Lawrence jejunal pouches had caused symptoms or complications. I believe creation of a pouch reservoir after total gastrectomy is usually unnecessary and may lead to late complications. Howard B. Kellogg (Seattle, WA): I have a question for the authors on this too, because I have been able to study ten or fifteen people with so-called alkaline reflux esophagitis by using a pH probe. To me the interesting thing is that while. the pH in the esophagus is alkaline, when you drip sodium hydroxide, which has a pH of 11, these people do not have symptoms; but if you place 0.1 normal hydrochloric acid in their esophagus, they have the same positive or Bernstein response as those people with so-called acid esophagitis. I do not know if the term “alkaline reflux esophagitis” is really correct. I think it has something to do with the enzyme system of the pancreas and not necessarily pH. Edward P. Passaro, Jr (closing): Doctor Thompson has made a very important observation: the esophagus in these patients is entirely different from the esophagus encountered in a patient with carcinoma of the stomach, for example. During resections it is particularly important that the remaining proximal esophagus is free of parietal cells. We have a frozen section made of a circumferential biopsy of the esophagus to make sure there are no parietal cells left. As Doctor Thompson suggested, this change in the esophagus is probably due to the potent trophic action of gastrin. There has not been any experimental work on the trophic effect of gastrin on the esophagus. It was also asked if there was an alkaline esophagitis. Esophageal pH measurements would be superfluous. The patients clearly state that they are vomiting up bile and I think there is very little argument as to what is producing the esophagitis. Whether or not it is only a function of pH, as Doctor Kellogg asked, is not clear. I was unaware for example, that an esophageal infusion of sodium hydroxide and perhaps sodium carbonate produced no pain. It is quite possible that the esophagitis may be a result of the action of enzymes and of the powerful surface membrane-disrupting activity of bile. We have had no experience with either a loop esophagojejunostomy or the Poth pouch.
291
As experience with total gastrectomy increased, the complications soon became apparent. Alkaline reflux esophagitis along with dumping and inability to maintain weight have emerged as the most important problems. These complications are related to the type of anatomic reconstruction after total gastrectomy. The usual procedures utilized to reestablish intestinal continuity after total gastrectomy are shown in Figure 1. The most commonly used form of reconstruction is end-to-side esophagojejunostomy with distal enteroenterostomy Loop EJEE) [I -51. Total gastrectomy is most frequently performed for gastric malignahcy. The postoperative survival time is short-approximately 10 per cent survive five years after resection [S]. Patients with gastric malignancy are often treated with adjuvant chemotherapy and radiation therapy, which lead to a confusing array of postoperative symptoms. In these patients, therefore, it is difficult to evaluate loop EJEE and other forms of alimentary tract reconstruction, such as Roux-en-Y esophagojejunostomy. The treatment of choice in patients with the Zollinger-Ellison syndrome is also total gastrectomy. Their postoperative survival time is much longer-55 per cent at five years and 42 per cent at ten years [7]. This provides an opportunity to evaluate the clinical advantages of each form of gastric reconstruction. The clinical experiences of twelve post total gastrectomy patients with Zollinger-Ellison syndrome, seven of whom had initial loop EJEE and five of whom had initial Roux-en-Y esophagojejunostomy, are compared here. Five of the seven patients with loop EJEE were later converted to Roux-en-Y esophagojejunostomy with a jejunal pouch (Roux-en-Y EJ). (Figure 2.) The five patients with severe alkaline reflux esophagitis after loop EJEE provided the impetus for this study. The significant symptomatic
From the Surgical and Medical Services, VA Wadsworth Hospital Center, and the Department of Surgery, UCLA School of Medicine, Los Angeles, California. Reprint requests should be addressed to Edward Ft. Passaro, Jr, MD, Surgical Service 691/i 12. VA Wadsworth Hospital Center, Los Angeles, California 90073. Presented at the Forty-Seventh Annual Meeting of the Pacific Coast Surgical Association, Monterey, California, February 15-18, 1976.
Volume 132, August 1976
improvement that occurred after their revision to a Roux-en-Y EJ prompted us to review the clinical course of other post total gastrectomy patients with Zollinger-Ellison syndrome. Case Reports Case I. EM, a fifty year old female, had vagotomyhemigastrectomy for a bleeding duodenal ulcer fifteen years ago. Ten years ago, she underwent 80 per cent gastric resection for a recurrent bleeding duodenal ulcer and seven
Flgure 1. Usual procedures for reestabitshing intestinal conthdty after total gastrecfomy.
LOOP
ROUX-en-
Y
Figure 2. Convedon from hwp EJEE to Roux-en-Y esophago~junostomy with a jejunai loop.
287
Morrow and Passaro
years ago total gastrectomy for the Zollinger-Ellison syndrome. Three tumors of the pancreas were excised. She was reconstructed with loop EJEE. Postoperatively, she had moderate dumping and severe alkaline reflux esophagitis manifested by dysphagia, retrosternal burning pain, eructations, and bile regurgitation. One year ago, her esophagojejunal anastomoeis was revised to Roux-en-Y EJ and the alkaline reflux esophagitis and dumping ceased. She gained 8 pounds and she has been able to work full-time postoperatively. Case II. RW, a fifty-five year old male, had vagotomypyloroplasty for duodenal ulcer disease four years ago, and biopsy of a tumor in the head of the pancreas showed an islet cell adenoma. Two years later when ulcer symptoms recurred, total gastrectomy with loop EJEE was performed. In his early postoperative course, he complained of bitter brash, eructations, and vomiting. The esophagitis did not respond to medical therapy. He became depressed and confused and lost 48 pounds. Because of his continued deterioration, his anastomoeie was converted to Roux-en-Y EJ six months after his total gastrectomy. In the two years since, he has become nearly asymptomatic. He has gained 10 pounds and has returned to work part-time. Serial endoscopies reveal no esophagitis. Case III. DS, a thirty-nine year old male, had total gastrectomy and loop EJEE four years ago. At operation a gastrinoma of the head of the pancreas and multiple liver nodules were noted. Postoperatively, he had recurrent vomiting and regurgitation of a bitter brash. A second enteroenterostomy below the first was created in an attempt to relieve symptoms of esophagi% There was no change in symptoms after this procedure. Approximately three years after total gastrectomy, the anastomosis was converted to Roux-en-Y EJ and subsequently he has been
asymptomatic. He has gained 30 pounds and has returned to work full-time. Case IV. DM, a forty-four year old female, noted the onset of continuous epigaatric pain and diarrhea two years ago. One year ago, persistent symptoms were associated with increased serum gastrin levels. At laparotomy no gastrinoma was found and vagotomy, antrectomy, and TABLE I
Bitter brash Retrosternal pain Dysphagia Eructations Vomiting Regurgitation Dumping Weight gain Working
288
Methods
Five patients with documented Zollinger-Ellison syndrome and loop EJEE after total gastrectomy presented with evidence of alkaline eeophagitis. They were interviewed by one of us and completed a standard questionnaire. After the conversions of their anastomosis to Roux-en-Y EJ, they were interviewed again and completed the same questionnaire. Seven additional patients who had total gastrectomy were also interviewed and asked to answer the standard questions. After the interview their records were reviewed to determine the type of esophagointestinal anastomosis that had been performed. Results
All five patients post total gastrectomy with loop had symptoms of severe alkaline reflux esophagitis. (Table 1.) In RW this was manifested primarily by a bitter brash, in DS by bitter brash and recurrent vomiting, in EM and DM by retrosternal burning pain, and in HB by severe retrosternal pain, vomiting, and bitter brash. All five patients described their symptoms as markedly incapacitating. After conversion to Roux-en-Y EJ, symptoms of reflux esophagitis abated. Diarrhea did not occur after loop EJEE or after conversion to Roux-en-Y EJ. Four patients comEJEE
Results of Conversion of Anastomosis after Total Gastrectomy from Loop EJEE to Roux-en-Y EJ in 5 Patients* RW
Note: *Data
distal pancreatectomy were performed. In the postoperative period, she had a penetrating gastric ulcer. Total gastrectomy with loop EJEE was performed and a gastrinoma-bearing lymph node was excised. Postoperatively, she had severe anorexia, retrosternal burning pain, regurgitation, and narcotic addiction. She lost 65 pounds. Barium and endoscopic examination revealed esophagitie and a tight eeophagojejunal stricture. Six months after total gastrectomy, the esophagojejunal anastomosis was converted to Roux-en-Y EJ. Postoperatively, her esophagitia has cleared completely. She has gained 20 pounds and works part-time.
+++/+ O/O
OS +++/o Q/Q
Q/+ +/+ +I0 Q/O Q/Q
O/Q 010 +++/o O/Q +I0
Yes No/Yes
Yes Yes/Yes
0 = absent; + = mild; ++ = moderate; presented as Loop EJEE/Roux-en-Y
EM Q/O +++/O
++/Q +I0 O/Q +I0 ++/+ Yes No/Yes
DM
HE
++/o +++/O
+++/+ +++/+
++/+ +I0 +/O 010 +++/+
++lO +/o +++/+ +/+ ++/o
Yes No/Yes
Yes No/Yes
+++ = marked. EJ.
lhoAmukulJwrnalofsurgafy
Postgastrectomy
are alkaline reflux esophagitis, secondary weight loss, and dumping [2,4,5,8]. The esophageal mucosa is very sensitive to the erosive effects of bile and pancreatic juice [I J. Both esophagoduodenostomy and loop esophagojejunostomy with or without enteroenterostomy allow free reflux into the esophagus [2,5,8,9]. Roux-en-Y esophagojejunostomy with or without a jejunal reservoir pouch is more effective in preventing alkaline reflux &d dumping [8,9]. Pearse, Radakovich, and Coghill [lo] noted in dog studies that an enteroenterostomy at the base of a loop fails to effectively divert all intestinal contents. A Roux-en-Y jejunal limb prevented reflux if it was greater than 12 inches in length. Scott and Weidner [3] showed in dogs that Roux-en-Y anastomosis with a limb of adequate length prevented drainage from an externally located jejunal fistula. All dogs in this group survived and maintained weight. By comparison, dogs with jejunal loop fistulas experienced marked drainage despite an enteroenterostomy proximal to the fistuia. All died in five to fourteen days. Nakayama [4], after comparing the clinical course in patients reconstructed with an esophagoduodenostomy, jejunal interposition, and esophagojejunostomy with enteroenterostomy (EJEE) concluded that EJEE was the least favorable. In particular, he noted a 58.6 and 33.3 per cent incidence of postoperative reflux esophagitis after esophagoduodenostomy and EJEE, respectively. Zollinger 1111has stated that “in general the Roux-en-Y type of anasto&osis has been preferred” after total gastrectomy for the ZollingerEIlison syndrome. Roux-en-Y esophagojejunostomy without a jejunal pouch has been criticized, however, since it does not provide a gastric substitute. Some authors contend that a gastric reservoir is a prerequisite for maintenance of ideal weight [2]. Our first group of five patients converted from loop EJEE to Roux-en-Y EJ
plained of mild to severe dumping prior to their conversion. Dumping improved in all four after conversion to Roux-en-Y EJ. Four patients, DS, RW, DM, HB, lost 25,45,70, and 75 pounds, respectively, after initial loop EJEE. After reconstruction with Roux-en-Y EJ, these four patients have regained between 10 and 35 pounds. The fifth patient, EM, reported a 10 pound weight gain after loop EJEE. After reconstruction, she has gained an additional 10 pounds. Two patients, EM and DS, were able to work full-time before and after conversion. Three patients, RW, DM, HB, were unable to work after loop EJEE. All three were able to work part-time shortly after conversion to Roux-en-Y EJ. In the second group of seven post total gastrectomy patients with Zollinger-Ellison syndrome interviewed, five were reconstructed with Roux-en-Y EJ and two had loop EJEE reconstruction. (Table IL) Tviro of the five Roux-en-Y patients had mild to moderate retrosternal pain, and three were pain free. Three complained of mild eructations. All denied vomiting, regurgitation or bitter brash, diarrhea, or dumping. One patient (with known residual tumor and extensive hepatic metastases) complained of initial mild to moderate weight loss which subsequently remained stable. By comparison, one of the two patients with loop EJEE has had severe alkaline relflux esophagitis, moderate dumping, and weight loss. He is unable to work. The second patient has done well with loop EJEE. He is symptom-free and is working. Comments The problems associated with total gastrectomy and subsequent reestablishment of esophagointestinal continuity are many. The primary complications following esophagoduodenostomy or loop esophagojejunostomy with or without enteroenterostomy TABLE
II
Results of Loop EJEE and Roux-en-Y EJ in 7 Patients after Total Gastrectomy Loop EJEE
,Bitter brash Retrosternal pain Dysphagia Eructations Vomiting Regurgitation Dumping Weight gain Working
Roux-en-Y EJ
WP
JW
ER
LS
CP
00
WPK
0 0 0 0 0 0 0 Yes Yes
+++ +++ 0 +-f-t ++ 0 ++ No No
0 + + + 0 0 + Yes Yes
0 ++ 0 4 0 0 0 Yes No”
0 0 ++ + 0 0 0 No Yes
0 0 0 0 0 0 0 Yes Not
0 0 0 0 0 0 0 Yes Yes
Note: 0 = absent; + = mild; ++ = moderate; *Extensive metastatic tumor. ‘f Severe coronary artery disease.
v0hm
182, m
Alkaline Reflux Esophagitis
1979
+++ = marked,
289
Morrow and Passaro
were all dramatically relieved of symptoms of alkaline reflux esophagitis. All five gained weight after
conversion. In the second group of patients, four were reconstructed with Roux-en-Y without and one with a jejunal pouch. All five patients have minimal to absent esophagitis and dumping. All are now maintaining or gaining weight. Inability to gain weight occurred in only one patient with extensive metastatic tumor. A jejunal pouch did not appear to be of importance in maintaining weight in our patients.
Esophagoduodenostomy and loop esophagojejunostomy with or without enteroenterostomy may not be the optimal reconstructive procedures after total gastrectomy because of esophagitis and dumping. More effective esophagointestinal anastomoses have been described [1,3,4,8,9,12]. We have had good success using a Roux-en-Y esophagojejunostomy with and without a jejunal pouch after total gastrectomy for the Zollinger-Ellison syndrome and agree that a jejunal pouch associated with Roux-en-Y esophagojejunostomy as described by Hunt and Lawrence is an excellent reconstructive procedure (1,131. Several reports using this type of procedure have emphasized the absence of alkaline reflux esophagitis and the ability of their patients to maintain ideal weight [1,2,8]. References 1.
2.
3.
4. 5. 6. 7.
6. 9.
10. 11. 12.
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HuntCJ:Cancerof the stomach, with description of formatii of a food pouch in total gastrectomy. So& Med J47: 883, 1954. Long RTL: Esophagogastric SubstiMlon after total gastrectomy and distal esophagectomy for locally advanced gastric cancer. South Med J 86: 1121. 1973. Scott HW Jr. Weidner MG Jr: Total gastrectomy with Ftoux+n-Y esophagojejunostomy in treatment of gastric cancer. Am Swg 143: 862.1956. Nakayama K: Evaluation of the various operative methods for total gastrectomy. Surgqv 40: 488, 1956. Stensrud N: Late results after total gastrectomy for high gastric carcinoma. Ann Surg 150: 63, 1959. Barber KW Jr, Remine WI-f, Priestly JT, Gage RD: A critical evaluation of total gastrectorny. Arch Surg 87: 23, 1963. Fox DS, Hofman JW, Decosse JJ. Wilson SD The influence of total gastrectomy on survival in malignant Zollinger-Ellison tumors. Ann Surg 180: 558, 1974. Lawrence W Jr: Reservoir construction after total gastrectomy, an instructive case. Ann Surg 155: 191. 1962. Scott HW Jr, Gobbel WG Jr, Law DH IV: Clinkzalexperience with a jejunal pouch (Hunt-Lawrence) as a substitute stomach after total gastrectcmy. Surg Gynecd Obstet 121: 1231, 1965. Pearse HE, Radakovich M, Co@ill CL: An experimental st&y of antiperlstaitic jejunal loops. Ann Surg 129: 57, 1949. Zollinger RM: Islet tumors of the pancreas and the alimentary tract. Am JSwg 129: 102. 1974. Beal JM, Briggs JD, Longmire WP Jr: Use of jejunal segment
to replace the stomach following total gastrectomy. Am J Surg 88: 194, 1954. 13. Miae WH, Priestley JT: Late results after total gastrectomy. Swg Gynecol Obstet 94: 519, 1952.
Discussion James C. Thompson (Galveston, TX): The first successful total gastrectomy was performed by Schlatter in Switzerland in 1897 with an end-to-side anastomosis between the esophagus and a loop of proximal jejunum. With and without an enteroenterostomy, this was the standard anaetomosis for total gastrectomy until about the middle of this century. The first use of Roux-en-Y esophagojejuno&my after total gastrectomy was by Goldachwend in 1909 but it did not become popular until the mid-1950s. I was surprised that the authors said that loop esophagojejunostomy is still the most common operation. I have no data, but that is not my impression. I would certainly agree with the authors that Roux-en-Y esophagojejunostomy is vastly preferable. We have been following twelve patients who have had total gastrectomy with Roux-en-Y esophagojejunostomy for the Zollinger-Ellison syndrome. We have usually performed end-to-end anastomosis, but on four occasions we have closed off the end of the jejunum and performed an adjacent end-to-side esophagojejunostomy. Their perioperative course has been uniformly good. I suspect that gastrin is a trophic hormone for the esophagus as well as for the stomach and this may account for the excellent tissue that the surgeon has to work with when he performs esophagojejunal anastomosis for the Zollinger-Ellison syndrome. Patients with the Zollinger-Ellison syndrome are usually in good nutritional condition (in contradistinction to patients with gastric carcinoma). I would like to know if the authors are sure that none of their patients had any residual fundic mucosa that might give rise to severe symptoms of esophagi& The term alkaline reflux esophagitis is used repeatedly and I wonder if the pH was actually measured in all patients. I am sure that alkaline esophagi& is the major problem. On two occasions, however, as we were about to anastomose the distal esophagus to the jejunum I obtained a frozen section and was surprised to see that we were leaving a rim of fundic mucosa with the esophagus. I am sure this would have led to further difficulty. The lesson to learn from this paper, I believe, is that certainly for the Zollinger-Ellison syndrome the operation of choice is Roux-en-Y esophagojejunostomy. Nutritional results in these patients are excellent; we have one patient who weighs 190 pounds and another patient who weighs more than 200 pounds and both are more than two years post total gastrectomy and are employed full-time. The larger man works as a stevedore. In patients who have had total gastrectomy for gastric carcinoma, I believe there is a great deal to recommend in the creation of a residual pouch, for example, the Hunt-Lawrence pouch. I would agree with the position of the authors that it is probably superfluous in patients with the Zollinger-Ellison syndrome.
Postgastrectomy
David A. Taft (Seattle, WA): I enjoyed the paper by Doctors Morrow and Passaro very much but would have enjoyed it more if it had not included one of my own patients. Four years ago I had two young patients with Zollinger-Ellison syndrome. I had previously used the Rouxen-Y method but thought it would be nice to create a reservoir for these young patients. I performed two loop esophagoenterostomies with lower enteroenterostomy. I had to convert one of them myself, and Doctor Passaro repaired the other one. Both Doctor Passaro and I had the privilege of training under Doctor Robert M. Zollinger. I wondered at the time how I could have the courage to go against his recommendation for performing Roux-en-Y anastomosis. Certainly the Hunt-Lawrence pouch, if you are taking down a loop esophagoenterostomy, is appealing, but if you haven’t had one formed already for you to work with, I would agree with the authors that I see no reason to create one. The Roux-en-Y anastomosis is the standard procedure. Arthur N. Thomas (San Francisco, CA): The use of a Hunt-Lawrence pouch reminded me of an experience using a jejunal pouch and the need to emphasize that long-term follow-up is necessary to evaluate these cases. A forty-seven year old male with carcinoma of the cardia of the stomach was treated by 90 per cent gastrect+my with the antral remnant anastomosed to the distal esophagus. The patient had no recurrence of carcinoma but had severe alkaline esophagitis, anorexia, and a 50 pound weight loss. The patient’s alkaline reflux symptoms were constant and severe for five and a half years after subtotal gastrectomy. There was no evidence of persistent carcinoma, but the patient was miserable and desired relief. We decided to treat him by use of a Poth jejunal interposition procedure. After this, he was dramatically improved. He gained 30 pounds in weight and was then one of the more grateful patients I have had. This situation began to change eighteen months later. Postprandial abdominal cramps and bloating occurred. There was roentgenographic evidence of delayed emptying of the jejunal pouch. He required periodic readmission for nasogastric tube treatment of pouch obstruction. He lived with these symptoms for another seven years and eventually died of cirrhosis. It is interesting that all of the patients with alkaline reflux esophagitis presented by the authors also had weight loss. In patients who have reflux gastroesophagitis and
Alkaline Reflux Esophagitis
hiatal hernia, obesity is the more usual finding. I hope that Doctor Passaro will comment on whether use of the Hunt-Lawrence jejunal pouches had caused symptoms or complications. I believe creation of a pouch reservoir after total gastrectomy is usually unnecessary and may lead to late complications. Howard B. Kellogg (Seattle, WA): I have a question for the authors on this too, because I have been able to study ten or fifteen people with so-called alkaline reflux esophagitis by using a pH probe. To me the interesting thing is that while. the pH in the esophagus is alkaline, when you drip sodium hydroxide, which has a pH of 11, these people do not have symptoms; but if you place 0.1 normal hydrochloric acid in their esophagus, they have the same positive or Bernstein response as those people with so-called acid esophagitis. I do not know if the term “alkaline reflux esophagitis” is really correct. I think it has something to do with the enzyme system of the pancreas and not necessarily pH. Edward P. Passaro, Jr (closing): Doctor Thompson has made a very important observation: the esophagus in these patients is entirely different from the esophagus encountered in a patient with carcinoma of the stomach, for example. During resections it is particularly important that the remaining proximal esophagus is free of parietal cells. We have a frozen section made of a circumferential biopsy of the esophagus to make sure there are no parietal cells left. As Doctor Thompson suggested, this change in the esophagus is probably due to the potent trophic action of gastrin. There has not been any experimental work on the trophic effect of gastrin on the esophagus. It was also asked if there was an alkaline esophagitis. Esophageal pH measurements would be superfluous. The patients clearly state that they are vomiting up bile and I think there is very little argument as to what is producing the esophagitis. Whether or not it is only a function of pH, as Doctor Kellogg asked, is not clear. I was unaware for example, that an esophageal infusion of sodium hydroxide and perhaps sodium carbonate produced no pain. It is quite possible that the esophagitis may be a result of the action of enzymes and of the powerful surface membrane-disrupting activity of bile. We have had no experience with either a loop esophagojejunostomy or the Poth pouch.
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