Dr R Botha

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Delayed gastric emptying after Roux-en-Y
reconstruction after gastrectomy Mechanism and
management.

• Dr R Botha
• Moderator Prof Mieny

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Background

• Cesar Roux described the Roux-en-Y
  gastrojejunostomy in 1897.
• Procedure was abandoned because of the high
  incidence of marginal ulceration (simultaneous
  vagotomy was not performed).
• 1950s it was used in patients with partial
  gastrectomy and Billroth I or II reconstruction
  who presented with alkaline reflux gastritis or
  dumping.
• In 1975 Davidson and Hersh reported on long term
  follow-up of patients after Roux-en-Y who
  presented with symptoms of delayed emptying from
  gastric remnant and Roux limb.

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Roux-en-Y gastrojejunostomy
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Gastric emptying

• Normal gastric emptying is controlled by an
  intact vagus nerve and a normally functioning
  antropyloric mechanism.
• Fundus of the stomach maintains its tone under
  vagal innervation that allows emptying of
  liquids.
• Solid emptying is dependent on an innervated
  antrum and rhythmical contractions to move solid
  particles and liquid across the pylorus.
• Duodenal receptors sensitive to pH and osmolality
  are responsible for feedback mechanism regulating
  antropyloric emptying.

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Total gastric vagotomy

• Total gastric denervation
• 80-90 decrease in basal acid output and a 50-60
  decrease in maximal acid output.
• Liquid emptying is increased due to the loss of
  accomodation and receptive relaxation, with
  weakening of the duodenal brake.
• Gastric emptying of solids are slowed due to
  motor paresis.
• The vagus nerve usually suppresses ectopic
  pacemakers, which can disturb gastric emptying.

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Parietal cell vagotomy

• 80-90 decrease in basal acid output and a 50-60
  decrease in maximal acid output.
• Gastric emptying of solids remain normal as the
  antrum and pylorus remain innervated.
• Slight acceleration of liquid emptying due to
  loss of fundal reflexes.

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Distal gastrectomy

• Removal of the antrum and pylorus leads to
  elimination of G-cells and loss of the synergism
  between gastrin and the vagus nerve.
• Basal and maximum acid output are decreased by
  approximately 60.
• Solids of increasing particle size will empty
  quicker into the small bowel due to decreased
  resistance to outflow.
• Gastric emptying of liquids is normal to rapid
  due to a decreased gastric reservoir combined
  with decreased accommodation with the loss of
  antral gastrin.

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Total gastrectomy

• Complete loss of reservoir function, acid and
  pepsin secretion.
• Truncal vagotomy usually accompanies total
  gastrectomy resulting in vagal denervation of the
  GIT.

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Delayed gastric emptying

• Presentation
• Nausea Intermittent vomiting
• Weight loss Postprandial vomiting
• Epigastric fullness Abdominal pain
• Rule out mechanical causes of obstruction
• Barium radiography Not reliable to evaluate
  gastric emptying of solids.
• Upper gastrointestinal endoscopy Document
  adequacy of the anastomosis.
• Radionuclide scanning is useful to quantify the
  delayed emptying of solids and liquids through
  the gastric remnant and Roux limb.

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Anatomic obstruction
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• In 1992 four types of partial obstruction were
  described by Gowen after Roux-en-Y
  gastrojejunostomy.
• Type I and II were found immediately after
  surgery when feeding was introduced.
• Type III and IV developed within 1-6 years of
  follow up.
• In 1984 the etiology of gastric outlet
  obstruction due to anastomotic obstruction after
  Roux-en-Y gastrojejunostomy was explored.

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Type I

• Kinked loop of jejunum 10-15cm below the
  anastomosis, where the jejunum passes through the
  transverse mesocolon.

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Type I

• Upper gastrointestinal series were misinterpreted
  as an anastomotic obstruction.
• Upper gastrointestinal endoscopy revealed a
  patent anastomosis, with 2-3cm narrowing of the
  jejunum 10-15cm distal to the anastomosis.
• Endoscopic treatment Manipulation of gastroscope
  in four directions at the anastomosis to loosen
  and stretch recently formed adhesions.
• Endoscopic manipulation needed to be repeated in
  2 of the 6 patients (33), with no further
  surgical intervention needed in the 5 12 year
  follow-up period.

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Type II

• Gastrojejunal anastomosis is too high on the
  gastric fundus creating a dependent sac that
  cannot empty by gravity.

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Type II

• Upper gastrointestinal series revealed delayed
  gastric emptying with a high anastomosis.
• Endoscopy confirmed a patent anastomosis but too
  high for effective drainage.
• Surgical treatment New side to end
  gastrojejunostomy in a more dependent position.

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Type III

• Marginal ulcer

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Approach to marginal ulceration

• Alkaline reflux
• Anti-inflammatory drugs (stomach side)
• Incomplete vagotomy
• Incomplete gastrectomy
• Retained antrum
• Zollinger-Ellison syndrome
• Malignancy

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Type IV

• Gradual development of jejunal pouch due to three
  possible mechansims.
• IV a Development of an overhanging pouch
  gradually increasing in size, that will later
  fill preferentially from gastric fundus. As the
  pouch increases in size it may start to
  compromise the outflow tract.

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• IV b Mesenteric wall of the jejunal segment
  tents upwards into the anastomosis with drainage
  of the stomach on both sides of the bar.
  Anatomic deformity develops similar to type IV a.

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• IV c Postoperative adhesion formation between
  anastomosis and the liver or abdominal wall,
  angulating the anastomosis with pouch formation.

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Anastomotic obstruction

• Gastric outlet obstruction after Roux-en-Y
  gastrojejunostomy. Van Marle J, Laage NJ,
  MaraisTJ and Mieny CJ. South African Journal of
  Surgery Vol 22 No 4 Nov/Dec 1984.
• Identified causes of anastomotic narrowing
• Too short Roux-en-Y limb
• Incomplete vagotomy
• Anti-inflammatory drug abuse
• Ischaemic fibrosis
• End-to-end anastomosis

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Anastomotic obstruction

• 1. Length of Roux-limb
• Recommended length of the Roux limb is between
  45-60 cm.
• If the distance between the jejunojejunostomy is
  less than 45cm bile reflux may still occur with
  ulceration leading to delayed gastric emptying.
• Surgical treatment Revision of
  gastrojejunostomy with revision of length of Roux
  limb to at least 45cm distal to
  gastrojejunostomy.

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Anastomotic obstruction

• 2. Incomplete vagotomy
• Marginal ulceration.
• 3. Anti-inflammatory drugs
• Remains an important cause of atrophic gastritis
  and marginal ulceration.
• Surgical treatment Revision of
  gastrojejunostomy.

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Anastomotic obstruction

• 4. Ischaemic fibrosis
• Excessive mobilization of the ascending limb or
  devascularization of the greater and lesser
  curvature of the stomach.
• 5. End-to-end anastomosis
• Predisposes to narrowing with a side-to-end
  anastomosis recommended.

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Other mechanical causes of delayed gastric
emptying

• Intussusception
• Malrotation
• Internal herniation

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Functional obstruction
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Roux-stasis syndrome

• In 1984 the term Roux-syndrome was coined to
  describe early and late symptoms of
  post-Roux-en-Y gastroparesis.
• The Roux stasis syndrome may appear in the
  immediate post-operative period (acute 20-30)
  or later (30).
• It is believed that patients presenting with this
  syndrome refers to a subgroup of patients with
  unrecognized pre-existing motility disorders.
• Preoperative radionuclide gastric emptying
  studies have so far been unsuccessful in
  predicting patients at high risk.

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Pathophysiology of Roux-stasis

• Gastric remnant
• Roux limb
• The relative contributions to stasis are not
  entirely clear.

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Gastric remnant

• Vagotomy decreases the tone of the gastric
  remnant and causes a motor paresis.
• Reflux of biliary and pancreatic secretions
  (Billroth I and II) may facilitate gastric
  emptying from an atonic vagotomized gastric
  remnant by liquifying undigested food.
• Roux-en-Y gastrojejunostomy prevents biliary
  reconstruction with dry and undigested food
  emptying from the gastric remnant.

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Roux limb

• Disordered motility of the Roux limb is due to
  separation of the Roux limb from the duodenal
  pacemaker.
• The duodenal pacemaker increases the frequency of
  jejunal contractions.
• After transection the frequency distal to the cut
  decreases.
• Ectopic pacemakers appear in the Roux limb.

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Ectopic pacemakers
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Roux limb

• Ectopic pacemakers has a 25 reduction in
  frequency.
• The pacemakers often appear downstream from the
  site of the transection with subsequent oral
  propagating electrical waves.
• Small intestinal content driven in a proximal
  direction increases the resistance to outflow
  from the gastric remnant.

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• Alterations in gastrointestinal emptying of
  99m-technetium labeled solids following
  sequential antrectomy, truncal vagotomy and
  Roux-Y gastroenterostomy. Vogel SB Vair DB
  Woodward ER.
• Three patterns of delayed gastric emptying in
  dogs following a vagotomy and Roux limb
  reconstruction
• Poor emptying of solids out of the stomach.
• Rapid emptying of solids out of the stomach, with
  regurgitation of material back into the stomach.
• Roux limb stasis itself.

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Medical Treatment

• Medical therapy for Roux stasis syndrome is
  seldom successful and revisional surgery is often
  required.
• Nutritional support should focus on attempts to
  use enteral feedings by tube with the tip of the
  tube well beyond the stomach.
• Metoclopramide has been the agent most widely
  used with variable success.
• Other agents Bethanechol, Domperidone and
  Cisapride.

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Surgical Treatment

• If studies discriminate the stomach as the cause
  of the stasis more than the Roux limb, extensive
  gastric resection or completion gastrectomy are
  advocated.
• Only a 1-3cm gastric rim is left of the proximal
  stomach to ensure a leakproof anastomosis.
• Adjustment of the retrocolic Roux limb to a final
  length of 40cm.

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Surgical Treatment

• Roux limbs longer than 50cm predisposes to
  stasis.
• Persistence of Roux stasis syndrome is the major
  negative outcome.
• No current method is available to reverse the
  motor abnormalities in the Roux limb once the
  limb has been constructed.

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Uncut-Roux-en-Y gastrojejunostomy
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Rho-shaped Roux-en-Y gastrojejunostomy

• Postulate the presence of ectopic pacemaker at
  the top of the rho-shaped intestine, will allow
  flow in two directions preventing delayed gastric
  emptying.
• Motohiro et al World J of Surgery 2009 (33)

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Rho-shaped Roux-en-Y gastrojejunostomy
Motohiro et al World J of Surgery 2009 (33)
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Randomized Controlled Trial of Roux-en-Y Versus
Rho-Shaped-Roux-en-Y Reconstruction (rRY) After
Distal Gastrectomy for Gastric Cancer. Motohiro
et al. World Journal of Surgery 2009(33).

• rRY is a safe method but no advantage could be
  found above the usual RY reconstruction.
• Extensive lymphnode dissection was not associated
  with delayed gastric emptying.
• Truncal vagotomy was associated with inhibition
  of delayed gastric emptying.

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Advantages and Disadvantages of Roux-en-Y
Reconstruction after a Distal Gastrectomy for
Gastric Cancer. Yoshiyuki et al. Surgery Today
2009 (39) 647-651.

• Advantages
• Prevention of reflux oesophagitis
• Prevention of gastritis and gastric cancer in
  residual stomach.
• Reduced risk of suture rupture
• Disadvantages
• Stomal ulcer
• Roux stasis syndrome

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Roux stasis syndrome

• Incidence of 30
• Uncut Roux-en-Y conserves duodenal pacemaker and
  prevent Roux stasis syndrome.
• Length of Roux-en-Y limb is 30-35cm as the
  frequency of symptoms are higher when limb is gt
  40cm.
• Food retention can be severe when large residual
  stomach is present.
• Recommend Not to leave a large section of the
  upper stomach as it is not needed for mixing or
  peristalsis.
• Yoshiyuki et al. Surgery Today 2009 (39)

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• In Japan Billroth I operation remains the first
  choice after a distal gastrectomy due to low
  incidence of anastomotic leakage and the shorter
  duration of surgery in comparison to Roux-en-Y.
• Roux-en-Y can be used in high risk patients for
  anastomotic leakage (elderly, obese, DM, liver
  cirrhosis, chronic renal failure) and in
  esophageal hernia because of reduced
  duodenogastric reflux.
• Yoshiyuki et al. Surgery Today 2009 (39)

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Long term follow-up of patients with Roux-en-Y
Gastrojejunostomy for gastric disease. McAlhany
JC et al. Annals of Surgery vol 219 451-457.

• Clinical condition that prompted surgery was
  corrected in 95.
• Roux-en-Y was successful in treating or
  preventing bile reflux gastritis in all cases.
• Clinical failure (Visick scale III or IV) was
  documented in 8 patients (36).
• Roux stasis syndrome developed in 27 (6 of 8
  patients).

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Latest Results (12-21 years) of a Prospective
Randomized Study Comparing Billroth II and
Roux-en-Y Anastomosis after a Partial Gastrectomy
Plus Vagotomy in Patients with Duodenal Ulcers.
Csendes et al. Annals of Surgery Volume 249 (2),
Feb 2009.

• Compared clinical endoscopic and histological
  findings in patients.
• Roux-en-Y gastrojejunostomy is significantly
  better than a Billroth II reconstruction.

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• Csendes et al. Annals of Surgery. Volume 249
  (2), Feb 2009.

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• Csendes et al. Annals of Surgery. Volume 249
  (2), Feb 2009.

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Conclusion

• Incidence of Roux stasis syndrome 20-30.
• Reserve for patients at high risk for anastomotic
  leakage, patients with concomittant oesophageal
  hernia and patients with dumping or biliary
  reflux after Billroth I and II.
• Small gastric remnant
• Roux limb 30-40cm.
• Uncut Roux-en-Y gastrojejunostomy
• Always exclude mechanical causes.

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Source

• Gastric atony and the Roux syndrome. Bruce
  David Schirmer. Gastroenterology Clinics of
  North America Volume 23 (2) June 1994.
• Mayo Clinic Gastrointestinal Surgery. Kelly,
  Sarr and Hinder.
• Preoperative and postoperative motility disorders
  of the stomach. Summers GE, Hocking MP.
  Surgical Clinics of North America.
• Postgastrectomy syndromes. Eagon JC, Miedema BW,
  Kelly KA. Surgical Clinics of North America
• Surgical options in postgastrectomy syndromes.
  Delcore R, Cheung LY.
• Woodwards Postgastrectomy Syndromes. Hocking
  and Vogel.
• An alternative to Roux-en-Y for treatment of bile
  reflux gastritis. Van Stiegmann G, Goff JS.
  Suregry, Gynecology and Obstetrics Jan 1988
  Volume 166.

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Source

• Gastric outlet obstruction after Roux-en-Y
  gastrojejunostomy. Van Marle J, Laage NJ, Marais
  TJ, Mieny CJ. SAJS 22229-235.
• Long term follow-up of patients with Roux-en-Y
  Gastrojejunostomy for gastric disease. McAlhany
  JC et al. Annals of Surgery Vol 219 451-457.
• Randomized Controlled Trial of Roux-en-Y Versus
  Rho-Shaped-Roux-en-Y Reconstruction (rRY) After
  Distal Gastrectomy for Gastric Cancer. Motohiro
  et al. World Journal of Surgery 2009(33).
• Advantages and Disadvantages of Roux-en-Y
  Reconstruction after a Distal Gastrectomy for
  Gastric Cancer. Yoshiyuki et al. Surgery Today
  2009 (39) 647-651.
• Latest Results (12-21 years) of a Prospective
  Randomized Study Comparing Billroth II and
  Roux-en-Y Anastomosis after a Partial Gastrectomy
  Plus Vagotomy in Patients with Duodenal Ulcers.
  Csendes et al. Annals of Surgery Volume 249 (2),
  Feb 2009.