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Background: Obese patients occasionally require either elective or emergency critical care services following bariatric surgery. We describe this subgroup of patients., Methods: From July 1, 1991 to July 31, 2004, we performed 1,279 bariatric operations; 241 (19%) required admission to the surgical critical care service. We retrospectively reviewed medical records for gender, body mass index (BMI), age, whether the operation was initial or revisional, and whether critical care admission was elective or emergent. 3 complication clusters (thromboembolic, pulmonary, and anastomotic) were identified using discharge ICD-9 codes. The costs and length of stay of these subpopulations was calculated., Results: Patients were on average 46+/-10 years old, with BMI 59+/-13. Critical care admission was emergent in 52.7% (n=127) of cases. Revisional cases did not differ from the initial cases in BMI (56.4 vs 59.2, P=0.42) and they were no more likely to require emergent critical care admission than initial cases (P=0.16). Revisional cases were hospitalized longer (27.2+/-25.6 vs 12.5+/-18.7 days, P=0.003); had higher total hospital costs (US$ 60,631+/-78,337 vs 27,697+/-52,351, P=0.025); and were more likely to die from their complications (revisional surgery mortality 6.5% vs 1.9% for initial surgery [P=0.002])., Conclusions: An increasing number of surgical revisions will likely accompany the recent increase in popularity of bariatric surgery. In our experience, these patients require significant critical care services, and have longer, complicated, and more costly hospitalizations.

The purpose of this study was to determine the long-term outcome of patients who had previously undergone subtotal colectomy for severe idiopathic constipation at the University of Florida between 1983 and 1987. In addition, we aimed to determine whether preoperative motility abnormalities of the upper gastrointestinal tract are more common among those patients who have significant postoperative complications after subtotal colectomy. We evaluated 13 patients who underwent subtotal colectomy for refractory constipation between 1983 and 1987 at the University of Florida. Preoperatively, all patients exhibited a pattern consistent with colonic inertia as demonstrated by means of radiopaque markers. Each patient was asked to quantitate the pain intensity and frequency of their bowel movements before and after surgery. In seven patients an ileosigmoid anastomosis was performed, whereas in six patients an ileorectal anastomosis was used. Abdominal pain decreased after subtotal colectomy. Patients with abnormal upper gastrointestinal motility preoperatively experienced greater postoperative pain than those with normal motility regardless of the type of anastomosis. In addition, the number of postoperative surgeries was similar in those patients with abnormal upper motility compared to those with normal motility. Overall, the total number of bowel movements per week increased from 0.5 +/- 0.03 preoperatively to 15 +/- 4.5 (P < 0.007) postoperatively. The results of our study suggest that patients with isolated colonic inertia have a better long-term outcome from subtotal colectomy than patients with additional upper gastrointestinal motility abnormalities associated with their colonic inertia., (Copyright 2002 The Society for Surgery of the Alimentary Tract, Inc.)

Objective: The diagnosis of gastroparesis implies delayed gastric emptying. The diagnostic gold standard is scintigraphy, but techniques and measured endpoints vary widely among institutions. In this study, a simplified scintigraphic measurement of gastric emptying was compared to conventional gastric scintigraphic techniques and normal gastric emptying values defined in healthy subjects., Methods: In 123 volunteers (aged 19-73 yr, 60 women and 63 men) from 11 centers, scintigraphy was used to assess gastric emptying of a 99Tc-labeled low fat meal (egg substitute) and percent intragastric residual contents 60, 120, and 240 min after completion of the meal. In 42 subjects, additional measurements were taken every 10 min for 1 h. In 20 subjects, gastric emptying of a 99Tc-labeled liver meal was compared with that of the 99Tc-labeled low fat meal., Results: Median values (95th percentile) for percent gastric retention at 60, 120, and 240 min were 69% (90%), 24% (60%) and 1.2% (10%) respectively. A power exponential model yielded similar emptying curves and estimated T50 when using images only taken at 1, 2 and 4 h, or with imaging taken every 10 min. Gastric emptying was initially more rapid in men but was comparable in men and women at 4 h; it was faster in older subjects (p < 0.05) but was independent of body mass index., Conclusions: This multicenter study provides gastric emptying values in healthy subjects based on data obtained using a large sample size and consistent meal and methodology. Gastric retention of >10% at 4 h is indicative of delayed emptying, a value comparable to those provided by more intensive scanning approaches. Gastric emptying of a low fat meal is initially faster in men but is comparable in women at 4 h; it is also faster in older individuals but is independent of body mass.

Laparotomy involving manipulation of the small intestine causes injury, initiating an inflammatory cascade in the small bowel wall, which generates eicosanoids and proinflammatory cytokines. We have shown that ketorolac and salsalate, nonselective cyclooxygenase (COX) inhibitors, ameliorate postoperative small bowel ileus in a rodent model. Others have shown that interleukin-1 receptor antagonism improves postoperative gastric emptying. We examined whether inhibition of the proinflammatory cytokines, tumor necrosis factor alpha (TNFalpha) and interleukin-1 (IL-1), or selective blockade of cyclooxygenase-2 (COX-2), the COX isoform induced during inflammation, would accelerate postoperative small bowel transit in our model. Duodenostomy tubes were inserted into male Sprague-Dawley rats. One week later, animals were randomized to receive TNF-binding protein (TNF-bp), IL-1 receptor antagonist (IL-1ra), or saline (NS) prior to standardized laparotomy. Additional rats were gavaged preoperatively with a selective COX-2 inhibitor (NS-398) or NS. Small intestinal transit was measured as the geometric center (GC) of distribution of (51)CrO(4) at 30 min, 3 h, or 6 h (n = 5-9 rats/group) following laparotomy. Selective inhibition of COX-2 significantly increased postoperative small bowel transit compared to controls (GC 2.9 +/- 0.3 vs 2.2 +/- 0.1 at 30 min, GC 2.9 +/- 0.3 vs 2.5 +/- 0.2 at 3 h, and GC 3.3 +/- 0.3 vs 2.8 +/- 0.2 at 6 h, P < 0.05). In contrast, neither TNF-bp nor IL-1ra altered postoperative small intestinal transit in this model. Use of selective COX-2 inhibitors may accelerate recovery of postoperative bowel dysmotility without the undesirable effects (e.g., gastrointestinal irritation and anti-platelet effect) of nonselective COX inhibitors., (Copyright 1999 Academic Press.)

Ablation of a-calcitonin gene-related polypeptide (CGRP) containing neurons with the afferent neurotoxin capsaicin improves postoperative foregut transit in a rodent model. Similarly, administration of a selective alpha-CGRP antibody or hCGRP((8-37)), a CGRP receptor antagonist, improves postoperative gastric emptying. Unlike the stomach, which contains only alpha-CGRP, the small bowel additionally contains beta-CGRP. The role of the latter in postoperative small bowel transit is unknown. The purpose of this study was to evaluate the effect of an alpha-CGRP antibody and hCGRP((8-37)) on postoperative small bowel transit. Male Sprague-Dawley rats underwent placement of duodenal catheters and were randomly assigned to 1 of 11 groups. Four groups were pretreated with 1% capsaicin. One week later, all animals underwent standardized laparotomy following administration of a control antibody or the alpha-CGRP mono-clonal antibody, or during infusion of hCGRP((8-37)) at varying doses. Small bowel transit was measured 25 minutes postoperatively. The alpha-CGRP antibody sped postoperative transit when given alone or in combination with capsaicin. In contrast, animals treated with hCGRP((8-37)) showed no significant improvement in postoperative transit, and the beneficial effect of capsaicin was blocked. Unlike their similar effects on postoperative gastric emptying, we found that hCGRP((8-37)) and the alpha-CGRP antibody had differing effects on postoperative small bowel transit. The reason for this is unknown but may be related to their differing specificities for alpha- and beta-CGRP.

A 78-year-old individual, who had a previous transthoracic Nissen fundoplication 20 years earlier, presented to our institution with hemoptysis. Initial workup included chest roentgenogram, upper gastrointestinal series, and upper endoscopy, all of which were nondiagnostic. A repeat upper endoscopy diagnosed a gastrobronchial fistula by revealing a large gastric ulcer that penetrated into the lung parenchyma. The patient underwent surgery for takedown of the fistula. One of the most common symptoms associated with gastrobronchial fistula is hemoptysis, although insidious cough, recurrent pneumonia, or gastrointestinal bleeding are also observed. The most useful diagnostic study is an upper gastrointestinal series, which must be read with a high index of suspicion. Gastrobronchial fistula is most commonly a long-term complication from hiatal hernia repair. The most frequently used procedure for repair of this disorder is the Nissen fundoplication. This can be done from either an abdominal or transthoracic approach. When the procedure is done such that the gastric wrap is left above the diaphragm, serious complications can occur. These include gastric ulceration, gastric herniation with gastric outlet obstruction, slippage or perforation of the wrap, and gastrobronchial fistula. Because of these serious complications, the Nissen fundoplication with the wrap left above the diaphragm should only be used in certain situations, such as obesity and shortened esophagus.

This study assesses the long-term results of jejunoileal bypass (JIB) in 43 prospectively followed patients whose surgical bypass remained intact. Follow-up was 12.6+/-0.25 years from JIB. Weight loss and improved lipid levels, glucose tolerance, cardiac function, and pulmonary function were maintained. Adverse effects such as hypokalemia, cholelithiasis, and B12 or folate deficiency decreased over time. The incidence of diarrhea remained constant (63% vs 64% at five years), while the occurrence of hypomagnesemia increased (67% vs 43% at five years, P < 0.05). Nephrolithiasis occurred in 33% of patients. Hepatic fibrosis developed in 38% of patients and was progressive. Overall, after more than 10 years, 35% of patients appeared to benefit from JIB as defined by alleviation of preoperative symptoms and the development of only mild complications (vs 47% at five years). On the other hand, irreversible complications appeared to outweigh any benefit derived from the JIB in 19% (vs no patients at five years; P < 0.01). In summary, patients with JIB remain at risk for complications, particularly hepatic fibrosis, even into the late postoperative period.

Gastroschisis is frequently associated with intestinal atresia and alterations in gastrointestinal function. The authors studied gastric and small bowel myoelectric activity in a child who had a complex course and prolonged inability to tolerate oral intake after staged repair of gastroschisis and an associated ileal atresia. The child remained unable to tolerate oral intake after repair of the atresia and was reexplored 3 months later to rule out a partial small bowel obstruction, with simultaneous placement of serosal electrodes on the stomach and proximal small bowel. Persistent gastric dysrhythmias were observed postoperatively, and the child was unable to tolerate gastrostomy tube feedings. Abnormalities were also seen in small bowel motility, including retrograde propagation of activity fronts of the migrating myoelectric complex. However, the intestine converted to a fed myoelectric pattern with tube feedings, and the child was subsequently able to tolerate feedings via a tube placed directly into the small bowel. The authors conclude that myoelectric recordings via implanted electrodes are safe and feasible in children, and may give information regarding underlying motility alterations. The ultimate clinical role of myoelectric recordings in treating children with suspected motility disorders will require further study.

Background: Previously, we demonstrated that ketorolac, a nonsteroidal antiinflammatory drug (NSAID), prevented postoperative small bowel ileus in a rodent model. The aim of this study was to evaluate the effect of salsalate, an NSAID without antiplatelet effect, on postoperative ileus alone or in combination with morphine., Methods: Forty-eight rats underwent placement of duodenal catheters and were then randomly assigned to one of eight groups (n = 6). Four groups had standardized laparotomy following drug administration, whereas 4 groups underwent the same treatment without laparotomy: control and morphine animals received 0.1 mL alcohol via the catheter, whereas salsalate and salsalate-plus-morphine animals received salsalate (15 mg/kg) dissolved in 0.1 mL alcohol. The animals also received 0.5 mg/kg morphine (morphine and salsalate plus morphine) or the same volume of saline (control and salsalate) subcutaneously. Transit was measured following the injection of a nonabsorbed marker via the duodenal catheter and is defined as the geometric center (GC) of distribution. An additional 20 rats had serosal electrodes placed on the jejunum, and were assigned to one of four treatment groups (control, salsalate, morphine, and salsalate plus morphine; n = 5 each group). Myoelectric activity was recorded until the reappearance of the migrating myoelectric complex (MMC) following laparotomy., Results: Laparotomy and morphine independently reduced small bowel transit (P = 0.0006 and 0.006, respectively, by three-way analysis of variance [ANOVA]; GC 4.3 +/- 0.2 control versus 2.2 +/- 0.3 laparotomy versus 3.6 +/- 0.4 morphine), but morphine did not further worsen postoperative transit (GC 2.4 +/- 0.4; P = 0.42). Although salsalate did not alter baseline transit, pretreatment improved postoperative transit (P = 0.0002; GC 3.6 +/- 0.4). This effect was lost with the addition of morphine (GC 2.7 +/- 0.2; P = 0.21). The MMCs returned earlier after laparotomy in salsalate-pretreated rats (63 +/- 18 minutes salsalate versus 160 +/- 12 minutes laparotomy; P < 0.01, one-way ANOVA). However, this effect was also lost in animals receiving morphine (106 +/- 16 min; P > 0.05)., Conclusion: Salsalate improves postoperative small bowel motility in a rodent model; however, this effect is masked by morphine.

Background: The "Roux stasis syndrome" is characterized by symptoms of upper gut stasis following Roux-en-Y gastrojejunostomy (RG). Whether symptoms result from delayed gastric emptying, altered Roux-limb transit, or both has never been settled, partly because of the difficulty of measuring Roux-limb transit. The aim of this study was to develop a model to simultaneously quantitate Roux-limb transit and gastric emptying., Methods: Rats underwent vagotomy and antrectomy with RG or Billroth II reconstruction (B-II). Gastrointestinal transit of a solid meal (Technetium-99m sulfur colloid-labelled egg white) was assessed 0.5, 1, and 1.5 hours postprandial (pp). Transit of a liquid marker (Na51-CrO4 injected through an efferent-limb catheter) was measured at 25 minutes pp., Results: Solid gastric emptying was slower in RG than in B-II rats at 60 and 90 minutes pp. More of the solid meal and of the liquid marker was retained in the Roux limb than the efferent limb of the B-II at all time points (P < 0.05)., Conclusions: In a rodent model, Roux-en-Y gastrojejunostomy is associated with delayed gastric emptying and slowed efferent-limb transit of solids and liquids.

Delayed gastric emptying and altered upper gut transit or both are common following Roux-en-Y gastrojejunostomy and are thought to be due to altered efferent limb transit secondary to isolation of the Roux limb from the duodenal pacemaker. We postulated that preservation of myoneural continuity of the Roux limb with the duodenal pacemaker would enhance solid gastric emptying, while division of the afferent limb of a Billroth II gastrojejunostomy (B-II), isolating the efferent jejunal limb from the duodenal pacemaker, would slow gastric emptying. Solid gastric emptying was measured in 14 dogs, who then underwent gastric vagotomy and antrectomy. Eight animals were reconstructed with a Roux-en-Y gastrojejunostomy, preserving myoneural but not luminal continuity of the Roux limb with the afferent limb via a muscularis bridge, while six dogs underwent standard B-II gastrojejunostomy. Serosal electrodes were placed on the afferent and efferent jejunal limbs. Gastric emptying was restudied, with fed and fasted myoelectric recordings. The bridge was then divided to create a standard Roux, while the afferent limb was transected and reanastomosed just proximal to the gastrojejunostomy in the B-II dogs to isolate the efferent limb from the duodenal pacemaker, with repeat studies. Bridge dogs had delayed solid gastric emptying compared to their preoperative state, despite normal efferent limb motility.(ABSTRACT TRUNCATED AT 250 WORDS)

Octreotide, a somatostatin analogue that inhibits the release of most gut peptides, hastens the resolution of experimental postoperative ileus, suggesting that gut peptides mediate this process. We studied the role of two gut peptides involved in the control of normal gut motility, vasoactive intestinal peptide (VIP), and substance P (SP), in the initiation and maintenance of postoperative small bowel ileus in rats by preoperative administration of VIP and SP receptor antagonists, (VIP-ra and SP-ra). Thirty male Sprague-Dawley rats (300-350 g) underwent laparotomy. One half underwent placement of a duodenal catheter for transit studies while the other half had serosal electrodes placed on the proximal jejunum for myoelectric recordings. Six days later, animals were separated into three treatment groups of five each. Control animals were pretreated with ip saline, while the others received either VIP-ra or SP-ra prior to standardized laparotomy. Following abdominal closure, [Na51]CrO4 was injected into the duodenum and the animals were sacrificed 25 min later. The small bowel was then excised and divided into 10 equal segments. Small bowel transit was calculated as the geometric center of [Na51]CrO4 distribution. The interval until the return of migrating myoelectric complexes (MMCs) was determined in animals with intestinal electrodes. VIP-ra-treated rats demonstrated a 67% improvement in the geometric center of radiolabel relative to controls and SP-ra-treated rats had a 23% improvement (3.67 +/- 0.06 VIP-ra vs 2.69 +/- 0.09 SP-ra vs 2.20 +/- 0.09 control, P < 0.01). MMCs returned 180 +/- 17 min in controls vs 99 +/- 14 min in VIP-ra-treated rats (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

We studied the effect of erythromycin on gastric emptying in nine patients with gastroparesis following truncal vagotomy and antrectomy, and assessed their clinical response to chronic oral erythromycin. Gastric emptying was evaluated using a solid-phase radio-labeled meal. Patients were studied after erythromycin 200 mg intravenously (N = 9) and after an oral suspension of erythromycin 200 mg (N = 7) each given 15 min after ingestion of the meal. Three parameters of gastric emptying were analyzed: half-emptying time (T1/2), area under the curve, and percent gastric residual at 2 hr. Nine patients were subsequently placed on oral suspension erythromycin 150 mg three times a day before meals (range 125-250 mg three times a day) and symptoms of nausea, vomiting, postprandial fullness, and abdominal pain were assessed before and after erythromycin. Intravenous erythromycin markedly accelerated the gastric emptying (all three parameters studied) of solids (P < 0.01) in seven of nine patients with postsurgical gastroparesis [baseline T1/2 154 +/- 15 min; after intravenous erythromycin, T1/2 56 +/- 17 min (mean +/- SEM)]. Oral erythromycin enhanced (P < 0.05) the gastric emptying rate (T1/2, area under the curve) in five of seven patients (baseline T1/2 146 +/- 16 min; after oral erythromycin, T1/2 87 +/- 20 min). Of the nine patients who were placed on oral maintenance erythromycin, three showed clinical improvement after two weeks. In summary, erythromycin significantly enhances gastric emptying in many patients with vagotomy and antrectomy-induced gastroparesis; however, only a small subset of patients respond clinically to chronic oral erythromycin.

Background: The purpose of this study was to correlate clinical course, gastric emptying, and gastric myoelectric activity in a patient after gastric operation and to determine the effect of electric stimulation and the administration of erythromycin on the patient's gastric rhythm., Methods: Daily myoelectric recordings were obtained through implanted gastric electrodes after truncal vagotomy and gastroenterostomy for an obstructing duodenal ulcer., Results: The patient had acute postoperative delayed gastric emptying, accompanied initially by stomal edema but subsequently associated with persistent tachygastria. The gastric rhythm was only transiently slowed by multiple attempts at electroversion but appeared to respond dramatically to intravenous erythromycin therapy. Although delayed gastric emptying persisted on radionuclide gastric emptying studies, the patient slowly improved clinically with continued erythromycin therapy., Conclusions: Disturbances in gastric rhythm may accompany postoperative gastroparesis, although in our patient the dysrhythmias appeared to occur secondary to gastric outlet obstruction. Although his stomach could be paced, pacing was not effective in restoring a normal gastric rhythm. In contrast, intravenous erythromycin therapy was associated with rapid restoration of a normal gastric rhythm and slow improvement in gastric function.

The effect of ketorolac, a parenterally administered, nonsteroidal anti-inflammatory drug, was examined in a rat model of postoperative ileus. Small intestinal transit was measured by calculating the geometric center (GC) of distribution of 51CrO4. Laparotomy significantly delayed transit (GC: 2.2 +/- 0.2 after laparotomy versus 5.6 +/- 0.5 for unoperated controls, p < 0.01). The administration of ketorolac (1 mg/kg) improved the GC to 5.2 +/- 0.2 (p < 0.01), indicating normal intestinal transit after surgery in ketorolac-treated animals. Small intestinal myoelectric activity was recorded in rats with implanted electrodes. Animals treated with saline 2 hours postoperatively did not show return of the migrating myoelectric complex (MMC) in 183 +/- 25 minutes. In contrast, rats receiving ketorolac postoperatively had return of MMC activity in 59 +/- 18 minutes (p < 0.01). Preoperative ketorolac treatment reduced the duration of MMC inhibition after surgery from 197 +/- 55 minutes to 13 +/- 5 minutes (p < 0.05) when compared with saline. In summary, ketorolac hastens the return of MMC activity when given postoperatively. When ketorolac is administered preoperatively, it completely prevents the delay in intestinal transit and the inhibition of myoelectric activity seen in postoperative ileus. We concluded that ketorolac may be of benefit in the prevention and treatment of postoperative ileus.

Postoperative gastric myoelectric activity, gastric emptying, and clinical course were correlated in 17 patients at high risk of developing gastroparesis after gastric surgery. In addition, an attempt was made to pace the stomach with an electrical stimulus and determine the effect of pacing on early postoperative gastric emptying. Gastric dysrhythmias (bradygastria, slow wave frequency < 2 cycles/min; tachygastria, slow wave frequency > 4 cycles/min) persisted beyond the first postoperative day in 6 patients (35%). Delayed gastric emptying was identified by a radionuclide meal in 15 patients (88%), but symptoms of gastroparesis developed in only 6 of 15 (40%). Patients with postoperative gastroparesis had more frequent dysrhythmias than asymptomatic patients (67% vs. 18%), but these differences were not significant, although we cannot exclude a type II statistical error. Gastric rhythm was entrained in 10 of 16 patients (63%). Pacing increased the gastric slow wave frequency (3.1 vs. 4.1 cycles/min; P < 0.01) but did not improve gastric emptying (gastric retention at 60 minutes, 86% +/- 6% for control and 90% +/- 2% for paced). In conclusion, gastric dysrhythmias do not appear to play a major role in the development of postsurgical gastroparesis. Although gastric rhythm could be entrained in the majority of patients, pacing did not improve gastric emptying overall.

Morbid obesity is a life-threatening disorder associated with medical and psychological complications. The failure of medical therapy has led to the development of a new surgical discipline called bariatric surgery, which has evolved over the past three decades. Initial techniques created malabsorption to produce weight loss. Due to complications, later techniques limited oral intake to produce weight loss. Currently, most bariatric surgeons perform either gastric bypass or gastric partition (vertical banded gastroplasty or vertical ring gastroplasty). However, other techniques are also being evaluated, including a modified intestinal bypass, gastric banding, and a new gastric balloon. Only with continued follow-up will we determine the ultimate risk/benefit ratio of these procedures and their place in the management of the morbidly obese. In the setting of an experienced multidisciplinary team committed to long-term follow-up, surgical therapy can be considered.

Improved technology has expanded the study and understanding of gastrointestinal motility. Although no clear cause and effect relation has been demonstrated, altered motility has been found in association with a variety of nonsurgical and postoperative settings. As this relation is better defined, perhaps patients who are at risk to develop complications of surgery can be better identified so that treatment can be tailored toward their specific defect. Technological advances can also be expected to provide new and more effective interventions in this expanding field.

Delayed gastric emptying occurs frequently following Roux-en-Y gastrojejunostomy. The role of vagal denervation in the etiology of this "Roux-stasis syndrome" is controversial. This study evaluates the effect of selective vagotomy on gastric emptying and motility following Roux-en-Y. Four dogs underwent control gastric emptying studies. The animals then underwent selective vagotomy, antrectomy, and Billroth II gastrojejunostomy, with placement of serosal electrodes. Gastric emptying was assessed with simultaneous myoelectric recordings, and the animals were converted to Roux-en-Y, followed by repeat studies. Gastric emptying was unchanged following selective vagotomy, antrectomy, and Billroth II gastrojejunostomy (T 1/2: 132 +/- 18 min [SEM] versus 118 +/- 14 min control) but was markedly delayed following Roux-en-Y diversion (T 1/2: 286 +/- 44 min; p less than 0.01). All animals went into the fed pattern following Billroth II gastrojejunostomy (migrating myoelectric complex [MMC] interval: 326 +/- 6 min postprandial versus 92 +/- 5 min fasting; p less than 0.01), but no fed pattern was recognized in three of four animals following Roux-en-Y diversion (MMC interval: 68 +/- 12 min postprandial versus 62 +/- 1.5 min fasting; p = NS). In a canine model, selective vagotomy does not prevent delayed gastric emptying or myoelectric alterations following Roux-en-Y.

A gastric restrictive procedure is usually performed simultaneous with takedown of a jejunoileal bypass (JIB) to prevent weight regain. However, the preferred gastric restrictive procedure has not been established. Currently, we combine JIB takedown with silastic ring vertical gastroplasty (SRVG), and report our experience with 36 patients treated over a 5-year period. Indications for JIB takedown were diarrhea (69%), arthralgias (53%), liver disease (34%), nephrolithiasis (25%), and increasing weight (33%). Mean weight at the time of JIB takedown was 232+/-12 (SEM) lb (105 +/- 5 kg) (77 +/- 8% EBW (excess body weight)). Follow-up was complete in 33 (92%) patients. Post-reversal weight was 202 +/- 14 lb (92 +/- 6 kg) (55 +/- 8% EBW) at 1 year and 218 +/- 12 lb (99 +/- 5 kg) (67 +/- 8% EBW) (not significant) at a mean follow-up of 2.9 years. Twenty-one (64%) patients lost weight or were stable (+/-% EBW), while 12 (36%) gained a mean of 39 +/- 7 lb (18 +/- 3 kg) (range 16-80 lb (7 +/- 36 kg)). Resolution of preoperative complaints was noted in all patients with diarrhea and 53% with migratory arthralgias. Major early postoperative morbidity occurred in 11%, with no mortality. We conclude that SRVG is a safe and effective procedure to combine with JIB takedown.

The effect of gastric surgery on the pharmacokinetics of ranitidine was studied in six dogs, all serving as their own controls. Prior to and after surgery, each dog received a single oral dose (5 mg/kg of body weight) of a ranitidine solution. The surgery consisted of partial gastrectomy (antrectomy) and truncal vagotomy. Ranitidine plasma and urine concentrations were measured by reversed-phase ion-pair liquid chromatography with UV detection. Pharmacokinetic parameters were estimated by noncompartmental data analysis techniques. Gastric surgery tended to slow the absorption of ranitidine as reflected by a slight increase of the time necessary to reach the peak plasma concentration. The maximum observed plasma concentration was slightly lowered. The amount of drug absorbed remained unchanged as reflected by no change in the AUCs. Other parameters such as mean residence time, elimination half-life, apparent oral clearance, and fraction excreted unchanged in the urine remained unchanged. However, due to the small number of animals and the considerable intersubject variability, none of these trends reached statistical significance.

Antiperistaltic and recurrent intussusceptions are extremely rare in the adult. We report a patient with both. The patient developed an antiperistaltic intussusception distal to her Roux enteroenterostomy years after a Roux-en-Y gastric bypass for morbid obesity. The diagnosis was made preoperatively with gastrointestinal contrast radiography and ultrasonography. At surgery, the intussusception was reduced, and 12 inches of nonviable bowel was resected, with a functional end-to-end anastomosis. An isoperistaltic intussusception occurred in the early postoperative period just distal to the anastomosis. Manometric evaluation of the Roux limb after the second operation showed altered gastrointestinal motility, consisting of orad-propagated and aboard-propagated migrating motor complexes, minimal phase 2 activity, and lack of conversion to the fed pattern with a liquid meal. Although manometry was not performed before the development of the intussusception, our findings are consistent with the hypothesis that altered intestinal motility may contribute to the development of intussusception.

Four hundred twelve patients underwent gastric bypass for treatment of morbid obesity between 1981 and 1985 at the University of Florida Affiliated Hospitals. Thirty-four patients (8.2%) developed marginal ulcers, considerably higher than the 0-3 per cent ulcer occurrence commonly reported in the literature. Factors predisposing to ulcer formation include: (1) a large gastric pouch; (2) a vertically oriented pouch; and (3) staple-line dehiscence. Twenty-two of 34 patients (65%) with symptomatic marginal ulcers were noted to have staple-line disruption. Twenty-one of these patients (95%) eventually required operative therapy for their ulcers compared with four of 12 patients (33%) with an intact gastric staple line. Surgical therapy consisted of takedown of the Roux-en-Y limb with resection of the ulcer and gastrogastrostomy. Staple-line dehiscence is a significant etiologic factor in the development of marginal ulcer following gastric bypass and when present constitutes an indication for reoperation.

We have demonstrated that erythromycin improves gastric emptying in dogs following truncal vagotomy and Roux-en-Y antrectomy (VRYA). To explore its mechanism of action we studied gastric emptying and myoelectric activity in a canine Roux model and administered atropine simultaneously with erythromycin. Tachyphylaxis was evaluated following short-term administration. Four dogs with delayed gastric emptying following VRYA were studied. Radionuclide solid gastric emptying was measured, with simultaneous myoelectric recordings obtained from the duodenum and Roux limb. Study groups were: (1) saline control (VRYA dogs); (2) erythromycin 1 mg/kg iv over 1 hr; (3) erythromycin 3 mg/kg po tid for 1 week, with repeat studies using erythromycin 1 mg/kg iv over 1 hr; and (4) atropine 0.5 mg/kg iv bolus, followed by a 1-hr infusion of atropine 0.05 mg/kg and erythromycin 1 mg/kg. Control Roux animals had severe gastric retention (73 +/- 5% at 2 hr, compared to 27 +/- 6% following iv erythromycin (P less than 0.01). Clustered spike bursts were observed in the Roux limb following erythromycin. Atropine abolished the gastrokinetic response and suppressed the myoelectric response to erythromycin (81 +/- 3% retention at 2 hr, P less than 0.01 compared to erythromycin alone). The response to erythromycin was unchanged after 1 week of tid administration (40 +/- 14% retention at 2 hr postprandial, P = NS). Erythromycin improves gastric emptying in VRYA dogs via a cholinergic pathway and does not exhibit tachyphylaxis following short-term administration.

Delayed gastric emptying occurs in up to 50% of patients after truncal vagotomy and Roux-Y antrectomy and is often resistant to nonsurgical therapy. This study evaluates the effect of erythromycin, metoclopramide, and motilin on delayed gastric emptying in four dogs after Roux-Y antrectomy. Solid food gastric emptying was measured using a radionuclide technique. Study groups were: (1) saline control; (2) erythromycin 1 mg/kg intravenously over 1 hour; (3) erythromycin 3 mg/kg by mouth 45 minutes prior to feeding; (4) metoclopramide 0.6 mg/kg intravenously over 1 hour; and (5) motilin 500 ng/kg intravenously over 1 hour. After Roux-Y antrectomy, saline control dogs had 73% +/- 5% (SEM) gastric retention at 2 hours. After intravenous and oral erythromycin, gastric emptying improved at 2 hours to 27% +/- 6% and 39% +/- 5% (p less than 0.01 compared with control). Erythromycin intravenously and by mouth improved gastric emptying compared with metoclopramide (64% +/- 8%, p less than 0.05). Motilin enhanced gastric emptying to a similar degree as erythromycin, with a 2-hour gastric retention of 37% +/- 4% (NS). Erythromycin improved gastric emptying in dogs with severe Roux-Y gastroparesis and may have clinical application.

Braun enteroenterostomy with stapled occlusion of the afferent limb has been advocated to treat bile gastritis and to avoid the motility effects of Roux-en-Y gastrojejunostomy. However, the motility effects of stapled occlusion are unknown. Myoelectric activity and histologic features were studied after stapled occlusion of the small bowel in a canine model. A 35 cm "recirculating loop" was created with a side-to-side anastomosis, beginning 25 cm from the ligament of Treitz. Serosal electrodes were placed at 5 cm intervals on the loop; at a second operation in one dog and simultaneously in three dogs, the bowel was occluded midway between two electrodes with 4.8 mm staples. Fasting recordings were obtained at weekly intervals to 6 months after surgery and were analyzed for slow wave frequency proximal and distal to the staple line and for propagation time of phase 3 of the migrating myoelectric complex across the staple line. The side-to-side anastomosis did not alter myoelectric activity. However, after stapled occlusion of the small bowel, the slow wave frequency dropped from a mean of 18.2 +/- 0.4 cpm proximally to 15.4 +/- 1.0 cpm distally (p less than 0.05). This correlated with loss of myogenic continuity in three of four animals. Propagation of phase 3 slowed across the staple line (115 +/- 27 seconds versus 47 +/- 9 seconds) (p less than 0.02). The bowel lumen recannulated in all animals. Stapling across the small bowel alters myoelectric activity, and occlusion of the bowel lumen may not be permanent.

The purpose of this study was to compare gastric emptying and Roux myoelectric activity in a canine model. Four dogs underwent truncal vagotomy, antrectomy, and 40 cm Roux-en-Y gastrojejunostomy, with placement of serosal electrodes. Following recovery, gastric emptying was determined scintigraphically with a radiolabeled solid meal, and fasting and fed small-bowel myoelectric activity was obtained. Gastric emptying was markedly slowed compared to control unoperated animals (202 +/- 91 versus 46 +/- 12 min; P less than 0.05). Slow wave frequency declined in the Roux limb compared to the duodenum (14.2 +/- 0.4 versus 18.0 +/- .06 counts per minute; P less than 0.01). No gradient in slow wave frequency was observed in the Roux limb, although one animal was noted to have reversed propagation of slow waves in the proximal Roux limb. Migrating myoelectric complexes (MMCs) were coordinated between the Roux limb and jejunum distal to the enteroenterostomy, but not with the duodenum. Periodicity of the MMCs was different in the Roux limb and duodenum (98.6 +/- 6.3 versus 138 +/- 17.5 min; P less than 0.05). None of the animals converted to the fed myoelectric pattern with a 272 kcal meal (MMC periodicity in the Roux limb = 99 +/- 10 min postprandially, P = N.S.). These quantitative and qualitative alterations in myoelectric activity may contribute to the observed delay in gastric emptying following Roux-en-Y gastrojejunostomy.

We have experienced a 14% (38 of 264 patients) incidence of pouch outlet obstruction following vertical ring gastroplasty. Initial management consisted of dilatation in 34 of 38 patients (94%). Ten of 34 patients (29%) were spared reoperation by 1 to 3 dilatations. Non-passage of an endoscope through the stoma immediately following dilatation predicted the need for surgery; 4 of 11 patients (36%) with passage underwent reoperation compared with 17 of 20 patients (85%) without passage (p less than 0.02). Surgical findings included "tipped bands" in 9 of 28 patients (32%); fibrous reaction to the band in 10 of 28 patients (36%); adhesions with angulation of the pouch in 2 of 28 patients (7%); and no identifiable cause of obstruction in 7 of 28 patients (25%). Surgical therapy consisted of removal of the band (2 patients), removal of the band and replacement with a similar length or larger band (20 patients), "tacking" the band in the horizontal position (4 patients), or conversion to a Roux-Y bypass (2 patients). The first three options were associated with an unacceptably high rate of weight regain and/or continued symptoms, whereas the last-named procedure met with good success.

Transient delayed gastric emptying is reported as a frequent complication following pancreas-preserving pancreaticoduodenectomy (PPW). We placed serosal electrodes on the stomach of a patient undergoing PPW. Myoelectric recordings were obtained postoperatively and correlated with simultaneous radionuclide liquid gastric emptying studies. The patient developed early postoperative gastric atony, associated with frequent gastric dysrhythmias. These dysrhythmias may have been exacerbated by a perihepatic abscess. The gastric dysrhythmias correlated with alterations in liquid gastric emptying. Gastric dysrhythmias may be a mechanism for gastric dysfunction in the early postoperative period.

The functional end-to-end technique with a gastrointestinal stapler is commonly used for small-bowel anastomosis, but the effects of this anatomically side-to-side anastomosis on motility are unknown. Fasting small-bowel myoelectric activity and culture results were compared in six animals undergoing handsewn end-to-end and functional end-to-end anastomoses. Serosal electrodes were placed at 10 cm intervals, and the small bowel was divided 25 and 55 cm from the ligament of Treitz. The functional end-to-end and end-to-end techniques were performed in each animal in random order. Fasting myoelectric recordings were obtained at weekly intervals for up to 20 weeks after operation. New electrodes were placed, and additional recordings were obtained from 29 to 39 weeks, 51 to 63 weeks, and 108 to 112 weeks after operation. The recordings were visually inspected for passage of phase 3 of the migrating myoelectric complex (MMC). By 12 to 20 weeks after operation, 91% of MMCs crossed the end-to-end anastomoses versus 22% across the functional end-to-end anastomosis (p less than 0.001). Even 2 years after surgery only 56% of MMCs crossed the functional end-to-end anastomosis. Quantitative bacterial cultures suggested a trend toward bacterial overgrowth in the functional end-to-end anastomosis. These results demonstrate that the functional end-to-end anastomosis alters small-bowel motility to a greater degree than an end-to-end anastomosis and may predispose to bacterial overgrowth.

The effect of partial gastrectomy on the pharmacokinetic parameters of (+)- and (-)-propranolol were investigated in six dogs. (+/-)-Propranolol (3 mg/kg body weight) was administered orally before and after surgery and the plasma concentrations of (+)- and (-)-propranolol were determined using an indirect enantioseparation technique. There were significant differences (p less than or equal to 0.05, paired t-test) in the area under the concentration-time curves (AUCs) and the maximum plasma concentration (Cmax) between (+)- and (-)-propranolol. The ratio AUC(+):AUC(-) was 1.73 +/- 0.28. These differences between the enantiomers remained unchanged after surgery. Other pharmacokinetic parameters showed no stereoselectivity. After partial gastrectomy, there was a slight, but nonsignificant decrease in time to reach maximum plasma concentration (tmax) and in the absorption half-life for both enantiomers. The maximum plasma concentration increased slightly. The elimination half-life and the mean residence time remained unchanged before and after surgery. Therefore, it is unlikely that there are any clinically relevant changes in the pharmacokinetics of (+)- and (-)-propranolol after partial gastrectomy.

Apudomas are a diffuse group of tumors that have interested surgeons for a long time. With recent developments in their radiological localization and pharmacological control, they are now treated in a truly multidisciplinary approach. In this chapter, recent developments in the radiological, surgical, and medical approaches to these tumors are reviewed. Emphasis is placed on how non-surgical developments have affected the surgical treatment of specific apudomas. Resulting changes in surgical philosophy are also reviewed.

A method is described for complete isolation of the stomach in the dog with vagal innervation intact. This involves esophagostomy, double mucosal closure of the pylorus and a Maydl gastric fistula combined with gastrojejunostomy. The latter is occluded during periods of study. In this preparation the responses to sham feeding and to insulin-induced hypoglycemia were reduced approximately 10-fold, reiterating the significant synergistic effect of gastrin on vagal stimulation of the parietal cell mass. However, significant acid secretion could still be induced in this preparation by both sham feeding and insulin-induced hypoglycemia.

The study of GI motility is an area of great current interest and excitement. Our knowledge of normal and abnormal GI motility is expanding exponentially. Perhaps one of the most satisfying consequences of this new knowledge is the ability to reassure patients that their symptoms may not be functional but may be based on a specific physiologic dysfunction. Unfortunately, our ability to treat effectively these newly described disorders has lagged behind our ability to diagnose them, but progress is being made, with promising new therapeutic agents on the horizon. Gastroenterologists remain the best friends of surgeons; most of these patients can and should be managed without surgical intervention. Therapeutic nihilism is not justified, because a carefully considered and properly timed operation may be of tremendous symptomatic benefit to selected patients. As more information and follow-up results are gained, the proper role of surgical intervention in these disorders will be better defined.

Supradiaphragmatic fundoplication has been useful in patients with an acquired short esophagus since the inception of the Nissen technique. Recent reports documenting a large number of life-threatening complications in relatively small groups of patients prompted us to review the records of all patients with supradiaphragmatic fundoplication. Forty-four supradiaphragmatic Nissen fundoplications were performed, with an average follow-up of 42 months. Operative mortality was 7 percent. Acceptable results were obtained in 82 percent (88 percent of patients not lost to follow-up). Poor results were obtained in 5 percent (one patient with scleroderma and one with diaphragmatic hernia). In another 5 percent, postoperative diaphragmatic hernia developed. In two patients, ulceration of the antrum developed that appeared unrelated to the operation. Sixteen patients have been followed for longer than 5 years, with no long-term complications. The wide variation in the incidence of these complications between our patients and those of others is probably related to varying details of operative technique. Supradiaphragmatic fundoplication provides uniformly effective protection against gastroesophageal reflux with an acceptable morbidity and low mortality.

Posterior gastropexy appears to be the treatment of choice in the occasional patient with persistent debilitating post-fundoplication syndrome. This syndrome occurs to this extent only rarely (less than 1%) and chronic small-bowel obstruction or dysfunction may be a predisposing factor. We prefer the posterior gastropexy of Hill in cases of reflux esophagitis uncomplicated by Barretts mucosa, stricture, or esophageal shortening. The authors especially caution against the use of fundoplication as an incidental procedure for anatomic repair of an asymptomatic hiatus hernia or in patients with a history of small bowel obstruction.

Our objective was to develop an operation for morbid obesity that would be simple, safe, and effective and yet have few long-term adverse physiologic effects. Vertical gastroplasty was chosen. A small proximal gastric pouch was fashioned by stapling vertically beginning 5 cm distal to the cardia along the lesser curvature of the stomach and ending just lateral to the esophagogastric junction along the greater curvature. A 1.1-cm channel through the staple line was left near the lesser curvature of the stomach. No gastric incisions, enterostomies, or anastomoses were necessary. Among 57 patients (with a mean +/- SEM preoperative weight of 136 +/- 4.5 kg) operated on since January 1981, no deaths occurred and no gastric reoperations were done. The hospital stay was short (mean, 9 days). In 32 patients who were followed up for 1 year or longer, the mean percentage of excess weight lost was 39% at 6 months, 43% at 12 months, and 34% at 24 months. Two patients had disruption of the staple line and regained weight by 24 months postoperatively. Channel stenosis occurred within 6 months after operation in seven patients, all of whom were managed successfully with endoscopic dilation. We conclude that vertical gastroplasty is a simple, safe operation for morbid obesity with few adverse sequelae, but the percentage of excess weight lost during a 1- to 4-year follow-up exceeded 50% in only 31% of our patients.

From 1973 to 1986, 22 patients underwent Roux-Y gastrojejunostomy for the early postgastrectomy dumping syndrome. In the early years, five patients underwent Roux-Y conversion with the addition of a 10 cm antiperistaltic jejunal segment interposed between the Roux-Y limb and the stomach. Within 4 years, all five patients had the jejunal segment removed due to severe symptoms of gastric retention. These patients underwent reconstruction to create Roux-Y limb only and joined the pool of 17 patients who underwent Roux-Y diversion only for the dumping syndrome. Overall, 19 of 22 patients (86 percent) had almost complete resolution of their dumping symptoms on long-term follow-up. Three patients showed no improvement, two with severe gastric retention and one with recurrent dumping symptoms. Overall, 5 of 22 patients (23 percent) had moderate to severe early and late postoperative gastric retention necessitating medical treatment in three and subsequent near-total gastrectomy in two. Although other procedures such as pyloric reconstruction or the addition of isoperistaltic or antiperistaltic jejunal interpositions have been reported to be equally successful in delaying gastric emptying and resolving dumping symptoms, we have preferred Roux-Y diversion for the treatment of combined alkaline reflux gastritis and dumping or the pure early vasomotor postgastrectomy dumping syndrome. As reported, we have abandoned the use of an antiperistaltic jejunal segment interposed between the stomach and the Roux-Y limb due to the high rate of postoperative gastric retention.

Optimum treatment of patients with esophageal strictures requires of the operating surgeon a wide repertoire of procedures suited to the individual circumstance. The Thal-Nissen procedure should be used in the patient with a longitudinal transmural stricture which cannot be easily dilated. When used in this setting, it widens the distal esophagus with a patch of well vascularized fundus and provides extremely effective protection against gastroesophageal reflux. Sixty-eight patients at the University of Florida underwent combined Thal-Nissen procedures for longitudinal peptic strictures. Operative mortality rate was 4%. The average length of follow-up was 68 months. Fifty-seven of 68 patients had an acceptable result (84%). Four per cent had an early recurrence of their stricture, while an additional 4% had late recurrence of their strictures, after an initially good response period of from two to 11 years. Four of the six patients with poor results had either achalasia, scleroderma, or diffuse esophageal spasm. The combined Thal-Nissen procedure represents the optimum therapy for the patient with an undilatable transmural stricture of the esophagus. When used in this setting, satisfactory results will be achieved in a large majority of patients with an extremely low operative mortality rate. Colonic or jejunal interposition should be reserved for those patients who either fail to respond to a combined Thal-Nissen procedure or who demonstrate sufficiently disordered peristalsis to render the esophagus an unsatisfactory conduit for the passage of food.

Peptic stricture of the esophagus and achalasia both cause dysphagia. They are not always readily distinguished by history. The usual workup with upper gastrointestinal x ray and endoscopy may also fail to differentiate the two disorders. Two cases are presented wherein antireflux procedures were mistakenly performed when achalasia was present rather than peptic stricture. Dysphagia was unrelieved and extensive further procedures were required. In a third patient referred for a peptic stricture, manometry revealed the correct diagnosis and heller myotomy provided relief. It is recommended that manometry be performed as a part of the preoperative workup in patients in whom there is any element of dysphagia.

To evaluate the results of jejunoileal bypass for morbid obesity, we studied 100 patients with intact bypasses an average of more than five years after surgery. Mean weight loss at five years was 102.7 lb (46.6 kg) (33 per cent). Although nearly half the patients regained some weight between one and five years after surgery, only 17 per cent regained 20 lb (9 kg) or more. Medical benefits (such as improved glucose tolerance and lowered blood pressure) were maintained at five years, but side effects and complications continued to occur in the late postoperative period. Diarrhea (more than three stools per day) persisted in 58 per cent of the patients, and electrolyte disturbances occurred in over a third. Diminished levels of B12 or folate or both were present in 88 per cent. Twenty-one per cent of the patients had nephrolithiasis, and 20 per cent of those who were at risk required cholecystectomy. Progressive hepatic structural abnormalities occurred in 29 per cent of the patients, and there was a 7 per cent incidence of cirrhosis. Although 81 per cent of the patients had satisfactory results at five years, side effects and complications continued to occur, mandating careful follow-up indefinitely. The risk-to-benefit ratio at five years after surgery seems acceptable, but the continued untoward effects of the bypass in the late postoperative period have led us to abandon this procedure in favor of gastric bypass. Only continued longitudinal follow-up will determine whether on balance jejunoileal bypass represents such a serious long-term health hazard that prophylactic restoration of intestinal continuity is indicated.

The most common types of postgastrectomy disorders are the dumping syndromes (early postprandial and late or hypoglycemic) and alkaline reflux gastritis. Both are caused by destruction of the pyloric mechanism. A third problem, Roux-en-Y duodenal diversion, frequently results in delayed gastric emptying.

The pre and postoperative incidence of cholelithiasis were investigated in patients undergoing bariatric surgery at the University of Florida. The first part of the study was retrospective and revealed a pre and 24-month postoperative incidence of cholelithiasis of 30 and 40 percent respectively. Age and postoperative interval were not predictive of cholelithiasis. Patients with cholelithiasis had a significantly greater weight loss (130 +/- 61.0 lbs) than those without stones (109 +/- 59.9 lbs) P = 0.04. Men had a significantly greater weight loss than women (160 +/- 15 lbs SEM versus 99 +/- 7 lbs SEM) as well as a higher incidence of cholelithiasis (53 and 24%, respectively). In the second, prospective part of the study, cholecystectomy was performed in 73 consecutive patients concomitant with their bariatric procedure. Ninety six per cent of removed gallbladders had gross or histologic abnormalities including cholelithiasis in 27 per cent and cholesterolosis/cholecystitis in 69 per cent. The incidence of cholelithiasis was higher than that found in the retrospective series by preoperative ultrasound. The bariatric surgical patient is clearly at risk for the development of postoperative cholelithiasis and cholecystitis. The risk appears to be related to the amount of weight loss. In addition, some gallstones may remain undetected at the time of surgery. We therefore recommend prophylactic cholecystectomy at the time of bariatric surgery.

During the last 20 years, several procedures have been introduced that effectively control gastroesophageal reflux. Nevertheless, little has been written regarding surgical management of patients with recurrent esophagitis following a failed antireflux procedure. The purpose of this study was to review the results of all operations for recurrent esophagitis. Fifty-five patients had undergone a total of 61 previous operations for reflux (initial operation: Hill, nine; Nissen, 30; Allison, eight; Thal, patch three; Belsey, 10; other, one). Eleven patients underwent a Hill procedure (indications: intractable "gas-bloat" syndrome, 4 patients, esophagitis, 7 patients). Two developed recurrent esophagitis (18%). Seventy-eight per cent had satisfactory results (mean follow-up 24 months), and there were no deaths. Three individuals had a transabdominal fundoplication. One patient was lost to follow-up while the other two had satisfactory results (follow-up, 1 and 6 years). Twenty-nine patients were subjected to a transthoracic fundoplication, with two deaths (seven per cent). One patient (four per cent) was lost to follow-up at 9 months; mean follow-up was 44 months). Eighty-six per cent had satisfactory results. The sole poor result occurred in a scleroderma patient who ultimately required colon interposition. Twelve patients underwent a Thal-Nissen procedure. One patient was lost to follow-up (eight per cent), while another with scleroderma had an unsatisfactory result (eight per cent); 83% had satisfactory results. The mean follow-up was 70 months. There were no deaths. Overall, 80% of patients subjected to reoperation had satisfactory results. Mortality was four per cent. Reoperations for gastroesophageal reflux constitute an effective means of controlling recurrent esophagitis and compare favorably with primary operations in both mortality and success rate.

Recent reports cite an increased incidence in delayed gastric emptying following Roux-en-Y biliary diversion for alkaline reflux gastritis. The effect of Roux-en-Y diversion on the gastric emptying of liquids and solids was evaluated following vagotomy and antrectomy and vagotomy and subtotal gastrectomy. Twenty dogs underwent placements of large Thomas cannula in the stomach. Four dogs with intact stomachs served a controls. Eight dogs each with vagotomy and antrectomy were subdivided into Roux-en-Y gastrojejunostomy (RYA) and a Billroth II (B-IIA) group. Eight dogs each with vagotomy and subtotal gastrectomy were subdivided into similar groups. Four dogs - Roux-en-Y (RSTG) and four dogs - Billroth II (B-IISTG). Gastric emptying of solid food, normal saline and 25% dextrose was evaluated. RYA dogs demonstrated a significant delay in gastric emptying of solids compared with corresponding B-IIA animals. RYA dogs had 76, 61 and 42% of solid food retained at three, five and eight hours while B-II animals retained 56, 41 and 20%, respectively. The results are highly significant at all time intervals (p less than 0.001 at five and eight hours). Control animals retained 34, 17 and 3% of solid food at three, five and eight hours. RSTG animals had 73, 52 and 28% retained solids at three, five and eight hours, while B-IISTG animals had 55, 42 and 13% retention, respectively (p less than 0.05 at eight hours). Normal saline was significantly delayed in both Roux-en-Y subgroups compared with B-II dogs (p less than 0.02 in V/A, p less than 0.05 in V/STG). There was a trend toward delayed emptying of 25% dextrose in the Roux-en-Y groups, but significance was achieved only in the RYA compared with B-IIA groups (p less than 0.02 at 30 minutes). Delayed gastric emptying following Roux-en-Y gastrojejunostomy is documented in the experimental animals which underwent vagotomy and appears greater in magnitude than that observed following vagotomy and B-II gastrectomy. These data corroborate the clinical observations of severe delayed gastric emptying in patients undergoing Roux-en-Y diversions for alkaline gastritis.

The effect of various prokinetic drugs was assessed in animals with Roux-en-Y gastrojejunostomy. The agents tested were (1) bethanechol 2.5 mg subcutaneously at 0 min and 30 min postprandially (pp); (2) metoclopramide 20 mg intravenous bolus at 0 min pp; (3) a combination of 1 and 2; (4) oxytocin 5 mg intramuscularly at 0 min and 240 min pp; (5) motilin at 100 ng/kg/hr; or (6) 300 ng/kg/hr continuous intravenous infusion from 0 to 270 min pp. Only bethanechol administration resulted in significantly less gastric retention (65 +/- 6% vs 32 +/- 5% retention at 5 hr). (P less than 0.002). The animal results with parenteral bethanechol were confirmed in humans with chronic delayed gastric emptying following Roux-en-Y gastrojejunostomy, with a decrease in gastric retention on radionuclide scan from 78.5 +/- 5% to 26 +/- 12% at 2 hr pp (P less than 0.01). Initially all patients responded with symptomatic improvement. However, subsequently 3/6 (50%) of patients required total or near total gastrectomy for recurrent symptoms of gastric stasis. Nevertheless, 2/6 (33%) of patients have no further evidence of gastric stasis, and a trial of bethanechol is recommended prior to considering further gastrectomy in patients with the Roux-stasis syndrome.