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A method of creation of choledochojejunoanastomosis (CJA) was developed experimentally on 12 dogs. The method lies in creation of valvular CJA using walls of the common bile duct and submucosous-mucosous membrane of the small intestine mobilized by Roux. According to this method 103 patients with obstructive jaundice due to lesion of distal part of common bile duct were operated. Postoperative complications were seen in 6 (5.8%) patients, 3 (2.9%) patients died. In the period from 3 months to 10 years after operation 63 patients were examined, there were no cases of reflux-esophangitis.

Since the end of the nineteenth century, numerous operations were designed to relieve reflux of duodenal content into the stomach and hence the esophagus under certain conditions. The basic surgical principle remains almost invariably the confection of a long Roux-en-Y jejunal limb. The most effective remedial operations are the total duodenal diversion and the supra papillary duodenal diversion. Although the latter technique seems to avoid some of the worst postoperative side effects caused by antrectomy and vagotomy, its feasibility implies the absence of a previous gastrojejunostomy.

An intussusception-type antireflux valve (ARV) has been introduced to prevent postoperative ascending cholangitis in the management of biliary atresia (BA). We investigated the characteristics of cholangitis in the management of BA using the ARV in 38 patients who had undergone an operation at our institution; 29 underwent ARV construction at the same time as portenterostomy (PEO) or hepaticojejunostomy. One patient underwent ARV construction for refractory cholangitis with cystic dilatation of the intrahepatic bile ducts (CDIB) long after the PEO. Five of 29 patients who had ARV construction developed CDIB complicated by severe, refractory cholangitis. One or two episodes of mild cholangitis were observed in 5 (20.8%) of 24 patients who did not show CDIB. An ARV created for postoperative recurrent cholangitis associated with CDIB was ineffective. Preoperative cholangitis associated with a type I choledochal cyst and CDIB was observed in 1 patient. In conclusion, the ARV was effective in preventing refractory cholangitis without CDIB, but ineffective in preventing cholangitis with CDIB. Our findings suggest that CDIB resulting from the ongoing process of BA could be a potential target of bacterial infection through other routes than bilioenteric reflux.

Primary bile reflux gastritis is an unusual and elusive problem. Postgastrectomy bile reflux has been long recognized and treated variously with Roux-en-Y gastrojejunostomy, Braun enteroenterostomy, and Henley jejunal interposition. All of these procedures have been fraught with postoperative side effects, the worst of which is stasis. A new procedure utilizing biliary diversion has been proposed to divert bile from the gastric lumen without vagotomy or gastric resection. This procedure was used for 16 patients with diagnosed bile reflux, and results were compared with those of a previous group of 21 patients who had been treated with Roux-en-Y gastrojejunostomy. The patient groups were similar in age, sex, weight, symptoms, and results of investigative studies. The earlier group all had vagotomy, antrectomy, and gastrojejunal anastomosis to a 45-cm Roux limb. The later group all had an end-to-side choledochojejunostomy to a 45-cm Roux limb, taken 45 cm from the ligament of Treitz. The patients in the bile diversion group had fewer complications and shorter hospital stays. In addition, they had few postoperative complaints, no further operations for either bile reflux or upper gastrointestinal stasis, and no long-term deaths due to gastrointestinal problems or malnutrition. Their eventual postoperative gastric emptying improved significantly when compared with the Roux-en-Y patients, suggesting that the dysmotility observed preoperatively may well have been a result of the bile injury to the stomach, rather than an underlying gastric dysmotility.

Background: A reflux of pancreatic juice into the biliary tract caused by pancreaticobiliary maljunction (PBM) has been considered important in the development of biliary tract carcinogenesis in choledochal cysts. We excised extrahepatic bile ducts in patients with choledochal cysts to terminate the reflux of pancreatic juice. We investigated whether this surgery could stop the development of the residual bile duct carcinoma., Methods: Fifty-six patients with a diagnosis of PBM with choledochal dilatation underwent surgical excision of extrahepatic bile ducts. We applied a person-year method to compare the relative risks (observed number/expected number) of biliary tract carcinoma before and after surgery., Results: In 3 patients, bile duct carcinoma developed in residual dilated segments 19 years 6 months, 8 years 8 months, and 2 years 5 months, respectively, after surgery. Although the relative risk in the post-surgery group was slightly decreased by surgery, it was still high compared with that of the general population., Conclusions: The incidence of bile duct carcinoma is still high, even after excision of extrahepatic bile ducts in PBM patients with choledochal dilatation. For these patients, careful long-term follow-up is necessary, especially after operations that leave the dilated bile ducts, such as cases of Todani's type IV-A.

Background/aims: The impressive breakthrough in laparoscopic surgery has urged several authors to adopt such an approach in the treatment of both benign and malignant gastric diseases, even though laparoscopic gastric resection has not yet met with widespread enthusiasm. The current work is aimed at illustrating the feasibility and assessing the efficacy of laparoscopic (LGRs) and laparoscopic-assisted (LAGRs) gastric resections in the treatment of non-malignant gastric conditions., Methodology: As of April 1997, we performed LGRs or LAGRs on a total of 24 patients (M:F = 15:9; mean age: 43 years; range: 19-65 years), among whom 8 presented with chronic gastric ulcer, 4 had benign pyloric stenosis, 8 were affected with recurrent duodenal ulcers no longer amenable to treatment, and 4 with persistent symptomatic biliary reflux. Pre-operatively, all patients underwent blood tests, upper GI endoscopy coupled with biopsy, and barium swallow. Post-operatively, all patients were administered saline solution and water dextrane for the first 5 days; antibiotics (cefuroxim 4 g i.v. daily) and analgesics (paracetamol 6 g i.v. daily) for the first 48 hours. A hydrosoluble swallow was scheduled for the 5th post-operative day., Results: The surgical procedure consisted of a Billroth II distal gastrectomy in 13 cases and total duodenal diversion with Roux-en-Y gastrojejunostomy in 11. Among such patients, 18 underwent a totally laparoscopic procedure, whereas 6 had laparoscopic-assisted gastrectomy, with the use of a Dexterity device in 1 case. The mean duration of the procedure was 150 min (range: 120-200), and blood losses were not remarkable. No intra-operative complication ever occurred. Post-operatively, we observed one case of retrogastric collection and incisional hernia in 1 patient who underwent a laparoscopic-assisted procedure. The abscess was drained percutaneously and hernia conventionally repaired 5 months post-gastrectomy. Post-operative hospital stay was 7 days on the average (range: 5-25). One patient was lost to follow-up. In the remaining cases, no major functional sequelae were observed at a mean follow-up of 19 months (range: 2-41), apart from 2 cases of transient diarrhea., Conclusions: Laparoscopic surgery appears to be an invaluable tool for the treatment of gastric diseases and LGRs are a valid option in experienced hands and in selected centers, allowing patients to benefit from a less cumbersome hospital stay and fewer functional sequelae. The economic impact of such a practice, however, needs better clarification.

Unlabelled: During a 15-month period 8 patients (1 male, 7 females, mean age 49 years) admitted from different institutions were treated with bile leaks after laparoscopic cholecystectomy. The diagnosis was established by endoscopic retrograde cholangiography. The site of the leakage was the cystic duct in five cases, the common bile duct in one case, the hepatic "bed" in one case and it was undetectable in one case. Five patients had common bile duct stone and one patients also had common bile duct stricture. Endoscopic sphincterotomy was performed in all cases with stone extraction if needed, and stent insertion (7 or 10 Fr straight endoprosthesis) in six cases. The stents were removed after 4-16 weeks in all cases, except the patients with common bile duct stricture, in whom the stent was exchanged for two other endoprostheses to prevent restricture after three months, she is still under treatment. Endoscopic sphincterotomy, stone removal and stent placement were successful in all cases. Symptoms resolved in hours, and the bile leakage stopped in days. Apart from transient serum amylase level elevation in one patient no other complication was observed., Conclusion: The endoscopic treatment of bile leakage after laparoscopic cholecystectomy has proved to be a safe and effective method. It may be considered the method of choice in the management of this complication.

The Roux-en-Y biliary diversion has varied in popularity, with poor results recently reported. A retrospective case note review was undertaken of all patients who underwent Roux-en-Y diversion, in a single consultant practice to assess a single clinician's results. Thirty-seven consecutive patients who underwent biliary diversion were studied: 22 had gastric malignancy and 15 had benign biliary reflux. The benign group revealed improvement in 80% with 40% being entirely asymptomatic and 66% being medication free. In the malignant disease group 15 patients were Visick grade I or II post-operatively; two were classified as Visick IV but one was converted to grade I after further gastric resection. The 30-day mortality in this group was 14 and 50% at 5 years. Good or satisfactory results can be obtained from Roux-en-Y biliary diversion for patients with benign (80% satisfied) and malignant (84% satisfied) disorders but care with patient selection in the benign group is required.

We propose a method of reconstruction after pancreaticoduodenectomy consisting of a double Roux en Y on the same jejunal loop without interruption of the mesentery and a third anatomical Roux en Y to reconstitute the alimentary tract. The construction of the double Roux en Y draining pancreas and bile ducts separately, requires a linear Stapler 3-4 centimeters from the biliary anastomosis. In this way, by employing the same loop without mesenteric interruption, two functional excluded loops will be obtained. The rationale of the suggested model is based on the separation of biliary and pancreatic secretions. This makes it possible to avoid a stagnant cul-de-sac coinciding with the pancreaticojejunal anastomosis and to obtain in the case of leakage, a pure biliary and/or pancreatic fistula as far as is possible. 99mTc HIDA scans demonstrated the efficiency, of the biliopancreatic limbs of the reconstruction, showing normal emptying time for the gastric remnant and the absence of radionuclide stagnation or any alkaline enterogastric reflux.

Background: The Roux-en-Y gastrojejunostomy is a popular method in the operative treatment of alkaline reflux gastritis and other postgastrectomy sequelae, but is associated with a high incidence of the so-called "Roux stasis syndrome." The Henley jejunal interposition has been used occasionally, albeit not widely, as an alternative to the Roux-en-Y reconstruction., Study Design: Six patients underwent Henley gastrojejunoduodenostomy to treat severe (Visick grade IV) symptoms following Billroth I and II procedures for peptic ulcer disease. All interposed jejunal segments were 40 cm in length and isoperistaltic in orientation. All patients had follow-up examination and telephone interview (mean 4.3 years, range 2.2 to 7.8 years)., Results: All patients noted dramatic improvement after remedial surgery in the first year of follow-up. After the first postoperative year, all patients remained virtually symptom-free (Visick grade I and II) with no complaints of gastrojejunal stasis or bile acid reflux., Conclusions: This experience suggests that the Henley jejunal interposition is our effective method of treating reflux gastritis and is not associated with the poor emptying frequently associated with the Roux-en-Y reconstruction.

Clinico-instrumental examination of 226 patients showed that there were no fatal outcomes directly after endoscopic papillosphincterotomy, the number of complications was approximately the same as after transduodenal operations on the major duodenal papilla but they took a much easier course. The high effectiveness of an endoscopic operation was confirmed in the immediate postoperative period (absence of biliary hypertension, jaundice, pancreatitis, cholangitis). In the late-term periods after EPST restenosis was rarely encountered (3.9%); duodeno-biliary reflux caused no serious disorders, while the functional activity of the sphincter Oddi which had been operated on was partly maintained in 84.2% of patients.

This study was designed to look for the presence of Campylobacter pylori in patients who had Roux-en-Y procedure to control symptoms of severe alkaline reflux gastritis (ARG) and to correlate findings with endoscopy and histology. Twenty five patients, who had been operated on for ARG during the last 15 years, were recruited into this study (mean age: 53 years). Surgical procedures were performed by a single surgeon (K.B.). Clinical symptoms of ARG improved after corrective surgery in all cases, but endoscopic pictures remained abnormal in 14 of 25 patients and histological gastritis was observed in all cases. Helicobacter pylori were detected in 8 patients using an urease test performed on gastric mucosa biopsies (CLO-Gistbrocades test). All 8 patients had their biliary diversion 10 or more years earlier, suggesting that H-pylori colonisation of the gastric mucosa develops only slowly once the bile reflux has been stopped. Longitudinal studies, looking for the presence of H-pylori in postoperative stomachs, may help in determining whether they have a role in the aethiology of the peptic ulcer and gastritis, or whether it really is only an innocent bystander.

Previously we reported the majority of lesions induced by bile reflux, in the absence of chemical carcinogens, in the rat remnant stomach to consist primarily of gastric type and secondarily of intestinal type cells, and that they are reversible after diversion of bile reflux. The present study was designed to evaluate changes in proliferative activities in cells of each type under these conditions. The frequency of adenomatous hyperplasia (AH) induced in the gastric stump mucosa by duodenal content reflux after Billroth II partial gastrectomy (BII) increased until the 54th week of the experiment. Roux-en-Y (RY) surgical procedure which prevents duodenal reflux performed at the 24th or 36th week after BII led to a decrease in AH. Cell content of the lesions was analyzed using routine H&E staining, immunohistochemical staining for pepsinogen isoenzyme 1 and histochemical procedures for mucins (paradoxical concanavalin A, galactose oxidase Schiff and sialidase galactose oxidase Schiff reactions) and proliferation in each compartment evaluated by an immunohistochemical method using bromodeoxyuridine (BrdU) and a monoclonal antibody against BrdU. At the 54th week the number of BrdU-labeled cells per normal pyloric column was significantly (P < 0.05) increased to 10.63/pit after the BII operation, while it diminished to 5.23/pit after RY diversion, this being the same level as with the RY procedure alone. AH maintained a high rate of BrdU incorporation at 12.7% after BII operation, which was also significantly reduced (P < 0.01) to 7.0% by the RY surgery. The intestinal type cell showed highest (22.2%), the surface mucous type cell showed the next (16.5%) and the pyloric gland type cell showed lowest (5.2%) BrdU labeling indices after BII operation. All the cell types in AH showed similar proportional decreases in BrdU incorporation after RY diversion. Thus surgical intervention reverses the cell proliferation caused by bile reflux in the gastric stump.

Morphological and phenotypical patterns of proliferative epithelial lesions induced in the gastric stump mucosa by duodenal content reflux after Billroth II partial gastrectomy (BII) were evaluated in rats. Control animals were either sham-operated or submitted at different times after BII to Roux-en-Y (RY) surgical procedure which prevents duodenal reflux. The lesions were analysed using routine haematoxylin and eosin staining, immunohistochemical staining for pepsinogen isoenzyme 1 and histochemical procedures for mucins (paradoxical Concanavalin A, galactose oxidase Schiff and sialidase galactose oxidase Schiff reactions). Mucosal hyperplasia (H) was observed in the group submitted to BII procedure 6 weeks after surgery. Adenomatous hyperplasia (AH) also appeared 6 weeks after induction of the reflux and its incidence and size increased until the 54th week of the experiment. RY procedure performed in the normal animals at the beginning of the experiment or at the 24th week after BII gastrectomy led to a significantly lower incidence of AH which was related to the moment of surgery. Most of H was due to pyloric mucosal hyperplasia. AH consisted mainly of gastric type glands but in some animals glands of the intestinal type were present probably originating from the intestinal mucosa. Six mucinous adenocarcinomas were observed, all of them of intestinal type. This study demonstrates that AH induced by BII procedure is a reversible lesion and that the anomalous epithelial proliferation in the stoma may lead to adenocarcinomas.

Two-third gastrectomy or supplementary gastrectomy was performed on 13 patients, between July 2, 1986 and September 30, 1988. Continuity of the gastro-intestinal tract was restored by end-to-side gastrojejunostomy according to Roux-en-Y. An antireflux valve according to Rumpf was inserted 15 cm below the gastroenteroanastomosis, and end-to-side jejunostomy was performed about six centimetres below the valve. This surgical method was applied to six patients for treatment for alkaline gastritis. The same method was used on another seven patients to prevent development of alkaline gastritis. All the 13 patients were males aged between 42 and 77 years. There were no postoperative problems in any of them. Follow-up checks were made 12 to 36 months after surgery and confirmed the effectiveness of this surgical approach for both healing and prevention of alkaline gastritis.

Gastric biopsy specimens were taken in 33 patients before and after procedures to divert bile (construction of Roux loop in 19, closure of gastrojejunostomy in 14). Each biopsy specimen was assessed for dysplasia, intestinal metaplasia, atrophy, and gastritis, each variable being given a score ranging from 0 to 6. Patients were given preoperative and postoperative scores for each of these variables based on the average score of all preoperative or postoperative specimens. Comparison between preoperative and postoperative histology showed that there was no difference for gastritis, atrophy, or intestinal metaplasia. Patients who underwent closure of a gastrojejunostomy showed improvement in dysplasia that was not statistically significant. There was, however, a significant improvement in dysplasia in patients in whom a Roux loop was fashioned (p = 0.006) and in all patients taken together (p = 0.002). It was concluded that procedures that divert bile improve dysplasia but not other histological abnormalities in the stomach postoperatively.

Alkaline reflex gastritis is a disabling clinical syndrome, occurring most often after gastric surgery. It is characterized by abdominal pain and bilious vomiting, and, presumably, is due to gastric irritation by regurgitated duodenal contents. The only known effective treatment is by surgical diversion to prevent the duodenal reflux. Unfortunately, the clinical diagnosis is difficult to prove, and the results of surgery are too often disappointing because of inaccurate patient selection. This is a report of a new test for distinguishing patients with symptomatic bile reflux gastritis. The test consists of blind sequential infusion into the stomach, via nasogastric tube, of 20 ml of 0.1 N HCl, normal saline, 0.1 N NaOH, and the patient's own gastric contents. Each solution is given twice. A positive test is defined as reproduction of the patient's usual pain by NaOH, and/or gastric contents, but not by acid or saline. Fifteen of 21 patients with clinical symptoms and endoscopic findings suggesting bile gastritis had a positive alkali infusion test, while only one of 18 normal controls and none of 17 controls with other causes of abdominal pain had a positive test (p less than 0.001). Of the 21 patients with clinical-endoscopic bile gastritis, 15 have had surgical treatment by Roux-en-Y gastrojejunostomy. Nine of ten patients with positive test had excellent symptomatic relief after surgery. Zero of five patients with a negative test were relieved of pain after the operation. Tis simple test appears to be a sensitive, specific, and accurate means for selecting patients for surgical treatment of alkaline reflux gastritis.

Because accurate diagnosis of the alkaline reflux gastritis syndrome has been elusive, surgical treatment has had a high failure rate, particularly with respect to relief of pain. We have used intragastric infusion of alkali as a provocative test in 147 patients with symptoms and endoscopic findings suggestive of bile gastritis and in 19 asymptomatic control subjects. Subjects received saline solution, 0.1 normal hydrochloric acid, and 0.1 normal sodium hydroxide solutions, as well as their own gastric aspirates in random blinded fashion by a nasogastric tube. There were no complications. A positive test result was defined as pain with sodium hydroxide but not with saline solution or hydrochloric acid infusion. All of the control subjects had negative test results. A total of 87 percent of the symptomatic patients have been followed (mean 4.3 years, minimum 1 year); 47 of those 128 had a Roux-Y gastrojejunal reconstruction to divert duodenal contents from the stomach. Correlation of the test results and the subsequent clinical status showed 87 percent of those with negative test results improved spontaneously or with other treatment versus 15 percent if the test results were positive (p less than 0.001), and 78 percent of those with positive test results had lasting relief of pain after surgical diversion versus a 30 percent success rate if the test results were negative (p less than 0.01). We conclude that positive alkali infusion test results predict that symptoms will likely respond best to surgical diversion of duodenal contents, and that negative test results should be a strong deterrent to surgical diversion. The test is safe, simple, and deserves further trial.

Alkaline reflux esophagitis occurs most frequently after gastric surgery, especially after total gastrectomy. Anastomoses causing this disease are esophagoduodenostomy or esophagojejunostomy end-to-side. As in the stomach bile, pancreatic juice and small bowel contents cause erosions and ulcers of the esophageal mucosa. For symptomatic treatment aluminium-hydroxide-antacids or cholestyramine can be tried. A definite cure of alkaline esophagitis can only be reached by reversing the anastomosis, creating an interposition of the jejunum between esophagus and duodenum of 50 to 60 cm in length or a Roux-Y-esophagojejunostomy, the minimum length of the loop being 40 cm.

The influence of the type of reconstruction after gastrectomy upon the postoperative reflux was analyzed in 30 patients. The refluxed material could be directly gained by the long-term reflux aspiration test and, thus, the quality including bile acids could be evaluated. After esophago-jejunoplication and Roux en Y-derivation 5 out of 7 patients were asymptomatic; only one patient suffered from mild esophagitis. Total bile acid concentration was near to the test systems sensitivity. The result in 11 patients after esophago-jejunostomy without Y-en Roux, but with a preserved lower esophageal sphincter (LES) are similar to the former group, whereas in all cases of 12 patients in whom the LES was resected, severe reflux esophagitis and excessively elevated bile acid concentrations were present. These results confirm that a jejunoplication supports the antireflux effect of preserved parts of the LES. If--for oncologic reasons--the LES has to be resected, free intestinal-esophageal reflux is following. In these cases a Roux en Y-derivation is required.

Nine post-Polya gastrectomy patients with symptoms of reflux gastritis were studied immediately before and 6 months after Roux-en-Y diversion with a 60 cm jejunal loop. Endoscopy, histology, HIDA radionuclide studies and acid secretory studies were performed to determine the effect of Roux-en-Y diversion. Symptomatic results were pleasing in that all patients were graded as Visick I or II. There was a statistically significant improvement in endoscopic evidence of mucosal damage (median score of 6 reduced to median of 1) and visible bile reflux (median score of 10.5 reduced to 0). Foveolar hyperplasia, superficial chronic gastritis and histological precursors of malignancy all improved. There was a significant decrease in the reflux of 99mTc-labelled HIDA into the gastric remnant while acid secretion remained unchanged. Roux-en-Y diversion with a 60 cm jejunal loop provides not only symptomatic relief but scintigraphic, endoscopic and histological evidence of pancreatobiliary diversion.

Cystic-cylindrical dilatation of the intrahepatic and extrahepatic bile ducts occurs rarely in childhood. Aetiologically, congenital pancreaticobiliary junction anomalies play a decisive part. Accurate preoperative diagnosis is by no means an easy matter. The best possible diagnostic approach to clarify the pathologico-anatomic conditions consists in sonography coupled with on-target partial intraoperative cholangiography presenting the preduodenal section of choledochus and pancreatic duct. Between 1979 and 1987 surgery was performed at the Paediatric Surgical Department of the Municipal Paediatric Hospital of Cologne on 18 patients suffering from intrahepatic and extrahepatic cysticocylindrical dilatation of the bile ducts due to confirmed ectopic pancreaticobiliary junction anomaly. This study does not include all other types of choledochus cysts or biliary duct dilatations without proven pancreaticobiliary junction anomaly. The treatment of choice is the resection of the dilated extrahepatic biliary ducts followed by hepatico-jejunostomy using the Roux-en-Y technique. To avoid cholangitis due to reflux of intestinal contents via the shunted jejunum loop, we are constructing a two-stage anti-refluxive muscular mucosa valve in the shunted loop; this practice has been followed by us since 1983. Permanent postoperative freedom from cholangitis in 10 children after construction of the valve prompts us to recommend this procedure also in other types of bile duct surgery, especially in the treatment of atresias.

A significant linear relationship exists between recumbent and postprandial intragastric bile acid concentration, net bile acid reflux/hour, and the severity of nonstomal histologic gastritis in the residual gastric pouch following gastrectomy. Using objective criteria, it is possible to identify symptomatic patients with greater than normal bile acid reflux and histologic gastritis. In these patients, Roux-Y reconstruction eliminates bile acid reflux, slows gastric emptying, improves histologic gastritis, and appears to ameliorate some (but not all) of the symptoms and signs ascribed to 'alkaline reflux gastritis'. However, because of the apparent clinical homogeneity between refluxing and non-refluxing symptomatic patients, these data, although supportive, do not clearly prove the existence of the syndrome.

The gastric mucosa of 19 mongrel dogs was submitted to a bilio-pancreatic, isolated biliary or isolated pancreatic reflux. With an isolated biliary reflux, there is a more rapid and more severe hyperaemia and foveolar hyperplasia of the mucosa of the fundus than with an isolated pancreatic reflux. There was no significant change in the basal serum level of gastrin with any of these different types of alkaline reflux, but we observed a statistically significant increase in the level of histamine in the gastric mucosa. Hyperaemia and foveolar hyperplasia of the fundic mucosa both disappeared when the alkaline reflux was suppressed, and there was a statistically significant decrease in the basal serum level of gastrin and in the level of histamine in the gastric mucosa.

Fifty-six patients were treated surgically for alkaline reflux gastritis, in each a consequence of subtotal gastrectomy and vagotomy for ulcer disease. Of these, 41 available for follow-up, 18 of whom had had Henley loop jejunal interpositioning and the remaining 23 Roux-en-Y (long-loop) gastroenterostomy. The conditions of most patients improved with respect to reflux symptoms of pain, vomiting, and weight loss, but the patients with Roux-en-Y procedure had uniformly better results that did those with the Henley loop. Although the Henley loops in this series of patients may have been too short to be completely effective in preventing bile reflux into the stomach, we prefer the Roux-en-Y diversion because it is technically easier and safer.

Even though controversy persists over the physiopathology of alkaline reflux gastritis, Roux-en-Y diversion is a well-accepted surgical treatment and was used in 23 patients over a 6-year period at the Hôpital St-Luc in Montreal. Of the 23 patients, 21 had complete relief of symptoms. Objective criteria for the selection of patients who would benefit from operation are still to be defined. The authors discuss the physiopathology through an extensive review of the literature.

The results of antrectomy performed for recurrent peptic ulceration after vagotomy and drainage are frequently marred by bilious vomiting. Consequently, there has been interest in combining antrectomy with Roux-en-Y drainage to prevent this complication. The experience of one surgeon in revisional gastric surgery has been studied retrospectively. Thirty-six patients have been reviewed in detail, 24 of whom had a combined antrectomy and Roux-en-Y anastomosis: 16 for recurrent peptic ulceration, 2 for non-ulcer dyspepsia and 6 for bile reflux gastritis. None of these has required reoperation, and 12 of the 16 with recurrent ulcers have had a good result. Four of 12 who underwent antrectomy alone subsequently required biliary diversion. Combining antrectomy with a Roux-en-Y anastomosis prevents postoperative bile reflux gastritis and thereby the need for further revision on this account. The results of this approach compare well with those of other procedures used in the treatment of recurrent peptic ulceration.

In a series of 565 morbidly obese patients having one of five gastric bariatric procedures done at North Carolina Memorial Hospital between May 1975 and December 1982, 55 patients had 58 complications requiring reoperation. These complications included a leak from the stomach or anastomosis, stomal obstruction, and subphrenic abscess. Weight loss after vertical banded gastroplasty appears to be comparable to that following gastric bypass with Roux-en-Y gastrojejunostomy. The complication rate of vertical banded gastroplasty is the lowest of the gastric obstructive operations we have done.

Bile reflux gastritis is a disabling postgastrectomy condition characterized by abdominal pain, bilious vomiting, and weight loss. The syndrome appears to be caused by free enterogastric reflux of bile and other proximal small bowel constituents. Endoscopic confirmation of bile reflux and documentation of gastritis support the diagnosis but are not specific for it. Results of medical therapy with chelating agents or drugs that promote gastric motility have been disappointing. Diet and antacids frequently aggravate symptoms. The only effective treatment is surgical diversion of bile away from the gastric mucosa. During a recent seven-year period, 15 patients had diversionary operation for bile reflux gastritis diagnosed by history and endoscopic findings. Before operation, medical management had failed to yield improvement in any case. After operation, all patients showed improvement, and pain was relieved in 85%. Based on our experience, we conclude that current medical therapy may alter but not cure symptoms of bile reflux gastritis; Roux-en-Y diversion is the treatment of choice in patients with persistent symptoms; and delayed gastric emptying is a common complication after the Roux-en-Y procedure, but in our series, the incidence was reduced by using the Tanner 19 modification. New cytoprotective agents that may offer an alternative to operation are currently being studied.

An experimental study investigated the effect of highly selective vagotomy (HSV) alone and HSV combined with cholecystectomy on bile reflux into the stomach. The amount of reflux was estimated by measuring the concentration of bile phospholipids in the stomach. Neither HSV alone nor HSV combined with cholecystectomy was associated with increased reflux. In fact HSV seems to prevent reflux and inhibit the production of lysolecithin, which is injurious to the gastric mucosa.

Exclusion jejunoduodenostomy has been successfully used as the primary operation in five patients with severe bile reflux gastritis and in one patient with disabling Roux-en-Y syndrome. The operation is simple to perform, requires one anastomosis and appears to eliminate bile reflux gastritis and avoid potential emptying complications associated with the Roux-en-Y segment.

A surgical technique is described which has been adapted from the operation known as "total duodenal diversion", but which is suitable for the anatomical conditions resulting from an upper pole gastrectomy. The method was used successfully in two patients with severe esophagitis from bile reflux resistant to all medical treatment and resulting from upper pole gastrectomies.