Plate 39

The diversion of bile away from the gastric outlet that has been altered by pyloroplasty or some type of gastric resection may be indicated in an occasional patient with persistent and severe symptomatic bile gastritis.

A firm diagnosis of postoperative reflux gastritis should be established. Endoscopic studies should demonstrate gross as well as microscopic evidence of severe gastritis of greater intensity than is routinely observed from the regurgitation of duodenal contents through an altered gastric outlet. A gastric analysis is performed in a search for evidence of previous complete vagotomy. Barium studies and serum gastrin determination are routinely performed. In addition to a firm clinical diagnosis of postoperative reflux bile gastritis, there should be evidence of persistent symptoms despite long-term intensive medical therapy. The operative procedure is designed to completely divert the duodenal contents away from the gastric outlet. Ulceration will occur unless the gastric acidity is controlled by a complete vagotomy combined with antrectomy.

Constant gastric suction by Levin tube is maintained. Systemic antibiotics may be given. The blood volume should be restored, especially in patients with long-standing complaints and loss of considerable weight.

General anesthesia combined with endotracheal intubation is satisfactory.

The patient is placed in a supine position with the feet 12 in. lower than the head.

The skin of the lower thorax as well as the abdomen is prepared in a routine manner.

The incision is made through the old scar of the previous gastric procedure. The incision should extend up over the xiphoid since exploration of the esophagogastric junction may be required to determine the adequacy of a previous vagotomy. Care is taken to avoid accidental opening of loops of intestine that may be adherent to the peritoneum.

Even when a previous vagotomy has been performed, it is advisable to search for overlooked vagal fibers, especially the posterior vagus nerves, unless firm adhesions between the undersurface of the left lobe of the liver and upper stomach make such a search too hazardous.

The site of the previous anastomosis is freed up to permit careful inspection and palpation for evidence of ulceration or stenosis, or evidence of a previous unphysiologic procedure such as a long loop, angulation, or partial obstruction of the jejunostomy. A patulous gastroduodenotomy may be found (Figure 1).

The extent of the previous resection must be determined to be certain that the antrum has been resected. A complete vagotomy as well as antrectomy is mandatory as a safeguard against recurrent ulceration.

When a Billroth I procedure is to be converted, it is essential to carefully isolate the anastomosis both anteriorly and posteriorly before applying straight Kocher clamps to either side of the anastomosis (Figure 2). Because a Kocher mobilization and medial rotation of the duodenum were previously made to ensure absence of tension in the suture line, it is important to sacrifice as little duodenum as possible (Figure 2). Unexpected injury to the accessory pancreatic duct or the common duct may occur if further mobilization of the first portion of the duodenum is carried out.

The end of the duodenum is closed with a row of interrupted sutures (Figure 3), although some prefer to close the duodenum with a double row of staples. This suture line is then reinforced with a second layer of interrupted silk sutures that bring the anterior duodenal wall down to the pancreatic capsule. The transverse colon is reflected upward, and the upper jejunum from the ligament of Treitz downward for at least 40 to 50 cm is freed from any adhesions that may have followed previous operations. An arm of jejunum (Figure 4) is mobilized as shown in Plate 34, Total Gastrectomy. The end of the jejunum is closed with a double layer of sutures. This suture line is inverted by a second layer of interrupted 00 silk sutures to evert the mucosal layer (Figure 6); the angles should be securely approximated. A retrocolic rather than an antecolic anastomosis is usually made (Figure 4) as the active link is brought through an opening in the mesocolon to the left of the middle colic vessels. The open end of the Roux-en-Y loop is closed in two layers. The first is a running absorbable suture (Figure 5). Alternatively, this may have been stapled if the jejunum was divided with a cutting linear stapler (GIA) instrument. A second layer of inverting interrupted silk mattress sutures is placed.

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