Severe Problems with Gastric Emptying after Gastric Surgery

GEORGE L. JORDAN, JR., M.D., LARRY L. WALKER, M.D.

FAILURE of the stomach or gastric remnant to evacuatepromptly after gastric surgery has been a problem for

surgeons over the past 100 years. There is considerablevariation in the speed with which patients regain normalgastrointestinal function after operation. Some patientsare able to resume oral alimentation within a few hoursafter operation, while others may require nasogastric suc-tion for one week. Whereas patients in the latter categorymay require a longer period of hospitalization, they do notdevelop major problems with fluid and electrolyte balanceand there is no danger to survival. Some patients, how-ever, fail to evacuate gastric remnants normally for pro-longed periods, and operative intervention may be re-quired. It is to this group that the current study is directed,for a review of the literature reveals only limited docu-mentation of the precise pathology which produces thisproblem, and few surgeons have an extensive experience,since it is not particularly common.4,8,10,11,12,14,15,18 Thus,a better understanding of the basic pathology and de-velopment of a more specific plan of management isneeded.

Materials and MethodsThree groups of patients requiring gastric surgery

were studied. The first group of 406 patients was treatedfor a variety of lesions by subtotal gastrectomy aloneduring a period ending in 1955.'3 The second group of300 patients was treated for duodenal ulcer by truncalvagotomy and hemigastrectomy.5 The third group in-cluded 565 patients treated in the past 6 years for a va-

Presented at the Annual Meeting of the Southern Surgical As-sociation, December 4-6, 1972, Boca Raton, Florida.

Reprint Address: The Cora and Webb Mading Department ofSurgery, Baylor College of Medicine, Houston, Texas 77025.

From The Cora and Webb Mading Department ofSurgery, Baylor College of Medicine,

and the Ben Taub General, The Methodist, andVeterans Administration Hospitals, Houston, Texas

riety of gastric lesions and by a variety of technical proce-dures. There were a total of 1261 patients in the threegroups. Duodenal ulcer was the lesion most com-monly requiring treatment, with gastric ulcer secondin frequency. There were a number of patients, how-ever, treated for hemorrhagic gastritis and others weretreated for gastric neoplasm. In addition, a few pa-tients were treated for marginal ulcer by procedureswhich included re-resection and formation of a new gas-troentric anastomosis (Table 1). Patients who requirednasogastric suction because of difficulty in emptying thestomach or gastric remnant following gastric surgery werestudied when the period of treatment extended morethan 10 days after operation.Among the 1261 patients studied, there were 21 who had

severe problems with gastric evacuation, an incidenceof 1.6%. There was no significant difference in the inci-dence of emptying problems after gastrectomy alone ascompared to vagotomy and hemigastrectomy. Interest-ingly, there were no severe problems with gastric empty-ing following treatment of 89 patients by vagotomy andpyloroplasty, while the incidence of problems followingvagotomy and gastrojejunostomy was 15%, although therewere only 20 patients in this group (Table 2). Further-more, the incidence of problems of evacuation afterreconstitution of gastrointestinal continuity by gastroduo-dectomy was virtually identical to that after gastroje-junostomy from a numerical standpoint although thecause was somewhat different in the two groups (Table3). In addition to the 21 patients among this group, sixpatients on the private service of one of us were in-

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PROBLEMS WITH EMPTYING FOLLOWING GASTRIC SURGERY

TABLE 1. A Tabulation of the Disease Processes Treated among TABLE 3. A Comparison of the Incidence of Obstruction following1261 Patients Reconstitution of Gastrointestinal Continuity after Resection

Disease Number Per Cent

Duodenal ulcer 971 77Gastric ulcer 153 12Gastritis 59 5Neoplasm 49 4Marginal ulcer 29 2

Total 1261 100

cluded, making a total of 27 patients studied. Roentgeno-graphic studies and/or abdominal exploration served todefine the site of obstruction in 21 of these 27 patients.The most frequent site of obstruction in the Billroth II

group was in the efferent loop, whereas, after the BillrothI operation, the problem most commonly existed at thestoma. In no instance could a technical error be identifiedas the cause of delayed gastric evacuations. The usualcause of this problem was adhesions occurring in theefferent loop or an unusual inflammatory response withthe omentum wrapped around the area of the anas-

tomosis, compressing it to the point that passage throughit was impeded (Table 4, Figs. 1 and 2). The cause ofthe marked inflammatory process in the omentumwrapped around the anastomoses in some patients couldnot be determined. Whether this simply represented a

response to trauma short of actual gross fat necrosis,whether it represented simply an excessive adhesiveformation, or whether the omentum may have sealed offa slight leak from the anastomosis could not be de-termined. In these patients, however, there was no gross

or radiographic evidence of a leak from the anastomosis.Furthermore, the presence of associated inflammatoryprocesses of this type produced a dysfunction of motil-ity in the portion of the bowel adjacent to the inflam-matory process so that proper passage was impeded.

oy Gastroauoaenostomy ana Gastrojejunostomy*Obstruction

Procedure No. No. Percent

Billroth I 247 5 2.2Billroth II 907 13 1.4

Total 1154 18 1.6* The mechanical problems which existed, though different,

occLirred with a remarkably similar incidence.

Herniation through the mesentery of the transversemesocolon, after retrocolic gastrojejunostomy, was theetiology of the problem in two patients, while in twoinstances traumatic fat necrosis was found at operation.In one of these patients traumatic fat necrosis had oc-curred at virtually every point where an incision hadbeen made through fat or in which clamping and tyingof bleeders had been accomplished. This involved thefat in the subcutaneous tissue as well as in the peritonealcavity. Pancreatitis had caused the formation of denseadhesions in one patient.When the site of obstruction was radiographically dem-

onstrated to be at the stoma, some of these patientswere found to have efferent loop obstructions due toadhesions at the time of surgical exploration, with theobstruction being just beyond the stoma so that no bariumcould be visualized in the efferent loop. The problem,nevertheless, was primarily one of efferent loop obstruc-tion rather than any abnormality in the stoma itself.

Treatment and ResultIn all patients, a trial of conservative therapy consisted

of nasogastric suction, the cessation of oral feeding, andthe initiation of intravenous fluids to maintain proper fluidand electrolyte control. On this regimen alone, 13 of the27 patients had spontaneous resolution with eventual re-

TABLE 2. A Tabulation of the Incidence of Obstruction of GastricEmptying According to Procedure*

Obstruction

Procedure No. No. Percent

Gastrectonmy 406 7 1.7B I 60 0 0.0B II 346 7 2.0

Vagotomy and Hemigastrectomy 748 11 1 .5B I 187 5 2.7B II 561 6 1.1

Vagotomy and Pyloroplasty 87 0 0.0Vagotomy and Gastrojejunostomy 20 3 15.0

Total 1261 21 1.6

* It was of interest that no serious delay in emptying occurredin any patient following vagotomy and pyloroplasty.

TABLE 4. The Site of Obstruction and the Etiologic Factors in thisGroup of 27 Patients

Etiology No. Percent

Efferent loop obstruction 14 51.9Adhesions 10 37.1Due to pancreatitis 1 3. 7

Herniation throuigh transversemesocolon 2 7.4

Fat necrosis 2 7.4Stomal obstruction 7 25.9

I nflammatory mass 3 11 1Adhesions 2 7.4Undetermined 2 7.4

Undetermined 6 22.2

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Total 27 100.0

JORDAN AND WALKER

sumption of oral feeding. The 14 patients who failed torespond to conservative therapy underwent surgical pro-cedures. The procedure varied depending on the etiologi-cal factor found at the time of operation. When severeinvolvement of the anastomosis with an inflammatory massprecluded the likelihood of early cessation of the problem,a second anastomosis or a revision of the gastrojejunostomywas done. One patient with herniation through thetransverse mesocolon underwent a take-down of theretrocolic anastomosis and conversion to an antecolicgastrojejunostomy. The other had had a vagotomy andgastrojejunostomy. A gastric resection and antecolic gas-trojejunostomy was performed. One patient was treatedby enteroenterostomy to bypass the point of adhesive ob-struction and other patients underwent lysis of adhesions,with or without gastrostomy and feeding jejunostomy(Table 5). Thirteen of these patients required no furthersurgical intervention, while in one patient, adhesive ob-struction of the efferent loop recurred, and reoperationwas necessary.

Several patients requiring operative intervention hadhad obstruction present for some period prior to opera-tion, and did not show early return of normal gastroin-testinal function following operation, even when theefferent loop was splinted with a tube passed throughthe gastrojejunostomy. Under these circumstances, how-ever, it was possible to maintain adequate nutrition, andwithin a relatively short period of time, it was possibleto allow some patients to ingest food by mouth, as-

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~L

FIG. 1. An illustration to depict the common causes of prolongedgastric emptying. The drawing on the left demonstrates the de-velopment of postoperative adhesions with kinking of the efferentloop. The drawing on the right demonstrates excessive reactionof the omentum encircling a gastro-duodenal anastomosis, pro-ducing obstruction by compression as well as causing motilitydysfunction due to the severe inflammatory process.

FIG. 2A. Radiographic ap-pearance of adhesive ob-struction of the efferent

loop. Barium has passed A}

freely through the gas-troenteric stoma but itsflow is completely ob-

structed a few inches be-yond in the efferent loop.Some filling of the affer-

ent loop is also demon-strated.

pirating the gastric pouch through the gastrostomy tubeand feeding the aspirated material into the jejunum viathe jejunal feeding tube. In this manner, fluid and elec-trolyte problems were avoided, the patient had the sat-isfaction of enjoying the taste and eating of food, andnutrition could be maintained totally by oral alimen-tation. In two patients this tube allowed early dischargefrom the hospital with care of the gastrostomy and je-junostomy on an outpatient basis. The longest periodrequired before complete oral alimentation was re-

sumed was 6 months. Jejunal feedings were suppliedduring almost 4 months of this time (Fig. 3). In otherpatients, jejunal feedings were possible through a longfeeding tube placed transnasally through the esophagus,stomach, and across the anastomosis into the jejunum.In one patient with fat necrosis, nutrition was main-tained in this manner for more than 6 weeks until theinflammatory response in the transverse mesocolonhad subsided and normal emptying occurred.Two deaths occurred among the patients treated.

One of these patients had a gastric malignancy and diedin the hospital of far-advanced carcinoma. The prob-lem with gastric emptying was a significant complicationin this patient, but in no way contributed to his death,

TABLE 5. Fifteen Surgical Procedures were Performed in 14 Patients*

Procedure Number Patients

Lysis of adhesions 5Lysis of adhesions and gastrostomy with

feeding jejunostomy 3Lysis of adhesions with gastrostomy 1Gastrostomy and jejunostomy 1Gastrojejunostomy 2Gastric resection 1Take-down of retrocolic anastomosis with

conversion to antecolic gastrojejunostomy 1Enteroenterostomy I

* The procedure performed varied according to the pathologicchanges found at operation.

Ann. Surg. * June 1973662

PROBLEMS WITH EMPTYING FOLLOWING GASTRIC SURGERY 663

SF.; - Stomal edema as it is classically described, occurs rarelyin patients with a properly constructed anastomosis,and we have never identified this as a cause of obstruc-tion. The cuff which is formed should be sufficientlysmall that obstruction does not occur. We do not believe that gastric atony is ever the basic problem withfailure of evacuation following gastric resection. Under

.f ...these circumstances, as noted in previous studies, there.it;....i.. >;Ea _ is no significant motility in that portion of the stomach

left after resection, and thus absence of motility is theusual circumstance, rather than the exceptional cir-

W4 0;0x;::cumstance after gastric resection.6 Gastric evacuationafter resection is in no way dependent upon contrac-

.....l.l.lM tion s of the stomach and gastric emptying may occurvery rapidly with no visible peristalsis on radiographicstudy and with no measurable peristalsis demonstratedby appropriate studies (Fig. 4).

Gastric atony certainly may be a significant factor inprolonged gastric emptying when vagotomy and a py-loroplasty has been accomplished. Under these circum-stances, the body of the stomach extends considerably

_. lower in the abdomen than does the pylorus, when thepatient is in the upright position; consequently, in theabsence of the forceful contractions which are normallypresent in the antrum, food is not propelled into the

FIG. 2B. Roentgenogram suggesting poor passage through a gas- duodenum where peristalsis will then carry it forward.troenteric stoma. In actuality, there was severe obstruction of both Severe problems with evacuation after vagotomy andafferent and efferent loops due to herniation through the transversemesocolon.

as it had been resolved for some period prior to death. ..yIn one patient, however, the problem with gastricemptying was a direct factor in patient's death. In thispatient, there was failure of resolution on conservativetherapy and operative intervention was undertaken. ._A Billroth II resection was accomplished. In the post-operative period following this procedure, breakdownof the gastrojejunostomy developed with leak of gas-trointestinal contents into the peritoneal cavity, and afatal peritonitis ensued. Thus, the overall mortality raterelated to the problem of gastric emptying among the27 patients was 4% and among the 1261 patients under-going gastric surgery, the mortality rate was less than0.2%. Late follow-up data are available on most ofthe patients, in some instances exceeding 10 years.One patient required another period of hospitalizationfor recurrent symptoms 1 year after discharge. All otherpatients have had normal oral alimentation during thefollow-up. -.

Discussion FIG. 3. Sequential roentgenograms of a patient with a severeemptying problem. A. Roentgenograms following gastric resec-

Failure of gastric emptying after gastric surgerv has tion demonstrated almost complete obstruction which was per-been ascribed to a variety of causes. Probably the most sistent. Operation was performed two days after this film wastaken. An adhesive obstruction of the efferent loop was found andcommon cause quoted in the literatture is stomal edema. relieved.

Vol. 177 * No. 6

664 JURJJALN AINU vvWAL Inn Anii. zurg.

Fi.3B.Rongnga.fteuprgsritsia rc ae

approximately 10 days after operation discloses that there is stillfailure of gastric emptying although as demonstrated in this film,a tube actually passes through the gastroenteric stoma. Severaldays following this film, reoperation was performed, demon-strating recurrence of obstruction of the efferent loop due to ad-hesions. A gastrostomy tube and a feeding jejunostomy tube wereplaced.

pyloroplasty thus have been observed, and it has even FIG. 3D. Roentgenogram taken 2 months after the film demon-been suggested that this operation should not be done strated in 3G. Barium now empties readily into the small bowel,in patients who are treated for pyloric obstruction and however another month passed before the patient was able tohave a markedly distended stomach without the ingest an adequate diet and sustain his nutrition without supple-presence of normal muscle tone. Deaths following treat-ment of obstructing ulcers by vagotomy and pyloroplastyhave been reported.' In this particular series, however,we did not encounter this problem.A number of other infrequent causes of obstruction

were not observed in this series. Retrograde gastricin

^ ..: : : . .. .. s | 4^ ., s s #~ ~~~ ~~~ ~~~ ~~~ ~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.....

FIG. 4. Roentgenogram demonstrating rapid gastric emptying fol-FiG. 3C. Roentgenogram of upper gastrointestinal tract taken 1 lowing gastric resection in a patient who roentgenographicallymonth following second operation. No emptying from the stom- showed no significant motility in twh gastric remnant nor dem-ach can yet be demonstrated. onstrated motility on pressure tracings.

Tf-%TD 7- A XT A XTIN \XV AT V7wD A,,,, .. . T,,-. 1072

PROBLEMS WITH EMPTYING FOLLOWING GASTRIC SURGERY

tussusception, a rare lesion, should be suspected in thepresence of abdominal pain and the commonly associ-ated findings of hemorrhage.7'17 We have observed thiscomplication only in the late postoperative period. Wedid not observe herniation of the efferent loop underthe afferent loop or vovulus of the efferent loop in theearly postoperative period, though these complicationsof gastrectomy have been reported.9"10"9 We have ob-served these as late complications, however. An unusualproblem is the development of acute necrotizing ul-cerative lesions in the efferent loop, which may resultin perforation and a fatal outcome.'6 Only a few suchcases have been recorded, and we did not observe thisproblem. We have observed the development of mar-ginal ulcer as early as 10 days postoperatively and sucha complication could produce obstruction in the stoma.Bodon and Ramath as well as Golden have reported

motility dysfunction of the efferent loop as a cause ofdelayed gastric emptying in patients, without a dem-onstrable cause for this abnormality on the basis of ra-diographic studies.23 On the basis of our experience,when such an observation is made, there is likely anunderlying cause for this dysfunction, namely, an ad-jacent inflammatory process impairing normal motilityin this segment. The dysfunction resolves when the in-flammatory process resolves.Our own observations, therefore, indicate that the

most common cause of prolonged problems with gastricemptying is mechanical obstruction. Fortunately, mostlesions, such as early postoperative adhesions, may re-solve spontaneously with the passage of time. The sec-ond common cause is the malfunction of the intestinaltract due to an associated inflammatory process. So faras we can determine, fat necrosis has not been em-phasized as such a cause. We have observed other pa-tients in whom fat necrosis not only caused difficultyin gastric emptying but also was the apparent cause ofileus following other surgical procedures. As notedabove, postoperative pancreatitis also presented inthis manner in one patient. A trial of conservativetherapy is thus routinely justified in patients who donot have abdominal pain or evidence of gastrointestinalbleeding as a part of their clinical picture and who donot demonstrate any signs suggesting peritonitis. Thepatients with these findings should be operated uponpromptly. In the absence of these findings, however, theuse of nasogastric suction and intravenous fluids shouldbe undertaken as previously described, and our pres-ent recommendation is as follows:

( 1 ) A trial of conservative therapy is instituted.(2) If the patient does not show resolution within a

week a roentgenographic study of the upper gas-trointestinal tract using bariurn as a contrast

FIG. 5. An illustration to demonstrate methods of gastrostomy andplacement of jejunal tube for feeding purposes. The drawingon the left illustrates a double lumen tube, with one lumen end-ing in the stomach for aspiration, and the second portion ofthe tube passed through the gastroenteric stoma well into theefferent loop for feeding purposes. The figure on the rightdemonstrates a double jejunostomy with one tube passed throughthe stoma for aspiration of gastric contents and the other tubepassed down the jejunum for feeding purposes. Either techniccan be used succesfully and should be chosen based upon anatomi-cal and technical considerations.

medium is performed. The subsequent treatmentdepends upon the findings of the roentgenographicstudy.

(3) If passage of barium through the gastrointestinaltract is observed, even though slowly, conserva-tive treatment is continued with the presump-tion that complete relief of the problem willoccur.

(4) If complete obstruction exists, however, conser-vative therapy is continued but repeat roent-genographic study is performed within a weekto 10 days. If improvement has occurred in thisperiod, further conservative therapy is justified,but if complete obstruction persists, operation isindicated.

(5) The operation performed will depend upon thefindings. Lysis of adhesions or performance of anew anastomosis may be necessary.

(6) The placement of a gastrostomy tube and afeeding jejunostomy tube should be routinelyaccomplished, for many patients, as noted above,have delayed return of gastrointestinal function,even though the anastomotic obstruction has beencorrected. This additional technic to insure ade-quate nutrition was performed in over a thirdof the patients on whom we operated. However,it is apparent in retrospect that a number of

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JORDAN AND WALKER Ann. Surg. * June 1973

additional patients could have benefited fromthis procedure, and their length of hospitalizationshortened (Fig. 5).

SummaryProlonged problems with gastric emptying following

gastric surgery usually represent a mechanical obstruc-tion due to adhesions or dysfunction of the bowel be-yond the anastomosis due to an adjacent inflammatoryprocess, such as pancreatitis or fat necrosis. An initialtrial of conservative therapy is justified, but evaluationwith roentgenographic studies using barium should beemployed. If the obstruction has not been resolveddefinitely within 2 to 3 weeks, operative intervention isindicated. The procedure to be employed will dependupon the pathologic changes found, but the use of tubegastrostomy and insertion of a feeding jejunostomy willaid many patients in maintaining a normal nutritionalstate without need for intravenous fluids until gastro-intestinal function has returned to normal.

References1. Bergin, W. F. and Jordan, Paul H., Jr.: Gastric Atonia and

Delayed Gastric Emptying After Vagotomy for Obstruct-ing Ulcer. Am. J. Surg., 98:612, 1959.

2. Bodon, G. R. and Ramanth, H. K.: The GastrojejunostomyEfferent Loop Syndrome. Surg. Gynecol. Obstet., 134:777,1972.

3. Golden, R.: Functional Obstruction of Efferent Loop ofJejunum Following Partial Gastrectomy. JAMA, 148:721,1952.

4. Herrington, J. L.: Remedial Operations for PostgastrectomySyndromes. Curr. Probl. Surg., April, 1970.

5. Johnston, R. H., Quast, D. C. and Jordan, G. L., Jr.: Hemi-gastrectomy and Vagotomy for Duodenal Ulcer. Arch.Surg., 88:860, 1964.

6. Jordan, G. L., Jr., Barton, H. L. and Williamson, W. A.: AStudy of Motility in the Gastric Remnant Following Sub-total Gastrectomy. Surg. Gynecol. Obstet., 104:257, 1957.

7. Lavadia, P., Jr., Haynes, B. W., Jr. and DeBakey, M. E.:Retrograde Jejuno-gastric Intussusception: Review of Lit-erature and Report of a Case. Am. Surg., 19:507, 1953.

8. Magnuson, F. K., Judd, E. S. and Dearing, W. H.: Compari-son of Postgastrectomy Complications in Gastric andDuodenal Ulcer Patients. Am. Surg., 32:357, 1966.

9. Markowitz, A. M.: Internal Hernia After Gastrojejunostomy.Surgery, 49: 185, 1961.

10. Moore, H. G., Jr.: Complications of Gastric Surgery, Surgeryof the Stomach and Duodenum, Harkins, H. N., andNyhus, L. M. (Editors), Little, Brown and Company, Bos-ton, Massachusetts, pp. 665-734, 2nd ed., 1969.

11. Palumbo, L. T., Sharpe, W. S., Lulu, D. J., Bloom, M. H. andDragstedt, L. R., Jr.: Distal Antrectomy with Vagectomyfor Duodenal Ulcer Disease. Arch. Surg., 100:182, 1970.

12. Patterson, H. C.: Morbidity Following Gastric Resection forDuodenal Ulcer With and Without Vagotomy. Am. Surg.,31:175, 1965.

13. Pearce, C. W., Jordan, G. L., Jr. and DeBakey, M. E.: Intra-abdominal Complications Following Distal Subtotal Gas-trectomy for Benign Gastro-duodenal Ulceration. Surgery,42:447, 1957.

14. Sawyers, J. L., Scott, H. W., Jr., Wimberly, J. E. and Green,J. W.: Is it Necessary to Excise the Duodenal Ulcer witha Billroth I Anastomosis? Am. Surg., 37:150, 1971.

15. Thompson, J. E. and Rodgers, J. B.: The Management andPrevention of Abdominal Complications Associated withGastric and Duodenal Surgery. Am. Surg., 30:553, 1964.

16. Tovey, F. I.: Early Postoperative Inflammation of the Effer-ent Loop After Polygastrectomy. Lancet, 2:1209, 1960.

17. Tuschka, O.: Jejunogastric Intussusception. JAMA, 186:126,1963.

18. Wallace, R., De chantal, Sister Jane, and Mitty, W. F.: Mor-bidity and Mortality of Subtotal Gastrectomy. Am. J. Dig.Dis. 9:745, 1964.

19. Warren, R. P.: Acute Obstruction of Afferent or EfferentLoop Following Antecolic Gastrectomy with Report ofThree Cases. Ann. Surg., 139:202, 1954.

DISCUSSION

DR. J. LYNWOOD HERRINGTON, JR. (Nashville): I thoroughlyenjoyed both of these papers and had the opportunity to reviewboth manuscripts prior to the meeting. Therefore, I would liketo make a few comments regarding each presentation.

Dr. McCune is to be congratulated for bringing subject ofreflux gastritis to our attention. It is only during the past fewyears that reflux gastritis has received its due attention in thesurgical literature, for this is indeed a not infrequent complica-tion following gastric surgery. As with the problem of dumping,if we carefully question our patients, we will find that symptomssuggesting reflux gastritis are much more common than we oncebelieved. There are all gradations of this symptomatology varyingfrom those which are mild and transit to severe symptoms whichthe patient may experience daily. As Dr. McCune mentioned,reflux gastritis is encountered more frequently after a Billroth IItype anastomosis or after simply gastroenterostomy, but it canoccur after pyloroplasty or a Billroth I anastomosis. I look uponthis problem as being entirely different from the afferent loopsyndrome which to me connotates a mechanical obstruction

occurring along the course of a long afferent loop or at the gas-trojejunostomy site.The diagnosis of reflux gastritis is highly suggestive on careful

questioning of the patient but it can only be documented, asDr. McCune stresses, by gastroscopy, cinefluoroscopy and biopsyof the gastric mucosa. We have actually encountered severalpatients with this condition in which upper gastrointestinal bleed-ing was a significant complication.

[Slide] This is the X-ray film of a patient who underwent atruncal vagotomy-antrectomy and a Billroth I reconstruction for aduodenal ulcer. His surgeon did an extensive Kocherization of theduodenum which I feel, to some extent, might have predisposedthe patient to reflux gastritis. As many of you know. Dr. JoeWeinberg several years ago stated that excessive Kocherizationof the duodenum was to be condemned. This patient was treatedby isolating a 15 cm. segment of jejunum approximately 24 inchesbeow Treitz's ligament and interpolating it in an isoperistalticmanner between the stomach pouch and duodenum. After severalmonths postoperatively the patient gained 40 pounds and wasrelieved of all objective and subjective evidence of reflux gastritis.

[Slide] This is the film of another patient who underwent trun-cal vagotomy-antrectomy and a Billroth I reconstruction. Again,