Total Duodenal Diversion

The technique that is most often used currently was described by Holt and Large52 (Figure 12.1). The standard operation is performed through an abdominal incision. When the diversion is performed in patients who have not undergone a previous gastrectomy, it includes resection of

MANAGEMENT OF ALKALINE REFLUX

h IV

teg.

Figure 12.1. On the left is illustrated truncal vagotomy, gastric antrectomy, and when necessary, segmental esophageal resection for a nondilatable stricture. On the right, reconstruction is shown using the 45-cm-long Roux-en-Y gastric drainage procedure to divert biliary and pancreatic secretions away from the stomach. (Reprinted from Payne.25 Used with permission of Mayo Foundation.)

the mobile part of the duodenum, an antrec-tomy (gastric division following a vertical line extending from the angle of the lesser curvature), and a bilateral truncal vagotomy. The digestive tract continuity is restored using an end-to-side gastrojejunostomy on a 45- to 60-cm Roux-en-Y jejunal limb. Some authors suggest closure of the diaphragmatic crura with an anti-reflux fundoplication. This may be seen as a therapeutic overkill when acid and bile exposure have been eliminated. Most authors agree on the necessity to perform a bilateral truncal vagotomy, as antrectomy and duodenal diversion is considered as an ulcerogenic operation. This is evidenced by frequently documented postoperative stomal ulcers as complications of TDD.53

Total duodenal diversion is considered a safe operation. No mortality is reported when TDD is used for severe esophagitis lesions. Postoperative morbidity ranges from 9 to 27%. The higher complication rate was seen when resection of an esophageal stricture was added. In general, TDD is very effective in controlling the reflux symptoms and healing related esophagi-tis. Most of the strictures are under control early after the operation or at the most within a year postoperatively, after 1-3 dilation sessions. Only 5% of all patients require resection of their esophageal strictures. Fekete et al.54 reported partial regression of Barrett's mucosa in 20% of their patients. Most authors, however, report no change of Barrett's metaplasia in the esophagus after TDD.

The results of TDD are frequently expressed in general terms, looking mostly at the overall functional results. After a few years of enthusiastic use of TDD, several reports emphasized the side effects and the postoperative complaints of the operation, namely, postprandial epigastric fullness, dumping, weight loss, or bile vomiting. These symptoms were very similar to the duo-denogastric reflux symptom complex that led to surgery. The postoperative assessment criteria used in these patients is mostly subjective, with the terminology of excellent, good, fair, or poor, which roughly encompasses the Visick grading system. This enables a relatively accurate comparison between the reported series. Ellis and Gibb55 observed significant improvement in 73-100% (mean 90%) of 14 patients in a series of TDD reported between 1955 and 1992. This represents a total of 293 patients treated for DGER. More recently, there have been reports of good to excellent results in 76-97% of patients.56-58

When the same operation is used to treat bil-iopancreatic gastritis, the results are less encouraging. Madura59 found that only 54% of 527 patients treated in such manner between 1980 and 1993 reported significant improvement. Hinder60,61 opted for TDD in association with an anti-reflux procedure whenever possible. He reported that 15-50% of patients operated for duodenogastric reflux complain of significant postoperative symptoms early after a TDD. On longer-term follow-up, 15-20% of patients continue to experience the same symptoms. The discrepancy in the results comparing biliopancreatic reflux esophagitis and biliopan-creatic gastritis without esophagitis remains unexplained because the basic pathophysiology is considered to be the same.

The length of the Roux-en-Y limb between the gastrojejunal anastomosis and the jejuno-jejunal anastomosis has been a matter of con

Anastomose Gastrojejunal

MANAGING FAILED ANTI-REFLUX THERAPY

troversy. Most authors consider that a 45-cm limb is a minimum.25 A 50- to 60-cm limb is usually preferred to minimize the risk of persistent or recurrent symptoms.

Why 15-20% of patients still have postoperative symptoms despite good to excellent endo-scopic results is still a matter of debate and controversy. Total duodenal diversion is in itself a procedure that causes sufficient foregut modification to explain at least part of the postoperative problems of either dumping or poor gastric emptying. The bilateral truncal vago-tomy and the partial gastrectomy are the most frequently suggested culprits in the literature. Denervating the stomach and the proximal foregut does create motility changes. Despite these well-documented effects, vagotomy is considered essential when an antrectomy and interruption of gastroduodenal continuity are the result of the operation.

Early in the assessment of this type of reconstruction, Welch et al.62 documented in the laboratory the increase in gastric secretion of acid resulting from a Roux-en-Y diversion without antrectomy or vagotomy. If an antrectomy is added to the diversion without a vagotomy, postoperative stomal ulcers on the gastrojejunal anastomosis are almost inevitable. Gustavsson et al.63 and Davidson and Hersh,64 however, suggest that the gastric stasis seen after gastrec-tomy and Roux diversion is not significantly influenced by truncal vagotomy. Most of the time, when TDD is indicated, an antrectomy has already been done, usually with a gastro-jejunal reconstruction (Billroth II). This operation has been the leading cause of bile reflux damage in the remaining stomach and in the esophagus.

The antrectomy is essential in order to gain good control of the gastric acid secretion in parallel to the control of the bile injury caused by the diversion. An inadequate gastric resection has been shown to be responsible for some of the worst postoperative gastric emptying problems. A limited antrectomy may result in a "dependent sump" causing early postoperative vomiting whereas the opposite, an extensive two-thirds gastrectomy, usually results in severe postoperative digestive discomfort. Vogel and Woodward65 reported that revisional surgery for gastric atony after TDD resulted in clinical improvement and normalization of gastric emptying. In these patients, the size of the gastric remnant correlated with the amount of improvement.

The effects of truncal vagotomy on gastric motility may result in various patterns of gastric emptying. However, there was no significant difference in solid meal emptying when Billroth II gastrectomy was performed compared with TDD.66 Furthermore, there may be no correlation between persistent postoperative symptoms and delayed gastric emptying. Gastric emptying problems are usually found to improve with time.

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