CLINICAL AND RADIONUCLIDE EVALUATION OF BILE DIVERSION BY BRAUN ENTEROENTEROSTOMY - PREVENTION AND TREATMENT OF ALKALINE REFLUX GASTRITIS -AN ALTERNATIVE TO ROUX-EN-Y DIVERSION

Objective and Summary Background Symptomatic, medically resistant post gastrectomy patients with alkaline reflux gastritis (ARG) have increas ed enterogastric reflux (EGR) documented by quantitative radionuclide biliary scanning. Even asymptomatic patients after gastrectomy have in creased EGR compared with nonoperated control patients. Roux-en-Y bili ary diversion, although successfully treats the clinical syndrome of A RG, has a high incidence of early and late postoperative severe gastro paresis, Roux limb retention (the Roux syndrome), or both; which often requires further remedial surgery. As an alternative to Roux-en-Y div ersion, this review evaluates the efficacy of the Braun enteroenterost omy (BEE) in diverting bile away from the stomach in patients having g astric operations. Based on previous pilot studies, the BEE is positio ned 30 cm from the gastroenterostomy. Methods Thirty patients had the following operations and were evaluated: standard pancreatoduodenectom y (8), vagotomy and Billroth II (BII) gastrectomy (6), BII gastrectomy only (10), and palliative gastroenterostomy to an intact stomach (6). All anastomoses were antecolic BII with a long afferent limb and a 30 -cm BEE. Four symptomatic patients with medically intractable ARG and chronic gastroparesis had subtotal BII gastric resection with BEE rath er than Roux-en-Y diversion. Eight control symptomatic patients and si x asymptomatic patients with previous BII gastrectomy and no BEE were evaluated. Radionuclide biliary scanning was performed within 30 days in all patients and at 4 to 6 months in 14 patients. Bile reflux was e xpressed as an EGR index (%). Results After operation, 18 of 34 patien ts (53%) had no demonstrable EGR while in the fasting state for as lon g as 90 minutes. The range of demonstrable bile reflux (EGR) in the re maining 16 patients was from 2% to 17% (mean, 4.5%). Enterogastric ref lux in the 14 control patients (with no BEE) ranged from 5% to 82% (me an, 42%). The four patients with ARG and chronic gastroparesis treated by subtotal gastrectomy and BEE had postoperative EGR of 0%, 2%, 2%, and 4%, respectively. They are asymptomatic with no evidence of bile r eflux gastritis. In the 14 patients who had late evaluation, EGR range d from O% to 16% (mean, 5.5%). No patient had signs or symptoms of ARG after operation. Conclusions Braun enteroenterostomy successfully div erts a substantial amount of bile from the stomach. The ARG syndrome m ight be prevented by performing BEE during gastric resection or bypass in a variety of operations. Conversion to a BII with BEE may be an al ternative to Roux-en-Y diversion in treating medically resistant ARG a nd subsequent may avoid the Roux syndrome.