Bile exposure of the denervated stomach as an esophageal substitute

Background. Both the supine position and the existence of a gastric drainag e procedure are suspected to promote reflux of duodenal juice into the dene rvated intrathoracic stomach. Erythromycin has been shown to weaken pyloric resistance to gastric outflow and to enhance antral motility, gastric empt ying, and gallbladder contractility. Methods. The presence of bile in the gastric transplant of 79 patients was monitored over a 24-hour period with use of the Bilitec 2000 optoelectronic device 3 to 195 months after subtotal esophagectomy. Ten patients were rei nvestigated after a 3-year period. Five groups were studied group I: n = 12 , no gastric drainage, never given erythromycin, group 2: n = 40, gastric d rainage, never given erythromycin, group 3: n = 7,no gastric drainage, give n erythromycin, group 4: n = 13, gastric drainage, given erythromycin, and group 5: n = 7,no longer given erythromycin (with or without gastric draina ge). The percentage of time gastric bile absorbance was more than 0.25 was calculated for the total, supine, and upright periods of recording in refer ence to data from 25 healthy volunteers. Results. The Bilitec test was pathologic in 9 of the 12 patients of group 1 whereas it was normal in three. Gastric exposure to bile was longer in gro up I patients than in controls for the total (p = 0.012) and supine (0.036) periods, but the difference did not reach statistical significance for the upright period (p = 0.080). Bile exposure in group 4 did not significantly differ from controls (total: p = 0.701; supine: p = 0.124; upright: p = 0. 712). Bile exposure for the total period did not significantly differ wheth er patients were taking erythromycin or the drug had been discontinued at t he time of the study (p = 0.234); and it tended to decrease with time in pa tients investigated twice (p = 0.046). Conclusions. Gastric exposure to bile after truncal vagotomy and transposit ion of the stomach up to the neck is pathologic in three quarters of patien ts. It is more marked in the supine than in the upright position and tends to decrease with time. The addition of a gastric drainage procedure in comb ination with erythromycin therapy tends to normalize gastric exposure to bi le. The effects of erythromycin may persist after discontinuation of the dr ug.