Duodenal diversion with vagotomy and antrectomy for severe or recurrent reflux oesophagitis and stricture: an alternative to operation at the hiatus.

In cases of mild symptomatic gastro-oesophageal reflux, standard antireflux surgery, such as fundoplication or the Angelchik prosthesis, produces satisfactory results. Duodenal diversion is recommended for use only in patients with severe oesophageal damage. This situation commonly arises where the gastro-oesophageal junction cannot be reduced into the abdomen, or where previous surgery has made reoperation at the hiatus difficult and hazardous. Fifty-seven patients with severe reflux oesophagitis have been treated by Roux-en-Y duodenal diversion and antrectomy. Thirty three patients had vagotomy in addition. Median follow-up after operation is 6.1 years. In 35 patients (61%), the technique was used as primary surgical treatment. These included 22 patients in a randomized trial of the method. Thirteen (23%) had previously had unsuccessful antireflux surgery. Nine (16%) had undergone previous operations for peptic ulcer or achalasia. There was no operative mortality. No patient in the series required stricture resection. Good or excellent overall results were achieved in 86% of patients. Eighteen of twenty seven patients with severe strictures required an average of three dilatations after operation before dysphagia was completely relieved. Heartburn was dramatically relieved and oesophagitis settled within an average period of 6 months. Poor or unsatisfactory overall results were observed in 8 (14%) patients. These included one tight fibrous stricture which required endoscopic intubation despite resolution of oesophagitis, and four patients who developed a stomal ulcer. No patients suffered from the dumping syndrome. Malignancy must be carefully excluded by biopsy in all cases of stricture.