Vogel S B, Drane W E, Woodward E R
Department of Surgery, University of Florida, College of Medicine, Gainesville.
Ann Surg. 1994 May;219(5):458-65; discussion 465-6. doi: 10.1097/00000658-199405000-00003.
OBJECTIVE AND SUMMARY BACKGROUND: Symptomatic, medically resistant postgastrectomy patients with alkaline reflux gastritis (ARG) have increased enterogastric reflux (EGR) documented by quantitative radionuclide biliary scanning. Even asymptomatic patients after gastrectomy have increased EGR compared with nonoperated control patients. Roux-en-Y biliary diversion, although successfully treats the clinical syndrome of ARG, has a high incidence of early and late postoperative severe gastroparesis, Roux limb retention (the Roux syndrome), or both, which often requires further remedial surgery. As an alternative to Roux-en-Y diversion, this review evaluates the efficacy of the Braun enteroenterostomy (BEE) in diverting bile away from the stomach in patients having gastric operations. Based on previous pilot studies, the BEE is positioned 30 cm from the gastroenterostomy.
Thirty patients had the following operations and were evaluated: standard pancreatoduodenectomy (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 rather than Roux-en-Y diversion. Eight control symptomatic patients and six 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 expressed as an EGR index (%).
After operation, 18 of 34 patients (53%) had no demonstrable EGR while in the fasting state for as long as 90 minutes. The range of demonstrable bile reflux (EGR) in the remaining 16 patients was from 2% to 17% (mean, 4.5%). Enterogastric reflux in the 14 control patients (with no BEE) ranged from 5% to 82% (mean, 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 reflux gastritis. In the 14 patients who had late evaluation, EGR ranged from 0% to 16% (mean, 5.5%). No patient had signs or symptoms of ARG after operation.
Braun enteroenterostomy successfully diverts a substantial amount of bile from the stomach. The ARG syndrome might be prevented by performing BEE during gastric resection or bypass in a variety of operations. Conversion to a BII with BEE may be an alternative to Roux-en-Y diversion in treating medically resistant ARG and subsequent may avoid the Roux syndrome.
目的和背景概述：经定量放射性核素胆道扫描证实，有症状的、药物治疗无效的胃切除术后碱性反流性胃炎（ARG）患者的肠胃反流（EGR）增加。与未手术的对照患者相比，即使是胃切除术后无症状的患者，其EGR也有所增加。Roux-en-Y胆肠分流术虽然成功治疗了ARG的临床综合征，但术后早期和晚期严重胃轻瘫、Roux袢滞留（Roux综合征）或两者兼有的发生率很高，这通常需要进一步的补救手术。作为Roux-en-Y分流术的替代方法，本综述评估了Braun肠肠吻合术（BEE）在胃手术患者中使胆汁从胃分流的疗效。根据先前的初步研究，BEE位于距胃肠吻合口30 cm处。
30例患者接受了以下手术并进行了评估：标准胰十二指肠切除术（8例）、迷走神经切断术和毕Ⅱ式（BII）胃切除术（6例）、单纯BII胃切除术（10例）以及对完整胃进行的姑息性胃肠吻合术（6例）。所有吻合均为结肠前BII式，输入袢长，BEE为30 cm。4例有症状的、药物治疗难以控制的ARG和慢性胃轻瘫患者接受了次全BII胃切除术加BEE，而非Roux-en-Y分流术。对8例有症状的对照患者和6例先前接受过BII胃切除术且未行BEE的无症状患者进行了评估。所有患者均在30天内进行放射性核素胆道扫描，14例患者在4至6个月时进行扫描。胆汁反流以EGR指数（%）表示。
术后，34例患者中有18例（53%）在禁食状态下长达90分钟未显示出EGR。其余16例患者中可显示的胆汁反流（EGR）范围为2%至17%（平均4.5%）。14例对照患者（未行BEE）的肠胃反流范围为5%至82%（平均42%）。4例接受次全胃切除术和BEE治疗的ARG和慢性胃轻瘫患者术后EGR分别为0%、2%、2%和4%。他们无症状，无胆汁反流性胃炎的证据。在14例接受后期评估的患者中，EGR范围为0%至16%（平均5.5%）。术后无患者出现ARG的体征或症状。
Braun肠肠吻合术成功地使大量胆汁从胃分流。在各种手术中，在胃切除或旁路手术期间进行BEE可能预防ARG综合征。在治疗药物治疗无效的ARG时，转换为带BEE的BII式手术可能是Roux-en-Y分流术的替代方法，随后可能避免Roux综合征。
