Indications, technical modalities and results of the duodenal switch operation for pathologic duodenogastric reflux

Abstract

Background/aims: Reflux gastritis is caused by the excessive reflux of alkaline duodenal content into the stomach and can lead to intractable symptoms. The main cause of pathologic duodenogastric reflux (DGR) is previous gastric surgery in which the pylorus is removed or rendered dysfunctional. The entity of abnormal DGR without previous gastric surgery is called "primary duodenogastric reflux". The main symptoms in these patients are severe upper abdominal pain, nausea and bilious vomiting. DGR remains very difficult to diagnose and treat. Investigations include endoscopy with histological examination, intragastric pH-monitoring, radionuclide scanning, gastric aspiration, antroduodenal manometry, and bile detection with special probes. Medical therapy is generally not helpful. Acid-blocking medications, sucralfate, prostaglandin E2 and cholestyramine used as an ion-exchange resin to bind bile salts do not usually improve symptoms. There is some evidence that ursodeoxycholate favorably affects symptoms but experience is limited.

Methodology: Surgical therapy was initially performed on selected patients with intractable symptoms. A variety of operative procedures have been used to treat pathologic DGR but cause significant side effects through changes in the normal physiology of the foregut. DeMeester et al proposed a suprapapillary duodenojejunostomy succinctly called the duodenal switch procedure. It has been reported to maintain the integrity of the antro-pyloro-duodenal mechanism with great patient satisfaction. Between 1984 and 1995, 32 patients (9 men and 23 women), mean age 50 years (range: 30-77), required pancreaticobiliary diversion using the switch procedure for symptomatic gastritis related to abnormal primary DGR. Symptoms were evaluated with a symptom score using a detailed questionnaire.

Results: After a mean follow-up of 4 years (n = 32, range: 0.5-8.2), 94% of the patients had a good clinical outcome as defined by a significant reduction in pre-operative symptoms. There was no mortality.

Conclusions: Suprapapillary Roux-en-Y duodenojejunostomy (duodenal switch procedure) is an effective surgical therapy in patients with pathologic primary DGR.