Alkaline reflux gastritis: early and late results of surgery

Abstract

Background: Alkaline gastritis is caused by excessive reflux of alkaline duodenal content into the stomach or gastric remnant following procedures that resect or de-functionalize/deviate the pyloric sphincter. The symptoms may be intractable and surgery may be required in a selected subgroup of patients. The goal of this study was to present our experience regarding surgical management of alkaline reflux gastritis.

Materials and methods: During a 15-year period, 26 patients underwent surgery for the management of refractory alkaline reflux gastritis. Preoperative evaluation included a detailed history, endoscopy, and histology; alkaline reflux gastritis was characterized as mild, moderate, or severe based on the results of this evaluation. The patients underwent remedial gastric surgery when conservative management was ineffective and the patient's symptoms-despite medical treatment-persisted for at least 2 years and affected quality of life. Most patients had previously undergone subtotal gastrectomy/gastrojejunostomy (the Billroth II procedure) (22/26, 84.6%); three patients (11.5%) had vagotomy and gastrojejunostomy, and 1 patient (3.9%) had vagotomy and pyloroplasty. In most patients (14/26, 54%), symptoms appeared 1-3 years after initial gastric surgery. Epigastric pain and bilious vomiting were reported by all (26/26, 100%) and by 25/26 (96%) of patients, respectively, while anemia and weight loss were observed in 11/26 (42.3%) and 18/26 (69.2%), respectively. Severe, moderate, and mild gastritis was present in 12, 9, and 5 patients, respectively. Most patients (18/26, 69%) were treated by Roux-en-Y anastomosis, and 8 (31%) by the Tanner (Roux-19) procedure. Long-term follow-up was completed in 23 patients (mean: 7.3 years), by clinical assessment (n=18), or by questionnaire (n=5). Results were assessed by using the Visick grading.

Results: One patient died from massive pulmonary embolism (mortality: 3.8%). Morbidity was 57%, with the Roux stasis syndrome being the most frequent complication (n=9). Both procedures achieved good early results, particularly regarding pain relief and absence of vomiting (84% and 96%, respectively). Endoscopic findings were ameliorated 6 months following surgery, whereas histological changes remained relatively unchanged. Eleven patients (47.8%) reported excellent (Visick I), 9 (39.2%) good, and 3 (13%) unsatisfactory late results.

Conclusions: Remedial gastric surgery was effective and achieved symptom relief in a significant percentage (87%) of our patients. The Roux stasis syndrome is a frequent complication following Roux-en-Y reconstruction, but quality of life is significantly improved. Careful patient selection is essential to achieve satisfactory results.