Duodenal switch operation for pathologic transpyloric duodenogastric reflux

Abstract

Objective: To assess the long-term results of the duodenal switch operation made for pathologic transpyloric duodenogastric reflux (DGR).

Summary background data: DGR symptoms and lesions are poorly responsive to medical treatment.

Methods: A duodenal switch operation was made on 48 patients suffering from pathologic transpyloric DGR either unrelated (n = 28) or secondary (n = 20) to previous upper gastrointestinal (GI) surgery, including cholecystectomy or vagotomy. The diagnosis was based on the combination of several objective arguments: a long history of gastric symptoms (ie, nausea, epigastric pain, and/or bilious vomiting) poorly responsive to medical treatment (48 of 48), gastroesophageal reflux symptoms unresponsive to proton-pump inhibitors (PPI) (23 of 29), gastritis on upper GI endoscopy (37 of 48) and/or at histology (28 of 41), presence of a bilious gastric lake at >1 upper GI endoscopy (30 of 48), DGR at diisopropyl iminodiacetic acid (DISIDA) scintigraphy scanning (7 of 13), pathologic 24-hour intragastric bile monitoring with the Bilitec device (40 of 41), and absence of Helicobacter pylori antral infection (39 of 41).

Results: At follow-up (median, 81 months), gastric symptoms were nil, had improved, and remained unchanged in 29 (60.4%), 16 (33.3%), and 2(4.2%) patients, respectively, and 1 patient experienced symptomatic recurrence after a 92-month symptom-free period (2.1%). Among the 44 patients who had postoperative upper GI endoscopy, 42 (95.5%) had no gastritis whereas 5 (11.3%) had an ulcer at the duodenojejunostomy. Gastric exposure to bile at postoperative 24-hour intragastric Bilitec test in 36 patients was nil, within the normal range, and still slightly pathologic in 15 (41.7%), 19 (52.8%), and 2 (5.5%), respectively.

Conclusions: The duodenal switch operation made on patients in whom diagnosis of pathologic transpyloric DGR is supported by several objective arguments provides most of them with symptomatic and endoscopic improvement parallel to abolishment or normalization of gastric exposure to bile. Postoperative PPI therapy during a 2-month period is to be recommended to prevent the development of an anastomotic ulcer.

FIGURE 1. Duodenal switch procedure.

FIGURE 2. Intragastric bile monitoring tracing showing 5 nocturnal absorbance peaks of high amplitude (black arrows) attesting to the existence of pathologic gastric exposure to bile.

FIGURE 3. Gastric symptom score before (blank boxes) and after (black boxes) duodenal switch operation (left: nausea; center: epigastric pain; right: bilious vomiting).

FIGURE 4. Exposure of the gastric mucosa to bile before (blank columns) and after (black columns) duodenal switch operation expressed as the percentage of time that bile absorbance >0.25 for the total (left), upright (center), and supine (right) periods of recording.