Br. J. Surg. 1990, Vol. 77, September, 1025-1 029
G. Bassotti*?, P. GullaS. C. Betti*, W . E. Whitehead? and A. Morelli* *Laboratorio di Motilita Intestinale, Cattedra di Gastroenterologia, lstituto di Clinica Medica Generale e Terapia Medica I, Universita di Perugia, SDivisione di Chirurgia Generale. Ospedale ‘Calai: Gualdo Tadino, Italy, and tGastrointestina1 Psychophysiology Laboratory, Francis Scott Key Medical Center, Johns Hopkins University, Baltimore, Maryland, USA Correspondence to: Dr G . Bassotti, Clinica Medica I, 061 00 Perugia, Italy
Manometric evaluation of jejunal limb after total gastrectomy and Roux-Orr anastomosis for gastric cancer Total gastrectomy with Roux-Orr anastomosis is frequently performed for gastric cancer. Since intestinal motility of the Roux limb has never been evaluated after this operation, pressure activity was investigated in the Roux limb of ten patients (aged 51-77 years) who had undergone total gastrectomy and Roux-Orr reconstruction. Investigations were carried out during a 6-hfast and 3 h after a 605 kcal mixed meal. During ,fasting only two patients had activity fronts and these were abnormal. All ten patients displayed non-propagating bursts of contractions and three had discrete clustered contractions and high amplitude jejunal contractions. The f e d state was characterized by a severely reduced motor activity pattern and other abnormalities. Total gastrectomy with Roux-Orr anastomoses provokes a relatively severe disturbance in intestinal activity. Keywords: Gastrectomy, intestinal, manometry, motility
The surgical approach to gastric cancer frequently involves total gastric excision followed by anastomosis of the oesophagus to the small bowel’.2. The most widely used surgical procedure is that reported by Goldschwend3 in 1908, using the technique proposed by CCsar Roux and modified by Om4. There is evidence that most gastric operations provoke motor disturbances and that symptoms such as abdominal pain, nausea, vomiting and diarrhoea occur in up to 30 per cent of patients5s6. Motor function has been evaluated in various subsets of gastrectomized patients’-l but manometric studies after total gastrectomy are rare and of short duration12. There are no studies on the effects of total gastric resection on small bowel m ~ t i l i t y ’ ~A. scintigraphic study in patients who had undergone total gastrectomy and Roux-en-Y reconstruction demonstrated that solid food passed rapidly from the gullet to the Roux limb and then became uniformly distributed throughout the long portion of the small bowel; transit time was p r ~ l o n g e d ’ ~In. Italy, gastric cancer is often treated by total gastrectomy with Roux-Orr anastomosis’.’ ’. However, this may result in troublesome abdominal symptom^^.'^. Manometric studies have been performed to evaluate motor behaviour of the reconstructed limb in both fasting and fed conditions after total gastrectomy.
Patients and methods Ten consecutive patients (six men and four women of mean(s.d.) age 63(7) years, range 51-77 years) who had undergone total gastrectomy for gastric cancer with end-to-side Roux-en-Y anastomosis were studied. The length of the Roux limb was about 50 cm. Manometric evaluation was carried out at least 1 year (mean(s.d.) 25.4(2.8) months) after surgery. All operations had been done by the same surgeon. No patient had detectable signs of cancer recurrence at the time of manometry, as judged by physical examination, blood chemistry, abdominal ultrasound scan, total body computed tomography scan, barium meal (to exclude obstruction at the level of the anastomosis) and endoscopy (to document no or only minimal inflammation of the distal oesophagus). Clinical characteristics are given in Tahle 1 . Each patient gave informed consent to the investigation. A 7-lumen manometric probe (Arndorfer Medical Specialties, Gleendale, Wisconsin, USA) with a tungsten-weighted tip and recording points at 7, 27, 37, 47, 48, 49 and 50 cm from the tip was used. Each lumen was connected to an external physiological pressure transducer (Bell and Howell Sensormedics Italia, Milan, Italy, type
4-327-1) and was constantly perfused with bubble-free distilled water at a rate of 0 5 ml/min by a low compliance system”. At this perfusion rate, the system yields a pressure rise to distal occlusion of more than 200 mmHg/s. Intraluminal pressures were recorded on a multichannel Beckman R-611 Dynograph recorder (Sensormedics Italia), with a paper speed of 0.25 mm/s. After an overnight fast the manometric probe was inserted through the nose to within the Roux limb. It was positioned under fluoroscopic control such that the four proximal, closely spaced recording points straddled the oesophagojejunal anastomosis, while the distal three points lay in the jejunum (Figure I). Once the probe had been positioned, recording began immediately and lasted for 6 h during fasting and for 3 h after consuming a 605 kcal standard mixed meal composed of rice (60 g) with olive oil (20 9). roast veal (100 g). boiled green beans (100 g), and stewed apples (200 g), with 18.2 per cent protein, 36.2 per cent lipids and 45.6 per cent carbohydrates. Patients were encouraged to eat as much of the meal as possible, at least as much as they ate at home, so that intestinal motor activity could be recorded under near normal conditions.
Table 1 Clinical features of manometrically evaluated patients with total gastrectomy and Roux-Orr anastomosis
Patient no.
Age (years) ~~
~
Sex
Bowel function
~~
Upper gut symptoms ~~
1
56
F
Diarrhoea, constipation
2
51
M
-
3 4
68 59
F M
-
5
51
F
6 7
77 61
M M
8 9
69 65
M M
10
66
F
Diarrhoea (rare) Diarrhoea (rare) Diarrhoea Diarrhoea (rare) Diarrhoea Diarrhoea (frequent) Diarrhoea
Dysphagia, food regurgitation, bile vomiting Abdominal pain (rare) Dyspepsia (rare) Dysphagia, pyrosis (rare) Dysphagia Dysphagia, pyrosis (rare) Pyrosis, dyspepsia Bile vomiting, pyrosis, bile regurgitation Bile regurgitation, nausea. abdominal pain, abdominal distension
.~
0007-1323/90/09l025-05
0 1990 Butterworth
Heinemann Ltd
1025
Intestinal motility in total gastrectomy: G. Bassotti et al.
contractions (Figure 4 ) and discrete clustered contractions (Figure 5 ) were recorded in three patients. During the fed period overall intestinal motor activity was rare and was represented by low amplitude contractions (Figure 6). Non-propagated bursts of contractions were registered in four patients postprandially, and early (within 6&90 min of eating) activity fronts were seen in three. Two patients also displayed early postprandial high amplitude (> 80 mmHg) contractions.
Discussion There are few data on intestinal motility in patients subjected t o gastric resection'2-'3 and the effects of total gastric resection with Roux-Orr anastomosis have never before been investigated by manometric techniques. In the present study most patients complained of upper and/or lower bowel disturbances. Manometric investigation revealed major motor abnormalities in the Roux limb in all patients in both fasting and fed states. Table 2 Manometric features Patient no.
Fasting state
Fed state
1
No MMC activity; nonpropagated bursts
2
Frequent (about every 15 min) irregularly propagated activity fronts; non-propagated bursts No MMC activity; non-propagated bursts
Consistent motor response for only 42 min. In the late postprandial period, nonpropagated bursts No consistent motor response; early (within 30 min) postprandial vomiting Nausea while eating; minimal postprandial activity; early (within 60 min) phase 111 activity front Accentuated response; phase 111-like non-propagated activity in the late postprandial period Early postprandial high amplitude contractions associated with abdominal pain; thereafter, low amplitude contractions with sporadic baseline elevation Low amplitude postprandial activity; non-propagated bursts Scarce response to food ingestion; three activity fronts (two with simultaneous onset) in the early (within 80 min) postprandial period Very scarce response to food ingestion; non-propagated postprandial bursts
3
Figure 1 Abdominal radiograph showing the manometric probe in situ. Side openings are located at lhe level of the metallic plugs
4
No MMC activity; non-propagated bursts
5
No MMC activity; non-propagated bursts; sporadic high amplitude contractions; discrete clustered contractions
6
No MMC activity; non-propagated bursts
I
No MMC activity; non-propagated bursts
8
Non-propagated bursts; three abnormal (simultaneous onset) activity fronts No MMC activity; non-propagated bursts; frequent high amplitude contractions; discrete clustered contractions No MMC activity; non-propagated bursts; frequent high amplitude prolonged contractions; discrete clustered contractions
Manometric anal-vsis
Manometric tracings for fasted and fed periods were visually analysed by one of the authors. The fasting period results were similar to those previously described's-22. The cyclic variations of motor activity, i.e. the migrating motor complexes (MMCs), were identified. Briefly, phase I is characterized by motor quiescence, phase I1 by irregular but persistent contractions, and phase 111 (activity fronts) by bursts of rhythmic contractions, propagated in a oroaboral direction, which last at least 3 min and occur at a maximum frequency in the intestinal segment under observation (10-11 per min for the jejunum). The following specific motor abnormalities were looked for23-26:aberrant propagation and/or configuration of activity fronts; bursts of non-propagated phasic pressure activity (defined as phasic pressure activity lasting for at least 2 min with amplitude > 2 0 mmHg and frequency of contraction of l&12 per min); and discrete clustered contractions (defined as groups of phasic waves with amplitude > 15 mmHg, occurring at a rate of 10-12 per min and duration of about 1 min, often with some tonic elevation, preceded and followed by at least 30 s of quiescence). The fed period has been described p r e v i o ~ s l y ~The ~ ~ postcibal ~~~~'. intestinal motor pattern was defined as short bursts of irregular, random contractions interspersed with transient, brief periods of quiescence. Previous studies from this laboratory have shown that the meal described above elicits a continuous fed motor pattern for the entire 3-h postprandial period in healthy subjects22.28.
9
Results Manometric features are summarized in Table 2. During the fasting period eight patients displayed no M M C activity. Abnormal (simultaneous onset, retropropagated o r irregularly propagated) activity fronts occurred in the remaining two patients (Figure 2). Non-propagated bursts of contractions (Figure 3 ) were noted in all ten patients. Unusually prolonged ( > 1 min in one patient) high amplitude ( > 8 0 m m H g )
1026
10
Early postprandial high amplitude contractions; thereafter, non-propagated postprandial bursts Good response of the first few cm of the jejunal limb, whereas the distal portions showed very minimal activity
MMC, migrating motor complex
Br. J. Surg., Vol. 77, No. 9, September 1990
Intestinal motility in total gastrectomy: G . Bassotti et al.
Figure 2 Manometric tracing showing irregularly propagated phase III activity .fronts during Jasting. The first four recordings are ,from the oesophagojejunal anastomosis: the last three are .from the Rous limb
1 1
1
1
1
Figure 4 High amplitude prolonged jejunal contractions recorded in the Roux limb in a subject. Note that some of the coniractions last for more than I min. Recording points as in Figure 2
rnin 1
1
1
1
1
1
1
1
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Figure 3 Representative manometric tracing showing non-propugutrd bursts o f contractions in the Roux limb. Recording points ure us in Figure 2
Br. J. Surg., Vol. 77, No. 9, September 1990
L
1
Figure 5 Representative manometric tracing showing discrere clustered contractions. All recording points are in the Roux limb
1027
Intestinal motility in total gastrectomy: G. Bassotti et al. 1 min 1
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References
Kelly KA. Effect of gastric surgery on gastric motility and emptying. In: Akkermans LMA, Johnson AG, Read NW, eds. I I 1 1 .I I ‘CI Gastric and Gastroduodenal Motility. Surgical Science Series. New York: Praeger, 1984: 24142. 2. Santoro E, Garofalo A. I1 cancro dell0 stomaco negli ospedali italiani. Rome: Edizione Scientifiche Romane, 1981. 3. Goldschwend F. Operations und Danerer folge be1 bosartigev maligner Geschwulstbildung Magens. Arch Klin Chir 1908; 88: 2 18-25. 4. Orr TG. A modified technique for total gastrectomy. Arch Surg 1947; 54: 279-86. 5. Thompson JC, Wiener I. Evaluation of surgical treatment of duodenal ulcer: short and long-term effects. Clin Gastroenterol 1984; 13: 569400. 6. Miedema BW, Kelly KA. Postoperative gastric emptying disorders: treatment by Roux gastrectomy. Contemp Gastroenterol 1989; 2: 9-17. 7. Malagelada JR, Rees WDW, Mazzotta LJ, Go VLW. Gastric motor abnormalities in diabetic and postvagotomy gastroparesis: effect of metoclopramide and bethanecol. Gastroenterology 1980; 78: 286-93. 8. Bortolotti M,Bersani G, Lab0 G . Effect of Billroth I1 operation on the intestinal interdigestive motor activity. Digestion 1985; 31: 194-9. 9. Mathias JR, Fernandez A, Sninsky CA, Clench MH, Davis RH. 1 Y, Nausea, vomiting, and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb. Gastroenterology 1985; 88: 101-7. 10. Azpiroz F, Malagelada JR. Gastric tone measured by an electronic barostat in health and postsurgical gastroparesis. Gastroenterology 1987; 92: 93443. 11. Perino LE, Adcock KA, Goff JS. Gastrointestinal symptoms, Figure 6 Postprandial manometric tracing showing minimal contractile motility, and transit after the Roux-en-Y operation. Am J activity of the Roux limb after the standard meal had been consumed. Gastroenterol 1988; 83: 38&5. Recording points are as in Figure 2 12. Gazzaniga GM, Cogolo L, Filauro M. Studio elettromanometrico dell’ansa interposta dopo gastrectomia totale e gastroresezione per gastrite alcalina. Minerva Chir 1982; 37: 1669-73. 13. Gustavsson S, Kelly KA. Effect of gastric and small Motility pattern alterations have been reported after Billroth bowel operations on gastrointestinal motility. In: Kumar D, I1 surgery**’. However, whereas MMCs (albeit abnormal) were Gustavsson S, eds. A n Illusrrated Guide to Gastrointestinal documented in all Billroth XI patients, activity fronts were Motility. Chichester: John Wiley, 1988: 291-310. recorded in only two patients in the present study and both 14. Pellegrini CA, Deweney CW, Patti MG, Devine M, Way LW. were abnormally propagated. Non-propagated bursts of Intestinal transit of food after total gastrectomy and Roux-Y contractions were observed in all ten patients during fasting, esophagojejunostomy. Am J Surg 1986; 151: 117-24. and in four postprandially. Three subjects also displayed 15. Gennari L, Bozzetti F, Bonfanti G et al. Subtotal versus total prolonged and discrete clustered contractions, probably due to gastrectomy for cancer of the lower two-thirds of the stomach: surgical intervention, which were believed to be responsible for a new approach to an old problem. Br J Surg 1986; 73: 5348. symptoms. 16. Hinder RA, Esser J, DeMeester TR. Management of gastric emptying disorders following the Roux-en-Y procedure. Surgery The Roux limb is an isolated segment ofjejunum that is not 1988; 104: 765-72. under appropriate electrical control’. Given that isolated 17. Arndorfer RC, Stef JJ, Dodds WJ, Linehan JH, Hogan WJ. intestinal segments may show pacemaker f ~ n c t i o n ~ ’ - ~and ’ Improved infusion system for intraluminal esophageal manometry. that a limited portion of the small intestine has been Gastroenterology 1977; 73: 23-7. demonstrated to be able to pace the remaining small b o ~ e l ’ ~ . ~ ~ ,18. Vantrappen G, Janssens J, Hellemans J, Ghoos Y. The it may be that the Roux limb for some reason behaves as a interdigestive motor complex of normal subjects and patients functionally obstructing intestinal segment. with bacterial overgrowth of the small intestine. J Clin Inues, Although vagotomy disrupts the fed pattern in humans and 1977; 59: 1158-66. animals, studies in both have shown that vagotomy has little 19. Malagelada JR, Stanghellini V. Manometric evaluation of functional upper gut symptoms. Gastroenterology 1985; 88: influence on the MMC34*35.Moreover, Thiry-Vella loops 1223-3 1. (intestinal segments without continuity with the remaining 20. Narducci F, Bassotti G, Granata MT el al. Functional dyspepsia bowel) are still able to generate MMC activity36. Finally, and chronic idiopathic gastric stasis. Role of endogenous opiates. experiments in dogs have shown that MMCs are preserved Arch Intern Med 1986; 146: 71620. after total gastrectomy, but that the initiation of a fed pattern 21. Bassotti G, Gaburri M, Farroni F, Fiorucci S, Pelli MA, has a shorter latency after the operation3’. Hence, the motor Morelli A. Selective gastric stasis for solid food. It J abnormalities observed in the Roux limb after total gastrectomy Gastroenterol 1987; 19: 9 1 4 . in humans probably have a complex pathophysiological basis 22. Bassotti G, Pelli MA, Morelli A. Duodeno-jejunal motor activity that cannot be satisfactorily explained in our present state of in patients with chronic dyspeptic symptoms. J Clin Gastroenrerol 1990; 12: 17-21. knowledge. 23. Summers RW, Anuras S, Green J. Jejunal manometry patterns In conclusion, this study shows for the first time that patients in health, partial intestinal obstruction and pseudo-obstruction. with total gastrectomy and Roux-Orr anastomosis have Gastroenterology 1983; 85: 129&1300. significant motor abnormalities in the reconstructed intestinal 24. Malagelada JR, Camilleri M, Stanghellini V. Manometric limb in both fasting and fed conditions. These abnormalities Diagnosis of Gastrointestinal Motility Disorders. New York: are probably responsible for the upper and lower gut symptoms Thieme Incorporated, 1986. reported by the patients and, especially in the early period after 25. Stanghellini V, Camilleri M, Malagelada JR. Chronic idiopathic operation, could account for the various bowel disturbances of intestinal pseudo-obstruction: clinical and intestinal manometric which virtually all patients complain. findings. Cur 1987; 28: 5-12. 1.
mmHg
1
1028
Br. J. Surg., Vol. 77, No. 9, September 1990
Case report
26. 27. 28. 29. 30. 31. 32.
Kellow JE, Phillips SF. Altered small bowel motility in irritable bowel syndrome is correlated with symptoms. Gastroenterology 1987; 92: 1885-93. Kerlin P, Phillips S . Variability of motility of the ileum and jejunum in healthy humans. Gastroenterology 1982;82: 694-700. Bassotti G, Bucaneve G, Betti C et al. Parenteral diclofenac sodium does not influence upper GI motility in man. Gastroenterology 1989; %: A31. Bunker CE, Johnson LP, Nelson TS. Chronic in situ studies of the electrical activity of the small intestine. Arch Surg 1967; 95: 259-68. Nelsen TS, Becker JC. Stimulation of the electrical and mechanical gradient of the small intestine. Am J Physiol 1968; 214: 749-57. Sarna SK, Daniel EE, Kingma YS. Simulation of slow-wave electrical activity of small intestine. Am J Physiol 1971; 221: 16673. Bass P, Code CF, Lambert EH. Electrical activity of
33. 34. 35. 36. 37.
gastroduodenal function. Am J Physiol 1961; 201: 587-91. Gullikson GW, Okuda H, Shimizu M, Bass P. Electrical arrhythmias in gastric antrum of the dog. Am J Phvsiol 1980; 239: G59-68. Thompson DG, Ritchie HD, Wingate DL. Patterns of small intestinal motility in ulcer patients before and after vagotomy. Gut 1982; 23: 517-23. Hall KE, El-Sharkawy TY, Diamant NE. Vagal control of canine postprandial upper gastrointestinal motility. Am J Physiol 1986; 250: G501-510. Wingate DL. The small intestine. In: Christensen J, Wingate DL, eds. A GQide to Gastrointestinal Motility. Bristol: John Wright, 1983: 128-56. Heppel J, Taylor BM, Kelly KA. Gastric influences of canine small intestinal myoelectric activity. Dig Dis Sci 1984;29: 849-52.
Paper accepted 5 April 1990
Case report Br. J. S u r g . 1990, Vol. 77, September, 1029
looo
Glyceryl trinitrate in the management of a biliary fistula
-
1
D. Sharma, G. T. Sunderland and 1. F. Kerr Department of Surgery, Stobhill Hospital, Glasgow G213UW, UK Correspondence to: Mr G. T. Sunderland, Department of Surgery, Royal Infirmary, Glasgow G 4 OSF, UK
z -
.-
0"
300 200 100
Biliary leakage after cholecystectomy is n o t uncommon'. It is accepted teaching that in an adequately nourished patient with no active disease an d no distal obstruction, fistulae will close spontaneously. We report a case of a postcholecystectomy fistula which resolved when distal obstruction due to presumed sphincter spasm was relieved by the use of glyceryl trinitrate.
C T N patches
900
1
I[I
2
3
4
5
6
7
8
9
10 1 1
12
13
Time after second laparotorny [days)
Figure 1 Volume of bile-stained.fluid recoveredfrom an intra-abdominal drain after second laparotomy. ERCP, endoscopic retrograde cholangiopancreatography; G TN, glyceryl trinitrate
Case report An obese 46-year-old man gave a 12-year history of abdominal pain due to proven gallstones. Cholecystectomy proved difficult because the gallbladder was firmly adherent to surrounding structures. A fundus first dissection was performed and during dissection in Calot's triangle the cystic duct was avulsed from the common bile duct. This was repaired primarily without narrowing and a tube drain was placed in the hepatorenal pouch. In the 2 days after operation there was no drainage and the patient was well. When the drain was removed on the second day 300ml of bile-stained fluid escaped from the drain site. Two days later the patient complained of right hypochondria1 pain and ultrasonography demonstrated a small intraperitoneal collection. This was treated conservatively and the patient appeared to settle. He was well enough to return home at 10 days but returned a week later complaining of abdominal pain and distension. Ultrasonography revealed an increased amount of intraperitoneal fluid and a 99Tc-Sn-2,6-diethylacetanilidoiminodiacetate (HIDA) scan showed continued leakage of bile from the common bile duct. A second laparotomy was performed and 3 litres of bile-stained fluid was aspirated. Drainage was re-established but the common bile duct was not disturbed. Over the next 6 days drainage was between 700 and 800 ml per day (Figure 1 ). Endoscopic retrograde cholangiopancreatography (ERCP) showed continuing leakage but no stricturing or retained stone. Contrast failed to drain from the bile duct during the examination and spasm of the sphincter of Oddi was diagnosed. Drainage from the intra-abdominal drain was unchanged by ERCP. Before offering endoscopic sphincterotomy, glyceryl trinitrate was administered in the form ofa trinitrin patch in a dose of 5 mg per day (Transiderm-NitroN,
0007-1
323/90/091029-01
0 1990 Butterworth-Heinemann Ltd
Ciba Laboratories, Horsham, UK). Following this the fistula output declined rapidly to zero (Figure I).
Discussion In t h e present case it is probable that spasm of the sphincter o f O d d i prevented fistula closure. In such a situation endoscopic sphincterotomy m ay be used to good effect but in our patient this was n o t needed following the use of glyceryl trinitrate. T h e delay in response after ERCP suggests that the eventual fall in fistula output is a genuine result of pharmacological relaxation of the sphincter. This medication is eaily administered in a slow-release form and is known t o induce sphincter relaxation*. It may prove t o be a practical alternative t o endoscopic sphincterotomy with its attendant morbidity a n d mortality rates.
References 1.
2.
Rayter Z, Tonge C, Bennett CE, Robinson PS, Thomas MH. Bile leaks after simple cholecystectomy. Br J Surg 1989; 76: 1 0 4 6 8 . Lebovics E, Heier SK,Rosenthal WS. Sphincter of Oddi motility: developments in physiology and clinical applications. Am J Gastroenterol 1986: 81: 73643.
Paper accepted 9 March 1990
1029
G. Bassotti*?, P. GullaS. C. Betti*, W . E. Whitehead? and A. Morelli* *Laboratorio di Motilita Intestinale, Cattedra di Gastroenterologia, lstituto di Clinica Medica Generale e Terapia Medica I, Universita di Perugia, SDivisione di Chirurgia Generale. Ospedale ‘Calai: Gualdo Tadino, Italy, and tGastrointestina1 Psychophysiology Laboratory, Francis Scott Key Medical Center, Johns Hopkins University, Baltimore, Maryland, USA Correspondence to: Dr G . Bassotti, Clinica Medica I, 061 00 Perugia, Italy
Manometric evaluation of jejunal limb after total gastrectomy and Roux-Orr anastomosis for gastric cancer Total gastrectomy with Roux-Orr anastomosis is frequently performed for gastric cancer. Since intestinal motility of the Roux limb has never been evaluated after this operation, pressure activity was investigated in the Roux limb of ten patients (aged 51-77 years) who had undergone total gastrectomy and Roux-Orr reconstruction. Investigations were carried out during a 6-hfast and 3 h after a 605 kcal mixed meal. During ,fasting only two patients had activity fronts and these were abnormal. All ten patients displayed non-propagating bursts of contractions and three had discrete clustered contractions and high amplitude jejunal contractions. The f e d state was characterized by a severely reduced motor activity pattern and other abnormalities. Total gastrectomy with Roux-Orr anastomoses provokes a relatively severe disturbance in intestinal activity. Keywords: Gastrectomy, intestinal, manometry, motility
The surgical approach to gastric cancer frequently involves total gastric excision followed by anastomosis of the oesophagus to the small bowel’.2. The most widely used surgical procedure is that reported by Goldschwend3 in 1908, using the technique proposed by CCsar Roux and modified by Om4. There is evidence that most gastric operations provoke motor disturbances and that symptoms such as abdominal pain, nausea, vomiting and diarrhoea occur in up to 30 per cent of patients5s6. Motor function has been evaluated in various subsets of gastrectomized patients’-l but manometric studies after total gastrectomy are rare and of short duration12. There are no studies on the effects of total gastric resection on small bowel m ~ t i l i t y ’ ~A. scintigraphic study in patients who had undergone total gastrectomy and Roux-en-Y reconstruction demonstrated that solid food passed rapidly from the gullet to the Roux limb and then became uniformly distributed throughout the long portion of the small bowel; transit time was p r ~ l o n g e d ’ ~In. Italy, gastric cancer is often treated by total gastrectomy with Roux-Orr anastomosis’.’ ’. However, this may result in troublesome abdominal symptom^^.'^. Manometric studies have been performed to evaluate motor behaviour of the reconstructed limb in both fasting and fed conditions after total gastrectomy.
Patients and methods Ten consecutive patients (six men and four women of mean(s.d.) age 63(7) years, range 51-77 years) who had undergone total gastrectomy for gastric cancer with end-to-side Roux-en-Y anastomosis were studied. The length of the Roux limb was about 50 cm. Manometric evaluation was carried out at least 1 year (mean(s.d.) 25.4(2.8) months) after surgery. All operations had been done by the same surgeon. No patient had detectable signs of cancer recurrence at the time of manometry, as judged by physical examination, blood chemistry, abdominal ultrasound scan, total body computed tomography scan, barium meal (to exclude obstruction at the level of the anastomosis) and endoscopy (to document no or only minimal inflammation of the distal oesophagus). Clinical characteristics are given in Tahle 1 . Each patient gave informed consent to the investigation. A 7-lumen manometric probe (Arndorfer Medical Specialties, Gleendale, Wisconsin, USA) with a tungsten-weighted tip and recording points at 7, 27, 37, 47, 48, 49 and 50 cm from the tip was used. Each lumen was connected to an external physiological pressure transducer (Bell and Howell Sensormedics Italia, Milan, Italy, type
4-327-1) and was constantly perfused with bubble-free distilled water at a rate of 0 5 ml/min by a low compliance system”. At this perfusion rate, the system yields a pressure rise to distal occlusion of more than 200 mmHg/s. Intraluminal pressures were recorded on a multichannel Beckman R-611 Dynograph recorder (Sensormedics Italia), with a paper speed of 0.25 mm/s. After an overnight fast the manometric probe was inserted through the nose to within the Roux limb. It was positioned under fluoroscopic control such that the four proximal, closely spaced recording points straddled the oesophagojejunal anastomosis, while the distal three points lay in the jejunum (Figure I). Once the probe had been positioned, recording began immediately and lasted for 6 h during fasting and for 3 h after consuming a 605 kcal standard mixed meal composed of rice (60 g) with olive oil (20 9). roast veal (100 g). boiled green beans (100 g), and stewed apples (200 g), with 18.2 per cent protein, 36.2 per cent lipids and 45.6 per cent carbohydrates. Patients were encouraged to eat as much of the meal as possible, at least as much as they ate at home, so that intestinal motor activity could be recorded under near normal conditions.
Table 1 Clinical features of manometrically evaluated patients with total gastrectomy and Roux-Orr anastomosis
Patient no.
Age (years) ~~
~
Sex
Bowel function
~~
Upper gut symptoms ~~
1
56
F
Diarrhoea, constipation
2
51
M
-
3 4
68 59
F M
-
5
51
F
6 7
77 61
M M
8 9
69 65
M M
10
66
F
Diarrhoea (rare) Diarrhoea (rare) Diarrhoea Diarrhoea (rare) Diarrhoea Diarrhoea (frequent) Diarrhoea
Dysphagia, food regurgitation, bile vomiting Abdominal pain (rare) Dyspepsia (rare) Dysphagia, pyrosis (rare) Dysphagia Dysphagia, pyrosis (rare) Pyrosis, dyspepsia Bile vomiting, pyrosis, bile regurgitation Bile regurgitation, nausea. abdominal pain, abdominal distension
.~
0007-1323/90/09l025-05
0 1990 Butterworth
Heinemann Ltd
1025
Intestinal motility in total gastrectomy: G. Bassotti et al.
contractions (Figure 4 ) and discrete clustered contractions (Figure 5 ) were recorded in three patients. During the fed period overall intestinal motor activity was rare and was represented by low amplitude contractions (Figure 6). Non-propagated bursts of contractions were registered in four patients postprandially, and early (within 6&90 min of eating) activity fronts were seen in three. Two patients also displayed early postprandial high amplitude (> 80 mmHg) contractions.
Discussion There are few data on intestinal motility in patients subjected t o gastric resection'2-'3 and the effects of total gastric resection with Roux-Orr anastomosis have never before been investigated by manometric techniques. In the present study most patients complained of upper and/or lower bowel disturbances. Manometric investigation revealed major motor abnormalities in the Roux limb in all patients in both fasting and fed states. Table 2 Manometric features Patient no.
Fasting state
Fed state
1
No MMC activity; nonpropagated bursts
2
Frequent (about every 15 min) irregularly propagated activity fronts; non-propagated bursts No MMC activity; non-propagated bursts
Consistent motor response for only 42 min. In the late postprandial period, nonpropagated bursts No consistent motor response; early (within 30 min) postprandial vomiting Nausea while eating; minimal postprandial activity; early (within 60 min) phase 111 activity front Accentuated response; phase 111-like non-propagated activity in the late postprandial period Early postprandial high amplitude contractions associated with abdominal pain; thereafter, low amplitude contractions with sporadic baseline elevation Low amplitude postprandial activity; non-propagated bursts Scarce response to food ingestion; three activity fronts (two with simultaneous onset) in the early (within 80 min) postprandial period Very scarce response to food ingestion; non-propagated postprandial bursts
3
Figure 1 Abdominal radiograph showing the manometric probe in situ. Side openings are located at lhe level of the metallic plugs
4
No MMC activity; non-propagated bursts
5
No MMC activity; non-propagated bursts; sporadic high amplitude contractions; discrete clustered contractions
6
No MMC activity; non-propagated bursts
I
No MMC activity; non-propagated bursts
8
Non-propagated bursts; three abnormal (simultaneous onset) activity fronts No MMC activity; non-propagated bursts; frequent high amplitude contractions; discrete clustered contractions No MMC activity; non-propagated bursts; frequent high amplitude prolonged contractions; discrete clustered contractions
Manometric anal-vsis
Manometric tracings for fasted and fed periods were visually analysed by one of the authors. The fasting period results were similar to those previously described's-22. The cyclic variations of motor activity, i.e. the migrating motor complexes (MMCs), were identified. Briefly, phase I is characterized by motor quiescence, phase I1 by irregular but persistent contractions, and phase 111 (activity fronts) by bursts of rhythmic contractions, propagated in a oroaboral direction, which last at least 3 min and occur at a maximum frequency in the intestinal segment under observation (10-11 per min for the jejunum). The following specific motor abnormalities were looked for23-26:aberrant propagation and/or configuration of activity fronts; bursts of non-propagated phasic pressure activity (defined as phasic pressure activity lasting for at least 2 min with amplitude > 2 0 mmHg and frequency of contraction of l&12 per min); and discrete clustered contractions (defined as groups of phasic waves with amplitude > 15 mmHg, occurring at a rate of 10-12 per min and duration of about 1 min, often with some tonic elevation, preceded and followed by at least 30 s of quiescence). The fed period has been described p r e v i o ~ s l y ~The ~ ~ postcibal ~~~~'. intestinal motor pattern was defined as short bursts of irregular, random contractions interspersed with transient, brief periods of quiescence. Previous studies from this laboratory have shown that the meal described above elicits a continuous fed motor pattern for the entire 3-h postprandial period in healthy subjects22.28.
9
Results Manometric features are summarized in Table 2. During the fasting period eight patients displayed no M M C activity. Abnormal (simultaneous onset, retropropagated o r irregularly propagated) activity fronts occurred in the remaining two patients (Figure 2). Non-propagated bursts of contractions (Figure 3 ) were noted in all ten patients. Unusually prolonged ( > 1 min in one patient) high amplitude ( > 8 0 m m H g )
1026
10
Early postprandial high amplitude contractions; thereafter, non-propagated postprandial bursts Good response of the first few cm of the jejunal limb, whereas the distal portions showed very minimal activity
MMC, migrating motor complex
Br. J. Surg., Vol. 77, No. 9, September 1990
Intestinal motility in total gastrectomy: G . Bassotti et al.
Figure 2 Manometric tracing showing irregularly propagated phase III activity .fronts during Jasting. The first four recordings are ,from the oesophagojejunal anastomosis: the last three are .from the Rous limb
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Figure 4 High amplitude prolonged jejunal contractions recorded in the Roux limb in a subject. Note that some of the coniractions last for more than I min. Recording points as in Figure 2
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Figure 3 Representative manometric tracing showing non-propugutrd bursts o f contractions in the Roux limb. Recording points ure us in Figure 2
Br. J. Surg., Vol. 77, No. 9, September 1990
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Figure 5 Representative manometric tracing showing discrere clustered contractions. All recording points are in the Roux limb
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Intestinal motility in total gastrectomy: G. Bassotti et al. 1 min 1
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References
Kelly KA. Effect of gastric surgery on gastric motility and emptying. In: Akkermans LMA, Johnson AG, Read NW, eds. I I 1 1 .I I ‘CI Gastric and Gastroduodenal Motility. Surgical Science Series. New York: Praeger, 1984: 24142. 2. Santoro E, Garofalo A. I1 cancro dell0 stomaco negli ospedali italiani. Rome: Edizione Scientifiche Romane, 1981. 3. Goldschwend F. Operations und Danerer folge be1 bosartigev maligner Geschwulstbildung Magens. Arch Klin Chir 1908; 88: 2 18-25. 4. Orr TG. A modified technique for total gastrectomy. Arch Surg 1947; 54: 279-86. 5. Thompson JC, Wiener I. Evaluation of surgical treatment of duodenal ulcer: short and long-term effects. Clin Gastroenterol 1984; 13: 569400. 6. Miedema BW, Kelly KA. Postoperative gastric emptying disorders: treatment by Roux gastrectomy. Contemp Gastroenterol 1989; 2: 9-17. 7. Malagelada JR, Rees WDW, Mazzotta LJ, Go VLW. Gastric motor abnormalities in diabetic and postvagotomy gastroparesis: effect of metoclopramide and bethanecol. Gastroenterology 1980; 78: 286-93. 8. Bortolotti M,Bersani G, Lab0 G . Effect of Billroth I1 operation on the intestinal interdigestive motor activity. Digestion 1985; 31: 194-9. 9. Mathias JR, Fernandez A, Sninsky CA, Clench MH, Davis RH. 1 Y, Nausea, vomiting, and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb. Gastroenterology 1985; 88: 101-7. 10. Azpiroz F, Malagelada JR. Gastric tone measured by an electronic barostat in health and postsurgical gastroparesis. Gastroenterology 1987; 92: 93443. 11. Perino LE, Adcock KA, Goff JS. Gastrointestinal symptoms, Figure 6 Postprandial manometric tracing showing minimal contractile motility, and transit after the Roux-en-Y operation. Am J activity of the Roux limb after the standard meal had been consumed. Gastroenterol 1988; 83: 38&5. Recording points are as in Figure 2 12. Gazzaniga GM, Cogolo L, Filauro M. Studio elettromanometrico dell’ansa interposta dopo gastrectomia totale e gastroresezione per gastrite alcalina. Minerva Chir 1982; 37: 1669-73. 13. Gustavsson S, Kelly KA. Effect of gastric and small Motility pattern alterations have been reported after Billroth bowel operations on gastrointestinal motility. In: Kumar D, I1 surgery**’. However, whereas MMCs (albeit abnormal) were Gustavsson S, eds. A n Illusrrated Guide to Gastrointestinal documented in all Billroth XI patients, activity fronts were Motility. Chichester: John Wiley, 1988: 291-310. recorded in only two patients in the present study and both 14. Pellegrini CA, Deweney CW, Patti MG, Devine M, Way LW. were abnormally propagated. Non-propagated bursts of Intestinal transit of food after total gastrectomy and Roux-Y contractions were observed in all ten patients during fasting, esophagojejunostomy. Am J Surg 1986; 151: 117-24. and in four postprandially. Three subjects also displayed 15. Gennari L, Bozzetti F, Bonfanti G et al. Subtotal versus total prolonged and discrete clustered contractions, probably due to gastrectomy for cancer of the lower two-thirds of the stomach: surgical intervention, which were believed to be responsible for a new approach to an old problem. Br J Surg 1986; 73: 5348. symptoms. 16. Hinder RA, Esser J, DeMeester TR. Management of gastric emptying disorders following the Roux-en-Y procedure. Surgery The Roux limb is an isolated segment ofjejunum that is not 1988; 104: 765-72. under appropriate electrical control’. Given that isolated 17. Arndorfer RC, Stef JJ, Dodds WJ, Linehan JH, Hogan WJ. intestinal segments may show pacemaker f ~ n c t i o n ~ ’ - ~and ’ Improved infusion system for intraluminal esophageal manometry. that a limited portion of the small intestine has been Gastroenterology 1977; 73: 23-7. demonstrated to be able to pace the remaining small b o ~ e l ’ ~ . ~ ~ ,18. Vantrappen G, Janssens J, Hellemans J, Ghoos Y. The it may be that the Roux limb for some reason behaves as a interdigestive motor complex of normal subjects and patients functionally obstructing intestinal segment. with bacterial overgrowth of the small intestine. J Clin Inues, Although vagotomy disrupts the fed pattern in humans and 1977; 59: 1158-66. animals, studies in both have shown that vagotomy has little 19. Malagelada JR, Stanghellini V. Manometric evaluation of functional upper gut symptoms. Gastroenterology 1985; 88: influence on the MMC34*35.Moreover, Thiry-Vella loops 1223-3 1. (intestinal segments without continuity with the remaining 20. Narducci F, Bassotti G, Granata MT el al. Functional dyspepsia bowel) are still able to generate MMC activity36. Finally, and chronic idiopathic gastric stasis. Role of endogenous opiates. experiments in dogs have shown that MMCs are preserved Arch Intern Med 1986; 146: 71620. after total gastrectomy, but that the initiation of a fed pattern 21. Bassotti G, Gaburri M, Farroni F, Fiorucci S, Pelli MA, has a shorter latency after the operation3’. Hence, the motor Morelli A. Selective gastric stasis for solid food. It J abnormalities observed in the Roux limb after total gastrectomy Gastroenterol 1987; 19: 9 1 4 . in humans probably have a complex pathophysiological basis 22. Bassotti G, Pelli MA, Morelli A. Duodeno-jejunal motor activity that cannot be satisfactorily explained in our present state of in patients with chronic dyspeptic symptoms. J Clin Gastroenrerol 1990; 12: 17-21. knowledge. 23. Summers RW, Anuras S, Green J. Jejunal manometry patterns In conclusion, this study shows for the first time that patients in health, partial intestinal obstruction and pseudo-obstruction. with total gastrectomy and Roux-Orr anastomosis have Gastroenterology 1983; 85: 129&1300. significant motor abnormalities in the reconstructed intestinal 24. Malagelada JR, Camilleri M, Stanghellini V. Manometric limb in both fasting and fed conditions. These abnormalities Diagnosis of Gastrointestinal Motility Disorders. New York: are probably responsible for the upper and lower gut symptoms Thieme Incorporated, 1986. reported by the patients and, especially in the early period after 25. Stanghellini V, Camilleri M, Malagelada JR. Chronic idiopathic operation, could account for the various bowel disturbances of intestinal pseudo-obstruction: clinical and intestinal manometric which virtually all patients complain. findings. Cur 1987; 28: 5-12. 1.
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Case report
26. 27. 28. 29. 30. 31. 32.
Kellow JE, Phillips SF. Altered small bowel motility in irritable bowel syndrome is correlated with symptoms. Gastroenterology 1987; 92: 1885-93. Kerlin P, Phillips S . Variability of motility of the ileum and jejunum in healthy humans. Gastroenterology 1982;82: 694-700. Bassotti G, Bucaneve G, Betti C et al. Parenteral diclofenac sodium does not influence upper GI motility in man. Gastroenterology 1989; %: A31. Bunker CE, Johnson LP, Nelson TS. Chronic in situ studies of the electrical activity of the small intestine. Arch Surg 1967; 95: 259-68. Nelsen TS, Becker JC. Stimulation of the electrical and mechanical gradient of the small intestine. Am J Physiol 1968; 214: 749-57. Sarna SK, Daniel EE, Kingma YS. Simulation of slow-wave electrical activity of small intestine. Am J Physiol 1971; 221: 16673. Bass P, Code CF, Lambert EH. Electrical activity of
33. 34. 35. 36. 37.
gastroduodenal function. Am J Physiol 1961; 201: 587-91. Gullikson GW, Okuda H, Shimizu M, Bass P. Electrical arrhythmias in gastric antrum of the dog. Am J Phvsiol 1980; 239: G59-68. Thompson DG, Ritchie HD, Wingate DL. Patterns of small intestinal motility in ulcer patients before and after vagotomy. Gut 1982; 23: 517-23. Hall KE, El-Sharkawy TY, Diamant NE. Vagal control of canine postprandial upper gastrointestinal motility. Am J Physiol 1986; 250: G501-510. Wingate DL. The small intestine. In: Christensen J, Wingate DL, eds. A GQide to Gastrointestinal Motility. Bristol: John Wright, 1983: 128-56. Heppel J, Taylor BM, Kelly KA. Gastric influences of canine small intestinal myoelectric activity. Dig Dis Sci 1984;29: 849-52.
Paper accepted 5 April 1990
Case report Br. J. S u r g . 1990, Vol. 77, September, 1029
looo
Glyceryl trinitrate in the management of a biliary fistula
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1
D. Sharma, G. T. Sunderland and 1. F. Kerr Department of Surgery, Stobhill Hospital, Glasgow G213UW, UK Correspondence to: Mr G. T. Sunderland, Department of Surgery, Royal Infirmary, Glasgow G 4 OSF, UK
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.-
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300 200 100
Biliary leakage after cholecystectomy is n o t uncommon'. It is accepted teaching that in an adequately nourished patient with no active disease an d no distal obstruction, fistulae will close spontaneously. We report a case of a postcholecystectomy fistula which resolved when distal obstruction due to presumed sphincter spasm was relieved by the use of glyceryl trinitrate.
C T N patches
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2
3
4
5
6
7
8
9
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12
13
Time after second laparotorny [days)
Figure 1 Volume of bile-stained.fluid recoveredfrom an intra-abdominal drain after second laparotomy. ERCP, endoscopic retrograde cholangiopancreatography; G TN, glyceryl trinitrate
Case report An obese 46-year-old man gave a 12-year history of abdominal pain due to proven gallstones. Cholecystectomy proved difficult because the gallbladder was firmly adherent to surrounding structures. A fundus first dissection was performed and during dissection in Calot's triangle the cystic duct was avulsed from the common bile duct. This was repaired primarily without narrowing and a tube drain was placed in the hepatorenal pouch. In the 2 days after operation there was no drainage and the patient was well. When the drain was removed on the second day 300ml of bile-stained fluid escaped from the drain site. Two days later the patient complained of right hypochondria1 pain and ultrasonography demonstrated a small intraperitoneal collection. This was treated conservatively and the patient appeared to settle. He was well enough to return home at 10 days but returned a week later complaining of abdominal pain and distension. Ultrasonography revealed an increased amount of intraperitoneal fluid and a 99Tc-Sn-2,6-diethylacetanilidoiminodiacetate (HIDA) scan showed continued leakage of bile from the common bile duct. A second laparotomy was performed and 3 litres of bile-stained fluid was aspirated. Drainage was re-established but the common bile duct was not disturbed. Over the next 6 days drainage was between 700 and 800 ml per day (Figure 1 ). Endoscopic retrograde cholangiopancreatography (ERCP) showed continuing leakage but no stricturing or retained stone. Contrast failed to drain from the bile duct during the examination and spasm of the sphincter of Oddi was diagnosed. Drainage from the intra-abdominal drain was unchanged by ERCP. Before offering endoscopic sphincterotomy, glyceryl trinitrate was administered in the form ofa trinitrin patch in a dose of 5 mg per day (Transiderm-NitroN,
0007-1
323/90/091029-01
0 1990 Butterworth-Heinemann Ltd
Ciba Laboratories, Horsham, UK). Following this the fistula output declined rapidly to zero (Figure I).
Discussion In t h e present case it is probable that spasm of the sphincter o f O d d i prevented fistula closure. In such a situation endoscopic sphincterotomy m ay be used to good effect but in our patient this was n o t needed following the use of glyceryl trinitrate. T h e delay in response after ERCP suggests that the eventual fall in fistula output is a genuine result of pharmacological relaxation of the sphincter. This medication is eaily administered in a slow-release form and is known t o induce sphincter relaxation*. It may prove t o be a practical alternative t o endoscopic sphincterotomy with its attendant morbidity a n d mortality rates.
References 1.
2.
Rayter Z, Tonge C, Bennett CE, Robinson PS, Thomas MH. Bile leaks after simple cholecystectomy. Br J Surg 1989; 76: 1 0 4 6 8 . Lebovics E, Heier SK,Rosenthal WS. Sphincter of Oddi motility: developments in physiology and clinical applications. Am J Gastroenterol 1986: 81: 73643.
Paper accepted 9 March 1990
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