Antireflux anastomosis following oesophagectomy

BACKGROUND: Reflux of duodeno-gastric fluid is a significant problem after oesophagectomy with gastric conduit reconstruction. It can impact considerably upon the patient's quality of life and can induce oesophagitis and Barrett's metaplasia in the remnant oesophagus. AIM: The aim of the present study was to describe the use of a modified fundoplication in controlling reflux after oesophagectomy. METHODS: Patients undergoing subtotal oesophagectomy at the Royal Adelaide Hospital were identified. Clinical and operative details were obtained from hospital records. All patients had an end oesophagus to side stomach anastomosis. Two cohorts were identified - one with a standard anastomosis only and the other in whom a modified fundoplication had been added. A structured phone interview was used to assess reflux in the two groups with a minimum of 6 months follow up. The interviewer was blinded to the operative details. RESULTS: The operative technique is described. A total of 44 patients were assessed, 33 having the fundoplication type anastomosis and 11 the standard anastomosis. Operative morbidity was not different between the groups. Symptoms of reflux were better controlled in patients with the fundoplication anastomosis than in patients with a standard anastomosis. Of those with a fundoplication, 14 of 33 patients (42%) were asymptomatic with respect to reflux compared to only one of 11 patients (9%) in the standard anastomosis group. Only four of the 33 patients (12%) with a fundoplication anastomosis had symptoms of severe reflux while seven of the 11 patients (63%) with a standard anastomosis had severe reflux symptoms. CONCLUSIONS: This initial evaluation of a modified fundoplication as an antireflux manoeuvre after oesophagectomy suggests that the technique is effective in controlling post-oesophagectomy reflux in the majority of patients. It is simple to perform and may have benefits in improving quality of life and preventing oesophagitis and metaplastic changes in the remnant oesophagus. A more detailed prospective study of the technique is warranted.     

An Antireflux Anastomosis Following Esophagectomy: A Randomized Controlled Trial

Background  

Reflux of duodeno-gastric fluid is a significant problem after esophagectomy with gastric conduit reconstruction. Symptoms may be severe and impact considerably upon the quality of life. Previous studies have suggested that a fundoplication type anastomosis may limit post-esophagectomy reflux.     

High incidence of reflux esophagitis observed by routine endoscopic examination after gastric pull-up esophagectomy

Abstract A gastric tube has been widely used for reconstruction of the esophagus after esophagectomy for esophageal cancer. Reflux esophagitis after esophagectomy is frequently observed. Therefore we retrospectively investigated the risk factors for reflux esophagitis after gastric pull-up esophagectomy in 74 outpatients with thoracic esophageal cancer. Reflux esophagitis was diagnosed endoscopically. Esophagitis was classified according to the Los Angeles classification. Reflux symptoms, medications, and the surgical procedure were reviewed. The relation between reflux symptoms and reflux esophagitis and the influence of the anastomotic site were evaluated. Reflux esophagitis was observed in 53 patients. Severe esophagitis (grade C or D) was found in 75.6% of these patients. Although all patients with esophagitis took antacid agents, histamine receptor-2 blocker was effective in only 35% of them. The correlation between reflux symptoms and reflux esophagitis was not significant. Reflux esophagitis was present in 56.4% of patients with neck anastomosis and in 88.6% of patients with intrathoracic anastomosis (p = 0.0039). We concluded that routine endoscopic examination is necessary after gastric pull-up esophagectomy because reflux esophagitis is not diagnosed based on reflux symptoms. When a gastric tube is used for reconstruction after esophagectomy, neck anastomosis is recommended to lower the risk of reflux esophagitis. Electronic Publication     

Effect of semifundoplication with subtotal gastrectomy for prevention of postoperative gastroesophageal reflux

BACKGROUND: Postgastrectomy patients often experience reflux esophagitis and a compromised quality of life. We hypothesized that reconstructive methods with antireflux procedures at operation should prevent reflux esophagitis and improve the likelihood of a better quality of life in patients after distal gastrectomy for gastric carcinoma. Our antireflux procedure was a subdiaphragmatic semifundoplication. We aim to substantiate, with objective arguments, potential advantages of Billroth I simple reconstruction versus Billroth I with semifundoplication. STUDY DESIGN: This study evaluated 60 patients who had Billroth I reconstruction with semifundoplication (30 patients; F group) and simple Billroth I reconstruction (30 patients; B group) after distal gastrectomy for gastric cancer. Assessments were made preoperatively and 6 months or later after surgical intervention. Results of the procedure, clinical evaluation (reflux symptoms), and esophageal alkaline reflux by ambulatory 24-hour pH memory were satisfactory. RESULTS: Operative evaluation time and procedural complications did not differ significantly between the two gastrectomy groups. Reflux symptoms only occurred in 12 patients in the B group. Lower esophageal sphincter pressure of patients in the B group was significantly lower than that of patients in the F group and in preoperative states (p < 0.05). The mean appearance of alkaline esophageal reflux in the F group and the B group were 2.6% and 13.6%, respectively (p < 0.01). Patients with semifundoplication had a significantly better quality of life and less physiologic regurgitation than patients with simple Billroth I. CONCLUSIONS: This study demonstrated that Billroth I reconstruction with semifundoplication for gastric cancer is not only effective for patients with a postoperative life expectancy, but also prevents reflux esophagitis after gastrectomy. We believe that our method is an effective and simple surgical option for many patients with gastric cancer.     

Functional evaluation of the intrathoracic stomach as an oesophageal substitute.

A study of duodenogastric reflux and gastric function was undertaken in 16 patients 1-7 years after oesophagectomy and high intrathoracic oesophagogastrostomy for oesophageal carcinoma. All were able to eat satisfactorily; ten complained of mild foregut symptoms and ten had endoscopic mucosal lesions. Biliary excretion scintigraphy demonstrated pathological duodenogastric reflux in 11 patients. The emptying of a semisolid radiolabelled meal from the intrathoracic stomach in the upright position was significantly quicker than in control subjects (P less than 0.01). No gastric motor activity was recorded on manometry, suggesting that the transposed stomach acts like an inert tube. Results of 24-h pH monitoring showed that the area under the curve at pH less than 4 in the stomach was significantly less than in control subjects (P less than 0.001). In addition, patients had a significantly greater oesophageal alkaline exposure (P less than 0.001). The vagotomized intrathoracic stomach therefore empties well in the upright position, but is subjected to reflux of alkaline duodenal contents and can retain the ability to produce acid. The interaction between alkaline and acid contents in the pathogenesis of symptoms and mucosal lesions needs further investigation.     

Gastroesophageal reflux in duodenal ulcer patients before and after vagotomy.

Gastroesophageal reflux was investigated in 80 patients with duodenal ulcer by analysis of symptomatology and the acid reflux test. Resting gastroesophageal sphincter pressure (GESP) and postvagotomy reduction in basal and pentagastrin stimulated gastric acid secretion were also studied. Reflux symptoms were present in 40% of the patients, and this incidence was significantly reduced two months after vagotomy. In patients studied late after operation reflux symptoms were still less frequent than before operation, but not significant. After vagotomy, no significant changes in the fasting GESP or in gastroesophageal reflux as determined by the pH glass electrode were demonstrated. Thus, the decrease in reflux symptoms may be explained by the significant reduction in gastric acid secretion. Denervation of the cardia and the lower esophagus does not influence GESP or gastroesophageal reflux.     

Gastric banding interferes with esophageal motility and gastroesophageal reflux

BACKGROUND: Gastroesophageal reflux and progressive esophageal dilatation can develop after gastric banding (GB). HYPOTHESIS: Gastric banding may interfere with esophageal motility, enhance reflux, or promote esophageal dilatation. DESIGN: Before-after trial in patients undergoing GB. SETTING: University teaching hospital. PATIENTS AND METHODS: Between January 1999 and August 2002, 43 patients undergoing laparoscopic GB for morbid obesity underwent upper gastrointestinal endoscopy, 24-hour pH monitoring, and stationary esophageal manometry before GB and between 6 and 18 months postoperatively. MAIN OUTCOME MEASURES: Reflux symptoms, endoscopic esophagitis, pressures measured at manometry, esophageal acid exposure. RESULTS: There was no difference in the prevalence of reflux symptoms or esophagitis before and after GB. The lower esophageal sphincter was unaffected by surgery, but contractions in the lower esophagus weakened after GB, in correlation with preoperative values. There was a trend toward more postoperative nonspecific motility disorders. Esophageal acid exposure tended to decrease after GB, with fewer reflux episodes. A few patients developed massive postoperative reflux. There was no clear correlation between preoperative testing and postoperative esophageal acid exposure, although patients with abnormal preoperative acid exposure tended to maintain high values after GB. CONCLUSIONS: Postoperative esophageal dysmotility and gastroesophageal reflux are not uncommon after GB. Preoperative testing should be done routinely. Low amplitude of contraction in the lower esophagus and increased esophageal acid exposure should be regarded as contraindications to GB. Patients with such findings should be offered an alternative procedure, such as Roux-en-Y gastric bypass.     

Surgical Management of Reflux Gastritis

Reflux gastritis is now recognized with increasing frequency as a complication following operations on the stomach which either remove, alter, or bypass the pyloric phincter mechanism. The entity may occasionally occur as a result of sphincter dysfunction in the patient who has not undergone prior gastric surgery. The diagnosis is made on the basis of symptoms (postprandial pain, bilious vomiting and weight loss), gastroscopic examination with biopsy and persistent hypochlorhydria. Remedial operation for correction of reflux is indicated in the presence of persistent symptoms when conservative measures fail. Only operative procedures which divert duodenal contents from the stomach or gastric remnant are effective. Both the isoperistaltic jejunal segment (Henley loop) and the Roux-en-Y diversion have been effective as remedial operations for reflux gastritis and merit greater awareness by gastroenterologists and surgeons. Our choice is the Roux-en-Y because of its technical simplicity and lower morbidity rate.     

Reflux control following gastric surgery

Reflux is a common complication in patients who have undergone gastric surgery. These patients have bile reflux, often associated with gastric disease, and are resistant to conservative management. In this study the authors have reviewed 124 patients who were treated surgically for reflux that occurred after gastric operations. They were assessed preoperatively by history, radiologic investigation, manometry with pH and endoscopy. Seventeen patients were treated by Belsey hernia repair, 42 by partial fundoplication gastroplasty and 65 by total fundoplication gastroplasty. Thirty-seven patients required additional gastric surgery. Continued reflux was the commonest problem postoperatively; it was effectively corrected by total fundoplication gastroplasty. Of eight patients who had persistent bile gastritis, four had had bile drainage as part of their operation for reflux. From this study the authors conclude that total fundoplication gastroplasty is the most effective procedure to control reflux, but it must be carefully tailored to avoid overcompetence and dysphagia. Associated gastric problems should be treated simultaneously.     

Gastroesophageal Reflux Following Gastric Operation

The combination of previous gastric operation and gastroesophageal reflux produces major difficulties in obtaining effective symptomatic relief. Seventy patients were studied by history, radiology, endoscopy, and esophageal manometry before surgical reflux control. Twenty-eight had had vagotomy and pyloroplasty; 4, vagotomy and gastroenterostomy; 11, Billroth I gastrectomy; and 27, Billroth II gastrectomy.In all patients reflux control was accomplished by hernia repair, and in 14 patients bile diversion was added for control of bile gastritis. A variety of reflux control operations were used. However, the most effective results were achieved with total fundoplication gastroplasty, and in this group of 22 patients there has been no anatomical recurrence and no reflux. The partial fundoplication gastroplasty (Belsey type) was ineffective in reflux control and should not be used in patients who have had a previous gastric procedure.Reflux control and, when necessary, bile diversion give effective relief to patients with bile gastritis and esophageal reflux following gastric operation.     

Fundoplication for laryngopharyngeal reflux disease

BACKGROUND: Laryngopharyngeal reflux (LPR) disease arises from the effects of refluxed gastric contents on the proximal aerodigestive tract. LPR patients are often lumped into the category of "atypical" reflux. LPR symptoms are hoarseness, globus, cough, and pharyngitis. Severe disease is associated with subglottic stenosis and laryngeal cancer. Treatment includes lifestyle modifications and medications. The role of fundoplication for LPR has yet to be defined. STUDY DESIGN: Forty-one patients underwent fundoplication for LPR. They were prospectively followed with three outcomes measures: The Reflux Symptom Index, a laryngoscopic grading scale (Reflux Finding Score), and a reflux-based specific quality-of-life scale. RESULTS: Average early followup was at 4 months and late followup was at 14 months. The Reflux Symptom Index improved by 5.4 early (p < 0.05) and 6.5 late (p < 0.05). Improvement between early and late periods approached significance (p < 0.09). Reflux Finding Score improved 3.8 (p < 0.05) early and 4.4 (p < 0.05) late. The Quality of Life Index improved 0.6 early and 2.3 (p < 0.05) late. By Reflux Symptom Index criteria, 26 patients were improved early versus 35 late (p < 0.05). Factors associated with poor outcomes were structural laryngeal changes in five patients (p < 0.05) and no response to proton pump inhibitors in six patients (p < 0.05). CONCLUSIONS: Fundoplication augments treatment of LPR. Improvement of symptoms continues past the first 4 months. Laryngoscopy is critical in patient selection because selected findings are associated with outcomes, diagnosis, and management.     

Oesophageal and gastric bile exposure after gastroduodenal surgery with Henley's interposition or a Roux-en-Y loop

BACKGROUND: The degree which the various reconstruction techniques prevent bile reflux after gastroduodenal surgery has been poorly studied. METHODS: Bile exposure in the intestinal tract just proximal to the jejunal loop was measured with the Bilitec 2000 device for 24 h after gastroduodenal surgery in three groups of patients. Group 1 comprised 24 patients with a 60-cm Henley's loop after total gastrectomy. Group 2 included 31 patients with a 60-cm Roux-en-Y loop after total (22 patients) or subtotal (nine) gastrectomy. Group 3 contained 21 patients with a 60-cm Roux-en-Y loop anastomosed to the proximal duodenum as part of a duodenal switch operation for pathological transpyloric duodenogastric reflux. Bile exposure, measured as the percentage time with bile absorbance greater than 0.25, was classified as nil, within the range of a control population of healthy subjects, or pathological (above the 95th percentile for the control population). Reflux symptoms were scored and all patients had upper gastrointestinal endoscopy. RESULTS: Bile was detected in the intestine proximal to the loop in none of 24 patients in group 1, eight of 31 in group 2 and 12 of 21 in group 3 (P < 0.001). The mean reflux symptom score increased with the degree of bile exposure, and the proportion of patients with oesophagitis or gastritis correlated well with the extent of bile exposure (P < 0.001). CONCLUSION: A long Henley's loop was more effective in preventing bile reflux than a long Roux-en-Y loop. Bilitec data correlated well with the severity of reflux symptoms and the presence of mucosal lesions.     

Clinical outcome of high segmental gastrectomy for early gastric cancer in the upper third of the stomach

BACKGROUND: Reflux oesophagitis is commonly encountered in the surgical treatment of cancer of the upper third of the stomach. The aim of this study was to describe a novel surgical technique and evaluate the clinical outcome of high segmental gastrectomy for early-stage proximal gastric cancer. METHODS: Thirty consecutive patients with early gastric cancer located in the upper third of the stomach were included, of whom 12 underwent high segmental gastrectomy and 18 underwent proximal gastrectomy with jejunal interposition. The incidence of reflux oesophagitis and nutritional parameters were compared between the two groups at 1 year after operation. RESULTS: One patient had mild reflux symptoms and two had endoscopic evidence of oesophagitis 1 year after high segmental gastrectomy. Half of the patients who had proximal gastrectomy had reflux symptoms of varying severity and 14 had endoscopic evidence of oesophageal changes at 1 year after surgery. There were significant differences between groups in the incidence of reflux symptoms (P = 0.016) and endoscopically detected gastro-oesophagitis (P < 0.001). There were no adverse events in either group, and the survival rate after high segmental gastrectomy appeared favourable. CONCLUSION: Selected patients with early-stage proximal gastric cancer benefit from high segmental gastrectomy in terms of reduced reflex oesophagitis, without jeopardizing curability.     

Human model of duodenogastro-oesophageal reflux in the development of Barrett's metaplasia

BACKGROUND: Patients with an intrathoracic oesophagogastrostomy after subtotal oesophagectomy experience profound duodenogastro-oesophageal reflux (DGOR). This study investigated the degree of mucosal injury and histopathological changes in oesophageal squamous epithelium after subtotal oesophagectomy with gastric interposition in relation to the extent of postoperative DGOR. METHODS: Serial endoscopic assessment and systematic biopsy at the oesophagogastric anastomosis was undertaken in 40 patients following curative radical subtotal oesophagectomy and reconstruction with a gastric conduit subjected to a pyloroplasty. Thirty patients subsequently underwent combined 24-h ambulatory pH and bilirubin monitoring. RESULTS: Grade I-III oesophagitis was identified in 14 patients and oesophageal columnar epithelium in 19 patients. Biopsies from columnar regeneration revealed cardiac-type epithelium in ten patients and intestinal metaplasia in nine. Seven patients followed serially showed progression from cardiac-type epithelium to intestinal metaplasia. The incidence of Barrett's metaplasia was similar irrespective of the histological subtype of the resected tumour. Patients with oesophageal columnar epithelium had significantly higher acid (P = 0.015) and bilirubin (P = 0.011) reflux. CONCLUSION: Severe DGOR occurs following subtotal oesophagectomy and provides an environment for the acquisition of Barrett's metaplasia via a sequence of cardiac epithelium and eventual intestinal metaplasia.     

Laparoscopic management of severe reflux after sleeve gastrectomy using the LINX® system: Technique and one year follow up case report

IntroductionManagement of severe reflux after sleeve gastrectomy (SG) usually requires converting to Roux-en-y gastric bypass (RYGB). We present a case of managing this problem using the LINX^® system.Presentation of caseIn February 2015, we performed a laparoscopic placement of LINX^® system to treat severe reflux after sleeve gastrectomy on a 25-year-old female. The operative time was 47 min. There were no intra or postoperative complications. The hospital stay was one day. The postoperative UGI showed no reflux. Ten days after surgery her Quality of life score (QOL) changed from 64/75 to 7/75 after the LINX^® placement. One year later the patient continued to enjoy no reflux and stayed off medication.DiscussionReflux after sleeve gastrectomy is usually managed by conversion to RYGB by most surgeons. This case report opens the door for an alternative management of this problem while maintaining the original sleeve gastrectomy. This technique is reasonably easy to perform in comparison to the conversion to RYGB with less potential post-operative complications. A one year follow up showed good control of reflux without medication.ConclusionLaparoscopic placement of the LINX^® system to correct severe reflux after sleeve gastrectomy is a safe alternative procedure to conversion to a RYGB.     

Results of the Gil Vernet procedure in preventing contralateral reflux in unilateral ureteric reflux

OBJECTIVE: To evaluate whether contralateral meatal advancement based on the technique described by Gil Vernet decreases the risk of postoperative contralateral reflux, which may occur after a unilateral reimplantation. PATIENTS AND METHODS: From January 1986 to 1997, 321 reimplantations were performed for unilateral vesico-ureteric reflux (VUR) using the Cohen procedure. In cases where the contralateral meatus was symmetrical or had a pathological appearance, preventive contralateral surgery with meatal advancement was performed. RESULTS: Ureteric reimplantation was exclusively performed unilaterally in 254 patients and in 67 a contralateral meatal advancement was performed. There were 29 cases of contralateral reflux at the 4-month follow-up. In nine patients contralateral reimplantation was necessary for persistent symptomatic VUR, the reflux resolved spontaneously in 14 and a radiological examination was necessary in six. Reflux also appeared on the Gil Vernet side in only 6% of patients; there were no clinical symptoms and the outcome was favourable. CONCLUSION: The advancement of the meatus using the Gil Vernet procedure is simple, with no surgical complications. We suggest that this technique constitutes a useful surgical alternative in the prevention of contralateral reflux.     

Characterization of reflux events after fundoplication using combined impedance-pH recording

BACKGROUND: Laparoscopic fundoplication effectively controls symptoms of gastro-oesophageal reflux disease (GORD) and decreases acid reflux, but its impact on non-acid reflux is not known. The aim of the study was to characterize reflux events after fundoplication using oesophageal combined multichannel intraluminal impedance (MII)-pH monitoring, to demonstrate its efficacy on acid as well as non-acid reflux events. METHODS: Thirty-six patients in whom ambulatory MII-pH recording was performed after laparoscopic fundoplication were reviewed retrospectively. There were 23 symptomatic and 13 asymptomatic patients, whose results were compared with those of 72 healthy volunteers. RESULTS: Oesophageal acid exposure was low in all but one operated patient, and there was no difference between those with and without symptoms. The median number of reflux events over 24 h was lower after fundoplication (11 in operated patients compared with 44 in healthy volunteers; P < 0.001). Almost all reflux events were non-acid after surgery whereas acid reflux episodes were predominant in healthy volunteers. Proximal reflux events were less common in operated patients. Non-acid reflux events were significantly associated with symptoms after surgery in some patients. CONCLUSION: Fundoplication restores a competent barrier for all types of reflux. Reflux events are mostly non-acid after surgery, and such events may be positively correlated with symptoms.     

Quantitation of vesico-ureteral reflux by radionuclide cystography and urodynamics

A method is described for the quantitation of vesico-ureteral reflux by synchronous combined direct radionuclide cystography and urodynamics. Intravesical pressures and volumes are co-ordinated with volumes of reflux. Peak reflux volumes in 11 children diagnosed as having severe (grades 3–4) reflux on conventional contrast cystography ranged from 1 to 50 ml/kidney. A number of different patterns of reflux were observed. Reflux may occur progressively throughout low pressure filling or incrementally with unstable bladder contractions. Reflux during voiding may be maximal as detrusor pressure falls. The method requires wider application to explore the potential for a functional classification of the reflux problem.     

Outcome of surgical fundoplication for extra-oesophageal symptoms of reflux

Background  The role of surgery in the management of extra-oesophageal symptoms of gastro-oesophageal reflux (EOR) is unclear. In this retrospective study we studied patients who had surgical fundoplication for EOR symptoms from 1995 to 2005. We analysed outcome with respect to symptomatic improvement and patient satisfaction. Methods  From our database of 240 patients who had surgical fundoplication for gastro-oesophageal reflux disease, 51 patients who had predominantly EOR symptoms were identified. All the patients had objective evidence of reflux and had been offered surgery because of failure of medical therapy and/or of development of complications. Patients were asked to score their symptoms before and after surgery using the Reflux Symptom Index, and to record their use of medicine before and after operation, their experience with surgery and their overall quality of life using a written questionnaire. Results  Forty of the 51 patients were available for analysis. Common symptoms were cough and breathlessness (32/40), throat clearing/postnasal drip (31/40), sensation of lump in the throat (29/40), and voice problems (22/40). Of these forty patients, 34 (85%) had associated classical symptoms as well. Mean follow up at the time of questionnaire was 53.3 (6–120) months. The mean Reflux Symptom Index score improved from 22.80 (SD 10.80) to 11.83 (SD 9.91) (p < 0.0001, paired t-test). Six of the 39 responders (15.3%) said they would not have had the operation knowing what they know now and that problems related to the operation outweighed any benefits. These problems included gas bloating, inability to retch and dysphagia lasting up to one year after surgery. Twenty-five percent of the 40 patients described their overall quality of life as excellent, 32.5% as good, 32.5% as satisfactory and 10% as bad. Conclusion  Surgery can be an effective treatment in the majority of patients with extra-oesophageal symptoms of reflux.     

Enterogastric reflux and gastric clearance of refluxate in normal subjects and in patients with and without bile vomiting following peptic ulcer surgery.

A noninvasive scintigraphic technique was used to estimate enterogastric reflux and subsequent gastric evacuation of refluxate in 35 normal, healthy subjects and 55 patients previously treated by vagotomy or partial gastrectomy. Reflux was provoked by a milk drink and quantitated by counting 99Tcm-EHIDA activity within the gastric area during gamma camera imaging. Seven normal subjects (20%) showed reflux of 5-18% of initial activity (mean: 10%), with peak values occurring at 5-30 minutes (mean: 14 minutes) following the milk. Gastric evacuation of activity in these subjects was monoexponential (r = 0.993, T1/2 = 24.1 minutes). Reflux occurred more frequently than normal in patients with truncal vagotomy and drainage (22/28 patients) and partial gastrectomy (20/21 patients). All of 16 patients with Billroth II anastomoses exhibited reflux, which was excessive compared with refluxing normal subjects (mean: 25%; p less than 0.01) and occurred later into the study (mean: 34 minutes; p less than 0.01). Ten of 11 asymptomatic patients showed reflux of similar amounts of activity (mean: 21%) compared with 16 patients who complained of bile vomiting (mean: 22%). However, asymptomatic patients exhibited gastric evacuation of refluxate at a rate similar to that of refluxing normal subjects, while bile vomiters showed significant gastric retention of refluxate at 25-30 minutes following peak gastric activity (p less than 0.05). This result confirms that post-operative bile vomiting is essentially a problem of gastric emptying.