Bile reflux after Roux-en-Y gastric bypass: an unrecognized cause of postoperative pain

BackgroundTo determine, in a private practice, whether symptomatic bile reflux can occur after Roux-en-Y gastric bypass (RYGB) for morbid obesity and the outcome after laparoscopic alimentary (Roux) limb lengthening. Bile reflux as a cause of pain after laparoscopic RYGB has not been previously described. We report on a series of patients with chronic pain after RYGB as a result of bile reflux owing an abnormally short alimentary limb.MethodsA prospective database of patients who underwent revisional surgery to treat symptomatic bile reflux at our center was retrospectively reviewed and analyzed for the onset of symptoms, interval to revision, length of alimentary limb, and outcome after revision.ResultsA total of 16 patients were diagnosed with bile reflux and underwent revisional surgery. The onset of symptoms occurred at 58.3 ± 22.2 months after RYGB. All patients complained of pain, 13 (81.3%) had vomiting, and 7 (43.8%) had dysphagia. Endoscopy was performed in all patients and confirmed the presence of bile in all patients and detected marginal ulceration in 5 (31.3%) and gastritis in 8 (50.0%). At revisional surgery, the mean alimentary limb length was 37.7 ± 12.4 cm (range 20–62 cm). At a mean follow-up of 14.9 months after revision, all patients had reported resolution of their symptoms.ConclusionAlthough previously unreported after RYGB, bile reflux can be an important possible cause of chronic pain. Bile reflux, however, responds favorably to alimentary limb lengthening to 100 cm and was not been seen in patients with an alimentary limb length >62 cm.     

The effect of laser photocoagulation on the gastric mucosa and bleeding gastric lesions: an experimental study.

An argon ion laser beam was tested experimentally with regard to its histological effect on and penetration of the gastric mucosa of the rat and man and its ability to induce haemostasis in traumatically produced gastric lesions and transected small blood vessels. Localized laser photocoagulation for periods of up to 5 minutes at 1 watt produced a coagulative necrosis of the gastric mucosa and half of the muscularis propria, but transmural necrosis required prolonged exposure. Laser phototherapy markedly reduced the bleeding time in experimental ulcers and small blood vessels, provided the superficial blood could be adequately dispersed from the direct beam of the laser.     

Impaired gastric motility in the gastroesophageal reflux rat model: an in vitro study

PURPOSE: The present study investigated the effects of acid and mixed reflux on the responsiveness of gastric smooth muscle in the gastroesophageal reflux (GER) rat model. MATERIAL AND METHODS: Three groups of rat were studied encompassing acid reflux, mixed reflux and sham operation. Acid reflux was induced by pyloric ligation (AR group) and mixed reflux was induced by jejunal ligation 1 cm distal to Treitz ligament (MR group). Similar surgical manipulations were carried out in the sham operated rats (SO group). Carbachol-, serotonin-, KCl-induced contractile response and nicotine-, sodium nitroprusside-, papaverine-induced relaxant response in isolated gastric fundus smooth muscle strips were determined using in vitro muscle technique 24 h after surgery. RESULTS: Isolated gastric fundus smooth muscle contractility to serotonin, carbachol or KCl was significantly reduced in the AR and MR groups with decreased Emax and pD(2) values compared with the SO group. Relaxant responses to nicotine was significantly increased in the AR and MR groups with increased Emax and pD(2) values compared with the SO group. Sodium nitroprusside and papaverine-induced-relaxant responses were similar in all of the groups and there was no change in agonist potency. CONCLUSION: The present study indicates that decreased contractile and increased nicotine-induced relaxant response of the gastric smooth muscle in the surgically created GER model. These findings suggest that impaired gastric smooth muscle reactivity at least in part may play a role in gastric dysmotility in GER.     

Oxidative damage in an experimentally induced gastric and gastroduodenal reflux model

The exact pathophysiologic mechanisms of esophageal cell damage and carcinogenesis by gastroesophageal reflux are not clearly understood. The aim of this study was to evaluate the damage to the esophageal epithelium that occurs after acid reflex and mixed acid and bile reflux by assessing histopathology, reactive oxygen species, and DNA damage. Eighty 10-week-old male Sprague-Dawley rats were divided into two groups, an acid reflux group and a mixed (acid/bile) reflux group. Acid reflux was achieved by esophagogastroplasty in which mixed reflux was encouraged via esophagoduodenal anastomosis. Each group contained a control subgroup that underwent sham laparotomy alone. The rats were killed 3, 6, 9, and 12 months after surgery. Malondialdehyde, protein carbonyl content, and DNA damage were determined in lymphocytes. Histopathologic analysis was performed according to the histologic activity index. Inflammation, ulcer, and regeneration in both reflux groups were significantly increased in the esophagus at 3, 6, 9, and 12 months compared with the control group. Mucosal damage was greater in the mixed reflux group compared with the gastric reflux group. Malondialdehyde and carbonyl content in the serum, and DNA damage in lymphocytes, were significantly increased in both reflux groups. At 9 and 12 months, oxidative damage was increased in the mixed reflux group compared with the acid reflux group. Oxygen-derived free radicals seem to be one of the important mediators in the evaluation and generation of reflux esophagitis. The impact of oxygen free radicals, as demonstrated in this study, can be evaluated by assessing the damage that they incur to lipid membranes, serum proteins, and circulating lymphocyte DNA. Serum malondialdehyde and carbonyl content as well as lymphocyte DNA damage were significantly increased in the setting of acid and mixed acid/bile reflux in these rodent models. Further, these serum and lymphocytic changes were associated with esophageal ulceration, inflammation, and regeneration. Evaluation of such markers as serum malondialdehyde and carbonyl content as well as evaluation of lymphocyte DNA might prove to be useful investigations in patients with precancerous and cancerous conditions in addition to conventional methods of diagnosis. Further studies, both animal and human are warranted.     

The importance of gastric emptying in reflux esophagitis: an experimental research on pigs

A study was conducted on pigs to evaluate the importance of gastric emptying rate in reflux esophagitis development. Gastric emptying was previously measured in 25 pigs. Then, the following operative procedures were carried out: Heller's cardiomyotomy, common bile duct ligature, cholecysto-gastric anastomosis, and extramucosal duodenal myotomy on 10 animals (group A); the same procedures except extramucosal duodenal myotomy on another 10 animals (group B); common bile duct ligature and cholecysto-gastric anastomosis on the last 5 animals (group C). Six months later, gastric emptying was measured again; whereas in group A a significant shortening of gastric emptying was found, the other 2 groups remained unchanged. Then, all the animals were sacrificed and the lower third of the esophagus was removed for histologic examination. In all the pigs undergoing cardiomyotomy (groups A and B) appearance of esophagitis was found. No signs of esophagitis were found in group C. The conclusions reached are cardiomyotomy is in all cases responsible for reflux esophagitis development; extramucosal duodenal myotomy is capable of shortening gastric emptying, but this does not affect reflux esophagitis development.     

胃手术后的胆汁反流与残胃粘膜病变的研究

为了解胃手术方式对胆汁反流及残胃粘膜的影响，作者观察了６５例残胃患者［毕氏１式１７例，毕氏Ⅱ式２０例，选择性迷走神经切断加胃窦部切除１６例，高选择性迷走神经切断（ＨＳＶ）１２例］及１５例溃疡病患者胃液胆酸浓度、ｐＨ及胃内细菌变化，并对残胃粘膜进行组织学检查。发现各种胃手术组胃液胆酸浓度均高于溃疡病组（对照组），其中Ｂ－Ⅱ组胃液胆酸浓度、ｐＨ及菌量升高最明显，而ＨＳＶ组则显著低于其他各手术组（Ｐ＜０．０１），残胃粘膜组织学异常改变的程度亦显著低于其他手术组（Ｐ＜０．０５，Ｐ＜０．０１）。结果表明：胃手术方式对胆汁反流可产生重要影响，残胃粘膜组织学异常改变与胃液胆酸浓度、ｐＨ的升高以及胃内菌量的增多有关。作者认为，选用保留幽门及生理功能的术式，能减少肠胃反流的发生，对预防残胃粘膜出现癌前病变及癌变有重要意义。     

Bile reflux and degree of gastritis in patients with gastric ulcer: before and after operation

The incidence and degree of bile reflux and gastritis has been measured in normal subjects and in patients with gastric ulcer before operation and after treatment by highly selective vagotomy with ulcer excision, Billroth 1 partial gastrectomy, and truncal vagotomy and drainage. Before operation patients had significantly higher (P less than 0.001) bile acid concentrations in the stomach than normal subjects. Treatment by highly selective vagotomy resulted in significantly lower bile acid concentrations than those before operation and those found after Billroth 1 partial gastrectomy. Antral and body gastritis was significantly less in normal subjects than in the preoperative and all postoperative groups. There was no significant difference in antral or body gastritis between the preoperative gastric ulcer patients and the patients after any of the surgical procedures despite the significant differences in bile acids. Though highly selective vagotomy in the treatment of gastric ulcer results in a reduction in duodenogastric reflux of bile there is no improvement in the gastritis that is present.     

Bile reflux in the constellation of gastroesophageal reflux disease

Gastric acid and bile acids are a particularly noxious combination when they interact with the mucosa of the upper intestinal tract. There is a critical pH range, between 3 and 6, in which bile acids exist in their soluble, un-ionized form, can penetrate cell membranes, and accumulate within mucosal cells. At a lower pH, bile acids are precipitated, and at a higher pH, bile acids exist in their noninjurious ionized form. Experimental, clinical, and immunohistochemical studies show that acid and bile reflux are increased in patients who suffer from GERD, are the key factor in the pathogenesis of Barrett's esophagus, and possibly are related to the development of esophageal adenocarcinoma.     

Bile aspiration: an experimental study in rabbits.

It has been shown that bile injected intratracheally in rabbits produces severe pulmonary edema, atelectasis, and focal hemorrhages. The authors investigated the effect of a number of solutions, including physiological concentration of bile, hydrochloric acid pH 1.0, bile salt diluted to 1%, and bile at 100% concentrations. Whenever the bile concentration exceeded 3%, none of the test animals survived. It is not possible to apply directly the results of an experimental animal study to humans. However, the severity of the pulmonary changes produced force the conclusion that bile is a potentially dangerous aspirate in humans.     

Effect of different fractions of alkaline reflux on the gastric stump and the esophagus: an experimental research on pigs

An experimental study was conducted to evaluate the effect of different fractions (bile and pancreaticoduodenal secretions) on the gastric stump and esophageal mucosa. Twenty pigs underwent partial gastrectomy (two-third distal) and cardiomyotomy in order to induce free gastroesophageal reflux. Then, reconstruction of the alimentary tract was performed to assess the effects of different types of alkaline reflux. A combined (biliary and pancreaticoduodenal) reflux, an isolated biliary reflux, and an isolated pancreaticoduodenal reflux were induced, respectively, in three different groups of five pigs each. In a control group a Roux-en-Y gastrojejunostomy was performed. Nine months later, the animals were sacrificed, the esophagus and the gastric stump were removed for histologic examination. The results show that the most severe histopathological lesions are determined by combined alkaline reflux; on the other hand, separated fractions can induce only mild changes on the gastric stump and esophageal mucosa.     

Bile acids, the "barrier," and reflux-related clinical disorders of the gastric mucosa.

The present communication represents an effort to provide an overview of the available evidence (and speculation) which suggests that an interrelationship exists between bile acids, the so-called "gastric mucosal barrier," and certain clinical diseases of the gastric mucosa in which reflux of upper intestinal content appears to be a pathophysiologic common denominator.     

Vertical gastric plication: an operation for gastro-oesophageal reflux

An operation has been devised to prevent gastro-oesophageal reflux in which a vertical partition is made parallel to the proximal gastric lesser curvature. The technique, which can be simply, safely and rapidly performed, prevents reflux in the following ways: 1. Increasing the effective length of the 'intra-abdominal oesophagus'; 2. Increasing the crural sling and mucosal flap valve effect; 3. Sharpening the angle of entry into the gastric reservoir; 4. Creating a flutter valve and markedly reducing the gastric cross-sectional area along which reflux can occur. The stomach is neither opened nor divided. The efficacy of the operation was investigated in six dogs which had their lower oesophageal sphincter excised by circular myomectomy before vertical gastric plication. Pre- and postoperative manometric and oesophageal pH studies were performed. Vertical gastric plication prevented the oesophagitis produced by circular myomectomy alone. The operation has been performed in 26 patients over a 2-year period. Assessment has been by clinical methods, ambulatory 24 h pH studies and endoscopy. Twenty-one patients were classified in Visick grades I and II and ambulatory pH recordings showed a marked reduction in reflux in 13 of 14 patients. The operation is technically simple, quick and safe to perform, being accurately and scientifically reproducible.