Role of vagal dysfunction in motility and transit disorders of jejunal roux limb after roux-en-Y gastrojejunostomy

After a Roux-en-Y gastrojejunostomy patients frequently complain about abdominal pain, fullness, nausea and vomiting, ie, the Roux-en-Y syndrome. Stasis in the Roux limb due to disordered motility is known to be a cause of these complaints. The aim of the present study was to determine whether vagal denervation contributes to the development of motility disturbances and stasis in the Roux limb. Forty-seven patients with a Roux-en-Y gastrojejunostomy after partial gastrectomy were studied. A truncal vagotomy had been performed in 26 of these 47 patients. Transit through the Roux limb was evaluated by radionuclide studies, motility in the Roux limb was studied by manometry, and vagal function was tested by measuring the pancreatic polypeptide response to an insulin-induced hypoglycemia (PP test). On the basis of the PP test patients were classified as having (1) normal, (2) moderately impaired, and (3) severely impaired vagal function. The PP test showed that two of the 26 patients subjected to vagotomy had a moderately impaired vagal function, the other 24 all had a severely impaired vagal function. In the patients not subjected to a vagotomy, vagal function was disturbed in 11 of the 21 patients. Motility disturbances were not observed more frequently in patients with either moderately or severely impaired vagal function than in patients with normal vagal function. Stasis in the Roux limb was seen even more frequently in patients with a normal vagal function than in patients with a severely impaired vagal function. The results of this study indicate that vagal denervation of the Roux limb is not the cause of motility and transit disorders in the Roux limb.This work was supported by the Jan Kornelis de Cock-Stichting.     

Myoelectric activity and motility of the Roux limb after cut or uncut Roux-en-Y gastrojejunostomy

INTRODUCTIONRoux-en-Y anastomosis is a commonly used surgical procedure in gastroenterological surgery; however, more than one third of the patients who experience such an operation suffer Roux stasis syndrome[1,2]. It has been proposed that the occurrenc…     

Effect of jejunal infusion of bile acids on small bowel transit and fasting jejunal motility in man.

The effect of jejunal infusion of glycochenodeoxycholic acid and glycocholic acid on small bowel transit time, fasting jejunal motility and serum bile acid concentrations was investigated in groups of five to six healthy subjects. Glycochenodeoxycholic acid at a concentration of 15 mmol/l (total amount: 5 mmol) and glycocholic acid 15 mmol/l (total amount: 5 mmol), both with lecithin 2.5 mmol/l, delayed (p less than 0.02) small bowel transit when compared with a bile acid free infusion [158.3 (12.5) min v 111.7 (17.6) min and 103.3 (21.8) min v 70.0 (14.9) min], inhibited (p less than 0.01 and p less than 0.05 respectively) the percentage duration of pressure activity of phase 2 [13.1 (1.8)% v 28.1 (3.4)% and 29.2 (5.5)% v 34.9 (3.9)%], but did not change duration of migrating motor complex, or of its phases. Glycochenodeoxycholic acid 10 mmol/l (total amount: 3.3 mmol), either with or without lecithin, did not delay small bowel transit significantly [145.0 (13.2) min v 115.0 (19.5) and 90.0 (11.7) min v 84.0 (8.3)]. When bile acids were infused, serum bile acid curves were similar to those obtained after a liquid meal and the peak serum bile acid concentration occurred 33.7 (6.6) min before (p less than 0.001) completion of small bowel transit. These observations suggest a role for endogenous bile acids in the regulation of small gut motility.     

Postprandial patterns of canine jejunal motility and transit of luminal content

The effects of different nutrient meals and a noncaloric viscous cellulose meal (control) on the motor activity of the canine jejunum were studied. Contraction patterns were detected through six closely spaced, strain-gauge transducers and were analyzed by a computer. Luminal transit was assessed videofluoroscopically. Control meals moved rapidly (1.9 cm/s) along the jejunum. This was achieved by contractions that occurred at a high frequency (12.8 cpm) and propagated over long distances (9.9 cm). In contrast, the transit rates of the nutrient meals were considerably slower (0.5-1.0 cm/s), the frequency of contractions (5.0-8.9 cpm) and the length of spread of contraction waves (2.6-4.8 cm) were decreased, and the incidence of stationary contractions occurring individually or in clusters was increased. A mathematical model incorporating frequency of contractions and the length of their propagation was used to predict the transit of jejunal contents. The results of correlation tests and of the mathematical model revealed that the length of spread of contraction waves was the most important factor that influenced transit.     

Migrating myoelectric complex and jejunal slow-wave propagation after Roux gastrectomy in dogs

Roux-en-Y gastrectomy is associated with a high incidence of symptoms of gastric stasis. Retrograde propagation of jejunal electrical slow waves and spike bursts has been implicated in the Roux Y stasis syndrome. Since the fasted state may persist after feeding, this study examined the extent of retrograde slow-wave propagation in the fasted state, particularly during aboral migration of phase III. Six dogs underwent Roux gastrectomy and placement of bipolar electrodes along the Roux limb. Four normal dogs with electrodes acted as controls. Thirty-five migrating myoelectric complexes were recorded in Roux dogs and 13 in controls. In Roux dogs, the incidences of retrograde propagation of slow waves during the migrating myoelectric complex were phase I 56±13%, phase II 60±12% and phase III 58±14% (not significant). For controls, the incidences were 0%, 0%, and 1%, respectively (P<0.006 versus Roux dogs). In the Roux limb, retrograde propagation of slow waves, and hence spike bursts, occurs even during aboral migration of phase III. This abnormality may contribute to the Roux Y stasis syndrome.An abstract of this work has previously been presented at American Federation for Clinical Research Mid Western Section, October 31, 1990, at Chicago.Supported in part by a grant from the Veterans Administration and from the Department of Surgery, SUNY Health Science Center at Syracuse, Syracuse, New York.     

Effects of nutrients on gastrointestinal motility and gastric emptying after distal gastrectomy with Roux-Y gastrojejunostomy in dogs

The aim of the study was to clarify whether nutrients are still capable of slowing gastric emptying following Roux-Y gastrectomy, as in normal dogs. Gastrointestinal motility and gastric emptying of acaloric and nutritive meals with different viscosities were measured in normal dogs and after a two-thirds Roux-Y gastrectomy. In gastrectomized dogs low-viscosity nutritive meals emptied unduly rapidly in an initial phase, although the frequency and spread of contractions, ie, the propulsive activity of the jejunal Roux limb were diminished. A slow emptying rate during the following period was due to a long-lasting inhibition of gastric and jejunal motility. Medium-viscosity nutritive meals emptied in gastrectomized dogs as slowly as in normal animals, but this effect was primarily caused by the meal viscosity and only secondarily by the nutrients. It is concluded that following Roux-Y gastrectomy a regulation of gastric emptying is preserved; however, the onset of an effective control is delayed, resulting in a rapid initial emptying of low-viscosity meals.Studies were supported by the Deutsche Forschungsgemeinschaft grant Eh 64/3-1.     

Effect of dietary fiber on gastrointestinal motility and jejunal transit time in dogs

Strain gauge recordings of the motility of the antrum, duodenum, and jejunum were made in 10 dogs receiving a daily meal of canned food. Addition of 30 g of either wheat bran, cellulose, or guar gum increased the duration of the postprandial pattern of motility by 41-54% in the duodenum. Only cellulose and gum caused increases in the duration of the postprandial pattern of motility in the jejunum. The normal postprandial pattern of duodenojejunal contractions consisted of bursts of 4-10 rhythmic contractions. When bran or cellulose were added, the bursts were prolonged (12-15 contractions per burst) with 4-15 min intervals between bursts. In contrast, when gum was added, contractions occurred continuously at a rate of 7-8/min, but their amplitude was one-half that seen with the other fibers. The increased number of low amplitude contractions when gum was added caused the postprandial motility index to double. There was no change in the motility index when cellulose was added. Guar gum also increased the frequency of antral contractions by 129%, while bran and cellulose had no effect. Jejunal transit time and flow of digesta were measured in four dogs 2 h after the meal. Addition of bran or gum increased the transit time by 28% and 51%, respectively, but cellulose caused a 900% increase in transit time associated with a 50% reduction in the flow of digesta. Addition of different fibers causes different alterations in postprandial motility. Jejunal transit of digesta appears unrelated to the pattern of contractions.     

5-Hydroxytryptophan and cisapride stimulate propulsive jejunal motility and transit of chyme in dogs

We investigated in conscious dogs the effects of intravenously administered 5-hydroxytryptophan (5-HTP) and cisapride on the postprandial jejunal mechanical activity by means of six closely spaced extraluminal strain gauge transducers. Drugs were given after administration of a nutrient meal. 5-HTP was given additionally after the administration of a noncaloric cellulose meal. Computer assistance was used to determine the temporal and spatial relationship of contractions and thereby to evaluate the length of spread of contractile waves. Both substances increased the propulsive activity, the contractile force and the motility index and fastened the transit rate of digesta. 5-HTP exhibited the most potent effect when given after administration of the nutrient meal.     

Enterogastric reflux after gastric surgery. A comparison between gastroduodenostomy and Roux diversion

Reflux of upper intestinal content to the gastric remnant after gastric resection is common and may cause damage to the gastric mucosa, resulting in gastritis, gastric ulcer, and possibly dysplasia. Different surgical procedures have been proposed to prevent reflux, among them Roux-en-Y diversion. In this study we have compared antrectomy followed by gastroduodenostomy (BI) with antrectomy followed by Roux-en-Y anastomosis with regard to enterogastric reflux. Reflux was recorded by cholescintigraphy, using a new method for quantification. In all patients biopsy specimens were taken for histopathological evaluation at gastroscopy. Twenty-seven patients were studied, 11 with gastroduodenostomy and 16 with Roux-en-Y diversion. All patients in the gastroduodenostomy group had reflux, compared with four in the Roux group (p less than 0.001). Under the light microscope all patients in the BI group showed a moderate to severe degree of inflammation compared with only seven in the Roux-en-Y group (p = 0.028). Our results show that Roux-en-Y drainage effectively diminishes reflux and may be an explanation for the lower extent of mucosal damage in these patients.     

Esophageal motility disorders after gastric banding

The long-term effects of gastric banding on esophageal function are not well described. This report describes a 28-year-old woman who developed signs and symptoms of abnormal esophageal motility and lower esophageal sphincter hypotension after gastric banding for morbid obesity. The current literature addressing the effects of gastric banding on esophageal function in light of this case report is discussed.     

Changes in the gastric mucosa after iso- and anisoperistaltic gastrojejunostomy in rats]

Gastrojejunostomies are frequently associated to postoperative manifestations, provoked by biliopancreatic reflux to the stomach. Not only the symptoms can be severe, but also regenerative and reactional transformations of the gastric epithelium, dysplastic alterations and perianastomotic ulcers may be formed. Changes of gastric mucosa and their relation to surgical iso and anisoperistaltic gastrojejunal anastomosis were carried out. Gastrojejunostomies non associated with gastrectomy were performed in two groups (n = 7) of Holtzman rats. In the 30th postoperative day, the stomach and the jejunum close to the anastomosis were removed for pathohistological study. The group with anisoperistaltic anastomosis had a greater extension of histological alterations compatible with the histological picture of reflux gastropathy than the isoperistaltic group (P < 0.05). Three anastomotic ulcers were identified in the anisoperistaltic group and only one in the isoperistaltic, but these results were not statistically significant. Among the gastric surgeries, the gastrojejunostomies are the ones which cause greater biliopancreatic reflux. This reflux may induce changes in the gastric mucosa close to the anastomosis and even lead to cancer. According to other papers, the amount of reflux to the stomach can be directly related to the histological alterations on its mucosa. In conclusion, the anisoperistaltic gastrojejunostomy causes more changes in the gastric mucosa than the isoperistaltic, in this experimental model.     

Changes in motility after jejunal and ileal resection: electromyographic study in rats

The aim of this work was to compare the effects of massive jejunal and ileal resections on intestinal motility using an electromyographic technique. Male Wistar rats were used: in the first group a massive jejunal resection was performed, conserving a 7-cm segment after the ligament of Treitz; the rats of the second group underwent an ileal resection, preserving 7 cm of the terminal ileum. Motility was studied at the 10th and 30th postoperative days by means of electrodes implanted throughout the remaining bowel and was expressed by the pattern of recurrence of the migrating myoelectric complex (MMC). In a fasting state, in both transected and resected animals at the 10th postoperative day, the gradient in the duration of MMC along the intestine still existed. However, on the 30th postoperative day, in animals with jejunal resection only, there was an adaptive process: the duration of MMC in the remaining jejunum was significantly increased to the duration in the ileum. After the end of the postprandial inhibition of the appearance of the MMC, on the 10th postoperative day there was a significant decrease in the duration of MMC in the ileum in both types of resection, compared to the controls. However, on the 30th postoperative day, the duration of MMC returned to its control value. In conclusion, jejunal resection seems to induce more important adaptive processes in intestinal motility than does ileal resection. The different results are discussed.     

The ileal brake--inhibition of jejunal motility after ileal fat perfusion in man

The possibility that malabsorbed fat passing through the human ileum exerts an inhibitory feedback control on jejunal motility has been investigated in 24 normal subjects by perfusing the ileum with a fat containing solution designed to produce ileal luminal fat concentrations similar to those in steatorrhoea (30-40 mg/ml). Mean transit times through a 30 cm saline perfused jejunal segment were measured by a dye dilution technique. Thirty minutes after ileal fat perfusion, mean transit times rose markedly to 18.9 +/- 2.5 minutes from a control value of 7.5 +/- 0.9 minutes (n = 5; p less than 0.05). This was associated with an increase in volume of the perfused segment which rose to 175.1 +/- 22.9 ml (control 97.6 +/- 10.3 ml, n = 5; p less than 0.05). Transit times and segmental volumes had returned towards basal values 90 minutes after completing the fat perfusion. Further studies showed that ileal fat perfusion produced a pronounced inhibition of jejunal pressure wave activity, percentage duration of activity falling from a control level of 40.3 +/- 5.0% to 14.9 +/- 2.8% in the hour after ileal perfusion (p less than 0.01). Ileal fat perfusion was associated with marked rises in plasma enteroglucagon and neurotensin, the peak values (218 +/- 37 and 68 +/- 13.1 pmol/l) being comparable with those observed postprandially in coeliac disease. These observations show the existence in man of an inhibitory intestinal control mechanism, whereby ileal fat perfusion inhibits jejunal motility and delays caudal transit of jejunal contents.     

Small intestinal motility and transit in disease

Disorders of small intestinal motility and transit are becoming increasingly recognized partly as a result of a greater awareness of their existence and partly because suitable diagnostic methods are more widely available. Usually, the neuropathic and myopathic forms can be separated, and gut disease secondary to a generalized neuromuscular disorder can be identified by the clinician. The availability of better non-invasive methods for the diagnosis of disorders of motility and transit would greatly facilitate their management. Treatment must include the restoration and maintenance of nutrition, attempts to improve intestinal motor function and resection of any segments of localized disease. Regrettably, all such measures are ineffective in the severest cases. In the future, a greater understanding of the enteric neural control of the smooth muscle and an ability to manipulate it with novel, specific drugs or peptidergic receptor agonists and antagonists, or electrical pacing, may lead to more effective therapies.     

Intestino-gastric reflux in dogs: spontaneous, after gastrojejunostomy, and after Roux-en-Y gastrojejunostomy with various lengths of the defunctioning loop.

Intestino-gastric reflux was measured in dogs with duodenostomy and gastrostomy by using chromium-51 injected through the duodenostomy. No transpyloric reflux was demonstrated. When gastrojejunostomy was performed, a large reflux was demonstrated. After conversion of the gastrojejunostomy into a Roux-en-Y gastrojejunostomy with various lengths of the defunctioning loop, a decrease in reflux was demonstrated, significantly correlated to the length of the loop. The calculated length corresponding to no reflux was found to be 49 cm.     

Gastrointestinal motility and gastric emptying after Billroth II gastrectomy in dogs

This study was undertaken to compare the effects of subtotal Billroth II gastrectomy on gastric emptying and gastrointestinal motility with previously published results in intact dogs and in dogs with subtotal Roux-Y gastrectomy. Extraluminal strain gauge transducers were used to study gastrointestinal motility after Billroth II gastrectomy in four conscious dogs. Gastric emptying was measured radiographically. In Billroth II dogs gastric emptying of low-viscosity meals was biphasic with an initial rapid emptying. The addition of nutrients to low-viscosity meals delayed gastric emptying accompanied with reduction in gastric and jejunal motility. Similar to that in Roux-Y dogs, gastric emptying of noncaloric medium-viscosity meals was delayed because of segmenting motor patterns of the jejunal loops, in contrast to the propulsive jejunal motor pattern in intact dogs. Nutrients added to medium-viscosity meals did not change the jejunal motor pattern; gastric emptying was delayed compared with intact dogs. Results show that meal viscosity and jejunal motor pattern influence gastric emptying after Billroth II gastrectomy.This study was supported by the Deutsche Forschungsgemeinschaft, grant Eh 64/3-2.     

Colonic motility and transit in health and ulcerative colitis

Preprandial and postprandial colonic motility and transit (scintigraphy), with respect to the splenic flexure, were studied in 10 patients with ulcerative colitis and in 9 healthy subjects. The healthy subjects had a postprandial increase in intraluminal pressure that was significantly (P less than 0.03) greater in the descending colon than in other regions of the colon. In ulcerative colitis, the pressure was decreased in all regions compared with healthy subjects, with no significant pressure gradient among different regions. In normal subjects, transit was quiescent during fasting; eating stimulated both antegrade and retrograde transit. In ulcerative colitis, transit was variable before as well as after the meal. Both healthy subjects and patients with ulcerative colitis had more rapid emptying from the splenic flexure into the sigmoid than into the transverse colon. More frequent, low-amplitude, postprandial propagating contractions occurred in ulcerative colitis (P less than 0.05) than in healthy subjects. Propagating contractions were always antegrade and caused a rapid movement of the tracer into the sigmoid. In conclusion, ulcerative colitis is characterized by (a) decreased contractility, (b) increased low-amplitude propagating contractions, and (c) variable transit. These disturbances may accentuate the diarrhea in ulcerative colitis.