θ����������θ������Roux-en-Y�Ǻ����Ĺ۲�

目的 进一步评价短袢Ｒｏｕｘ－ｅｎ－Ｙ吻合术的抗返流效果,探讨Ｒｏｕｘ淤积综合征的防治方法。方法 随访１９８９年７月至１９９７年６月完成的胃癌切除胃空肠短袢Ｒｏｕｘ－ｅｎ－ｙ吻合术１５１例,通过症状调查。消化道钡餐、罗镜并活检、Ｂ超、ＣＴ检查确定短袢Ｒｏｕｘ－ｅｎ－Ｙ吻合术的抗返流效果及Ｒｏｕｘ淤积综合征的发病率。结果 １４３例（９５％）获随访结果,未发现有明显症状的返流性胃炎,无倾倒综合征和Ｒｏｕｘ淤积综合征。结论 扩大胃的切除范围,同时缩短Ｒｏｕｘ袢的长度可防治Ｒｏｕｘ淤积综合征,对空肠吻合口进行抗返流加工,短袢Ｒｏｕｘ－ｅｎ－Ｙ吻合抗返流效果满意。     

Alteration of the Roux Stasis syndrome by an isolated Roux limb: correlation of slow waves and clinical course.

The Roux-Y stasis syndrome after antrectomy and vagotomy has been well described. Delayed gastric emptying after vagotomy and antrectomy with Roux-Y anastomosis has been attributed to loss of the duodenal pacemaker and to the effects of retrograde slow-wave activity arising from distal small bowel pacemakers. Small bowel contractions are closely coupled with slow-wave activity. Transection and anastomosis of the small bowel distal to the jejuno-jejunostomy has been shown to electrically isolate the Roux limb from distal small bowel pacemakers. Using a canine model, a vagotomy and hemigastrectomy with Roux-Y were performed in five dogs using the standard operation (control); in four dogs (experimental), an additional transection and reanastomosis of the jejunum 25 cm distal to the Y anastomosis of the Roux limb was performed. All specimens had six electrodes implanted along the Roux limb at 5-cm intervals, used for weekly analysis of the jejunal slow-wave activity. The isolated loop cohort had reduced incidence of retrograde slow waves, reduced emesis, improved gastric emptying by upper gastrointestinal series, and reduced gastric pouch size at autopsy. Adding a distal transection and anastomosis, thus creating an isolated Roux-Y segment, may improve the course of the Roux stasis syndrome.     

胃癌切除胃肠袢Roux—en—Y瓣式吻合术183例临床观察

目的 胃肠短袢Roux-en-Y瓣式吻合术的抗反流效果,探讨Roux淤积综合征的防治方法。方法 随访986年10月至1997年6月胃癌切除胃空肠短袢Roux-en-Y瓣式吻合术183例,通过症状调查,按改良Visick标准评级,有症状借助消化道钡餐、胃镜并活检、B超、CT检查排除吻合口狭窄、残胃溃疡和肿瘤复发后,确定短袢Roux-en-Y瓣式吻合术的抗反流效果及Roux淤积综合征的发病率。结果 172例（94．0％）获随访结果,5例不满2年因肿瘤复发死亡,3例术后胃瘫,2例因粘连性肠梗阻接受粘连松解术,2例因腹膜广泛种植转移癌致肠梗阻。可进行改良Visick评级165例,Ⅲ、Ⅳ级12例皆为肿瘤复发,未发现有明显症状的反流性胃炎,无倾倒综合症和Roux淤积综合征。结论 扩大胃的切除范围,同时缩短Roux袢的长度,可防治Roux淤积综合征,对空肠空肠吻合口进行抗反渡加工,短袢Roux-en-Y吻合抗反流效果满意。     

Teflon buttress inhibits recanalization of uncut stapled bowel

The uncut Roux limb operation is designed to have the benefits of a Roux limb but still have electrical continuity from proximal to distal bowel, thus eliminating the risk of Roux stasis syndrome. The main complication has been recanalization of the uncut staple line leading to bile reflux. This study aims to employ a new technique, which will not allow recanalization of an uncut staple line but will not interfere with normal bowel myoelectric activity. Fourteen mongrel dogs, 25 to 35 kg, underwent a midline laparotomy under general anesthesia. An uncut staple line was placed 25 cm from the ligament of Treitz. In seven animals an uncut staple line alone was placed, and in the other seven animals the bowel was stapled between a sandwich of Teflon reinforcing strips such that the staples were held on both sides of the bowel by the Teflon. A jejunojejunostomy was placed 6 cm proximal to the staple line. Insulated bipolar electrical leads were placed around the staple line. After the electrical leads were monitored 2 days to 3 months postoperatively for bowel myoelectric activity, the animals were killed and the operative sites inspected. No animal suffered morbidity or mortality from the procedure. All seven unreinforced staple lines recanalized and all seven reinforced staple lines remained competent. The duodenal pacemaker potentials were transmitted through the staple line in five animals (3 controls and 2 with Teflon reinforcement) within 1 week postoperatively. The uncut staple line does not reliably transmit the duodenal pacemaker potentials. The staple line does not recanalize when it is reinforced with a permanent material, increasing the utility of the “uncut” Roux limb operation. Supported by Ethicon Endosurgery and W.L. Gore & Associates, Inc. Presented at the Annual Meeting of The Society for Surgery of the Alimentary Tract and the SSAT/Ross Conference, May 1997, Washington, D.C.     

The Roux stasis syndrome. Treatment by pacing and prevention by use of an 'uncut' Roux limb.

Ectopic pacemakers in the Roux limb are associated with delayed gastric emptying after Roux gastrectomy. The aim herein was to suppress the ectopic pacemakers by electrical pacing or to prevent them by maintaining enteric myoneural continuity with an "uncut" Roux limb, and so improve the delayed emptying. Among eight dogs with truncal vagotomy and Roux hemigastrectomy, four dogs had a pacing electrode applied to the proximal end of the Roux limb. The other four dogs had a gastrojejunostomy to an uncut Roux limb. In them, the afferent jejunal limb was occluded by staples but not divided, and a diverting jejuno-jejunostomy was performed. Roux pacing and the uncut Roux operation abolished ectopic pacemakers in the Roux limb and speeded the slow gastric emptying present in unpaced control tests. At autopsy, however, dehiscences were found in the staple line in the dogs with the uncut Roux procedures. In conclusion, electrical pacing and the uncut Roux limb show promise as techniques to prevent ectopic jejunal pacemakers and gastric stasis after Roux gastrectomy. Both must be improved before they can be used in patients.     

The Roux operation for postgastrectomy syndromes

The aim of this paper is to describe the technique, indications, and results of the Roux operation as used in the treatment of postgastrectomy syndromes. A Roux gastrojejunostomy with a 40-cm Roux limb is the procedure of choice for alkaline reflux gastritis, because it virtually eliminates reflux of bile and pancreatic juice into the stomach. The slow transit through a Roux limb can also be used to good advantage to slow gastric emptying in patients with dumping. Patients with delayed gastric emptying respond to the combination of near-total gastric resection, which removes the atonic gastric remnant and speeds emptying, and Roux-Y gastrojejunostomy, which prevents reflux esophagitis and provides a reservoir for ingesta in the upper gut. After all Roux operations, however, the Roux limb may slow emptying so much that pain, fullness, nausea, and food vomiting result, the so-called Roux stasis syndrome. Prevention of the Roux stasis syndrome with an "uncut" Roux limb and the treatment of the syndrome by using electrical pacing to suppress the ectopic pacemakers that emerge in the limb offer possible new solutions to this vexing problem.     

Ectopic jejunal pacemakers and gastric emptying after Roux gastrectomy: effect of intestinal pacing

The aims of this study were to determine whether ectopic pacemakers are present after meals in the Roux limbs of dogs after vagotomy and Roux gastrectomy, whether these pacemakers slow gastric emptying of liquids or solids, and whether abolishing the pacemakers with electric pacing might speed any slow emptying that occurs. In six dogs that underwent vagotomy and Roux gastrectomy and in four dogs that underwent vagotomy and Billroth gastrectomy (controls), myoelectric activity of the Roux limb or duodenum was measured during gastric emptying of a 500 kcal mixed meal of 99mTc-labeled cooked egg and 111In-labeled milk. Roux dogs were tested with and without pacing of the Roux limb. Roux dogs showed ectopic pacemaker in the Roux limb that drove the pacesetter potentials of the limb in a reverse, or orad, direction during 57% of the postprandial recordings. Billroth dogs had no ectopic pacemakers (p less than 0.05). Liquids emptied more slowly in Roux dogs (half-life (t1/2) = 121 +/- 15 minutes) than in Billroth dogs (t1/2 = 43 +/- 9 minutes; p less than 0.05), but solids emptied similarly in both groups of dogs (t1/2 approximately 8 hours). Pacing the Roux limb abolished the ectopic pacemakers, restored the slow emptying of liquids to the more rapid rate found in the Billroth dogs (t1/2: paced Roux, 72 +/- 15 minutes; Billroth, 43 +/- 9 minutes; p greater than 0.05) and did not change emptying of solids. The conclusion was that ectopic pacemakers present in the Roux limb after vagotomy and Roux gastrectomy drove the limb in a reverse direction and slowed emptying of liquids after the operation. The defect was corrected by pacing the Roux limb in a forward direction.     

Study of the antireflux function of the Roux-en-y jejunal loop in reconstruction following gastrectomy

Persistence of global orthograde peristaltic propulsion in the Y jejunal loop according to Roux makes this latter adequate for reconstruction of digestive transit after gastric resection or total gastrectomy, simultaneously avoiding reflux. Ectopic pacemakers can set in its proximal tract and favor intestinal and bile juice reflux in the gastric stump or esophagus, especially if the loop is too short and the new pacemaker is far from its superior margin. Moreover, the slower peristaltic waves can favor a relative stasis and, thus, a containing function, which could represent an element of morbidity over a certain limit. If the Y loop is not too long, but long enough to include the higher frequency ectopic pacemaker, which overcomes the lower frequency ones located distally, the positive aspects of both these characteristics can be exploited for satisfying and free of morbidity results. We believe that the best length is 35-40 cm, with positive clinical results. 99Tc-HIDA sequential scintigraphy clearly shows the absence of bile material reflux in the digestive tract proximal to the anastomosis.     

Ectopic jejunal pacemakers and enterogastric reflux after Roux gastrectomy: effect of intestinal pacing

The aims of this study were to determine whether ectopic pacemakers are present in the Roux limb of dogs after vagotomy and Roux gastrectomy, whether these pacemakers lead to enterogastric reflux, and whether abolishing the pacemakers with electric pacing might correct such reflex, were it to occur. In five dogs that had undergone gastric vagotomy and Roux gastrectomy and five dogs that had undergone gastric vagotomy and Billroth I gastrectomy (controls), myoelectric activity of the Roux limb or duodenum was recorded during saline infusion (154 mmol/L NaCl) or nutrient (Meritene) infusion into the limb or the duodenum. Reflux of infusate into the stomach was determined via a gastric cannula. Tests in Roux dogs were done with and without limb pacing. Roux dogs showed ectopic pacemakers in the Roux limb that drove the pacesetter potentials of the limb in a reverse, or orad, direction during 76% of the recordings; Billroth dogs rarely had such pacemakers (p less than 0.001). Enterogastric reflux occurred in both groups of dogs but was greater during phase III of the interdigestive migrating myoelectric complex in Roux dogs (12% +/- 6%) than in Billroth dogs (3% +/- 1%; p less than 0.05). Pacing abolished the ectopic pacemakers in the Roux dogs and reduced enterogastric reflux from 12% +/- 6% to 3% +/- 2% when phase III was present (p less than 0.05). In conclusion, the Roux limb was driven by ectopic pacemakers that contributed to, but were not solely responsible for, jejunogastric reflux. Pacing abolished the ectopic pacemakers and decreased reflux when phase III was present in the limb.     

Use of an ileal roux limb to prevent the roux stasis syndrome

The aim of this study was to determine whether the use of an ileal Roux limb, rather than a jejunal Roux limb, would prevent the Roux stasis syndrome that can occur after Roux gastrectomy. An ileal Roux limb was constructed in eight dogs and anastomosed to the gastric remnant after distal hemigastrectomy. Flow of chyme through the jejunum was preserved via an ileojejunostomy and a jejunoileostomy. Six dogs with distal gastrectomy and a conventional Roux gastrojejunostomy served as a control group. Chronic enteric recording electrodes and intraluminal, open-tipped pressure catheters were implanted in all dogs. After recovery, the electrical activity and motility of the Roux limbs and the rates of gastric emptying of liquids and solids were measured. Dogs with a Roux gastroileostomy had a slower frequency of pacesetter potentials in the Roux limb, a greater Roux motility index, and a faster rate of gastric emptying of liquids and solids than did dogs with a Roux gastrojejunostomy. Stomal ulcers, however, developed in seven of the eight ileal Roux limbs but in none of the jejunal Roux limbs. It was concluded that Roux gastroileostomy does ameliorate the Roux stasis syndrome, but there is a greater risk of stomal ulceration in the limb. Supported by the Mayo Foundation, Tohoku University, and the Nigro Grant. Presented at the Annual Meeting of the American Gastroenterological Association, May 22, 1996, San Francisco, Calif.     

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-h fast 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 fed 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.     

Improvement of the Roux limb function using a new type of "uncut Roux" limb

BACKGROUND: The Roux stasis syndrome is characterized by symptoms of upper gut stasis following Roux-en-Y gastrojejunostomy. The aim of this study was to compare a new type of uncut Roux-en-Y gastrojejunostomy with the conventional Roux-en-Y gastrojejunostomy after subtotal gastrectomy. METHODS: 51 patients (31 men and 20 women) had the conventional Roux-en-Y reconstruction and 54 patients (38 men and 16 women) had the new type of uncut Roux-en-Y reconstruction. The new type of uncut Roux-en-Y gastrojejunostomy consisted of an artificial jejunal occlusion and a short Roux limb (20 to 30 cm). RESULTS: The criteria included one of the four following conditions at the time of follow-up: chronic abdominal pain, postprandial fullness, persistent nausea, and intermittent vomiting that are worsened by eating. According to the criteria, the Roux stasis syndrome occurred in 19 patients (37.3%) with conventional Roux-en-Y reconstruction, and in 10 patients (18.5%) with uncut Roux-en-Y reconstruction (P = 0.033). CONCLUSIONS: A new type of Roux operation is able to alleviate not only the Roux stasis syndrome but also alkaline reflux gastritis or esophagitis by preserving motility of the Roux limb and diversion of duodenal juice from the gastric remnant.     

胃癌全胃切除Roux—en—Y食管空肠重建对Roux肠袢运动的影响

采用持续灌注式测压系统研究１０例胃癌患者全胃切除后ＲｏｕｘｅｎＹ食管空肠吻合的Ｒｏｕｘ肠袢运动功能。结果显示：大多数病例Ｒｏｕｘ肠袢运动表现异常，消化间期缺乏移行性运动综合波（ＭＭＣ），ＭＭＣⅢ相活动呈逆行传播或为非传播性压力活动暴发群等；餐后４例患者消化间期向消化期运动转换障碍，多数消化运动减弱。本研究结果提示：全胃切除ＲｏｕｘｅｎＹ吻合可诱发Ｒｏｕｘ肠袢运动紊乱，可能与患者术后上腹部不适相关。     

Identification and management of an errant antiperistaltic roux limb after total gastrectomy

We recently evaluated two patients because of persistent, unexplained bilious vomiting following total gastrectomy with Roux-en-Y esophagojejunostomy. With the aid of intestinal manometry and reoperation, an antiperistaltic Roux limb was discovered in both cases. Isoperistaltic repositioning of the Roux limb led to resolution of both patients’ symptoms. These case reports illustrate the devastating consequences of a poorly constructed Roux-en-Y esophagojejunostomy and demonstrate the utility of intestinal manometry in aiding the diagnosis of problems related to the Roux limb, particularly when surgical reexploration is not preferred or is inconclusive. By highlighting this avoidable technical error, we hope to prevent its future occurrence.     

Surgical treatment of Roux stasis syndrome

We wondered whether the slow gastric emptying of the Roux stasis syndrome could be improved by performing a corrective ‘uncut’ Roux operation. Five dogs had a standard Roux gastrectomy and placement of serosal electrodes on the proximal jejunum and Roux limb. After recovery, baseline myoelectrical and gastric emptying data were collected. The animals then underwent a second operation: take down of the Roux limb, restoration of jejunal continuity, and construction of an ‘uncut’ Roux limb. After the animals recovered, the tests were repeated. The slow frequency of pacesetter potentials (PPs) in the standard Roux limb (mean ± standard error of the mean 14 ± 0.4 cpm) was unchanged after the uncut Roux operation (14 ± 0.5 cpm, P>0.05). However, a greater percentage of PPs propagated aborally in the uncut Roux limb (81% ±4%) than in the standard Roux limb (53% ±7%, P <0.05). Nonetheless, gastric emptying of a 250 ml 10% dextrose liquid meal was not speeded by the uncut Roux operation (uncut Roux = 36% ±5% emptied by 20 minutes vs. standard Roux = 35% ±7%; P >0.05). Bile acid concentrations in gastric aspirates were minimal after both operations (0.7 ± 0.2 μmol/L vs. 0.6 ±0.1 (μmol/L; P >0.05). The conclusion was that more PPs propagated in the aborad direction in the uncut Roux limb than in the standard Roux limb, but gastric emptying was not speeded by the uncut Roux operation. Both operations were equally effective in preventing bile reflux into the gastric remnant. Supported by National Institutes of Health grant DK18278 and the Mayo Foundation. An abstract of this work was presented at the Annual Meeting of the American Gastroenterological Association, San Diego, Calif., May 17, 1995, and published in Gastroenterology 108:A101, 1995.     

Uncut Roux-en-y esophagojejunostomy: A new reconstruction technique after total gastrectomy

Purpose  

Uncut Roux-en-y is a reconstruction method with a main purpose of diminishing Roux stasis syndrome. In this study we performed this procedure to evaluate utility and complications of this technique, as well as its effect on Roux stasis syndrome.     

Electrical dysrhythmias in the Roux jejunal limb: cause and treatment

Electrical dysrhythmias in the Roux limb after Roux gastrojejunostomy are associated with upper gut stasis of food. The aim of this study was to determine the cause of the dysrhythmias and whether they could be eliminated with pacing. A set of four dogs (Group A) underwent three sequential operations: placement of jejunal electrodes at sites corresponding to the Roux limb; construction of a Roux limb without vagotomy, gastrectomy, or gastrojejunostomy; and transthoracic truncal vagotomy. A second set of five dogs (Group B) underwent truncal vagotomy, distal gastrectomy, and Roux gastrojejunostomy with recording electrodes placed on the Roux limb and a pacing electrode situated at the proximal end of the limb. Electrical recordings were obtained on four separate occasions after each operation. In Group A dogs, orad and disordered propagation of jejunal pacesetter potentials occurred in the Roux limb 56 +/- 5% of the time after limb construction but never before construction. The pattern was not changed with vagotomy. In Group B dogs, electrical dysrhythmias in the Roux limb also occurred and were corrected with electrical pacing. We concluded that electrical dysrhythmias in the canine Roux limb are secondary to the jejunal transection done during Roux limb construction, and are not due to gastrectomy, gastroenterostomy, or vagotomy. The dysrhythmias can be corrected with pacing.     

Standard Roux-en-Y gastroieiunostomv vs. “Uncut” Roux-en-Y gastrojejunostoki: A matched cohort study

Roux-en-Y gastrojejunostomy is a common method of reconstruction after subtotal gastrectomy. Maintaining myoneural continuity has been proposed to decrease the incidence of Roux stasis syndrome, with an “uncut” Roux-en-Y reconstruction. The aim of our study was to compare the clinical results in patients who have undergone uncut Roux-en-Y gastrojejunostomy with those in patients who have undergone a standard Roux-en-Y gastrojejunostomy. Eleven patients underwent gastrectomy and uncut Roux-en-Y gastrojejunostomy and were compared with a cohort of 14 patients who underwent gastrectomy and standard Roux-en-Y gastrojejunostomy. Patients were contacted and charts were reviewed for Visick grade, early and late morbidity and mortality, and incidence of staple line dehiscence. Early postoperative morbidity was 18% in patients undergoing uncut Roux gastrojejunostomy and 28% in patients under-going standard Roux reconstruction. There were no early postoperative deaths in either group. In the patients undergoing the uncut Roux procedure, no cases of staple line dehiscence were detected clinically (mean follow-up 9 months, range 1 to 48 months). Visick grade improved following the uncut Roux procedure, but changed little after standard Roux reconstruction. Uncut Roux-en-Y gastrojejunostomy can be performed safely with improvement in symptoms. The uncut Roux procedure may provide an alternative for reconstructive gastric surgery. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

Follow up studies on various reconstruction methods of the biliary tract including our new method (Roux Y-duodenojejunal anastomosis)

Thirty six patients with benign diseases of the biliary tract (14 patients with congenital choledochal dilatation, 15 patients with postoperative stricture and 7 patients with others) were divided into three groups: 21 patients who underwent a Roux Y (RY), 7 patients who underwent a jejunal interposition (IP) and 8 patients who underwent a side to side anastomosis between the jejunal limb of the Roux Y and the duodenum (RY-DJ). The RY-DJ was designed to decompress the Roux Y jejunal limb and to allow an inflow of bile into the duodenum. Significant complications, including cholangitis, infection, or abdominal pain, developed in 10 of the patients with RY (48 per cent), 7 of the patients with IP (100 per cent) and 1 of the patients with RY-DJ (13 per cent). None had a postoperative peptic ulcer. Simultaneous scintigraphy showed the time required for the two agents,^99mTc-IDA and¹¹¹In-DTPA, to mix at the upper jejunum, which revealed that the time taken by the patients with RY-DJ was similar to that of the patients with IP and to that of healthy controls. The time was markedly longer in the patients with RY, presumably due to a prominent stasis of the bile tracer in the Roux Y jejunal limb. Our new method (RY-DJ) for reconstruction of the extrahepatic biliary tract is more physiological and has less postoperative complications than other conventional methods.     

全胃切除后非离断式Roux—en—Y空肠储袋消化道重建的临床研究

目的探讨全胃切除术后非离断式Roux-en—Y空肠储袋消化道重建方式的临床效果。方法对168例胃癌患者行全胃切除手术后分别行非离断式Roux-en—Y空肠储袋吻合术（A组，69例）、P型空肠食管Roux-en-Y吻合术（B组，50例）和Orr式空肠食管Roux—en-Y吻合术（C组，49例）进行消化道重建。观察各组患者消化道重建的时间和术后并发症发生率；并对其中无瘤生存超过1年的121例患者的生活质量[术后6和12个月时的体重、进食量、预后营养指数（PNI）和Visick分级指数]进行分析对比。结果A、B、C组消化道重建时间分别为（30±7）min、（57±6）min和（48±6）min；A组时间最短，与B、C组比较差异有统计学意义（P〈0．05）。3组患者术后均顺利恢复，未发生吻合口瘘或十二指肠残端瘘等术后并发症。A、B、C组碱性反流性食管炎发生率分别为4．3％（2／46）、7．7％（3／39）和5．6％（2／36），差异无统计学意义（P〉0．05）；Roux潴留综合征发生率分别为2．2％（2／46）、17．9％（7／39）和19．4％（7／36），A组明显低于B、C组（P〈0．01）。术后6个月和12个月，A组体重和进食量的恢复均优于B、C组（P〈0．05）。与术前相比，术后6个月3组PNI均下降（P〈0．05）；12个月时，A组PNI与术前比较差异已无统计学意义（P〉0．05），而B、C组的差异仍有统计学意义（P〈0．05）。A组术后6个月和12个月时的Visick分级指数Ⅰ～Ⅱ级均优于B、C组（P〈0．05）。结论非离断式Roux-en—Y空肠储袋术是全胃切除术后理想的消化道重建术式。