ANNALS OF SURGERY - NCBI

ANNALS OF SURGERY

November 1965

Remedial Operations for Severe PostgastrectomySymptoms (Dumping): '

Emphasis on an Antiperistaltic (Reversed) JejunalSegment Interpolated between Gastric Remnant

and Duodenum and Role of Vagotomy

J. LYNWOOD HERBINGTON, JR., M.D.

From the Department of Surgery, Vanderbilt University School of Medicine andthe Edwards-Eve Clinic, Nashville, Tennessee

LONG-RANGE postprandial symptoms,which frequently follow subtotal resectionand total excision of the stomach, collec-tively are termed the dumping syndromeand usually comprise both vasomotor andgastrointestinal components. The symp-toms are considered more common andmore severe following radical resection;however, they may follow any gastric op-eration involving disruption or alteration ofthe pyloric sphincter mechanism. Also, thedisorder seems to occur more frequentlyfollowing operation for duodenal ulcer thanfor gastric ulcer. This report concerns thesurgical treatment of this syndrome fol-lowing operation for gastroduodenal ulcer.

* Submitted for publication October 23, 1965.Guest presentation: The Georgia Surgical So-

ciety, Sea Island, Georgia, Sept. 18, 1964.

789

It is estimated that 10 to 50 per cent ofpatients operated upon for duodenal ulcereventually experience some degree of post-prandial distress, with an average of about25 to 30 per cent.1' 5,8,10,29,53,73 Thesesymptoms usually are mild and transient;when they persist, control can be gainedby diet and simple instructive measures.Severe symptoms which may be disablinginclude excessive weight loss, profoundanemia, malnutrition, marked abdominaldistress, weakness and intractable diarrhea.In such cases remedial operation may berequired as an alternative to invalidismand possible drug addiction.Postgastrectomy symptoms presumably

result from loss of the stomach as a storageorgan, brought about by ablation or altera-tion of the regulatory emptying mechanism,

Vol. 162 No. 5

790 HERRIN

TABLE 1. Technical Modifications ofOriginal Procedure

1. Conversion of Billroth II to Billroth I2. Attempt to construct valve at gastroenterostomy3. Narrowing of gastroduodenostomy or gastro-

enterostomy4. Enteroenterostomy5. Jejunoplasty

mainly the pyloric sphincter. The symptomcomplex apparently is initiated by rapidpassage of hypertonic gastric contents intothe proximal small intestine. Physiologicalterations incident to the dumping syn-drome have been well documented byMachella,41 Hinshaw,25 Randall,60 Harkins 17

and others.219-3, 51Remedial procedures to alleviate severe

dumping symptoms not responding to con-servative therapy have not been employedextensively in this country, although re-ported from Great Britain and Europe.These secondary operations are designedto improve storage function of the gastricremnant and to increase emptying time ofthe stomach, thereby preventing suddenexit of foodstuffs into the jejunum withresultant sequelae. Remedial operations incurrent use may be classified as 1) thosewhich tend to preserve the basic plan ofthe original operation but add certain tech-nical modifications or 2) those designed tocreate a larger gastric reservoir by utilizingan adjacent hollow viscus and interpolatingit between the gastric pouch and duode-num or between the gastric remnant andjejunum (Table 1, Fig. 1).

Technical Modifications of the OriginalOperation Designed to Alleviate

the Dumping Syndrome

The most widely employed operation de-signed to correct the dumping syndromehas been the conversion of a Billroth IIanastomosis to a Billroth I type. Billroth IIresection has long been popular for treat-ment of both duodenal and gastric ulcer. Itis only recently, and mainly through the ef-

IGTON Annals of SurgeryNovember 1965

forts of Harkins,", 29 that interest has beenstimulated in Billroth I operation; accord-ingly, most patients with severe dumpingsymptoms were originally operated uponby the Billroth II method. Conversion ofthe Billroth II to Billroth I has been disap-pointing in many patients as a correctivemeasure to control the dumping syndromebut rewarding in those who develop af-ferent loop syndrome with bilious vomitingfollowing a Billroth II reconstruction.31' 79

Other operative modifications for allevi-ating the dumping syndrome include con-struction of a valve-like flap at the gastro-enterostomy site following a Billroth IItype reconstruction. Plastic narrowing ofthe gastroenterostomy or gastroduodenalstoma and performance of a reversedMikulicz procedure at the previous gastro-duodenal suture line each have met withvarying degrees of success, while entero-enterostomy and jejunoplasty have not re-sulted in overall patient improvement.

In general, neither secondary plastic pro-cedures carried out at the stomal site norsimple conversion operation have provedeffective in alleviating severe postgastrec-tomy symptoms.

Substitute Gastric Reservoir for theControl of Dumping Symptoms

Use of a Segment of Colon

Segments of the right and left colonrecently have been employed extensivelyas replacement organs for the diseased

(j) USE OF A SEGMENT OF COLON

® ISOPERISTALTIC SEGMENT OF JEGJUNUM

DOUBLE OR TRIPLE ISOPERISTALTIC PLICATED POUCH

ANTIPERISTALTIC SEGMENT OF JEJUNUM

( ANTI-ISOPERISTALTIC JEJUNAL POUCH

FIG. 1. Current remedial operations which create asubstitute gastric reservoir.

REMEDIAL OPERATIONS FOR POSTGASTRECTOMY SYMPTOMS

esophagus and, to a lesser extent, for theentire stomach following removal for malig-nant disease. However, colonic segmentshave been used infrequently as a substitutereservoir for control of severe dumping fol-lowing subtotal gastrectomy.Moroney 49 in 1951 reported the first use

of a segment of transverse colon as a sub-stitute gastric pouch after operation forduodenal ulcer. He used the colonic seg-ment as both a primary and remedial pro-cedure, with good results in the early fol-low-up period. The segment of transversecolon was interpolated in an antiperistalticmanner, with the distal end anastomosed tothe gastric remnant and the proximal ex-

tremity to the duodenum. Most colon trans-fers designed to replace the distal stomachhave added the transverse colon in thismanner, as the anatomic relationship of thecolon and stomach allow this procedure tobe accomplished with relative ease.

Moroney 47, 48 later reported 8 per centunsatisfactory results in 143 patients utiliz-ing the colon transfer. Three recurrentulcers were described in this series. Va-gotomy did not routinely accompany the

MORONEY 143 CASES

19518%

U N SATISFACTO RYRESULTS

WATKINS - 40% MARGINAL ULCERATION

PHYSIOLOGIC DISADVANTAGES

SENSITIVITY TO ACID-PEPSIN SECRETION

MASS PERISTALSIS

BACTERIAL CONTENT

FLUID ABSORPTION

EXCESSIVE BULK

FIG. 2. Results with a colon segment as a substitutegastric reservoir.

colon pouch, but it was added in somecases.

Watkins 78 reported seven cases of duo-denal ulcer treated by 75 to 80 per cent re-section with interpolation of an antiperistal-tic segment of transverse colon between thegastric remnant and duodenum. Vagotomywas not added, but achlorhydria was ob-served during early postoperative studies.High resection of the stomach was recom-mended when reversed colon transfer wasemployed. Extensive resection was believedresponsible for the absence of free hydro-chloric acid. Increase in emptying time ofthe pouch was described, but patients didcomplain of upper abdominal distress fora few weeks following operation. This was

attributed to motility disturbances of thepouch, which improved with the passageof time. In later follow-up studies, Wat-kins 77 noted marginal ulceration in about40 per cent of colon pouches and statedthat this procedure was inapplicable forduodenal ulcer (Fig. 2). Various workersreported a high incidence of marginal ulcerwhen colonic mucosa contacts gastric mu-

cosa capable of acid pepsin secretion.Hunt26 maintains that the colon is an

unsuitable replacement for a portion of, or

the entire, stomach. Mass peristalsis, bac-terial content, fluid absorption and exces-

sive bulk present physiologic disadvantageswhich render it a poor substitute.

Use of an Isoperistaltic Jejunal SegmentAccording to Hedenstedt,22 Schoemaker

of the Hague was the first to employ an

isoperistaltic segment of small bowel as an

interposition procedure in gastric surgeryin 1911. However, Sacharow 64 is creditedwith stimulating interest in this operationfollowing his original work in 1939 andclassic treatise published in 1958. Biebl,4also of Germany, reported use of this pro-

cedure in 1947. Henley 23 of London, in a

preliminary paper in 1952, interposed a

4 to 8-inch isoperistaltic segment of je-junum between the stomach and duode-

Volume 162Number 5 791

792 HERRINGTON

FIG. 3. The Soupault principle used in the cor-rection of the dumping syndrome. (Courtesy ofRevue de Chir., 1954.)

num. Thirty-five cases were reported, andthe operation was performed both as a

primary and remedial operation for duo-denal ulcer. Satisfactory results were re-

ported during a brief follow-up period.Weight gain was noted and no dumpingsymptoms occurred. The interpolated seg-

ment increased emptying time of the stom-ach, and contrast media were retained inthe pouch after 2 hours. In his early opera-

tion Henley did not employ vagotomy.Soupault and Bucaille 69 in 1954 de-

scribed a remedial operation for dumpingsyndrome occurring after a Billroth II re-

construction in which the efferent jejunallimb was divided and anastomosed to theduodenum. The afferent limb was dividedand the distal end closed near the gastro-enterostomy. The proximal end of the af-ferent look was then anastomosed to thedistal efferent loop (Fig. 3). Jezioco,28 inGermany, also reported experience with thejejunal interposition operation. RecentlyWalters 74' 75 recommended the Soupault-Bucaille procedure for the control of dump-ing and even more recently Rutledge 1 62

has used either the efferent or afferent je-junal limb for anastomosis to the duodenumin patients with severe postgastrectomysymptoms.

Hedenstedt 19-21 reported the use of theisoperistaltic jejunal transfer with a BillrothI reconstruction. Early in his work he be-lieved that vagotomy should always beadded unless a high resection of the distal

Annals of SurgeryNovember 1965

stomach was done. Later, he modified hisviews and combined vagotomy with a mod-erate resection of the stomach when usingthe interpolated jejunal segment. The op-eration was performed both as a primaryprocedure for duodenal ulcer and as aremedial operation. In 1961 he reported347 cases. The majority of patients wereoperated upon for duodenal ulcer, butmany operations were remedial for thedumping syndrome. There was a 30 percent recurrence of ulcer in those caseswithout vagotomy, and no recurrence inthose with vagotomy.

Hedenstedt,22 as of May 1964, had per-formed the jejunal interposition procedurein 500 cases. Most were primary operationsfor duodenal ulcer, but 90 represented sec-ondary procedures for the control of dump-ing. In this latter group, 90 per cent haveobtained excellent results. The mortality inhis series after the primary operation hasbeen 1 per cent and after the remedial pro-cedure 2 per cent (Fig. 4).Henley24 stated that the operation of

isoperistaltic jejunal replacement is gradu-

HEDENSTEDT L I

1964

500 CASES

410 PRIMARY OPERATIONS FORDUODENAL ULCER

I % MORTALITY

90 REMEDIAL PROCEDURES

90 % EXCELLENT RESULTS

2% MORTALITY

FIG. 4. Results with the interpolation of an iso-peristaltic jejunal segment between the gastricremnant and duodenum. Vagotomy is added.


ally establishing its place in the surgicalfield, now being used extensively through-out Europe as a remedial operation forcontrol and eradication of postgastrectomysymptoms. He has performed the opera-tion for the postgastrectomy syndrome in287 patients, and all have been improved.If the original lesion is a duodenal ulcer,he performs vagotomy at the time of thecorrective procedure. He further statedthat in his early experience 100 patientswith duodenal ulcer were treated by re-

section, jejunal replacement and a BillrothI anastomosis without vagotomy, and 17per cent subsequently developed recurrentulceration. In a later series of 150 patientsin which vagotomy was routinely added,there was no recurrence of ulcer. In addi-tion, 154 patients were operated upon forbenign gastric ulcer by distal resection, je-junal replacement and Billroth I anasto-mosis. Vagotomy was not performed, andthere were no recurrent ulcers.

Krause in 1962 39 reported the use of je-junal transposition operation in 80 patients.The average follow up was 2 years. Onehalf of the patients had been operated uponfor duodenal ulcer and one half for gastriculcer. There was an overall 16 per cent re-

currence of ulcer, 22 per cent in the duo-denal ulcer group and 14 per cent in thegastric ulcer group. He concluded that inpatients with hyperacidity and in patientswith normal acid values, vagotomy shouldbe added to the operation. This also ap-

plied to patients with a benign gastric ulcer(Table 2).A less frequently used procedure for

the treatment of dumping symptoms, witha modified isoperistaltic gastric reservoirprinciple, is the triple plicated jejunalpouch, originally described by Hay 18 aftertotal gastrectomy but modified by Wood-ward83-85 and by Lawrence40 for the con-

trol of dumping symptoms following sub-total gastrectomy. Woodward anastomosedthe plicated pouch to the gastric remnantand duodenum after resecting the previ-

TABLE 2. Rate of Vagotomy Accompanying IsoperistalticJejunal Segments in Treatment of Dumping Syndome

(Rate of Ulcer Recurrence)

Vagot- Recur-Patients Ulcer omy rence

Henley

100 Duodenal No 17%150 Duodenal Yes 0154 Gastric No 0

Krause

40 Duodenal No 22%40 Gastric No 14%

ous gastroenterostomy. Lawrence, however,simplified the procedure by applying theSoupault principle of maintaining the gas-troenterostomy, dividing the afferent limb,closing its distal end and using the efferentlimb as the plicated pouch (Fig. 5). Wood-ward83 reported one excellent, two goodand two fair results among five patientsoperated upon. Lawrence mentions one ex-

cellent, two good and two unsatisfactoryresults among his five cases.

Employment of an Antiperistaltic JejunalSegmentReversal of a segment of jejunum with re-

anastomosis has been used experimentallyfor many years, but only recently has this

A C D

FIG. 5. The triple plicated pouch has an iso-peristaltic inlet and an isoperistalitc outlet. (Cour-tesy of Walter Lawrence, Jr.)


794 HERRINGTON

principle been employed in the treatmentof patients who have undergone massiveresection of the small intestine."' 12, 45, 67, 68,70, 71 Likewise, use of an antiperistaltic je-junal segment as a substitute gastric reser-

voir only recently has been applied fortreatment of the dumping syndrome.

Kirstein 37 in 1889 was the first to reportexperimental reversal of segments of smallintestine. The animals died of intestinal ob-struction, and at autopsy spindle-shapeddilatation was noted just above and justbelow the proximal suture line. Mall 44made similar observations in 1896. Most ofthe earlier observers * utilized long re-

versed segments of small intestine, andsimilar discouraging results were reported.In addition, foreign body impaction was

noted at the proximal suture line, but nor-

mal bowel was observed at the distal anas-

tomosis. Peristalsis and antiperistalsis were

noted in the reversed segment, with anti-peristalsis predominating (Fig. 6).

* 9, 27, 36, 38, 46, 50, 59, 63, 75.

_ ~ ~~~~~~__

FIG. 6. Dilatation and obstruction of .the smallintestine when a long segment is reversed and re-anastomosed. (Courtesy Johns Hopkins HospitalBulletin.)


Hammer 14-16 in 1959 was apparently thefirst to reverse short segments of intestine(1 to 2 inches long) and found that theanimals survived. He was able to maintainsurvival in dogs that had undergone 80 to90 per cent small bowel resection, provideda short segment of the remaining intestinewas reversed. In contrast, control animalsdied. Singleton67' 68 also reported survivalof animals with reversal of a short (6-inch) segment of small instine. Stahlgren 70stressed the importance of the short re-versed segment and states that there isa fine line between producing intestinalobstruction and physiologic delay. BothMackby42 and Gibson13 have credited asingle survival following massive smallbowel resection to reversal of a short seg-ment of the remaining intestine. Mackbyalso has used a circular loop of remainingintestine to decrease intestinal hurry andimprove nutrition. Madding43 treated a pa-tient with intractable diarrhea and a sprue-like syndrome by reversal of a short jejunalsegment, with a good result.

Discouraging early results with reversedintestinal segments undoubtedly dampenedinterest in applying this principle to thesurgical treatment of dumping syndrome.Willms and Jordan 34' 80-82 in 1961 re-

ported treatment of the postgastrectomydumping syndrome experimentally. Theyreversed a short jejunal segment and inter-polated it between the stomach remnantand gastrojejunostomy following a BillrothII type reconstruction. They conceived theidea from the experimental work of Ham-mer 14 and others with the use of short re-versed jejunal segments in the preventionof malnutrition after massive intestinal re-section. In Jordan's experiments the re-versed segment served as a regulatoryvalve and governed emptying of the stom-ach pouch. Actual antiperistaltic wavesfrom the reversed segment directed towardthe gastric pouch were observed, and theemptying time of the stomach remnantwas prolonged. The antiperistaltic segment

Volume 162 REMEDIAL OPERATIONS FORNumber 5

was observed to contract in relation to con-tractions in the adjacent jejunum ratherthan in relation to those of the gastricpouch. The reversed intestinal segment re-sulted in restoration of the reservoir func-tion of the gastric pouch, yet the fecal lossof fat and nitrogen in the animals remainedelevated. Weight gain following insertionof the reversed segment was credited toincreased oral intake. Extensive dumpingstudies performed in these animals showednone of the physiologic alterations whichwere demonstrated in control animals withBillroth II reconstruction but without thereversed segment. Vagotomy was not usedin the experimental preparations, but nomarginal ulcers were reported after a 3-year study. No free HCl was present in thegastric pouches postoperatively, and thefactor of jejunal regurgitation was thoughtto be a potent neutralizer. Jordan35 has ap-plied this operative procedure on 3 pa-tients, with good early results.

Christeas 6 reported a similar procedurefor the control of dumping syndrome fol-lowing Billroth II type reconstruction inwhich a short jejunal segment is reversedin the efferent limb just distal to the gas-troenterostomy. This reversed segment re-tards emptying of the gastric pouch andallows food to fill the afferent loop, thusstimulating bile and pancreatic secretions(Fig. 7).Poth 55-58 described an ingenious double-

plicated jejunal pouch which consists ofboth an isoperistaltic and antiperistalticcomponent. The isoperistaltic limb or inletis anastomosed to the gastric pouch, andthe antiperistaltic limb or outlet is anasto-mosed to the duodenum. A large reservoiris thus constructed from the two segmentsand empties slowly and in piecemeal fash-ion. He used the procedure in eight in-stances for severe dumping symptoms fol-lowing subtotal gastrectomy.55 Free regur-gitation from duodenum into the pouch isobserved, and all patients have been re-lieved of symptoms of dumping. Weight

POSTGASTRECTOMY SYMPTOMS 795

FIG. 7 ( a). The remedial operation describedby Jordan.

FIG. 7(b). The remedial operation used byChristeas.

gain occurred in several patients, and func-tion of the pouch improves with time.Vagotomy is not used as a part of the pro-cedure. Poth also devised a pouch to beused after Billroth II type reconstructionwhich utilizes the iso-antiperistaltic prin-ciple but excludes the duodenum (Fig. 8).

Steinberg72 described a remedial opera-tion in 1934 which consisted of constructinga jejunal pouch from the afferent and ef-ferent limbs of the gastroenterostomy fol-lowing Billroth II anastomosis. This pouchwas fashioned to supplement the gastricremnant in providing a large reservoir. Theprocedure was termed a pantaloon anasto-mosis. It was not appreciated at the timethat this pouch is similar in principle to thePoth pouch in that it possesses both iso-and antiperistaltic components. Steinbergused the procedure in 400 cases, both asa primary and remedial operation. The re-current ulcer rate, however, has been be-tween 3 and 4 per cent. The pantaloonanastomosis has been used as a remedialoperation in 60 patients; 46 were improvedover a 1 to 13 year follow up. RecentlySteinberg stated that vagotomy is neces-sary if the pouch operation is employed(Fig. 9). Christiansen 7 employed a simi-lar operation.The use of a single short antiperistaltic

jejunal segment interpolated between the

796 HERRINGTON

POTH I t

FIG. 8. (Left) The double plicated pouch withan isoperistaltic inlet and an antiperistaltic outlet.(Right) The same procedure with exclusion of theuodenum.

gastric remnant and duodenum for treat-ment of the dumping syndrome apparentlyhas been reported rarely (Fig. 10). Bar-nett2' 3 described the operation in the ex-perimental animal and found that such apreparation did not increase fat absorptioncompared to a conventional resection withBillroth I anastomosis. Schlicke 65' 66 ap-plied the procedure to a patient with se-vere dumping and diarrhea which occurredfollowing vagotomy, antral resection and

FIG. 9. The pantaloon pouch utilized by Stein-berg for the correction of dumping. (Courtesy ofM. E. Steinberg, 1964.)


FIG. 10. Antecolic interpolation of a short anti-peristaltic jejunal segment between the gastricpouch and duodenum. Vagotomy is added.

Billroth I reconstruction. A marked delayin emptying time of the gastric pouch wasobserved after the remedial operation, andthe patient gained 40 pounds. She has nowbeen followed more than 3 years and hascontinued to do well.

Present Experience

During the past 4 years, 12 patients onour service have undergone remedial op-eration for the control of severe dumpingsymptoms not responding to intensive con-servative therapy. Three of the 12 patientsinitially had undergone a high partial gas-trectomy, and nine had been subjected tovagotomy and antrectomy with either Bill-roth I or II reconstruction. Each operationhad been performed for a complication ofduodenal ulcer. The interval between theprimary and the remedial operation variedfrom 1 to 12 years. Eight of the 12 patientswere subjected to the remedial operationdescribed by Poth, consisting of construc-tion of an anti-isoperistaltic jejunal pouch,and four patients had a single short anti-


ANTI-ISOPERISTALTIC JEJUNAL POUCH

FIG. 11. Results withanti-isoperistaltic jejunalpouch.

PATIENT

NAME AGE

S.F.C. 48

BEFORE POUCHPRIOR WEIGHT LOSS DUMPING,

OPERATION IN POUNDS DIARRHEA

e) 85 ++++

peristaltic jejunal segment interpolated be-tween the gastric remnant and duodenum.Each of the two groups will be discussedseparately.

patient prioreration.

AFTER POUCHWEIGHT GAIN DUMPINGIN POUNDS DIARRHEA RESULTS

50 0 EXCELLENT

40 0 FAILURE*

I0 0 GOOD

20 0 GOOD

10 0 IMPROVED

0 0 IMPROVED

0 0 IMPROVED

0 0 FAIR

to advising the remedial op-

Result

Anti-Isoperistaltic Jejunal Pouch

Of eight patients, three had undergoneextensive partial gastrectomy and five hadbeen subjected to vagotomy with antralresection. There were seven men and one

woman, and the ages ranged from 34 to 58years. Each had obtained a poor clinicalresult from the original operation, andmarked dumping symptoms were present.Postoperative weight loss was pronouncedamong most of the group, varying from 10to 85 pounds. Diarrhea was a prominentfeature with several of the patients experi-encing 10 to 25 loose stools per 24 hours.Anemia was present in each patient, andeach was incapacitated for work. An in-ternist or gastroenterologist had partici-pated in the conservative treatment of each

Of three patients who had previously un-

dergone high distal gastrectomy, one ob-tained an excellent result following inser-tion of the Poth pouch, one had a goodresult and one operation resulted in a fail-ure. The patient who obtained an excellentresult has now been followed 3 years andweight gain has been impressive. Vagotomywas not done at the time of insertion of thePoth pouch. The patient with a good re-

sult had a bilateral truncal vagotomy per-

formed at the time the Poth pouch was

inserted and subsequently has gained 10pounds. The patient in whom failure fol-lowed insertion of the Poth pouch did nothave a vagotomy performed. Postopera-tively he did well for 2 years, gained an

enormous amount of weight, but subse-quently developed abdominal pain and re-


798 HERRINGTON

currence of an ulcer in the jejunal pouch.Treatment then consisted of vagotomy andpouch revision, with relief of all symptoms.Diarrhea disappeared following the pro-cedure in each case and the dumpingsymptoms have been eliminated.Of five patients who had vagotomy with

antrectomy as the original operation, oneobtained a good result with disappearanceof all dumping symptoms. Improvementhas been striking in three patients, and oneobtained only a fair result. Among the fivepatients weight gain, however, has not beenimpressive, even though oral intake has in-creased. Diarrhea, which was a strikingfeature in each of the eight patients, hasceased and anemias have been corrected(Fig. 11).The eight patients have been followed

from 1 to 4 years, and improvement hascontinued in seven. One patient notesvague abdominal distress but states thathe is better since the diarrhea has beenalleviated. Postoperative gastrointestinalx-ray studies show delayed emptying of


FIG. 12. Case 1. X-rayshowing the small gastricremnant which remains.

the gastric reservoir and residual barium isnoted in the pouch after three hours.

Case ReportsCase 1. A 48-year-old man was admitted to

St. Thomas Hospital May 18, 1961 with the com-plaints of nausea, weakness, diarrhea, weight lossand swelling of the legs and ankles. Two yearsprior he had undergone a gastric resection else-where for massive bleeding from a duodenal ulcer.Since operation he gradually had lost 85 pounds,experienced weakness, nausea, vomiting and pro-fuse diarrhe aand was totally disabled.

On examination the patient was emaciated andmalnourished. Blood pressure was 120/80, pulse76, respiration 20, temperature 36.70 C. There wasgeneralized loss of muscle mass, periorbital edemaand swelling of both lower extremities.

Laboratory tests showed hemoglobin of 9.5 Gm.,white blood cell 4,000, total serum proteins 4.6,albumin 1.7, globulin 2.9. Serum potassium levelwas 2.8, fasting sugar 66 and blood urea nitrogen10. Blood calcium level was 8 mg./100 ml. Liverfunction tests were normal. Peripheral blood stud-ies revealed a macrocytic anemia. Bone marrowbiopsy was normal.

Gastrointestinal x-ray series showed a normalesophagus and a very small remnant of stomach

Volume 162Number S


FIG. 13. Case 1. Tech-nical steps in construc-tion of the Poth pouch.

remaining with a gastrojejunostomy present. Nomarginal ulcer was demonstrable (Fig. 12). Bariumenema and chest x-rays, and EKG were not re-markable. Gastric analysis revealed no free HC1.

The patient was treated with blood transfu-sions, high protein, low carbohydrate diet, vita-mins and albumin infusions. Improvement was

slight, and he was discharged after 5 weeks ofintensive therapy. He was readmitted to the hos-pital August 2, 1961 at which time his conditionwas unchanged. Repeat studies revealed similarfindings as on previous admission. It was believedthat the malnutrition and postgastrectomy symp-toms could not be corrected by nonoperativemeans, and a remedial operation was advised.

At reoperation on August 9, 1961 a very smallgastric remnant was found, and an anterior gastro-jejunostomy was present with no evidence of mar-

ginal ulcer. It was decided to construct an anti-isoperistaltic type pouch from the afferent andefferent jejunal limbs but to leave the gastro-enterostomy intact. Therefore the jejunal limbswere fashioned, each about 12 to 15 cm. long,and intestinal continuity was re-established witha jejunojejunostomy. The isoperistaltic limb (inlet)was closed at its distal end, and the distal end ofthe antiperistaltic limb (outlet) was anastomosedto the duodenal stump. A double-plicated pouchwas then created using the two jejunal segments.

Vagotomy was not performed. Liver, pancreas andother abdominal viscera were normal (Fig. 13).The postoperative course was uncomplicated, andthe patient was discharged on the 16th postopera-tive day.

Two months following operation, he hadgained 50 pounds. He has now been followed 3years and has continued to maintain his weight.Results of blood studies are normal, dumpingsymptoms, including diarrhea, have disappearedand he has returned to a useful occupation.Gastrointestinal x-ray series demonstrate that thepouch acts as a reservoir. It empties slowly, andafter 3 hours contrast media still remains in thepouch (Fig. 14). Gastric analysis showed no freeHCI after fasting.

Comment. This is an example of themarked emaciation and malnutrition thatsometimes follows extensive resection ofthe stomach. Prolonged and intensive medi-cal therapy failed to improve this patient'scondition. The application of the pouch inthis case appeared to be a life saving meas-

ure. After 3 years, no free HCI is presentin the pouch. No doubt the small size ofthe gastric remnant explains the absence offree HC1.

799

800 HERRINGTON Annals of SurgeryNovember 1965Case 2. A 48-year-old man was admitted to

St. Thomas Hospital on February 9, 1962 withthe complaint of weight loss, diarrhea and weak-ness. Nine years prior he had undergone vagotomy,antrectomy and Billroth II reconstruction for duo-denal ulcer. He obtained a poor clinical resultfrom this procedure and complained of diarrhea,weight loss of 20 pounds and weakness. Five years

M! | _ before the present admission he was thoroughlyexamined and showed severe dumping syndrome.He was reoperated upon, and the Billroth II re-construction was converted to Billroth I. Verylittle, if any, clinical improvement took place, andphysiologic studies again showed plasma volumedrop and EKG patterns almost identical with pre-operative controls. Despite diet, instructive meas-ures, and serotonin antagonists, symptoms in-creased and diarrhea became almost uncontrollable,with the patient having 20 to 25 stools per 24hours.

Upon admission the patient appeared palewith evidence of weight loss. Hemoglobin was 10Gm./100 ml., Poth cell volume 33, calcium 9.9,phosphorus 3.6. Total proteins were normal. Bloodsugar was 98, and amylase was not elevated. Liverfunction tests were normal. EKG and chest x-ray

FiG. 14. Case 1. Postoperative x-ray showing were not remarkable.the pouch filled with barium. A gastrointestinal x-ray series showed rapidemptying of the gastric remnant, and no ulcera-

tion was demonstrated at the gastroduodenostomy(Fig. 15). The stomach emptied so rapidly thatit was difficult for the radiologist to obtain a filmof this structure filled with barium. Within 15minutes the column of barium had traversed theentire small intestine and appeared in the distalcolon.

At reoperation the gastroduodenostomy wastaken down, and two 12 to 15 cm. segments ofproximal jejunum were isolated. The isoperistalticsegment, or inlet, was anastomosed to the stomach

AM remnant and the distal end was closed. The anti-..... peristaltic segment, or outlet, was anastomosed at

its distal end to the duodenum. The proximal endof the antiperistaltic segment was closed. A reser-voir was then constructed from the two segments

# u]F 1 J Kv ~~~(Fig. 16).:r; ; Postoperatively the patient did well, and was

discharged on the 18th postoperative day. Duringthe follow-up period he has done well. He hasgained 20 pounds and hemoglobin has risen to14 Gm./100 ml. Stools have reduced from 20 to25 daily to two to three formed stools. A gastro-intestinal x-ray series shows slow emptying of thegastric reservoir, and barium remains in the pouchafter 3 to 4 hours (Fig. 17).

FIG. 15. Case 2. X-ray of a patient with marked Comment. Conversion from a Billroth IIdumping following vagotomy, antrectomy andBillroth I reconstruction. to Billroth I was ineffectual in controlling

Volume 162 REMEDINumber 5

FIG. 16. Case 2. Con-struction of Poth pouchfrom two jejunal seg-ments.

[AL OPERATIONS FOR POSTGASTRECTOMY SYMPTOMS

A

18-20 CM

-.- cB8-20 cm

marked dumping symptoms in this patient.Intestinal hurry with incapacitating diar-rhea was the main indication for reopera-tion. The patient at present has no freeacid after fasting in the reservoir pouch,but vagotomy had been performed at theinitial operation.

Case 3. A 59-year-old man was admitted toSt. Thomas Hospital on May 13, 1962 with thecomplaints of abdominal pain, weakness, weightloss and diarrhea. Fifteen years previously he hadundergone closure of a perforated duodenal ulcerand 14 years before admission had had an esti-mated 80 per cent gastric resection for ulcer com-

plications. He had fared poorly since the latteroperation and symptoms referable to the dumpingsyndrome were incapacitating.

On examination there was evidence of markedweight loss and the patient appeared pale. Hemo-globin was 4.5 Gm./100 ml. and the white bloodcell count was 5,300. A gastrointestinal x-ray se-

ries showed that the major portion of the stomachhad been resected and a Billroth II type of anas-

tomosis had been done. No marginal ulcer was

noted. Barium enema, cholecystogram, intravenousurogram and chest x-rays were normal. Liver func-tion tests showed no derangement. Gastric analysisshowed no free fasting HCI and no acid withhistamine stimulation.

The patient was treated with blood transfu-sions, vitamins and frequent bland feedings. Itwas believed that a remedial operation was neces-

sary to correct the severe dumping symptoms as

he had failed to improve with conservative meas-

ures carried out for several years by other ob-servers.

At operation on May 23, 1962 no marginalulcer was found. About 80 per cent of the stomachhad been resected previously. A Poth pouch was

constructed at this time by leaving the gastro-enterostomy intact and utilizing the afferent and

-MQFIG. 17. Case 2. Postoperative barium x-ray study

shows the pouch filled with contrast media.

801

802 HERRINGTON

efferent jejunal limbs (Fig. 18). A vagotomy wasnot done. The postoperative course was uncompli-cated and the patient was discharged on the 12thpostoperative day. At the time of discharge a gas-trointestinal x-ray study showed the pouch toempty slowly and in piece-meal fashion (Fig. 19).

The patient was seen at frequent intervals

Aw

FiG. 19. Case 3. Postoperative x-ray shows

pouch filled with barium. Pouch empties slowlyand in piece-meal fashion.


FIG. 18. Case 3. Con-struction of plicatedpouch with isoperistalticinlet and antiperistalticoutlet.

during the postoperative follow up, and during thefirst 3 months he gained 40 pounds. The weaknessand diarrhea cleared up and he returned to a use-ful occupation.

He remained in excellent health for about 2years but returned to the hospital on July 31, 1964with a 3-month history of nausea, vomiting, se-vere upper abdominal distress and weight loss of20 pounds. The pain was described as typical ofthe old ulcer-type pain and penetrated through tothe back. A gastrointestinal x-ray series revealeda large ulcer crater in the jejunal pouch just distalto its connection with the gastric remnant (Fig.20). No anemia was present and the stools werenegative for occult blood. A 12-hour gastric se-cretory study revealed an output of 1,000 cc. ofgastric juice with 14 mEq. of free HCI. A Hol-lander test demonstrated strong vagal activity. Re-peated serum amylase values were not elevated.

The patient was observed for several days andcontinued to have severe discomfort. It was be-lieved that a transthoracic vagotomy should bedone and on August 19, 1964 this operation wascarried out.

Postoperatively the complete relief of abdomi-nal discomfort was dramatic. However, when theLevine tube was removed and oral alimentationstarted, symptoms of gastric retention occurredwhich were not corrected with reinstitution ofsuction. A gastrointestinal x-ray series 2 weekspostoperatively showed complete obstruction atthe junction of the stomach remnant and substi-tute pouch (Fig. 21).

At abdominal operation on September 14, 1964the ulcer at the junction of the gastric remnantand jejunal pouch had healed completely and was

REMEDIAL OPERATIONS FOR POSTGASTRECTOMY SYMPTOMS 803

FIG. 20. Case 3. X-ray 2 years postoperative showsa large ulcer crater in the jejunal pouch.

replaced by a stenosing area of scar tissue whichwas producing complete obstruction. This areawas excised and a new anastomosis done betweenthe gastric remnant and substitute pouch (Fig.22). The area where the pouch originally had beenanastomosed to the duodenum was entirely normal.

The postoperative course was excellent andthe patient was able to take solid foods on thefourth postoperative day. He has had no furtherabdominal discomfort and gastrointestinal x-raystudy shows a normally functioning gastric rem-

nant and pouch (Fig. 23). A 12-hour gastric se-

cretory study prior to discharge revealed 150 cc.

of gastric juice with no free HCI. The Hollandertest was negative (Fig. 24).

Comment. At the time of the pouch con-

struction it was observed that the patientpreviously had undergone a high gastricresection. Vagotomy was purposely notdone at this time. It is of interest that thepatient was completely asymptomatic for 2years following insertion of the Poth pouch,

but at this time symptoms of ulcer returned.When the recurrent ulcer was demon-strated in the jejunal pouch, it was believedthat a transthoracic vagotomy should bedone rather than an abdominal exploration.The transthoracic vagotomy would serve

FIG. 21. Case 3. X-ray 2 weeks following trans-thoracic vagotomy shows complete obstruction atthe junction of gastric remnant and substitutepouch.

FIG. 22. Case 3. At laparotomy 3 weeks fol-lowing transthoracie vagotomy, complete ulcerhealing is demonstrated resulting in cicatricialstenosis. Dotted lines show the area removed.

V'olume 162Number 5

804 HERRINGTON

FIG. 23. Case 3. Barium x-ray study 1 weekfollowing excision of the stenosed area shows thepouch functioning nicely.

as a beautiful clinical experiment to see ifit would result in healing of the ulcer. Re-lief of pain following vagotomy was dra-matic, and the ulcer healed readily but re-sulted in cicatrix obstruction proved byx-ray and subsequent abdominal explora-tion.

2

HOURS AFTER INSULIN

FIG. 24. Case 3. Hollander test before and aftertransthoracic vagotomy. There is no free HCI fol-lowing vagotomy.


This case serves to stress the importanceof adding vagotomy when a Poth pouch isemployed. Vagotomy should be given seri-ous consideration in such circumstanceseven though the patient has had a previ-ous radical gastric resection. Addition ofvagotomy with an antiperistaltic jejunalpouch component has not produced ob-struction in our patients. This, however,has presented a theoretical disadvantageand some observers are reluctant to addvagotomy when an antiperistaltic jejunalsegment is used as a pouch component.

Reversed (Antiperistaltic) JejunalSegment

During the past 2 years, four patientshave undergone reoperation for severedumping symptoms with interpolation ofa single 6 to 8 cm. antiperistaltic jejunalsegment between the gastric remnant andduodenum (Fig. 25). Each patient initiallyhad been subjected to vagotomy-antrec-tomy for duodenal ulcer. Marked dumpingsymptoms, weight loss and diarrhea oc-curred and were not amenable to conserva-tive treatment. The patients were all men,and an interval of 1 to 12 years passed be-fore remedial operation was advised. Agesof patients ranged from 41 to 59 years.

Result

Clinical results in two patients have beenexcellent. All gastrointestinal symptomshave disappeared, and both are perfectlysatisfied with the operation. In the tworemaining patients, symptomatology hasbeen greatly improved, and each has re-turned to work. Intermittent mild abdomi-nal discomfort of a minor nature, however,is still experienced. Appreciable weightgain following the remedial operation hasnot been observed, but diarrhea which wasso disturbing to each of the four patientshas disappeared. Blood counts have re-turned to normal in each instance. Appetitehas increased, and each patient is able to


consume a normal size meal (Fig. 26).Postoperative gastrointestinal studies dem-onstrate that the antiperistaltic segmentacts as a true reservoir and empties slowlyinto the duodenum.

Case ReportCase 4. A 49-year-old man was admitted to

St. Thomas Hospital on August 26, 1962 complain-ing of weakness, diarrhea and 40-pound weightloss for the past year following vagotomy andantrectomy performed for duodenal ulcer. Sinceoperation these symptoms had increased in se-verity. Treatment had consisted of diet, anti-spasmotics, sedation and serotonin antagonists,without benefit. Diarrhea had increased to 10 to12 stools daily, and, for fear of diarrhea and ab-dominal cramps, the patient had restricted hisoral intake.

On examination the patient appeared pale andchronically ill. Hemoglobin was 10 Gm., bloodurea nitrogen 9 and protein determinations werenormal. Liver function tests showed no derange-ment. An EKG, chest and barium enema x-rayswere normal. Gastrointestinal x-rays showed thatapproximately 50 per cent of the stomach hadbeen resected, and a well functioning gastroduo-denostomy was present. No marginal ulcer was

demonstrated. The gastric remnant emptied rap-

idly, and the barium column traversed the entiresmall bowel in 30 minutes. There was no freeHC1 in the gastric pouch.

At reoperation the gastroduodenostomy was

dismantled, and a 6 to 7-cm. antiperistaltic je-junal segment was isolated and delivered throughthe transverse mesocolon and interpolated betweenthe gastric remnant and duodenum. And end-to-

FIG. 26. Results fol-lowing insertion of asimple reversed jejunalsegment for control ofdumping.

FIG. 25. X-ray shows the reversed jejunal seg-ment interposed between the gastric remnant andduodenum.

end jejunojejunostomy was done to restore intes-tinal continuity.

The postoperative course was uneventful, andthe patient was discharged on the ninth postopera-tive day. Since discharge he has gained 20 poundsand has been relieved of all dumping symptoms.He has one to two formed stools each 24 hours.Hemoglobin has risen to 14 Gm. and he has re-turned to work. Oral intake is now adequate andsymptoms of lassitude and weakness have disap-

ANTIPERISTALTIC =JE JEJUNAL POUCH

PATIENT BEFORE POUCH AFTER POUCHPRIOR WEIGHT LOSS DUMPING, WEIGHT GAIN DUMPING,

NAME AGE OPERATION IN POUNDS DIARRHEA IN POUNDS DIARRHEA RESULTS

J|T.J. 41 | 25 ++++ 20 0 EXCELLENT

S.S. 49 40 + + ++ 20 0 EXCELLENT

C. C. 48 10 ++++ 10 0 GOOD

S.B. 59 20 ++++ 10 0 GOOD


HERRINGTON Annals of SurgeryNovember 1965

4i. .-AN^FIG. 27. Case 4. Barium x-ray study several weeks following insertion of a reversed jejunal

segment between the stomach pouch and duodenum. After 3 hours the pouch contains residualbarium and the barium column has not yet reached the colon.

peared. Gastrointestinal x-rays show reversed je-junal segment emptying slowly. After 3 hours thepouch has not completely emptied and the headof the column of barium has not yet reached thececum (Fig. 27).

Comment. Interpolation of the reversedjejunal segment between the gastric pouchand duodenum eliminated completelysymptoms of the dumping syndrome in thispatient. He has no dietary restrictions, andnow works daily as a postal letter carrier.

Discussion

In this country, only within recent yearshas interest been stimulated in the use of

organ transposition for the treatment ofdumping syndrome. British and Europeansurgeons have been more aggressive intheir surgical efforts to rehabilitate patientswith severe postgastrectomy symptoms.

Conversion from a Billroth II to BillrothI anastomosis for dumping symptoms hasresulted in some benefit to patients, as evi-denced by isolated case reports, but overallresults with this maneuver have been dis-appointing. Six such operations have beenperformed by the author with very littlepatient improvement. Procedures directedtoward decreasing the size of the stoma toretard gastric emptying also have been

806

Volume 162 REMEDIAL OPERATIONS FORNumber 5

fraught with difficulty, as partial obstruc-tion may result which is even more un-pleasant to the patient than is rapid gastricevacuation. With stomal narrowing, thepossibility of producing recurrent ulcera-tion from gastric stasis is another complica-tion worthy of consideration.

Segments of small intestine are at presentthe most frequently utilized hollow viscerafor replacing a portion of the stomach intreatment of the dumping syndrome. En-thusiasm for employment of colonic seg-ments has lessened, and perhaps this viscusis an unsuitable replacement organ for thetreatment of dumping. Isoperistaltic limbsof jejunum from 6 to 20 cm. in length havebeen widely used, and, when interpolatedin this manner, experience has shown thatadded vagotomy is mandatory to pre-vent recurrent ulceration.52 No doubt, thisshould apply whether the original lesionwas a duodenal or gastric ulcer. There isobjective evidence to show that the iso-peristaltic jejunal segment will retard gas-tric emptying, but possibly not to the de-gree that can be obtained with an anti-peristaltic segment.Lawrence prefers the isoperistaltic jeju-

nal pouch because he believes that it ispreferable for food-stuffs, particularly car-bohydrates, to undergo enzymatic hydroly-sis in the small intestine in order to off-setthe initiation of the dumping syndrome.With an antiperistaltic type pouch he be-lieves that duodenal secretions regurgitatedinto the pouch possibly might bring aboutrapid hydrolysis of starches with triggeringof the dumping syndrome. However, thisphenomenon has not occurred with the op-erations described by Poth or Jordan.The operation, originated by Jordan, of

interpolation of a short antiperistaltic jeju-nal segment between the stomach remnantand gastroenterostomy has had an exten-sive experimental trial and may result inimprovement in patients with severe dump-ing. The ideal length of the reversed jeju-nal segment to produce best results has not

PC)STGASTRECTOMY SYMPTOMS 807

yet been defined. Jordan uses a segment 6to 8 cm. long, whereas Poth describes asegment as long as 20 cm. Poth believesthat the segment should be longer than thegastric remnant and has observed no ob-struction in his patients. No doubt, a muchlonger reversed segment of jejunum canbe employed safely when interpolated be-tween the stomach and duodenum thanwhen a segment is reversed and placedback in continuity. The gastric remnant iscapable of strong and forceful contractions.A reversed segment of jejunum, whenplaced between the esophagus and stom-ach, invariably produces obstruction due toineffectual peristalsis.54The pouch described by Poth hyper-

trophies during the follow-up period, andparticularly is this true of the antiperistalticcomponent. An occasion presented itself inthe present series to inspect directly a Pothpouch 1 year postoperatively at the time ofrepair of a ventral hernia. Both componentsof the pouch had elongated and had hyper-trophied considerably.

In the present group of patients, al-though the series is small, clinical resultsobtained with the Poth pouch and thoseobtained with a single reversed jejunal seg-ment appear to be about equal. Weightgain has not been impressive with eitherremedial operation except in patients whooriginally had undergone high distal gas-trectomy. However following both pro-cedures the vasmotor components of thedumping syndrome were greatly improved.Even more impressive was diappearance ofgastrointestinal disturbances, for diarrheahad been disabling preoperatively in mostpatients. The single most striking objec-tive finding following either operation hasbeen correction of intestinal hurry as evi-denced by postoperative barium x-ray stud-ies and clinical evaluation.

Several patients who have undergoneremedial operation in this series were origi-nally operated upon by the author, whileseveral had the original operation per-

808 HERRINGTON

formed elsewhere. In our series of over1,600 patients who have undergone opera-tion for complications of duodenal ulcerduring the past 18 years, the incidence ofsevere dumping symptoms has been lessthan 1 per cent. Therefore, experience withremedial operations in the hands of any oneindividual will be somewhat limited.

Results of this study suggest that thesingle interpolation of an antiperistalticjejunal segment is just as effective as is themore complicated procedure described byPoth in treatment of the dumping syn-drome. The latter is more time consuming,technically more difficult and associatedwith increased patient morbidity. Three ofour eight patients developed anastomaticleaks which closed spontaneously.

In both groups of patients comprisingthe present study, at fluoroscopy and withcine studies, the radiologist was able todemonstrate a delay in emptying of theantiperistaltic segment which approachedthe emptying time of a normal stomach.Regurgitation back into the gastric pouch,however, was not observed in any of the12 patients.The question arises of whether vagotomy

should be performed when an antiperistal-tci pouch is inserted. All but two of ourpatients either had vagotomy performedinitially or at the time of the remedial op-eration. Of the two, one developed a re-current ulcer in the Poth pouch 2 yearsfollowing its insertion-and this patienthad been subjected to a high gastric resec-tion before the pouch was inserted. Pothhas not observed a recurrence in his series.He believes that when the antiperistalticcomponent of the pouch is used, vagotomyis not necessary, but this does not agreewith our experience. Although vagal inter-ruption with the Poth pouch perhaps maynot be as essential as with an isoperistalticjejunal pouch, only further laboratory andclinical experience will provide an answer.Since most patients in the present serieshad only a gastric resection of modest ex-


tent, it is our belief that vagotomy was anecessary addition. Even if the remedialoperation is done following a high resec-tion, we would favor the addition of vagot-omy. Further investigation also is neededto determine the desired length of theantiperistaltic jejunal segment necessary toproduce optimum rates of gastric empty-ing. No obstruction has taken place in pa-tients in the present studies in whom seg-ments of 6 to 20 cm. were used. Schlicke 65employed a reversed segment 15 cm. longin the single case that he reported.

It is our opinion that vagotomy is notcontraindicated by an antiperistaltic com-ponent to the pouch or by a simple re-versed jejunal segment. Vagotomy has notresulted in obstruction in such circum-stances and probably affords added pro-tection against recurrent ulceration. Inaddition, we believe that when a reversedjejunal segment is employed with vagot-omy, the segment should be less than 20cm. long.The anti-isoperistaltic jejunal pouch and

single reversed segments of jejunum asdescribed by Jordan and Christeas, and theremedial procedure cited in the presentcommunication, seem to show early promisein improving or alleviating severe dumpingsymptoms in patients who have not re-sponded to prolonged and intensive non-operative measures. It is hoped that ad-ditional experimental work will accumulateregarding this interesting problem. Clinicalapplication of these remedial proceduresshould, perhaps, remain restricted at pres-ent to those surgeons interested and ex-perienced in the problems of gastric sur-gery. Cases should be selected carefullyfor remedial operations, and there is needfor further evaluation of experimental andclinical data before these operations aregenerally adopted.

SummaryRemedial surgical procedures for the

control of severe dumping symptoms not

Volume 162 RENIEDIAL OPERATIONS FOR POSTGASTRECTOMY SYMPTONIS 809Number 5

responding to intensive medical therapyshould be considered in properly selectedcases.

Current concepts and results of varioussecondary operations designed to improveor alleviate the dumping syndrome havebeen discussed.Emphasis has been directed toward em-

ployment of a reversed (antiperistaltic)jejunal segment to serve as a substitutegastric reservoir for control of dumpingsymptoms.

Early results in a small group who under-went this latter operation have been en-couraging, but additional experimental andclinical date are necessary before the op-eration should be put to more widespreaduse.

References

1. Abbott, W. E., H. Krieger and S. Levey:Technical Surgical Factors Which Enhanceor Minimize Postgastrectomy Abnormalities.Ann. Surg., 148:567, 1958.

2. Barnett, W. O., J. K. Goodrich and T. L. Kil-gore, Jr.: Intestinal Absorption. Amer. J.Surg., 105:73, 1963.

3. Barnett, W. O.: Personal communication.4. Biebl, M.: Interpositions-Billroth I Mittels-

Ausgeschalleter Dunndarmschlinge ein neuesPlastiches Anastomosierugverfohren bei derMagenresektion mit Gultigkeit nur fur, das-Ulkus. Zbl. Chir., 72:1668, 1947.

5. Capper, W. M. and R. B. Welbourn: EarlyPost-Cibal Symptoms Following Gastrec-tomy, Etiologic Factors, Treatment andPrevention. Brit. J. Surg., 43:24, 1955-56.

6. Christeas, N. G., G. Kotlahis, A. Perimenisand A. Megalooeconomore: ExperimentalStudy of the Rate of Evacuation of Gastrec-tomized Stomach, EKG Findings, and theBlood Volume and Blood Chemistry ChangesAfter Segmental Antiperistaltic Position ofthe Efferent Loop. Acta Chir. Belg., 6:3,1960.

7. Christiansen, P. M. and K. H. Koster:Pantaloon Anastomosis for Dumping andSimilar Symptoms Following Partial GastricResection. Acta Chir. Scand., 127:379, 1964.

8. Dragstedt, L. R.: Personal communication.9. Enderlen and Hess: Ueber Antiperistaltik.

Duetsche Z. Chir., 59:240, 1901.10. Friesen, S. R. and E. Rieger: A Study of the

Role of the Pylorus in the Prevention of theDumping Syndrome. Ann. Surg., 151:517,1960.

11. Gerwig, H. W., Jr.: Personal communication.12. Gerwig, H. W., Jr. and A. Ghaphery: Experi-

mental Attempt to Delay Alimentary Transitafter Small Bowel Exclusion. Arch. Surg.,87:50, 1963.

13. Gibson, L. D., R. Carter and D. H. Hinshaw:Segmental Reversal of Small Intestine afterMassive Bowel Resection. J.A.M.A., 182:154, 1962.

14. Hammer, J. M., P. H. Seay, R. L. Johnson,E. J. Hi l, F. H. Priest and R. J. Campbell:The Effect of Antiperistaltic Bowel Seg-ments on Intestinal Emptying Time. Arch.Surg., 79:537, 1959.

15. Hammer, J. M., P. H. Seay, E. J. Hill, F. W.Priest and R. J. Campbell: Intestinal Seg-ments as Internal Pedicle Grafts. Arch.Surg., 71:625, 1955.

16. Hammer, John M.: Personal communication.17. Harkins, H. N.: Personal communication.18. Hay, R. P.: Anatomic and Physiologic Recon

struction Following Total Gastrectomy b3the Use of a Jejunal Poth Pouch. Surg.Forum, 4:291, 1954.

19. Hedenstedt, S. and F. Heijkenskjold: Sec-ondary Jejunal Transposition for SevereDumping Following BilEroth I Partial Gas-trectomy. Acta Chir. Scand., 121:262, 1961.

20. Hedenstedt, S.: Gastrectomy with Jejunal Re-placement. Acta Chir. Scand., 117:295,1959.

21. Hedenstedt, S. and F. Heijkenskjold: PartialGastrectomy with Jejunal Transposition andVagotomy. Paper given before the 19thCongress of International Society of Sur-geons, Dublin, Ireland, Sept. 6, 1961.

22. Hedenstedt, S.: Personal communication.23. Henley, F. A.: Gastrectomy with Replacement.

British J. Surg., 40:118, 1952-1953.24. Henley, F. A.: Personal communication.25. Hinshaw, D. B., E. J. Jorgenson, H. A. Davis

and C. E. Stafford: Peripheral Blood Flowand Blood Volume Studies in the DumpingSyndrome. Arch. Surg., 74:686, 1957.

26. Hunt, C. J.: Personal communication.27. Ivy, A. C.: Brief Review of Physiology of the

Duodenum. Radiology, 9:47, 1927.28. Jezioro, Z. and H. Kus: Zur Frage der Sachar-

row-Henleyschen Operationstechnik-Lentrall-blatt fur Chir., 83:1229, 1958.

29. Johnson, L. P., R. D. Sloop, J. E. Jesseph andH. N. Harkins: Serotonin Antagonists in Ex-perimental and Clinical Dumping. Ann.Surg., 156:537, 1962.

30. Johnsrud, R. L.: Treatment of PostgastrectomyDumping Syndrome with Thiazide Deriva-tives. West. J. Surg., 70:1, 1962.

31. Jordan, G. L., Jr.: The Afferent Loop Syn-drome. Surgery, 38:1027, 1955.

32. Jordan, G. L., Jr., R. C. Overton and M. E.DeBakey: The Postgastrectomy Syndrome.Ann. Surg., 145:471, 1952.

33. Jordan, G. L., Jr., J. W. Overstreet and G. H.Peddie: The Use of Blood Transfusions inthe Treatment of the Postgastrectomy Syn-drome. Surgery, 42:1055, 1959.

34. Jordan, G. L., Jr., R. T. Angel, J. S. Mc-Ilhaney, Jr. and R. K. Willms: Treatmentof the Postgastrectomy Dumping Syndromewith a Reversed Jejunal Segment Interposedbetween the Gastric Remnant and the Je-junum. Amer. J. Surg., 106:451, 1963.

35. Jordan, G. L., Jr. Personal communication.36. Kelling, G.: Studies Zur Chirugie des Magens.

Langenbecks Arch. Klin. Chir., 62:362,1900.

8 10 HERRINGTON Annals of SurgeryNovember 1965

37. Kirstein, A.: Experimentelles Zur Pathologiedes Ileus. Deutsche Med. Wschr., 15:1000,1889.

38. Kocher, T.: Textbook of Operative Surg.,Ed. 3. New York, MacMillan Co. 2:625,1911.

39. Krause, U.: Partial Gastrectomy with JejunalTransposition: A Follow-Up Investigation of80 Patients Treated Operatively. Acta Chir.Scand., 123:132, 1962.

40. Lawrence, XV., Jr.: Personal communication.41. Machella, T. E.: MIechanism of the Postgas-

trectomy Dumping Syndrome. Ann. Surg.,130:145, 1949.

42. Mackby, M. J.: Personal communication.43. Madding, G. F.: Personal communication.44. Mall, F.: Reversal of the Intestine. Johns Hop-

kins Hosp. Rep., 1:93, 1896.45. May, A. M.: Reversed Intestinal Flow: Recur-

rent Anastomosis. West. J. Surgery, 65:151,1957.

46. McClure, R. D. and H. F. Derge: A Studyof Reversal of the Intestine. Johns HopkinsHosp. Bull., 18:472, 1907.

47. Moroney, J.: Colonic Replacement and Resto-ration of the Human Stomach. Ann. Roy.Coll. Surg. Eng., 12:328, 1953.

48. Moroney, J.: Colonic Replacement and Res-toration of the Normal Stomach. Ann. Roy.Coll. Surg. Eng., 12:328, 1953.

49. Moroney, J.: Colonic Replacement of theStomach. Lancet, 1:993, 1951.

50. Muhsam, R.: Experimentelles Zur Frage desAntiperistaltik, Mittheilungen aus d. Grenz-gebieten d. Medizin U. Chirurgie, 6:451,1900.

51. Muir, A.: Postgastrectomy Syndromes. Brit.J. Surg., 37:165, 1949.

52. Nyhus, L. M.: Jejunal Loop Interposition.Arch. Surg., 85:223, 1962.

53. Peskin, G. WV. and L. D. Miller: The Role ofSerotonin in the Dumping Syndrome. Arch.Surg., 85:701, 1962.

54. Pories, W. J., R. D. Gerle, C. D. Sherman andJ. R. Hinshaw: The Danger of EsophagealReplacement with Antiperistaltic Loops ofSmall Bowel. Ann. Surg., 156:68, 1962.

55. Poth, E. J.: Surgical Correction of SevereDumping and Postgastrectomy Malnutrition;A Therapeutic and Diagnostic Test. Ann.Surg., 160:488, 1964.

56. Poth, E. J.: The Dumping Syndrome and ItsSurgical Treatment. Amer. Surg., 23:1097,1957.

57. Poth, E. J.: The Substitution Gastric Pouch.Texas Rep. Biol. Med., 17:238, 1959.

58. Poth, E. J. and B. R. Cleveland: A FunctionalSubstitution Pouch for the Stomach. Arch.Surg., 83:58, 1961.

59. Prutz, W. and A. Ellinger: Ueber die Folgendes Darmgegenschalting. Zugleich ein Beit-rag Zur Lebre Von des Indicancine. Arch.Klin. Chir., 67:964, 1902.

60. Roberts, K. E., H. T. Randall, H. XV. Farrand A. P. Kidwell: Cardiovascular andBlood Volume Alterations Resulting fromIntrajejunal Administration of HypertonicSolutions to Gastrectomized Patients. Rela-tionship of These Changes to Dumping Syn-drome. Ann. Surg., 140:631, 1954.

61. Rutledge, R. H.: Comments on Henley'sRemedial Operation for Dumping Syndrome.Surgery, 55:762, 1964.

62. Rutledge, R. H.: Personal communication.63. Sabbatani and Fasola: Arch. Ital. Biol., 34:

195, 1900.64. Sacharow, E. I. and A. E. Sacharow: Dunn-

darmplastik bei der Magenresektion. Zbl.Chir., 83:1221, 1958.

65. Schlicke, C. P.: Complications of Vagotomy.Amer. J. Surg., 106:206, 1963.

66. Schlicke, C. P.: Personal communication.67. Singleton, A. O., Jr. and E. B. Rose: Peri-

stalsis in Reversed Loops of Bowel. Ann.Surg., 139:853, 1954.

68. Singleton, A. O., Jr., D. C. Redmond, II andJ. E. McMuray: Effects of Ileocecal Resec-tion on Small Bowel Transit and Absorption.Ann. Surg., 159:690, 1964.

69. Soupault, R. and M. Bucaille: La Transplanta-tion de L'anse Efferente an Duodenum Op-eration Correctrice de Certaines Gastrec-tomies Subtotales. Rev. Chir., 92:93, 1954-55.

70. Stahlgren, L. H., G. Umana, R. Roy and J.Donnelly: A Study of Intestinal Absorptionin Dogs Following Mlassive Small IntestineResection and Insertion of An AntiperistalticSegment. Ann. Surg., 156:483, 1962.

71. Stahlgren, L. H.: Personal communication.72. Steinberg, M. E.: Gastric Surgery-Errors,

Safeguards and Management of MalfunctionSyndromes. Appleton-Century-Crofts, 1963.

73. Walker, J. M., K. E. Roberts, A. Medwid andH. R. Randall: The Significance of theDumping Syndrome. Arch. Surg., 71:543,1955.

74. Walters, W. and J. W. Nixon, Jr.: DoubleJejunal Loop Replacement of Resected Stom-ach for Bilious Vomiting. Arch. Surg., 79:479, 1959.

75. Walters, W. and L. Tana: Jejunal Loop In-terposition. Arch. Surg., 82:171, 1961.

76. WVangensteen, 0. H.: Intestinal Obstruc-tions, Ed. 3. Springfield, Illinois, Charles C.Thomas, 1955.

77. Watkins, D. H.: Personal communication.78. WVatkins, D. H. and G. Withenstein: Subtotal

Gastric Resection with Colon Substitution.Arch. Surg., 70:843, 1955.

79. Wells, C. A. and I. W. MacPhee: The AfferentLoop Syndrome. Lancet, 2:1189, 1952.

80. Willms, R. K., H. L. Barton, R. T. Angel andG. L. Jordan, Jr.: Reversed Intestinal Seg-ments and Their Effects Upon Gastroin-testinal Mortality, Nutrition, and the Dump-ing Syndrome Following Subtotal Gastrec-tomy in Dogs. Amer. Surg., 29:356, 1963.

81. Willms, R. K., R. T. Angel and G. L. Jordan,Jr.: Effect of Reversed Jejunal SegmentUpon Gastric Emptying, Nutrition andPlasma Volume Following Subtotal Gas-trectomy. Surg. Forum, 12:317, 1961.

82. Willms, R. K. and G. L. Jordan, Jr.: ReversedJejunal Segment, Effect on Gastric Empty-ing and Nutrition Following Subtotal Gas-trectomy in Six Days. J.A.M.A., 178:1008,1961.

83. Woodward, E. R. and N. Hastings: SurgicalTreatment of the Postgastrectomy DumpingSyndrome. Surg. Gynec. & Obstet., 111:429,1960.

Volume 162 REMEDIAL OPERATIONS FOR POSTGASTRECTOMY SYMPTOMS 8Number 5

84. Woodward, E. R.: The Postgastrectomy Syn-dromes. Charles C Thomas, Springfield, Ill.,1963.

85. Woodward, E. R.: Personal communication.

Additional References86. Annersten, S.: Gastric Resection with Jejunal

Replacement; A Method Attended by Negli-gible Post Cibal Symptoms. Acta Chir.Scand., 117:311, 1959.

87. Baldwin, Price, H. K. Coppd, A. 0. Singleton,Jr.: Reversed Intestinal Segments in theManagement of Aneretic Malabsorption Syn-drome. Ann. Surg., 161:225, 1965.

88. Christiansen, P. M. and K. H. Foster: Panta-loon anastomosis for dumping and similarsymptoms following partial gastric resection.Acta. Chir. Scand., 127:379, 1964.

89. Hedenstedt, S.: Experience with Gastric Re-sections with Transposition of the Jejunumand Vagotomy. Acta Chir. Scand., 125:518,1963.

90. Hedenstedt, S. and F. Heijkenskjold: Twen-tieth Congress de la Societe Internationalede Chirurgie 1070, 1963. Imprimerie Medi-cale et Scientifiolie, Bruxelles.

91. Kay, A. W. and A. G. Cox: Jejunal Trans-position for the Postgastrectomy Patient.Brit. J. Surg., 51:763, 1964.

92. Keller, James W., W. R. C. Stewart, R. West-erheide and W. G. Pace: Prolonged Survivalwith Paired Reversed Segment After Mas-sive Intestinal Resection. Arch. Surg., 91:174, 1965.

93. Knox, W. G.: Use of a Jejunal Pouch in Treat-

ing Post-Gastrectomy Malnutrition. Ann.Surg., 161:35, 1965.

94. Lawrence, W. J., M. Kim, NI. Isaacs and H. T.Randall: Gastric Reservoir Construction forSevere Disability after Subtotal Gastrectomy.Surg. Gynec. & Obstet., 119:1219, 1964.

95. Lilljekvist, R.: Results in 53 cases of Gas-trectomy with Jejunal Transposition. ActaChir. Scand., 119:182, 1960.

96. Mackby, M. J., V. Richards, R. S. Gilfillanand R. Floridia: Methods of Increasing theEfficiency of Residual Small Bowel Seg-ments. Amer. J. Surg., 109:32, 1965.

97. Madding, G. F., P. A. Kennedy and R. T. Mc-Laughlin: Clinical Use of Anti-peristalticBowel Segments. Ann. Surg., 161:601, 1965.

98. Sako, K. and G. E. Blackman: The Use of aReversed Jejunal Segment after Massive Re-section of the Small Bowel: An ExperimentalStudy. Amer. J. Surg., 103:202, 1962.

99. Silver, D., W. G. Anlyan, R. W. Postlethwait,C. V. Morgan and C. E. Mengel: SeratoninMetabolism and the Dumping Syndrome.Ann. Surg., 161:995, 1965.

100. Williams, J. S.: Effect of Duodenal and Je-junal Transposition on Iron Absorption inDogs. Surg. Forum, 14:370, 1963.

101. Winchester, David P., J. P. Fotopoulos andR. P. Hohf: Reversed Jejunal Segment Re-placement of the Stomach. Surg. Gynec. &Obstet., 120:1213, 1965.

102. Wirts, C. W., J. Y. Templeton, III, C. Fine-berg and F. Goldstein: The Correction ofthe Postgastrectomy Malabsorption followinga Jejunal Interposition Operation. Gastro-enterology, 49:141, 1965.

Book ReviewsAtlas of Hand Surgery: Horace Iselin, M.D., Translated by John C. Colwill, McGraw-

Hill Book Co., 1964, 325 pages, $19.50.This book contains 693 line drawings illustrating the anatomy, splinting technics

and operative procedures used by Dr. Marc Iselin, a prominent European hand surgeon.Preoperative evaluation and postoperative care are not considered. The technics de-scribed are not unfamiliar since most are based upon contributions of American pioneers-Knavel, Bunnell, Koch and Mason-who inspired the author to study in the UnitedStates at the Johns Hopkins Hospital.

Illustrations and descriptions of procedures for treatment of acute trauma andreconstructive procedures for disabilities resulting from trauma are extensive andcomplete. Operative technics for treatment of infections are also considered as well ascongenital anomalies, and operations on the arthritic hand are inadequately discussedand prosthetic appliances and microsurgical technics are not mentioned. The illustra-tions documenting an eminent author's personal experience are excellent; addition ofthe deficient material would make the atlas superior.

The illustrations are clear. The text (translated by Dr. J. C. Colwill) is idiomatic,concise and instructive. Printing is excellent and binding is good. The table of contentsis logically arranged. There is neither an index or a bibliography.

The book is recommended for institutional libraries and for students and practi-tioners of surgery of the hand. As is true of any atlas of surgical technic, this one, ofitself, will not make a hand surgeon.

THEOBALD REICH, M.D.

Continued on page 862

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