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Surgeons Abandon Roux en Y
"And, indeed, since 1981, J C McAlhany, Jr., Department of Surgical Education, Greenville Hospital System, South Carolina, Ann Surg. 1994 May; 219(5): 451–457. Long-term follow-up of patients with Roux-en-Y gastrojejunostomy for gastric disease.
DR. WALLACE P. RITCHIE, JR. (Philadelphia, Pennsylvania): ... what the authors have shown is that on a consecutive series of 24 patients, converted for a variety of reasons to a Roux-en-Y gastrojejunostomy over a 5-year period, a substantial number experienced clinical failure on longterm follow-up, averaging in this case almost 11 years. And of note the majority of these failures were ascribed to the rapid development of what was thought to be, and very probably was, As one looks at the rapidly accumulating clinical literature on this topic, one comes to the unhappy conclusion that the results we've heard detailed today are about as good as they're going to get. A single accomplished surgeon using standard, widely agreed-upon indications for the use of the Roux-en-Y, employing an accepted technique in a careful, consistent manner, achieving excellent perioperative results in terms of morbidity and mortality-and what do we wind up with? After careful evaluation of the long-term outcome of his efforts, he's found precisely what numerous others before him have also found to their own dismay. At best, unfavorable, and at worst, unacceptable clinical outcomes in one third of patients, 75% of which were the consequence of the Roux stasis syndrome. I have three specific questions, iterating some of what Dr. Sawyers said, and one somewhat more provocative query which is probably unanswerable. First, with respect to those patients who do develop Roux stasis, were you able to identify any preoperative or intraoperative factors which might have contributed? For example, was there a gender element, as some have suggested? Did any ofthese patients experience early satiety or delayed emptying before conversion to the Roux, as Dr. Sawyers intimated? Were any of these patients addicted to analgesics? "The nervous pukers of the world" tend to take a lot of analgesics, I've noted? Also, coincident with the creation of the Roux, 11 patients in the group underwent concomitant vagotomy. Do you think this contributed? My second question relates to the technical conduct of the operation. Specifically, did you make any concerted attempt to leave a small residual gastric pouch in these patients? Others have suggested that this may lessen the incidence of Roux stasis. Did you perform the gastrojejunostomy in those primary reconstructions in an antecolic or retrocolic fashion? Some also feel these are important considerations. Now, third, how did you manage those patients who developed Roux stasis? How should we manage them? What do you do? My philosophical query is this. I note that your series ended in 1981. Have you created many Rouxs since that time? Or have your results discouraged you from doing so? There certainly is no sin in that, as Cesar Roux himself exemplified. Roux was a man of considerable intellect and great scholarly integrity. And shortly after being appointed the first Professor of Surgery at Lausanne in 1892, he devised his operation which he called the L'Anse en Y. Between 1892 and 1900, he performed 1 6 procedures, which he then proceeded to analyze detail. Based on that analysis, he completely abandoned the operation in 1911 because of poor outcomes. My query to you, Dr. McAlhany, is, should we consider doing the same thing? If not, when and to whom should apply it? If so, is there an acceptable substitute, as Dr. Vogel and his colleagues are about to try to convince us? |
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