Randomized trial of three types of gastrojejunostomy in unresectable periampullary cancer

Background. A gastrojejunostomy with duodenal partition was designed to clarify whether so-called circulus vomiting exists and, if so, its clinical significance, by comparing it with two other types of gastrojejunostomy commonly used for gastric bypass in unresectable periampullary cancer. Methods. Forty-five patients with unresectable periampullary cancer complicated by gastric outlet obstruction (GOO) were recruited into this study between May 1992 and November 1995. They were randomized to receive one of the three types of gastrojejunostomy. The anastomosis in type I gastrojejunostomy was performed at the jejunum 20 cm distal to the ligament of Treitz. Type II was similar to type I except to that in type II a duodenum partition was done by linear stapler 1 cm beyond the pylorus. Type III gastrojejunostomy was performed at the Roux-limb jejunum 60 cm distal to biliojejunostomy. Results. 'Food reentry' was noted in three (21%) of the type I patients, as determined by upper gastrointestinal (UGI) study. Of the three, one patient had severe circulus vomiting, one had anorexia, and one had no major symptoms. When patients were evaluated immediately after oral diet intake resumed, the incidence (27%) of clinical GOO symptoms and mean value of gastric emptying time (GET(1/2), 118.1 ± 39.2 min) were significantly lower in type II patients than in types I and III patients. When evaluated 1 month after operation, the incidence (7% and 17%, respectively) of clinical symptoms of GOO and mean value of GET( 1/4 ) (42.0 ± 23.0 and 35.6 ± 5.4 min, respectively) were significantly lower in both type II and type III patients than in type I patients. The type II patients resumed oral diet after operation 3.5 days earlier than type I patients, p < 0.05. Conclusions. Circulus vomiting induced by food reentry does exist if the gastrojejunostomy is performed as the type I gastrojejunostomy in this study. The newly designed type II gastrojejunostomy with duodenal partition is an easy, safe, and effective gastric bypass and avoids the problem of food reentry.