after Gastrojejunostomy

An Analysis of When Patients
after Gastroj ejunostomy
Eat
DAVID FROMM, M.D., DENNIS RESITARITS, M.D., and ROBERT KOZOL, M.D.
Eighty-five patients who underwent a gastrojejunostomy either
alone or in conjunction with vagotomy or gastric resection were
evaluated for the day of beginning an oral intake adequate
enough to sustain nonoliguric output. This occurred on the
average by the seventh to eighth postoperative day, by which
time at least 78% of patients were consuming an adequate oral
intake. Adequate liquid intake occurred on the average 53
days in the absence of vagotomy and 8.8 days in the presence of
vagotomy. However, this significant difference is accounted for
by the patients who had gastrojejunostomy with vagotomy.
Vagotomy with antrectomy, antrectomy alone, and subtotal
gastrectomy were not significantly different. The apparent influence of vagotomy on gastrojejunostomy may be due to a type
II statistical error. However, 92% of patients who had vagotomy with pyloroplasty consumed adequate liquids by the seventh postoperative day compared with 56% of patients who had
vagotomy with gastrojejunostomy.
From the Department of Surgery, SUNY-Health Science
Center at Syracuse, Syracuse, New York
viewed for the years 1979-1986. To qualify for analysis,
the patients had to satisfy specific criteria. These include
the absence of( 1) carcinoma, perforation, peritonitis, or
sepsis either before or after operation, (2) renal or respiratory or cardiac failure either before or after operation,
(3) inflammatory bowel disease or insulin-dependent
diabetes, (4) anastomotic leak and/or wound complications, (5) operative placement of either a prograde nasogastric or a retrograde jejunal tube through the anastomosis, (6) nonanastomotic bowel obstruction distal to
the duodenum either before operation or in the immediate postoperative period, (7) emergent operation, (8) infection outside of the peritoneal cavity, and (9) hypokalemia. An additional criterion for inclusion into the
study was access to an unrestricted intake of a liquid diet
within 12 hours of passing flatus after operation. Fortyeight patients did not meet these criteria and were excluded from analysis unless stated specifically to the
contrary. There was no operative mortality in patients
who met the above criteria.
A data sheet was established before the study. The
data sheet was designed to obtain specific information to
answer specific questions to avoid random correlations
that might appear as a result of statistical analyses. Information on the data sheets was entered into a data
base computer file, the contents of which were rechecked against the original patient records to ensure
accuracy. Three patient records did not contain the information required and were excluded from analysis.
Adequate oral liquid intake was prospectively defined
as consumption of enough liquid to maintain a urinary
output of greater than 480 ml/24 h for the rest of the
patient's required hospitalization. However, three
~
ELAYED GASTRIC EMPTYING is the most frequent immediate postoperative complication
directly related to a gastroenteric anastomosis.' However, the definition of a postoperative delay in
gastric emptying varies and thus the incidence also
varies. Information about when patients are able to
consume an adequate oral liquid intake after gastrojejunal anastomosis is difficult to find. In this study we
examine this question and some factors that may predispose to a delay in gastric emptying.
D
Methods
The charts of all patients who underwent a gastrojejunal anastomosis with or without gastric resection or
with or without vagotomy at the University Hospital of
the SUNY Health Science Center at Syracuse and the
Syracuse Veterans Administration Hospital were re-
Reprint requests and correspondence: David Fromm, M.D., Department of Surgery, Wayne State University, 6C, University Health
Center, 4201 St. Antoine, Detroit, MI 48201.
Submitted for publication: July 20, 1987.
14
VOL. 207 . NO. I
ORAL INTAKE AFTER GASTROJEJUNOSTOMY
fourths of the patients were still receiving intravenous
fluids when they started oral intake. If the intravenous
fluids were continued for more than 24 hours for any
reason after the start ofwhat appeared to be an adequate
oral intake, the patient was not included in the analysis.
This criterion resulted in the exclusion of an additional
17 patient records. If a patient met the definition of
adequate oral intake while still receiving intravenous
fluids within 24 hours of starting oral fluids, the patient
had to continue to meet the requisite urinary output
after discontinuation of the intravenous line in order to
continue to qualify for adequate intake. The requisite
urinary output also had to be met when the patient was
taking solid food, but no value was assigned to the adequacy of solid food intake.
Statistical analyses included frequency and independent t-test.
Results
Age, Sex, and Operation
The age of the patients ranged from 19 to 86 years
with a mean (±SE) of 52.4 ± 1.9 years and a median and
mode of 49 years. Forty-three patients were men and 42
were women. The various types of operations are shown
in Table 1. There is a relatively large group of patients
who underwent a gastrojejunostomy without an accompanying vagotomy. Eight patients in this group had prophylactic gastrojejunostomy done for what was erroneously diagnosed as carcinoma ofthe pancreas at the time
of operation or duodenal obstruction due to chronic
pancreatitis (these assessments are based on the subsequent clinical course extending 4-8 years after operation); three had duodenal obstruction related to prior
operative trauma occurring at least 7.5 months previously; three had prior inadvertent vagotomy during
operations for esophageal reflux at least 12 months previously; and three had prior vagotomy with a poorly
functioning pyloroplasty performed at least 15 months
previously.
Day ofLiquid and Solid Intake
The mean postoperative day of starting an adequate
oral liquid intake for the entire group ofpatients was 7.7
+ 0.9 and for solid intake it was 10.9 ± 1.1.
The cumulative frequencies of the postoperative days
when liquid and solid intake were started and continued
without difficulty are shown in Table 2. By the fourth
postoperative day 29% of patients and by the seventh
postoperative day 78% of patients were taking adequate
liquids. In contrast, by the sixth postoperative day 28%
of patients and by the eleventh day 78% of patients were
taking solids. The mean difference in number of days
15
TABLE 1. Operations Performed
Type
N
Gastrojejunostomy
Vagotomy + gastrojejunostomy
17
16
11
26
15
85
Antrectomy
Vagotomy + antrectomy
Subtotal gastrectomy
Total
between starting liquids and solids was 3.2 ± 0.4 and the
difference was 3 days in 77% of the patients.
Obstruction Versus No Obstruction
The mean postoperative day of starting an adequate
oral liquid intake for patients undergoing operation for
obstruction was 6.5 0.4 and for those without obstruction it was 8.3 1.3. The mean difference is not
significant.
The cumulative frequencies of the postoperative days
when liquid and solid intake were started and continued
without difficulty in patients with preoperative obstruction (28%) and no obstruction (78%) are shown in
Tables 3 and 4. By the seventh postoperative day, an
almost equal percentage of patients began a liquid diet
(Table 3). By the ninth postoperative day, an almost
equal percentage of patients began a solid diet (Table 4).
Vagotomy was performed in 11 of 24 patients with
obstruction. There was no significant difference in terms
TABLE 2. Cumulative Frequencies of Days Starting Liquid and Solid
Intakefor All Patients with Gastrojejunostomy
Solid Intake
Liquid Intake
Day
Cum %
Z Score*
Day
Cum %
Z Score*
3
4
5
6
7
8
10
11
12
22
23
39
65
8.2
29.4
55.3
69.4
77.6
83.5
87.1
90.6
91.8
95.3
97.6
98.8
100.0
-0.56
-0.44
-0.32
-0.20
-0.08
-0.03
0.27
0.39
0.51
1.69
1.81
3.70
6.77
3
4
5
6
7
8
9
10
11
12
13
14
16
1.2
8.2
15.3
28.2
45.9
56.5
69.4
72.9
77.6
78.8
82.4
84.7
85.9
88.2
91.8
92.9
94.1
97.6
98.8
100.0
-0.82
-0.71
-0.61
-0.51
-0.40
-0.30
-0.20
-0.10
0.01
0.11
0.21
0.32
0.52
0.62
0.93
1.45
1.65
2.58
2.89
5.87
17
20
25
27
36
39
68
* Z score = SD below or above mean.
TABLE 3. Cumulative Frequencies ofDays Starting Liquid Intake
Obstruction N = 24
Day
Cum %
3
4
5
6
7
4.2
16.7
8
9
10
11
12
22
23
39
65
*
Z score
=
Z Score*
33.3
62.5
75.0
87.5
-1.46
-1.02
-0.57
-0.13
0.31
0.76
100.0
2.08
Cum %
Z Score*
9.8
34.4
57.4
72.1
78.7
80.3
82.0
86.9
-0.54
-0.43
-0.33
-0.23
-0.13
-0.03
0.07
0.17
88.5
93.4
96.7
98.4
100.0
0.38
1.39
1.49
3.12
5.76
Vagotomy
A comparison of all patients who had a vagotomy was
made with all but one patient who did not have a vagotomy. This patient did not start adequate oral intake
until the 65th day after a gastrojejunostomy and was
excluded from this analysis. Liquid intake was started
on the fifth postoperative day (5.3 ± 2.1, N = 42) when
vagotomy was not done. This is in contrast to the ninth
mean postoperative day (8.8 ± 7.4, N = 42) when vagotTABLE 4. Cumulative Frequencies of Days Starting Solid Intake
Day
No Obstruction N = 61
Cum %
Z Score*
Cum %
8.3
12.5
20.8
29.2
50.0
66.7
70.8
75.0
-1.43
-1.16
-0.90
-0.64
-0.37
-0.11
0.15
0.42
83.3
87.5
0.94
1.21
8.2
16.4
29.5
52.5
59.0
70.5
73.8
78.7
80.3
82.0
83.6
91.7
100.0
1.73
2.00
3
4
1.6
5
6
7
8
9
10
11
12
13
14
15
16
17
20
25
27
36
39
68
Z score
=
SD below or above mean.
Z Score*
-0.76
-0.67
-0.58
-0.49
-0.41
-0.32
-0.23
-0.14
-0.05
0.04
0.13
0.22
88.5
90.2
91.8
96.7
0.76
1.20
1.38
2.18
98.4
100.0
2.45
5.04
A+V
80+
c
CT
0~
G+V
60 +
L.
4,
40+
0
E
20 +
0
0
SD below or above mean.
Obstruction N = 24
100T
No Obstruction N = 61
of the day liquids or solids were started in patients with
or without vagotomy.
*
Ann. SUrg. . January 1988
FROMM, RESITARITS, AND KOZOL
16
5
10
Postoperative Day
FIG. 1. Cumulative frequencies of postoperative day of starting adequate liquid oral intake after the various operative procedures. STG
= subtotal gastrectomy. A = antrectomy. G = gastrojejunostomy. A
+ V = antrectomy with vagotomy. G + V = gastrojejunostomy with
vagotomy.
done. This 3.5-day difference in means is significant (p < 0.004).
Analysis by operative procedure is shown in Figure 1,
which compares the cumulative frequencies of the various operations up to the 12th postoperative day. There
is no significant difference between patients who had
gastrojejunostomy alone, antrectomy alone, antrectomy
with vagotomy, and subtotal gastrectomy. However,
there is a significant difference between these groups of
patients and those who had vagotomy with gastrojejunostomy (p < 0.01).
Because ofthe sharp difference observed for the day of
starting adequate liquid oral intake after vagotomy with
gastrojejunostomy, this procedure was compared with
vagotomy with pyloroplasty (Heineke-Mikulicz) done
during the same period of review and meeting the criteria listed in Methods (Fig. 2). By the seventh postoperative day, 92% of the patients who had vagotomy with
pyloroplasty were taking adequate liquids orally in contrast to 56% of the patients who had vagotomy with
gastrojejunostomy (p = 0.02). This difference did not
appear to be attributable to variations in suture technique or use of an electrosurgical unit. The mean time
for the start of an adequate liquid intake for patients
who had vagotomy with pyloroplasty did not significantly differ from the operative procedures (other than
vagotomy with gastrojejunostomy) listed in Table 1.
omy was
Antecolic Versus Retrocolic Anastomosis
Most of the anastomoses (76%) were done in a retrocolic fashion. All but four of the gastrojejunostomies
without vagotomy (76.5% = 13 patients), all but one of
the gastrojejunostomies with vagotomy (93.8% = 15 patients), all but eight of the antrectomies with vagotomy
(69.2% = 18 patients), all but three of the antrectomies
Vol. 207 - No. I
ORAL INTAKE AFTER GASTROJEJUNOSTOMY
without vagotomy (72.7% = 8 patients), and all but four
of the subtotal gastrectomies (73.3% = 11 patients) were
performed in a retrocolic fashion. No significant difference for the group as a whole was apparent in comparing
antecolic to retrocolic anastomoses. Significant differences also were not apparent by nonparametric analyses
of the individual operative procedures.
Nasogastric Tube
A nasogastric tube was used after operation in 81.2%
of the patients. Analysis of a 24-hour nasogastric tube
output for each of the first three postoperative days
showed no correlation with the time of starting adequate
oral intake of liquids or solids. Furthermore, there was
no correlation between the total or average nasogastric
tube output and day of starting adequate oral liquids or
solids. The average output for all patients was 397 ± 34
ml (mean ± SE, N = 68) for the first postoperative 24
hours, 541 + 66 ml (N = 68) for the second 24 hours,
and 403 ± 58 ml for the third 24 hours (N = 58). There
were some significant differences in mean nasogastric
outputs when comparing the various operative procedures. The mean output during the first postoperative
day for patients who had gastrojejunostomy alone was
significantly greater (p < 0.05) than the other operations. In addition there were some random significant
differences in mean 24-hour outputs among the operative procedures on the second and third postoperative
days.
No Nasogastric Tube
Only 16 patients did not have a nasogastric tube during their postoperative course. Ten of these patients
began adequate oral intake by the end of day 5. The
remaining six patients began adequate oral intake by
days 6 to 12.
Electrosurgical Unit
Only 34% of the patients had their gastroenterostomy
stomas fashioned exclusively using an electrosurgical
unit. This did not significantly affect the day of starting
liquid or solid food.
Suture Versus Staples
Suture alone was used to construct the anastomosis in
96.5% of patients. Two layers of sutures were used in
65.9% of these patients. No significant difference was
apparent between the use of a one- or two-layered anastomosis.
A valid comparison between sutures and staples cannot be made. Nevertheless, the three patients who had a
17
100T
)Vogotomy
Pyloroplasty
N-12
>0
U
80+
60
0
E
0r
40-
20±
0
2
4
6
8
10
Postoperative Day
FIG. 2. Cumulative frequencies of postoperative day of starting adequate liquid oral intake after the vagotomy with gastrojejunostomy
and vagotomy with pyloroplasty.
stapled anastomosis began adequate liquids on days 4, 8,
and 11 and solids on days 9, 1 1, and 14, respectively.
Surgeon
No analysis of individual surgeons was made because
of the varible number of involved operative teams.
Reoperation
Eight patients had reoperation and were not included
in any of the above analyses. Two reoperations were for
small bowel obstruction occurring on postoperative
days 18 and 35. Both patients were discharged from the
hospital eating a regular diet before being readmitted for
the obstruction. Three patients who had gastrojejunostomy alone had reoperation because of failure of gastric
emptying on postoperative days 10, 14, and 28. Three
patients who underwent antrectomy with vagotomy had
reoperation because of failure of gastric emptying on
postoperative days 10, 14, and 60. Upper gastrointestinal radiographs showed virtually no emptying in four
patients and two showed minimal emptying. In all six of
these patients, however, there was evidence of edema at
the anastomosis. At reoperation, an instrument or finger
passed through the anastomosis, indicating that it had
not strictured to the point of closure, and no obvious
technical errors from the original operation were evident. All patients undergoing reoperation consumed an
adequate liquid diet by the eighth postoperative day
(days 3, 4, 4, 5, 5, 8). Further analysis of the six patients
who had reoperation because of failure of emptying was
not carried out because of their small number and the
arbitrary, variable criteria used for the timing of reoperation.
Discussion
The definition of delayed gastric emptying beginning
in the immediate postoperative period of a gastrojejunostomy varies. It ranges from inability to tolerate oral
Ann. Surg. January 1988
FROMM, RESITARITS, AND KOZOL
intake by 48 hours,2'3 or by 5 or 8 days4`6 to 10 days after issue that there appears to be some agreement on is the
operation7-9 or inability to tolerate solid food for more lack of apparent relationship between delayed emptying
than 14 days after operation.'0 Others use the require- and an antecolic or a retrocolic gastrojejunal anastoment of a nasogastric tube for more than 311 or 1012 days mosis.4"6
Often no predisposing factors are identified' and the
after operation. Delayed emptying that persists for less
than 3 weeks has been considered to be a milder form of cause of postoperative gastric retention frequently is not
the problem. 13 Few if any define what is meant by toler- found at reoperation. This suggests that many of the
ating oral intake. The incidence of delayed gastric emp- anatomic and some of the functional causes are preventying after gastrojejunostomy also vanes'-3 5' because table. Thus, it appears that transient functional and/or
of the spectrum of definitions. Thus, the incidence anatomic changes account for delayed emptying in the
majority of instances. The observation that most paranges from 0 to 20%.29,1
The current study involves otherwise healthy patients tients progress to an adequate oral intake with conservaand defines an adequate oral intake as that which is tive management support these interpretations.
Edematous swelling is probably the most common
sufficient to prevent oliguria. Inability to do so constitutes a reasonable clinical definition of delayed gastric cause of early postoperative stenosis of the stoma.17 In
emptying when it is associated with nausea, vomiting, or contrast, others have reasoned that mechanical causes
a sensation of epigastric fullness that prevents further should produce obstruction equally as often in the afferoral intake. The mean time by which all patients under- ent stomal inlet as in the efferent outlet; however, affergoing a gastrojejunal anastomosis with or without gas- ent inlet dysfunction is unusual.18 However, afferent
tric resection or vagotomy can consume an adequate limb peristalsis might overcome any edema at the anasoral intake is 8 days. However, 84% of the patients could tomotic site. Such edema most often is not related to
swallow an adequate liquid intake by this time. Only 8% plasma colloidal oncotic pressure. No relationship was
of patients had sufficient oral intake of liquid by the found in one study between delayed gastric emptying
third postoperative day, but this figure increased to 55% and postoperative serum protein values or colloidal osby the fifth day and to 91% by the eleventh day. Solid motic pressure.'9 Although extreme forms of hypoprofood was tolerated on the average 3 days after the start of teinemia may be associated with anastomotic edema,
such hypoproteinemia is rarely seen in patients underan adequate oral liquid intake.
Multiple reasons have been proposed to explain why going operation. Use of an electrosurgical unit to divide
gastric emptying may be delayed after gastroenteric an- the stomach and jejunum might be expected to cause
astomoses. Several of the causes are either speculative or greater edema, but our data do not support the contenanecdotal. Explanations include edema, hematoma, an- tion that such a unit contributes to delayed emptying.
astomotic leak, ileus resulting from intra- or extra-ab- What is interpreted as anastomotic edema is seen on
dominal infection, starch peritonitis, adhesions, potas- virtually every upper gastrointestinal radiograph obsium deficiency, pancreatitis, too small a stoma, inad- tained in the immediate postoperative period. However,
vertent suture of anterior to posterior walls of it is difficult to correlate the degree of apparent edema
anastomosis, too much inversion oftissue at the anasto- with delayed emptying of radiographic contrast matemosis, scarred (unsuitable) bowel used for anastomosis, rial.
It is also difficult to distinguish by radiography bemesocolic compression, retroanastomotic hernia, jejunogastric intussusception, marginal ulceration, kinking tween anastomotic edema and submucosal hemorrhage.
of the efferent loop, prolapse of mucosa through the Submucosal hemorrhage at the site of anastomosis can
anastomosis, nondependent anastomosis, malalignment contribute to stomal obstruction, but there are no subof the anastomosis, and colonic distention compressing stantive data indicating how long a hematoma contriban antecolic gastrojejunostomy. Other proposed causes utes to the problem. The opinion has been expressed
include chronic preoperative obstruction, inanition, that submucosal hemorrhage at the site of the anastogastritis, a blind loop, too large an anastomosis, food mosis usually subsides within 10 days.20 In contrast, obbolus impaction, two-layer as opposed to one-layer struction from a spontaneous hematoma of the jejunum
anastomosis, an improperly placed stoma, too long or in a patient receiving watfarin is known to usually subtoo short a jejunal loop, narcotic medication, the efferside within 48-72 hours.2' Experimentally, however,
ent loop situated higher than the afferent loop, the direc- anastomotic hematoma or edema generally subsides by
tion of peristalsis in the efferent loop not corresponding the 29th postoperative day.22
to normal direction of emptying by the stomach, autoFew, if any, would argue that gentle handling of tissue
nomic nerve dysfunction or gastric atony, and experi- is essential to minimize the degree of anastomotic
ence of the surgeon.3611"4'15 About the only technical edema. While roughness contributes, delayed gastric
18
-
Vol. 207 * No. I
ORAL INTAKE AFTER GASTROJEJUNOSTOMY
emptying frequently cannot be explained on the basis of
trauma alone. No matter how gently the stomach is
handled, a problem with emptying may still occur23 in
the absence of an obvious technical error. Delicate partition alone of the bowel can result in edema, as is often
seen after division of a transverse colostomy.
Some believe that atony of the gastric remnant as a
result of vagotomy is a common cause of delayed emptying. This explanation is based on the frequent observation that radiographic contrast or an endoscope or, at
reoperation, an instrument or finger can be passed
through the anastomosis. Although these maneuvers
may be reassuring that no gross technical error was
made to account for delayed emptying, they do not help
to quantitate the degree of resistance (for example, from
edema) offered by the anastomosis. Gastric atony has
even been invoked as a cause of efferent stomal dysfunction in patients who have subtotal gastrectomy
without vagotomy. 18 Others, however, believe that atony
of the gastric remnant is rare.24 The notion of atony
associated with vagotomy is not in keeping with a currently accepted physiologic concept that parasympathetic denervation of the fundus and antrum cause a loss
of receptive relaxation of the stomach and thus faster
emptying of liquid. Furthermore, postoperative gastric
atony may be euphemistic, as an atonic stomach with a
patent outlet should empty by gravity. If this is the case,
even '"mild" anastomotic edema may play an important
role in delayed emptying. The concept of atony also
does not account for the fact that a prolonged period of
delayed emptying is frequently overcome by redoing the
gastroenteric anastomosis in this circumstance. On the
other hand, impaired tone of the residual gastric pouch
has been described after gastrectomy with vagotomy
beyond the immediate postoperative period,25 but the
prevalence and significance of this finding is still unclear.
One study suggests that gastric tone, jejunal peristalsis, changes in intra-abdominal pressure, diaphragmatic
motion, and gravity are probably the primary factors in
emptying the gastric remnant.26 Gastric evacuation requires a pressure gradient from stomach to intestine, but
the significance of gravity or respiratory movements has
been questioned.27 However, prolonged gastric emptying ofbarium (at least twice as long) was observed in the
head down compared to the upright position in 80% of
patients after subtotal gastrectomy without vagotomy.26
It is not difficult to imagine that in the presence of a
certain degree of anastomotic edema, the pressure gradient might be insufficient for drainage to occur by
gravity.
No significant differences were observed in the current study for the time it took patients to consume an
19
adequate oral liquid intake after gastrojejunostomy or
subtotal gastrectomy without vagotomy or vagotomy
with antrectomy. In contrast, it took significantly longer
for patients who underwent vagotomy with gastrojejunostomy to consume an adequate oral intake; this was
particularly noticeable after the fifth postoperative day
(Fig. 1). At least 77% of the former group of patients
consumed an adequate intake by the seventh postoperative day, which is in contrast to 56% of the patients who
had a gastrojejunostomy with vagotomy. This observation could be due either to a speculative perturbation
resulting from vagotomy or a type II statistical error,
which is also a problem with other studies reporting
some or no differences between various types of operations.2'9"2'13'28 These studies are difficult to compare because of the lack of reasonably precise definitions of
adequacy of oral intake and variable technical, operative
details.
The current data suggest that vagotomy per se does
not account for the apparent delay in consumption of an
adequate oral liquid intake. If vagotomy alone were important, one would expect delayed emptying also to
occur after vagotomy with pyloroplasty and vagotomy
with antrectomy. This was not observed in the current
study. Similar reasoning also suggests that gastroenterostomy alone also does not account for delayed emptying. Motor incoordination of the efferent loop might
increase resistance to gastric outflow,29 but the prevalence and significance of this possibility in the immediate postoperative period is unclear.
Some believe that longstanding gastric outlet obstruction is a predisposing cause of delayed gastric emptying.6'30 The usual explanation is that obstruction leads to
a loss of gastric tone. It has been suggested that subtotal
gastrectomy is associated with a lower incidence of delayed gastric emptying than vagotomy with drainage
done for obstructing ulcer disease.7 The current study
suggests that gastroenterostomy with or without vagotomy is not associated with prolonged emptying in the
presence of obstruction. Vagotomy with gastroenterostomy is a very satisfactory long-term procedure for ob-
struction.3'132
Whatever the causes of delayed emptying may be, it is
difficult to distinguish the basis of obstruction by radiographic8 and/or endoscopic means. Some degree of anastomotic narrowing was seen in all of our patients who
had gastrointestinal radiographs in the immediate postoperative period. Anastomotic edema is also observed
after low anterior resection of the rectum,33 but clinically significant "outlet obstruction" is unusual following this procedure. However, an important difference
between intestinal and gastroenteric anastomoses is that
the former have different proximal peristaltic properties
20
FROMM, RESITARITS, AND KOZOL
than the residual stomach anastomosed to the proximal
Jejunum.
The number of confounding variables involved in a
patient's ability to consume an adequate oral intake of
liquids or solids after operation makes it exceedingly
difficult to identify those aspects that are significant.
This is further compounded by the observations that
gastric emptying judged to be normal or abnormal by
barium flowing through a gastrojejunal anastomosis or
more objective studies such as kinetic analyses of isotopic rates of gastric emptying do not necessarily correlate with adequacy of postoperative oral intake and
maintenance of normal hydration or even nutrition.
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