Roux limb revision for recalcitrant bile reflux after total gastrectomy

Bile reflux is a postgastrectomy syndrome that impacts quality of life. Management includes lifestyle modifications and medical therapy; however, the efficacy of operative intervention for refractory bile reflux is unknown. We aimed to characterize outcomes of Roux limb lengthening for management of recalcitrant bile reflux after total gastrectomy.

Retrospective analysis of 159 individuals with germline CDH1 mutations who underwent prophylactic total gastrectomy with Roux-en-Y reconstruction. Patient demographics, frequency of recalcitrant bile reflux, type of medical management, operative details, and clinical outcomes were measured.

Fourteen (8.8%, 14/159) individuals developed bile reflux recalcitrant to medical therapy after prophylactic total gastrectomy and elected for operative Roux limb lengthening of 20-25 cm. Median time from prophylactic total gastrectomy to Roux limb revision was 2.6 years (interquartile range, 2.1-2.9). After revisional surgery, all patients self-reported improvement in bile reflux symptoms. Post-Roux limb revision, almost all (86%, 12/14) patients reported rare or no bile reflux symptoms. Bile reflux severity scores improved to no symptoms in 3 patients (21%), followed by mild (50%, 7/14) or moderate (29%, 4/14) symptoms after Roux limb revision. All individuals (100%, 14/14) who underwent Roux limb revision reported "major improvement" in bile reflux symptoms with a median follow-up of 16 months (interquartile range, 7.5-21.5). Most patients regained weight post-Roux limb revision (+3.3 kg, standard deviation 4.7, P = .02) with a mean percentage weight gain of 5.9% (standard deviation, 7.4). There were no intraoperative or postoperative complications with revisional surgery.

Roux limb revision is effective for management of recalcitrant bile reflux. Additional study to identify potential risk factors for bile reflux after total gastrectomy is warranted.