The first step in solving a problem is identification of the cause. Unlike many surgeons in the Western world, Slim et al recognize that "circulus vitiosus" is the prime reason that many patients have malfunction of gastric emptying after a palliative gastrojejunostomy for unresectable pancreatic cancer. In lieu of antrectomy, these authors prefer antral exclusion, which may be performed more quickly and with less difficulty. Their observations are correct in cases when the unresectable cancer extends into the pylorus and distal antrum. When the distal antrum and pylorus are free of tumor, there is little added time or technical difficulty with antrectomy. There are 2 potential difficulties with antral exclusion. The first is staple-line dehiscence, which occurs in 20% of patients undergoing Roux-en-Y gastric bypass for morbid obesity.1 Staple-line dehiscence, which would allow for the duodenal circulus vitiosus to develop, can be avoided by complete division of the stomach between
Lucas CE. Antrectomy: A Safe and Effective Bypass for Unresectable Pancreatic Cancer-Reply. Arch Surg. 1996;131(6):677. doi:10.1001/archsurg.1996.01430180102025
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