Recent advances in surgery

Conducted by ALFRED BLALOCK, M.D.

The blind-loop syndrome after gastric operations

ince the earliest reports by Whitees time, several examples of the blind-loop

ANATOMIC CONFIGURATION OF BLIND LOOPS Various examples of gastrointestinal blind

and Wangensteen;O a side-arm loop has been employed as in Fig. 1, A, in which the loop is arranged so as to be self-filling. The side loop arrangement is the one which most 849 850 Recent advances in surgery Surgery ;.$ Nouernbcr 1961 & ad

cumulated from observations on lesions at differing sites in the . The principles involved apply, with varia- tions, to blind loops at all levels. The best- known feature of the blind-loop syndrome is megaloblastic anemia, which is due to dis- ruption of vitamin BI2 absorption. Normally, dietary vitamin B12 (Castle's extrinsic fac- tor) is absorbed after an incompletely under- stood interaction with intrinsic factor (Fig. 3, A), a mucoprotein secreted by the gastric rnu~osa.*~In man, the principal site of B,, absorption is the .7* Vitamin B,, deficiency can develop by a number of alternative mechanisms. Rarely loops which have caGsed the blind-loop- syndrome.- is there dietary deficiency of this nutritional A, Anastomosis with formation of a self-filled stagnant loop, B, with jejunal , C, factor. Commonly, as in pernicious anemia with intestinal strictures, D, after enteroenteros- (Fig. 3, B) or after total gastrectomy,Sgthere tomies or , and E, after gastric operation. is absent intrinsic factor due to gastric atrophy or the absence. of the stomach, re- resembles a blind loop which develops after spectively. can also occur4*25* gastrojejino~tom~(Fig. 1, E) . The structural conditions necessary for the blind-loop syndrome are not present after the Billroth I anastomosis. In all re- ported cases there has been either a Billroth I1 resection (8 patients) or a gastroenteros- Pi- ..?* .. . tomy (1 patient). The anastomoses (Fig. 2, -5.'. ?: A and 3) were both antiperistaltic, with . . the afferent loop to the greater curva- t~re,~~'45 and isoperistalti~.~~~45 In 2 cases (Fig. 2, C and D), an enterostomy had also been performed.'. 49 Commonly, the afferent loop was excessively long and dilated.2" 30* 45 The exact site of obstruction was sometimes difficult to define by roentgenogram or even

at operation.l3~459 4B U sually, the distended loop ended abruptly at the gastrojejunos- tomy, but in some cases it extended beyond this. Excessively long afferent loops, kinking at the site of anastomosis, and partially ob- structing adhesions have all been described as the factor causing blind-loop stasis.'. 13* 25, 30. 45, 49

ABNORMALITIES IN VITAMIN B,, METABOLISM IN BLOOD-LOOP *-& SYNDROME Fig. 2. Anatomic conditions after gastric opera- -q tion which have caused blind-loop syndrome. A. ?:. General information concerning the mech- 1 3 CM, B, 3 cases, C, 1 cue, D; 1 case, and E, anism of the blind-loop syndrome has ac- 1 case. ;*&% i Starzl, Butz, and Hartman: Blind-loop syndrome 851

absent absorption

Fig. 3. Mechanisms of Bu utilization in normal and diseased patignts. f 2'- 20, 27, ?8, 35, 40, 43, 52, 54 , r with adequate intrinsic drome can proceed to subacute combined ' factor and dietary vitamin BIZ in patients degeneration of the spinal cord.'* s*20* "% who have undergone ileal resection (Fig. 3, Virtually all authorities agree that a t. ,: D) or who have diffuse small bowel disease change in the bacterial flora of the torpid 1' ! (Fig. 3, C). Here, the malabsorption is due imp is responsible for the B,, malabsorption. I 6: to damage or removal of the normal site of Much of the evidence is based upon clinical - absorption. Vitamin BIZ deficiency also de- impression, but there is solid experimental

- the presence of intrinsic factor and dietary employing strictures to study the blind-loop ( :, BIZ (Fig. 3, F). The malabsorption in this effect in dogs, related the presence or ab- '", circumstance is thought to be due to bac- sence of infection above the to the terial overgrowth in n poorly emptying blind development or absence of anemia. Watson #'

' :%. -L- . d.2 v' ,or,, 60 ,or,, . Fig. 4. Various hypotheses to explain malabsorption of vitamin Bu.

growth in the small bowel distal to the blind min. The application of these disclosures to loop was changed with a reduction in Lacto- the diagnosis and treatment of the blind-loop bacilli and increases in Esche~ichiacoli and syndrome will be discussed subsequently. alpha hemolytic streptococci. Perhaps the Despite the generous support accorded the most conclusive evidence for the bacterial bacterial theory, the precise mechanism of etiology of the malabsorption was provided vitamin B12 malabsorption is not known. One by Toon and \Yangen~teen,~Oand later con- widely accepted theory is that propounded firmed by \lratson and Witt~.~Theseauthors by M'itts6@in which B,, metabolism is sup- showed that the anemia of the experimental posedly affected by direct alimentary con- blind loop syndrome could be prevented by tamination of bacteria or their toxic by- oral administration of chlortetracycline. The products which spill out of the stagnant loop therapeutic value of antibiotics in man has (Fig. 4, A). Since certain strains of Escheri- been confirmed by Siruala and Kaipainensa chia coli and Streptococcus fecalis metabo- and numerous other observers,', 3. 17, 259 26* 2F, lize folic acid or vitamin BIZ,"* s1 it has been 309 34. 437 49, 50, 54 who noted that certain suggested that the anomalously located mi- antibiotics could not only prevent the de- croorganisms use up the available oral sup- velopment of, but also reverse, B12 deficiency ply. Contrary to this reasoning is the fact by restoring normal absorption of this vita- that Neomycin and sulphonamides, which Starzl, Butz, and Hartman: Blind-loop syndrome 853

are nonabsorbable and which sterilize the OTHER NUTRITIONAL nonstagnant intestine are of no therapeutic DEFICIENCIES IN BLIND- LOOP SYNDROME value'7* 25* 28 despite the fact that they would be expected to come into contact with efflux Absorption of other nutritional substances from the loop. In contrast, oral antibiotics is often impaired. Fat is probably the most such as chlortetracycline, oxytetracycline, commonlg affected. Using experimental mid- and tetracycline can restore normal absorp- intestinal loops, Aitken and colleagues2 found tion of B,,. that virtually all rats exhibited However, if the offending agent were a whether or not the animals became anemic. toxin, its production in a sequestered loop The development of anemia alone, without would be suspended only with a systemic steatorrhea, was uncommon. antibiotic. Drexler18 has shown on the basis As with , it is of in vitro experiments that indole com- thought that bacterial overgrowth in the pounds are able to inhibit normal utilization blind loop is the causative factor in the of vitamin B12, and he has suggested that steatorrhea. Specific evidence has been pre- indole might be one of the blind-loop "tox- sented by Sammonssl and by Goldstein and ins." Recently, Hoffman and Spiro30 have his group25 that the bacterial growth ad- failed to support either the bacterial or toxin versely affects fat utilization. The latter theory of direct intestinal contamination. authors have shown that the steatorrhea of They instilled into a normal patient's stom- the blind-loop syndrome is favorably influ- ach the contents of a resected blind loop enced by antibiotics. with Coeo-taggedvitamin BIZ.B12 absorption Why some blind loops do and others do was not depressed. not cause steatorrhea is not known. There is Other theories to explain the B12 deficiency some evidence that the location of the blind involve blood-stream mechanisms. Ungleys2 loop is influential in this respect. BoothT has suggested that a toxin was absorbed from the pointed out that a blind loop of the ileum, blind loop which destroyed the vitamin in where normal vitamin B12 absorption occurs, the blood and tissues (Fig. 4, B). He sup- may lead to pure B12 deficiency. Blind loops ported this opinion by the demonstration of the , where fat is normally ab- that plasma added from a resected blind sorbed,'. s* 259 33 usually produce prominent loop suspended megaloblastic maturation in teato or rhea.^* 54* 83 While such localization is bone marrow culture. Cardla also proposed admittedly crude, it may help to explain dif- that B,, was actually absorbed, but that in- ferences in the malabsorption defect in dif- crements were returned by enteric recircula- ferent cases. Of 9 $atients who had blind- tion (Fig. 4, C) to the blind loop and de- loop syndromes after gastric operations, 7 he stroyed. Both theories were weakened by the had steatorrhea. of results of studies of urkary and fecal excre- Other nutritional deficiencies are also com- ne tion of radioactive vitamin B12 which show mon. Numerous cases of protein deficiency ed that the block in metabolism is primarily at, have been noted with blind loops at various ! p- rather than after, the absorption phase.,' 3t 17* levels, including the blind loops after gastric m- 25, 28, 28, SO, 34, 40, 43, 45, 49. 50, 54 operation^.^" 259 45 Usually this is reflected in 'Y- ~1.'. An unexplored possibility is that bacterial low plasma protein levels, but 1 example of OP : toxins are picked up from the blind loop frank kwashiorkor has been reported in a ri- '"- and circulated to the uninvolved portion of patient with an intestinal blind loop.38 Pel- m- - the small bowel where they alter the absorp- lagra and vitamin C and vitamin K de- en . - tive capacity (Fig. 4, D). Such a hypothesis ficiencies have been recorded. Badenach3 has xi- is compatible with the evidence obtained warned against the dangerous complication :p- - from antibiotic therapy, and with present of spontaneous retroperitoneal hemorrhage Kt knowledge of the fundamental defect in BIZ resulting from vitamin K deficiency. ch , ,utilization. 854 Recent advatlcrs in surgery Surgery Nouernbcr 1961

INCIDENCE OF BLIND-LOOP to this .cause. M~Lean~~has summarized the SYNDROME AFTER GASTRIC results of investigations of patients with OPERATIONS macrocytic anemia which developed after The blind-loop syndrome has not been gastroenterostomy or partial gastrectomy. Al- thoroughly evaluated as a cause of poor most invariably, these patients have de- . results after gastric operations. It is probable veloped atrophy of the gastric remnant with that this complication is more important loss of the intrinsic factor (Fig. 3, E). Dif- than the 9 recorded cases1*Is* 45- in- ferentiating patients with the blind loop syn- lis dicate. For example, KinsellaSZrecently re- drome from those with gastric atrophy is a th ported 7 cases which are probably examples crucial step in correct diagnosis. te: of the blind-loop syndrome, but there is in- ot. sufficient data to be certain of this. Several CLINICAL MANIFESTATIONS & 1 hc factors make the diagnosis an obscure and OF BLIND-LOOP SYNDROME 8 ( ne dficult one which is apt to be overlooked. AFTER GASTRIC OPERATIONS -43.$5 , ba First, the interval between operation and The clinical features of the blind-loop a the onset of symptoms can be prolonged for syndrome are seldom overt. The diagnosis KI many years, which tends to minimize the has usually been made only after months or rac etiologic role of the remote operation in years of disability. Commonly, a gastroenter- tio relation to the presenting complaints. In ad- ostomy or Billroth I1 gastric resection per- in1 dition, the symptoms often are subtle and formed as long as 26 years previously had 1 nonspecific and resemble psychoneurotic initially been considered to have a good re- ab ' complaints. sult. When anemia, weight loss, malaise, du Undoubtedly, an additional hindrance has hypoproteinemia, steatorrhea, or neurologic loc been the preoccupation with macrocytic complaints developed, the possible relation stc anemia as a prerequisite for this diagnosis. to the previous operation was often over- In point of fact, this feature may be ab- looked. nic

sent as it was in 7 of the 9 cases collected in Anemia was present in all cases.l~ls9 25* diz this review. Macrocytic anemia was fre- "1 In only 2, however, was it macrocytic mz quently masked by prior vitamin BIZ therapy in type.'. 4"teatorrhea was the next most thr or by the presence of other and equally im- common feature and was found in 7 pa- mi portant absorption defects of fat, iron, and tients.'* ls*25*45 Five of these had . exc other materials. Even in the untreated pa- Some evidence of malnutrition was always cre tient, the body stores of \itamin BIZ are not present, and 5 patients had edema or hypo- Scl dissipated for 3 to 4 )-ears in the complete proteinemia.ls. 45 Glossitis, blepharitis, Par absence of BI2 intake,?') ". 239 so the de- cheilosis, or other signs of vitamin deficiency B,, velopment of megaloblastic anemia is a late were seen in 3 patients. Neurologic findings of manifestation. However, techniques and suggestive of subacute combined degenera- mu knowledge acquired in the past few years tion of the cord were present in 3 patients of allow the blind-loop syndrome to be defined with calf pain, changes in deep tendon re- spe in tenns of specific and measurable para- flexes, and decreased sense of vibration and the meters of malabsorption rather than in terms proprio~eption.~~4s sor of their end results. These techniques, out- Vomiting and abdominal pain were re- Co lined in the section on diagnosis, should in- ported in lS0 and 3'. cases, respectively. 7 crease the frequency and accuracy of de- The vomitus consisted of pure or foul BIZ tection. brown material, and the emesis probably Pee It should be emphasbed not only that resulted from convulsive emptying of the of macrocytic anemia is not a prerequisite to blind loop. Sporadic bilious vomiting is ant the diagnosis of the blind-loop syndrome, known to be a characteristic symptom in pa- whe but also that most cases of megaloblatic tients with an obstructed or distended affer- exc anemia after gastric operations are not due ent loop,'5, 30, 32, 31, 41, 42, 44, 46, 48, 53, 61, 689 66, 67 Starzl, But~,and Hartman: Blind-loop syndrome 855

; and it is possible that this symptom will diagnosis of blind-loop syndrome is ex-

If the combination of Coeo-taggedBIZ and intrinsic factor does not increase urinary excretion, the blind-loop syndrome becomes a strong possibility. CoGo-taggedB12 is again Radiologic studies may be helpful in estab- given, this time after several days of therapy .is lishing the presence of dilatation or stasis in with tetracycline, chlortetracycline, or oxytet- .<,tat.'*. ,:-., the afferent loop. In some cases, barium en- racycline. In many cases, the antibiotics re- +&.?- tered a dilated, tortuous l00p.~~9 In store absorption and the urinary excretion others, barium was held up, often for many will become normal. Should this occur, the hours, in an unidentifiable pouch (Fig. 5) diagnosis of blind-loop syndrome is virtually established.l, 3. 17. 25, 26, 29, 30, 34, 13, 13, 49, 30, 51 1 , near the gastrwntero~tomy.~~~4g In some, . ?x barium did not enter the afferent In Failure of the antibiotics may be due to

i$-.these are tests employing Coao-tagged vita- J* --= min B12 either for determination of fecal 3 excretion,ls hepatic uptake:' or urinary ex- cretion..' The urinary excretion method, the ( .$,r. &. Schilling test,52is the most widely used. The 1 patient is given 0.5 to 1.0 pg of CoGo-tagged - i -2 B12 orally, and 2 hours later a flushing dose ! . of 1,000 pg of nontagged B12 is given intra- i -% - muscularly or subcutaneously. The amount : of radioactivity in the ensuing 24-hour urine .-,i.y 1 specimen provides an indirect measure of i the amount of oral Cow-tagged BIZ ab- 1 >:: sorbed. Normally 8 to 40 per cent of the <$ CoeO-taggedBIZ is excreted in the urine. .,* - - .. . When urinary excretion of the CoGO-tagged 1 .%>. B,cir subnormal or absent, the test is re- peated with concomitant oral administration .-2,-. Fig. 5. Gastrointestinal series in patient with blind of intrinsic factor' In cases of pernicious +..--h> . loop syndrome after Billroth I1 gastrectomy. Note anemia and in postoperative patients in pouch at gastrojejunostomy site and dilated and whom gastric atrophy has occurred, urinary elongated afferent loop (left). Barium remained excretion will be restored to normal, and the in pouch for 6 houn. 856 Recent advances in surgery Surgery November 1961

Experimental and clinical data previously syndrome. With tetracycline, chlortetracy- alluded to emphasize the importance of cline, oxytetracycline, chloramphenicol, and studying the absorption of other substances, possibly other antibiotics, the absorption of particularly fat. Jackson and Linder31 and vitamin BIZ, fat, and probably other nutri- Butler and associates1* recognized the resem- ents may be restored toward normal. The blance of gastroenterostomy and Billroth I1 improvement may outlast a course of anti- gastrectomy to the better-known intestinal biotic therapy by weeks or months,'* 25- O4 but blind loops. They speculated that bacterial relapse eventually is expected. Specific vita- growth in the afferent limb might account min deficiencies, especially of B,,, should be for the higher incidence of steatorrhea after corrected. High protein, high calorie diet, Billroth I1 than after Billroth I gastrectomy. correction of low blood volume, and resto- Recently, Goldstein and his colleagues25 ration of electrolytes are other adjuncts. studied bacterial counts by afferent limb in- Definitive therapy requires surgical correc- tubation in postoperative patients, and tion of the blind afferent loop. In the 9 demonstrated a strong correlation between collected cases, 6 patients had been oper- the degree of contamination in the afferent ated upon at the time of the rep~rt.'~*~~* loop and the magnitude of steatorrhea. They 459 '@In 4, the Billroth 11 anastomosis also showed that antibiotic therapy reduced was taken down and converted to a Billroth steatorrhea, presumably by the same mecha- 2s9 4a and in a fifth similar recon- nism as B12 absorption is improved in other struction was carried out with the inter- blind loops. This type of testing may prove position of a jejunal segment between the to be of great value in the study of post- stomach and duoden~m.~" good result was gastrectomy malabsorption syndromes and in obtained in all with complete or partial cor- the detection of afferent blind loops. rection of the pre-existing absorption defects. Other tests may be useful in individual In the sixth case, the dilated and elongated cases. Gastric analysis for acid should always afferent loop was resected and a short-loop be carried out, since the presence of free Billroth I1 anastomosis performed with a acid excludes gastric atrophy as a cause of good result.30 From a mechanical point of B12 malabsorption. Badenach5 has performed view, other operations have beexi proposed endoscopic gastric biopsy and studied urinary for the treatment of afferent loop obstruc- uropepsinogen in order to evaluate the secre- tion, such as enteroenterostomy, jejunoplasty, tory capacity of the stomach. support of the afferent loop by suture, and In the diagnosis of the blind-loop syn- defunctionalization of the afferent loop by drome, reliance upon a single symptom, find- Roux Y anastomosis. There ark objections ing, or abnormality of absorption is not wise. to each of these operations, especially in The absorption defects are frequently mul- terms of late results, and they probably tiple, and other deficiencies may be of should not be used. greater importance than those which would lead to a specific hematologic picture. Unifi- REFERENCES cation of the different aspects presented by 1. Adams, J. F. : Postgastrectomy megaloblastic the blind-loop syndrome into a well-under- anemia and the loop syndrome, Gastroentero- logia 89: 326, 1958. stood entity would undoubtedly lead to a 2. Aitken, M. A., Badenoch, J., and Spray, higher rate of recognition of this complica- G. H.: Fat excretion in rats with intestinal tion of gastric operations. culs-de-sac, Brit. J. Exper. Path. 31: 355, 1950. TREATMENT OF THE BLIND- 3. Badenoch, J.: The blind loop syndrome, Prdc. LOOP SYNDROME AFTER Roy. Soc. Med. 53: 657, 1960. GASTRIC OPERATION 4. Badenoch, J.: Bedford, P. D., and Evans, J. R.: Massive diverticulosis of the small Medical therapy can temporarily improve intestine with steatorrhea and megaloblastic the health of patients with the blind-loop anemia, Quart. J. Med. 24: 321, 1955. 5. Badenoch, J., Evans, J. R., Richards, W. C. 22. Glass, G. B. J.: Hematopoietic activity of D., and Witts, L. J.: Megaloblastic anemia glandular mucoprotein of human gastric followifig partial gastrectomy, Brit. J. Haemat. juice, Gastranterology 23: 219, 1953. 1: 337, 1955. 23. Glass, G. B. J.: Intestinal absorption and I 6. Barker, W. H., and Hummel, L. E.: Macro- hepatic uptake of vitamin Bar in diseases of cytic anemia in association with intestinal the gastrointestinal tract, strictures and anastomoses, Bull. Johns Hop- 30: 37, 1956. kins Hosp. 64: 215, 1939. 24. Glass, G. B. J., Boyd, L. J., and Stephanson, 7. Booth, C. C., and Mollin, D. L.: The blind L.: Intestinal absorption of vitamin Bu in loop syndrome, Proc. Roy. Soc. Med. 53: humans as studied by isotope technique, Proc. I 658, 1960. Soc. Exper. Biol. & Med. 86: 522, 1954. 8. Booth, C. C., and Mollin, D. L.: The site 25. Goldstein, F., Wirts, C. W., and Krarner, S.: of absorption of vitamin Bu in man, Lancet The relationship of afferent limb stasis and 1: 18, 1959. bacterial flora to the production of post- 9. Borgstrom, B., Dahlquist, A., Lundh, G., and gastrectomy steatorrhea, Gastroenterology 40: Sjovall, J.: Studies of intestinal digestion and 47, 1961. absorption in the human, J. Clin. Invest. 36: 26. Halsted, J. A., Lewis, P. M., and Gasster, M.: 1521, 1957. Absorption of radioactive vitamin B1, in the 10. Brodine, C., Friedman, B. I., Saenger, E. L., syndrome of megaloblastic anemia associated and Will, J. J.: The absorption of B1, follow- with intestinal stricture of anastomosis, Am. ing subtotal gastrectomy, J. Lab. & Clin. J. Med. 20: 42, 1956. Med. 53: 220, 1959. 27. Halsted, J. A., Swendseid, M. E., Gasster, 11. Burkholder, P. R.: Microbiological studies M., and Lewis, P. M.: Absorption of radio- on materials which potentiate oral vitamin active BIZ in disease of the : B,, and intrinsic factor activity, Arch. Bio- relation to macrocytic anemia, Tr. Am. Clin. chem. 39: 322, 1952. & Climatol. A. 66: 18, 1954. 12. Butler, T. J., Capper, W. M., and Naish, 28. Halsted, J. A., Swendseid, M. E., Lewis, J. M.: Ileo-jejunal insufficiency following P. M., and Gasster, M.: Mechanisms involved different types of gastrectomy, Gastroenter- in the development of vitamin BII deficiency, ologia 81: 104, 1954. Gastroenterology 30: 2 1, 1956. 13. Butz, G. W., Jr., Hartman, C. F., and 29. Heinle, R. W., Welch, A. D., Scharf, V., Stanl, T. E.: The blind loop syndrome Meacham, G. C., and Prushoff, W. H.: following subtotal gastrectomy, A. M. A. Studies of excretion (and absorption) of COeO Arch. Surg. In press. labeled vitamin Bu in pernicious anemia, Tr. 14. Cameron, D. G., Watson, G. M., and Witts, A. Am. Physicians 65: 214, 1952. L. J.: Clinical association of macrocytic 30. Hoffman, W. A., and Spiro, H. M.: Afferent anemia with intestinal stricture and anasto- loop problems, Gastroenterology 40: 201, mosis, Blood 4: 793, 1919. 1961. 15. Capper, W. M., and Welbourne, R. B.: 31. Jackson, W. P. U., aM Linder, G. C.: Small Postcibal symptoms following gastrectomy, gut insufficiency following intestinal surgery, Brit. J. Surg. 43: 24, 1955. South African J. Clin. Sc. 2: 205, 1951. 16. Card, W. I.: Blind loop syndrome. Proc. 32. Kisella, V. J., and Hennessy, W. B.: Gas- Roy. Soc. Med. 52: 28, 1959. trectomy and the blind loop syndrome, Lan- 17. Doscherholmen, A., and Hagen, P. S.: Ab- cet 2: 1205, 1960. sorption of Co60 labeled vitamin Bu in in- testinal blind loop megaloblastic anemia, J. 33. Kremen, A. J., Linner, J. H., and Nelson, Lab. & Clin. Med. 44: 790, 1954. C. H.: An experimental evaluation of the 18. Drexler, J.: Effect of indole compounds on nutritional importance of proximal and distal vitamin Bat utilization, Blood 13: 239, 1958. small intestine, Ann. Surg. 140: 439, 1954. 19. Faber, K.: Pernicious anemia following in- 34. Krevans, J. R., Conley, C., and Sachs, M.: testinal stricture, Klin. Wchnschr. 34: 643, Influence of certain diseases on the absorption 1897. of vitamin BIZ from the gastrointestinal tract, 20. Girdwood, R. H.: Megaloblastic anemia: J. Clin. Invest. 33: 949, 1954. their investigation and classification, Quart. 35. Krevans, J. R., Conley, C. L., and Sachs, J. Med. 25: 87, 1956. M. V.: Radioactive tracer tests for the recog- 21. Girdwood, R. H.: The occurrence of growth nition and identification of vitamin Bzt de- facton for Lactobacillus leichmannii, Strep ficiency status, J. Chronic Dis. 3: 234, 1956. tococcus fecalt, and Leuconostoc citrovorum 36. Krikler, D. M., and Schrire, V.: "Kwashior- in the tissues of pernicious anemia patients kor" in an adult due to an intestinal blind and controls, Biochem. J. 52: 58, 1952. loop, Lancet 1: 510, 1958. 1

858 Recent advances in surgery Surgery November 1961

37. Lake, N. C.: The aftermath of gastrectomy, laeger, E. E., and Owen, C. A.: Diverticulosis Brit. M. J. 1: 285, 1948. of the small intestine and macrocytic anemia 38. Lowenstein, F.: Labeled vitamin Bu after sub- with report of 2 cases and studies on ab- total gastrectomy, Blood 13: 339, 1958. sorption of radioactive vitamin Bu, Gaatro- 39. MacLean, L. D.: Megaloblastic anemia fol- enterology 34: 66, 1958. lowing total and subtotal gastrectomy, Surg. Seyderhelm, R., Lehman, W., and Wichels, Gynec. & Obst. 106: 415, 1958. P.: Experimental intestinal pernicious anemia 40. McIntyre, P. A., Sachs, M. V., and Conley, in the dog, Klin. Wchnschr. 3: 1439, 1924. C. L. J.: Pathogenesis and treatment of Siurala, M., and Kaipainen, W. J.: Intestinal macrocytic anemia, A. M. A. Arch. Int. megaloblastic anemia treated with aureomy- Med. 98: 541, 1956. cin and terramycin, Acta med. scandinav. 41. McNealy, R. W.: Problems with the duodenal 147: 197, 1953. stump in gastric resections, SURGERY12: 207, Stammers, F. A. R.: Complications associated 1942. with the use of a long afferent loop in the 42. Mimpriss, T. W., and Birt, St. J. M. C.: Polya type of partial gastrectomy, Brit. J. Results of partial gastrectomy for peptic ulcer, Surg. 44: 358, 1956. Brit. M. J. 2: low, 1948. Stammers, F. A. R.: Remarks on 15 cases of 43. Mollin, D. L., Booth, C. C:, and Baker, S. J.: small following retrocolic The absorption of vitamin Bar in control sub- partial gastrectmy, Brit. J. Surg. 42: 34, jects, in Addisonian pernicious anemia and in 1954. malabsorption syndrome, Brit. J. Haemat. 3: Taylor, D. W.: Absorption from intestine of 412, 1957. rats with blind self-filling pouch, Nature 170: 44. Muir, A.: Postgastrectomy syndromes, Brit. 80, 1952. J. Surg. 37: 165, 1949. Toon, R. W., and Wangensteen, 0. H.: 45. Naish, J., and Capper, W. M.: Intestinal Anemia associated with blind intestinal seg- cul-de-sac phenomena in man, Lancet 2: 597, ments and its prevention with aureomycin, 1953. Proc. Soc. Exper. Biol. & Med. 75: 762, 46. Noring, 0.: The afferent-loop syndrome 1950. elucidated by three cases, Acta chir. scan- Tonnis, and Brusis, A.: Changes of morpho- dinav. 115: 276, 1958. logical blood picture in acute and chronic 47. Pearse, A. E.: Experimental chronic intestinal intestinal obstruction, Deutsche Ztrchr. Chir. obstruction from blind loops, Surg. Gynec. & 233: 133, 1931. Obst. 59: 726, 1934. Ungley, C. C.: Megaloblastic anemia follow- 48. Quinn, W. F., and Gifford, J. H.: Syndrome ing operations on intestine, Gastroenterologia of proximal jejunal loop obstruction follow- 79: 338, 1953. ing anterior gastric resection, California M. J. Watkinson, G., Feather, D. B., Marson, F. 72: 18, 1950. G. W., and Dossett, J. A.: Massive jejunal 49. Ragins, H., and Oberhelman, H. A.: Anemia diverticulosis with steatorrhea and mealoblas- associated with a stagnant ("blind") je- tic anemia improved by excision of diver- junal loop, A. M. A. Arch. Surg. 80: 524, ticula, Brit. M. J. 2: 58, 1959. 1960. Watson, G. M., Cameron, D. G., and Witts, 50. Reilly, R. W., and Kirsner, J. B.: The blind L. J.: Experimental macrocytic anemia in the loop syndrome, Gastroenterology 37: 491, rat, Lancet 2: 404, 1948. 1959. Watson, G. M., and Witts, L. J.: Intestinal 51. Sarnmons, H. G., Vaughan, D. J., and Frazer, macrocytic anemia, Brit. M. J. 1: 13, 1952. A. C.: Synthesis of long-chain fats by bacteria Watson, P. C.: Acute distention of afferent isolated from human feces, Nature 177: 237, loop after Polya gastrectomy, Brit. M. J. 1: 1956. 1334, 1958. 52. Schilling, R. F.: Intrinsic factor studies. 11. Wells,. C. A., and Mac Phee, I. W.: The The effect of gastric juice on the urinary afferent loop syndrome, bilious regurgitation excretion of radioactivity after the oral ad- after subtotal gastrectomy and its relief, ministration of radioactive vitamin Bsr, J. Lancet 2: 1189, 1952. Lab. & Clin. Med. 42: 860, 1953. White, W. H.: On the pathology and prog- 53. Schofield, J. E., and Anderson, P. St. G.: nosis of pernicious anemia, Guy's Hosp. Rep Postgastrectomy syndrome deviation of the 47: 149, 1890. afferent loop from the gastrointestinal anas- Witts, L. J.: Anaemia and the alimentary tomosis, Brit. M. J. 2: 598, 1953. tract, Edinburgh, 1956, Royal College of 54. Scudmore, H. H., Hagedorn, A. B., Wol- Surgeons of Edinburgh, Publication NO. 7.