The Value of Reoperative Procedures After Unusual Reconstructions in the Gastrointestinal Tract Associated With Substantial Morbidity Hueseyin Bektas, M.D., Harald Schrem, M.D., Frank Lehner, M.D., Ursula Schmidt, M.D., Helmut Kreczik, Ju ¨ rgen Klempnauer, M.D., Thomas Becker, M.D. Reconstructive procedures of the gastrointestinal tract after resection or for bypass surgery are well established and almost completely standardized but still may cause significant morbidity. Deviations from standard reconstructive procedures have pitfalls, especially when complex reconstructions are required, and may lead to substantial morbidity. Scientific evidence for the indication to reoperate as well as the best methods to be applied is lacking and surgical experience indispensable. We report on 10 reoperative cases between 1999 and 2003 after uncommon reconstructive procedures in the gastrointestinal tract associated with substantial morbidity. In five cases (five of seven), operative correction of uncommon reconstructions in the upper gastrointestinal tract after gastrectomy, completion gastrectomy, or distal gastric resection could completely alleviate the complaints including reflux esophagitis, whereas incomplete relief of symptoms was achieved in the remaining two cases (two of seven). Corrective procedures used end-to-side esophagojejunostomy or end-to-side gastrojejunostomy with a retrocolic isoperistaltic jejunal Roux-en-Y loop and end-to-side jejunojejunostomy approximately 40 cm distal to the proximal anastomosis for biliary and exocrine pancreatic drainage. After biliodigestive anastomosis, problematic cholangitis could be completely alleviated in three cases (three of three) using end-to-side hepaticojejunostomy with a retrocolic isoperistaltic jejunal Roux-en-Y loop and end-to-side jejunojejunostomy 40 cm distal to the hepaticojejunostomy for reconstruction of the continuity of the gastrointestinal tract. Compliance with well-established standard reconstructive procedures is of elementary importance in the gastrointestinal tract. Operative correction of uncommon reconstructions associated with morbidity is usually indicated. ( J GASTROINTEST SURG 2006;10:111–122)  2006 The Society for Surgery of the Alimentary Tract KEY WORDS: Reflux esophagitis, biliary reflux, cholangitis, reconstruction after gastrectomy, biliodiges- tive anastomosis Reoperation of the foregut and midgut remains a frequent challenge for the general surgeon. Complex reconstructive procedures following major gastroin- testinal surgery in this area can lead to a series of physiologic and functional complications that, in some cases, require a second operation. 1,2 The most frequent long-term complications are biliary reflux following gastrectomy and recurrent cholangitis fol- lowing biliodigestive anastomosis. Both symptoms can occur individually or in combination following pancreaticoduodenectomy. Some uncommon recon- structive procedures can have widely varying and dra- matic consequences in individual patients. 2–4 Patients From the Klinik fu ¨ r Viszeral- und Transplantationschirurgie (H.B., H.S., F.L., U.S., T.B., J.K.), Medizinische Hochschule, Hannover; and Digitale Medien—Arbeitsbereich Grafik (H.K.), Medizinische Hochschule, Hannover, Germany. Reprint requests: Hueseyin Bektas, M.D., Klinik fu ¨ r Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, D-30623 Hannover, Germany. e-mail: Bektas.Hueseyin@mh-hannover.de  2006 The Society for Surgery of the Alimentary Tract 1091-255X/06/$—see front matter Published by Elsevier Inc. doi:10.1016/j.gassur.2005.02.007 111 who have undergone uncommon reconstructive pro- cedures of the gastrointestinal tract associated with morbidity are often referred to tertiary referral cen- ters like our institution for further therapy. We ana- lyzed the data for such problematic reconstructive procedures that was collected retrospectively over the last 5 years in our institution. Using selected cases, we illustrate the problems associated with uncommon reconstructive procedures and bring the approach to them into discussion. At the outset, it must be pointed out that the examples chosen are individual cases and the symptoms and the possible surgical proce- dures used should be discussed within that context.