The Henley Operation (Henley Loop / Isoperistaltic Jejunal Interposition)

What It Is

Indications (Why It Is Done)

1. Bile reflux gastritis / alkaline reflux gastritis after distal gastrectomy - especially post-Billroth II
2. Post-proximal subtotal gastrectomy (esophago-antral anastomosis) - interposed between the esophagus and the antral remnant to buffer bile/pancreatic reflux

Surgical Steps / Technique

1. Patient positioning and access: Standard laparotomy (upper midline or subcostal).
2. Mobilize the jejunum: Identify the ligament of Treitz. Select a loop of proximal jejunum approximately 15-20 cm distal to Treitz. Transilluminate the mesentery to identify a good vascular arcade.
3. Isolate the 40-cm interposition segment:
   • Divide the jejunum at two points ~40 cm apart, preserving the mesenteric blood supply to the isolated loop.
   • The isolated loop is kept isoperistaltic (i.e., its natural peristaltic direction is maintained in the direction of food flow - from stomach toward duodenum).
4. Restore small bowel continuity: Perform a jejuno-jejunostomy (end-to-end or end-to-side) to reconnect the cut ends of the jejunum proximal and distal to the resected segment, so the remaining small bowel remains in continuity.
5. Anastomose the interposition loop:
   • Proximal end: Anastomose to the gastric remnant stump (gastro-jejunostomy) end-to-end or end-to-side.
   • Distal end: Anastomose to the duodenum (jejuno-duodenostomy), restoring the duodenal food path.
6. Mesenteric defect closure: Close all mesenteric gaps to prevent internal hernias.
7. Combined vagotomy (optional): Because all these revisions risk marginal ulceration on the jejunal side, a concurrent generous distal gastrectomy (if not already done) and consideration of truncal vagotomy is advised to reduce acid. Acid-suppressive medications may be used as an alternative. - Schwartz's Principles of Surgery, 11th Ed

Key Technical Points

Limitations / Why It Is Not Always Used

• In the context of dumping syndrome, the Henley loop "has not been successful in ameliorating severe dumping over the long term." The Roux-en-Y is preferred for dumping. - Schwartz's Principles of Surgery, 11th Ed
• Excessively long limbs (>40 cm) risk obstruction or malabsorption.
• All interposition operations carry a risk of marginal ulceration at the jejunal anastomosis.
• Adds "additional complexity" compared to simpler Roux reconstruction.

Context Within Reconstruction Options After Gastrectomy

• Roux-en-Y gastrojejunostomy (Roux limb ≥45 cm, preferably 60 cm) - most commonly used
• Henley loop - 40 cm isoperistaltic jejunal interposition between gastric remnant and duodenum
• Billroth II + Braun enteroenterostomy
• Total gastrectomy with Roux esophagojejunostomy (for severe cases)

Henley Loop vs. Roux-en-Y After Gastrectomy: A Head-to-Head Comparison

1. Mechanism of Action - How Each Prevents Complications

2. Efficacy by Complication Type

Bile Reflux Gastritis / Alkaline Reflux Gastritis

• Roux-en-Y is the standard of care for alkaline reflux gastritis - Roux limb of 50-60 cm is very effective at eliminating bilious vomiting. However, persistent pain occurs in up to 30% of patients, and 20% develop postoperative delayed gastric emptying. - Maingot's Abdominal Operations
• The Henley loop is listed as a valid alternative revision option alongside Roux-en-Y and Braun enteroenterostomy. - Sabiston Textbook of Surgery, 28th Ed
• Sleisenger & Fordtran recommends that at the time of original gastric surgery, constructing a 30-cm Roux-en-Y limb or performing a 10- to 12-cm isoperistaltic jejunal interposition can help prevent bile gastropathy and subsequent metaplastic/atrophic changes. - Sleisenger & Fordtran's Gastrointestinal and Liver Disease

Dumping Syndrome

• Roux-en-Y is preferred for dumping. The disrupted myoelectric continuity of the Roux limb actually slows gastric emptying, which counteracts rapid transit. "Surgeons have used this operation successfully in the management of the dumping syndrome." - Schwartz's Principles of Surgery, 11th Ed
• Henley loop does NOT work for dumping: "Isoperistaltic interposition (Henley loop) has not been successful in ameliorating severe dumping over the long term." - Schwartz's Principles of Surgery, 11th Ed
• Roux-en-Y wins clearly here.

Nutritional Recovery

3. Current Evidence: 2023 Meta-Analysis (24 studies, 1887 patients)

4. Conflicting RCT Evidence (2020)

• At 12 months, food intake per meal, Prognostic Nutritional Index, weight loss, and GI Symptom Rating Scale were all significantly worse in the functional jejunal interposition group vs. Roux-en-Y (all p<0.05).
• No significant differences in operative time, blood loss, perioperative complications, or survival.
• Conclusion: "For patients with long-term survival after total gastrectomy for gastric cancer, the Roux-en-Y anastomosis is a better choice compared with functional jejunal interposition."

5. The Roux Stasis Problem - Roux-en-Y's Key Weakness

"The obligate transection of the jejunum disrupts myoelectric continuity... of the Roux limb with the duodenal pacemaker; this leads to erratic, non-coordinated contractions in the Roux limb with some contractions actually going upstream, thereby delaying gastric emptying - the so-called Roux stasis syndrome." - Current Surgical Therapy, 14th Ed

• Roux stasis (delayed gastric emptying from the Roux limb) occurs in a significant subset of patients.
• "20% of patients develop postoperative delayed gastric emptying" after Roux-en-Y for alkaline reflux gastritis. - Maingot's Abdominal Operations
• The Henley loop maintains jejunal continuity with the duodenal pacemaker, so peristaltic coordination is preserved and Roux stasis does not occur.
• Roux-en-Y is also associated with internal hernia risk through mesenteric defects, and risk of marginal ulceration. - Fischer's Mastery of Surgery, 8th Ed

6. Summary Table

Bottom Line

Recent Clinical Guidelines on Post-Gastrectomy Reconstruction (2024-2026)

1. Japanese Gastric Cancer Association (JGCA) Guidelines 2025 - 7th Edition

By Gastrectomy Type:

• Vitamin B12 supplementation is weakly recommended after total gastrectomy (Consensus 90%, Evidence C)
• H. pylori eradication is recommended after gastrectomy
• Pneumococcal vaccination is weakly recommended after splenectomy

2. Chinese Expert Consensus on Function-Preserving Gastrectomy 2025

• Individualized reconstruction based on tumor location and stage
• Integration of AI-assisted imaging, lymphatic visualization, and vascular navigation into surgical planning
• Pylorus-preserving and proximal gastrectomy with appropriate reconstruction as preferred where feasible over total gastrectomy in selected patients

3. ESMO 2024-2025: Surgical Reconstruction Not the Focus

4. Recent High-Level Evidence (2024-2026 Systematic Reviews & Meta-Analyses)

A. Roux-en-Y vs. Billroth II After Distal Gastrectomy

• No significant difference in delayed gastric emptying between Roux-en-Y and Billroth II (OR 0.90, 95% CI 0.48-1.67, p=0.73)
• Roux-en-Y had significantly fewer overall postoperative complications (OR 0.54, 95% CI 0.37-0.79, p=0.001)
• Roux-en-Y had shorter hospital stay (-0.92 days, p=0.02)
• No significant differences in mortality, anastomotic leak, operative time, or blood loss
• Conclusion: "Roux-en-Y reconstruction offers superior postoperative morbidity outcomes... these findings support Roux-en-Y as the preferred reconstruction when Billroth I is not feasible."

B. Proximal Gastrectomy + Double-Tract Reconstruction vs. Total Gastrectomy + Roux-en-Y

• Double-tract reconstruction (DTR) had better hemoglobin (+7.12 g/L, p=0.003) and needed less vitamin B12 supplementation (OR 0.12, p<0.00001) vs. total gastrectomy + Roux-en-Y
• No significant differences in early complications, late complications, reflux symptoms, or 5-year survival
• Total gastrectomy had slightly shorter operative time (+4.92 min, p=0.04)
• Conclusion: Proximal gastrectomy + DTR offers comparable oncological outcomes with better nutritional outcomes and may be an alternative to total gastrectomy in appropriately selected patients

C. Double-Flap Technique (DFT) for Proximal Gastrectomy

• DFT anastomotic leakage 1.4%, stricture 5.9%, pancreatic fistula 1.8%
• Only 3.4% reported subjective reflux symptoms; 5.1% had endoscopic esophagitis at 1 year
• DFT associated with significantly reduced PPI usage vs. esophagogastrostomy
• Longer operative time but reduced blood loss vs. esophagojejunostomy
• Conclusion: DFT is "a safe and effective method... offering a balance between surgical complexity and favorable short-term outcomes" - but large-scale RCTs are still needed

D. Metabolic Effects of Different Reconstruction Methods

• Duodenal bypass (vs. Billroth I): significantly higher T2DM remission (RR 1.43, 95% CI 1.27-1.62) and HBP remission (RR 1.30)
• Roux-en-Y (vs. Billroth II): significantly greater T2DM remission (RR 1.19, 95% CI 1.08-1.31)
• Roux-en-Y esophagojejunostomy showed a trend toward best T2DM remission (p=0.06)
• Conclusion: Gastrectomy with Roux-en-Y reconstruction appears most effective for T2DM remission - relevant for patients with comorbid metabolic disease

5. Practical Synthesis: What the 2024-2026 Evidence Supports

Post-Gastrectomy Reconstruction: Quick Reference by Complication Type

Table 1 - Complication Control by Reconstruction Method

Table 2 - Nutritional & Metabolic Outcomes

Table 3 - Surgical & Practical Considerations

Table 4 - Best Reconstruction by Clinical Scenario