One-stage segmental pylorus-preserving resection of the stomach and duodenum in stenosing duodenal ulcer]

The analysis of the results of surgical treatment of 32 patients with duodenal ulcer disease complicated by postpyloric stenosis of the duodenum, using the original technique--combination of selective proximal vagotomy with segmental pylorus-preserving resection of the stomach and duodenum was carried out. A good immediate and long-term result was noted, there were no ulcer recurrences. Such an operative intervention is expedient in stenosing duodenal ulcer, its combination with a gastric ulcer, and as well in postvagotomy ulcer recurrency developing against the background of high gastric acid production.     

Pylorus-preserving gastric resections in gastroduodenal ulcers]

The article analyses the results of pylorus-preserving resections of the stomach in 116 patients among whom 80 had gastric ulcer, 29 ad duodenal ulcer, and 7 had gastroduodenal ulcers. Changes of acidity and motor-evacuation function of the gastric stump were studied according to the method of pylorus-preserving resection. The late-term results of treatment in follow-up periods of 2 to 5 years are shown, they were found to be good in 96.6% of patients treated by operation and poor in 1.7%. It is noted that the function of the gastric stump is better when the vagus innervation of the pylorus is preserved. Mediogastric resection with selective proximal vagotomy in patients suffering from duodenal ulcer with a superacidic stomach led to stable normalization of acid production, which was a reliable measure for the prevention of a recurrent ulcer.     

Pylorus-reconstructing operations in complicated gastric and duodenal ulcer]

The results of treatment of 185 patients with complicated gastric and duodenal ulcer disease have been analysed. The results of operative treatment in 132 patients followed up for the period of from 1 to 7 years were studied. In gastric ulcer, resection of the stomach with preservation of the pyloric sphincter, or its reconstruction by means of the flaps taken from the antrum, is indicated; in duodenal ulcer--vagotomy, ulcer excision added by pylorus-preserving and pylorus-reconstructing methods of drainage operations.     

The advantages of pylorus-preserving pancreatoduodenectomy in malignant disease of the pancreas and periampullary region.

The aim of this study was to establish whether the pylorus-preserving pancreatoduodenectomy (PPPD) is a safe and radical procedure in malignant disease of the head of the pancreas and periampullary region, without increased morbidity and mortality rates compared with the standard Whipple's procedure. During the period 1984 to 1990, a Whipple's procedure (n = 44) or PPPD (n = 47) was performed in 91 patient. In-hospital mortality rates were 2% after PPPD and 5% after Whipple's procedure. Median duration of the resection procedure and median blood loss in the PPPD group were 210 minutes and 1800 mL, respectively. After Whipple's procedure, these figures were 255 minutes and 2500 mL, both significantly different (p less than 0.01) as compared with PPPD. No difference was found during follow-up with respect to days of gastric suctioning, start of liquid diet, normal diet, complaints of ulcer disease, postoperative complications, recurrence of disease, and survival. In all patients, curative resection was performed with comparable TNM (tumor, nodes, metastases) staging. The number of tumor-containing duodenal or gastric resection margins did not differ in both groups of patients (two patients after PPPD, two patients after Whipple's procedure). Hospital stay was significantly (p = 0.02) shorter after PPPD; median 14 days, compared with median 18 days after Whipple's procedure. The advantage of the PPPD is that it is an easier and less time-consuming operation, with less blood loss, a shorter hospital stay, and better weight gain (p = 0.02) during follow-up. In conclusion, PPPD is a safe and radical procedure for cancer in the head of the pancreas or periampullary region, with the same survival and appearance of locoregional recurrence and distant metastases as after standard Whipple's resection.     

Prognosis of gastric ulcer: twenty-five year followup.

Four hundred twenty-two patients with gastric ulcer treated during 1950-1960 were followed up to 25 years with a mean followup of 9 years. Nonoperative treatment was used in 59% with a hospital mortality of 35%, one-third of these deaths being directly due to gastric ulcer perforation or hemorrhage. Operative treatment was used in 41% of patients. The most common operation (86%) was gastric resection without vagotomy. Overall operative mortality was 16%; 34% for emergency procedures and 6% for elective procedures. Cachexia seemed to be the most important factor related to operative mortality. Nonoperative treatment resulted in more than twice the hospital mortality compared to operative treatment. Approximately one-half of all patients treated non-operatively had a recurrent gastric ulcer at some time during this study. The recurrence rate following definitive gastric resection was 1.3% compared with 16% during nonoperative therapy. Three-fourths of recurrences occurred later than two years and nearly half of recurrences after more than 5 years of followup. Patients with a prior history of overt bleeding from gastric ulcer disease particularly were at risk for further bleeding. There were coincidental duodenal ulcers in 10% of our patients and a 0.8% incidence of gastric cancer during followup. Long term followup demonstrates the superiority of operative treatment of gastric ulcer and also reveals the continuous propensity of such ulcers to recurrence following nonoperative treatment. Earlier elective operation in patients with overt bleeding, recurrence or persisting symptoms should decrease overall mortality and result in a lower overall long-term risk of ulcer complications.     

Gastric emptying and small bowel transit of solid food after pylorus-preserving pancreaticoduodenectomy

We examined the gastric emptying and small bowel transit of solid food in ten patients one to 45 months after pylorus-preserving pancreaticoduodenectomy. Gastric emptying and small bowel transit were measured by computer analysis of data from a scintillation camera using technetium Tc 99m-tagged chicken liver mixed with beef stew and were compared with the results in five control subjects. The nutritional status of the patients was also evaluated. Gastric emptying was normal in six patients, rapid in three patients, and delayed in one patient. Small bowel transit was normal in two patients, rapid in seven patients, and delayed in one patient. Most of the patients were asymptomatic, ate three meals a day, and gained weight after the operation. These findings show that after pylorus-preserving pancreaticoduodenectomy, most patients consume a regular diet and achieve an excellent nutritional status. Gastric emptying is normal, not slowed. Small bowel transit is faster than normal but is without clinical sequelae.     

Surgical treatment of high bleeding gastric ulcer

In the surgical treatment of 68 consecutive patients with benign, high, bleeding gastric ulcer between 1966 and 1981, the following operative procedures were used; high gastric resection in 31 (45.5%) cases, local ulcer excision with truncal vagotomy and pyloroplasty in 23 (33.8%), local ulcer excision with low gastric resection in 11 (16.2%) and a local procedure alone in three (4.5%) cases. Of these 68 operations, 40 (59%) were early elective operations and 28 (31%) acute or emergency operations. Altogether, six (8.9%) patients died postoperatively, all but one after acute or emergency operation. High gastric resection was the most risky operation and five of the six deaths were in this operative group. Nonfatal complications developed in 18 (26.4%) cases but without correlation to the timing or to the type of operation. Early rebleeding during the hospital stay necessitating reoperation occurred in three (4.4%) patients, two of these among the three cases operated on using a local procedure and without a definitive operation. During the follow-up five (7.3%) recurrent ulcers developed, four after local ulcer excision with truncal vagotomy and pyloroplasty and one after high gastric resection. It seems to us that in the treatment of patients with high gastric ulcer, local operation alone is never acceptable. High gastric resection is often technically hazardous with a high postoperative mortality rate. The best methods seemed to be local ulcer excision combinated with truncal vagotomy and pyloroplasty or, perhaps preferably, with low gastric resection.     

Is there an advantage in performing a pancreas-preserving total duodenectomy in duodenal adenomatosis?

BACKGROUND: Duodenal adenomatosis is a premalignant condition often not treatable by local resection or endoscopy. An option for treatment is a pylorus-preserving (pp)-Whipple resection. Since the introduction of pancreas-preserving total duodenectomy (PPTD), the question has arisen whether a pp-Whipple resection is still needed to treat duodenal adenomatosis. PATIENTS AND METHODS: In a 5-year period 23 PPTDs were performed for duodenal adenomatosis. In a matched-pairs analysis the outcome following PPTD (16 patients with a follow-up longer than 12 months) was compared with pp-Whipple. RESULTS: Hospital mortality in all 23 patients was 4.3% and total morbidity 30% after PPTD. Operation time, intensive care and hospital stay, morbidity, and mortality were comparable between the matched paired groups (16 patients). Patients with PPTD had significantly lower intraoperative blood loss. No PPTD patient required pancreatic enzyme substitution, compared with 12 patients after pp-Whipple. Quality-of-life analysis in PPTD patients revealed no difference compared to a normal control population and the pp-Whipple group. CONCLUSIONS: PPTD is a safe surgical procedure for duodenal adenomatosis that avoids pancreatic head resection, provides high quality of life, and shows advantages over the pp-Whipple procedure.     

The impact of pylorus-preserving pancreatoduodenectomy on surgical treatment for cancer of the pancreatic head

Pylorus-preserving pancreatoduodenectomy (PPPD) was reintroduced in 1978. This pylorus-preserving modification was designed to minimize complications related to gastric resection, such as early satiety, marginal ulceration, and bile reflux gastritis, as well as diarrhea and dumping. Since 1978, PPPD has been performed preferentially for benign and malignant diseases of the periampullary region and pancreatic head. Some groups have argued against PPPD for cancer of the pancreatic head, because the pylorus-preserving procedure is likely to compromise the field of resection and does not allow lymph node dissection of the peripyloric and perigastric groups. However, comparative survival rates after PPPD have been the same as, or better than, those with classic pancreatoduodenectomy, showing the rationale for PPPD as a radical resection procedure for cancer of the pancreatic head. PPPD can be performed with low mortality. Delayed gastric emptying, which is the most common complication in the immediate postoperative period after PPPD, is always transient. Many investigators have shown that body weight and the majority of nutritional parameters are better than after PD. PPPD does not appear to cause any negative outcomes. We conclude that PPPD is the surgical procedure of choice for cancer of the head of the pancreas. Received: April 13, 2001 / Accepted: June 6, 2001     

Prospective trial of proximal gastric vagotomy

Forty men who were to have elective operation for nonobstructive duodenal or pyloric channel ulcer were randomized prospectively to undergo either proximal gastric vagotomy without drainage (PGV, n = 18) or selective vagotomy, antrectomy, and gastroduodenostomy (SVA, n = 22). Gastric acid analyses were accomplished before and 3 and 12 months after operation. Clinical interviews were conducted yearly. Thirty-nine patients were evaluable at 2 years, 25 at 4 years, and 15 at 5 years. No operative deaths occurred. Recovery was more rapid and the incidence of serious operative morbidity was lower after PGV than after SVA. Reduction of basal and stimulated gastric secretion was greater after SVA than PGV. Significant long-term sequelae other than recurrent ulcer were less frequent after PGV compared to SVA. Recurrent ulcer may occur more often after PGV; 3-month gastric secretory studies may be helpful in anticipating recurrence. Patients who undergo PGV have a particularly increased risk of developing pyloric channel ulcer disease, and low secretory values indicating an adequate vagotomy do not assure future protection from pyloric channel ulcer recurrence. Long-term sequelae after SVA, particularly dumping, do not have dependable reoperative options, whereas antrectomy should be a reliable reoperative solution to ulcer recurrence after PGV. PGV, performed correctly with a 5 to 7 cm vagal-esophageal separation, is preferable to vagotomy and resection for elective treatment of nonobstructing duodenal ulcer disease.     

Pylorus-preserving Pancreaticoduodenectomy in the Treatment of Chronic Pancreatitis

The pylorus-preserving pancreaticoduodenectomy (PPPD) is an alternative to the standard Whipple resection in the treatment of chronic pancreatitis. The operation is safe and can be performed with a low mortality rate. The most common early complication is delayed gastric emptying, which occurs in 25% to 30% of patients, and generally results in longer hospital stays than the standard Whipple procedure. Follow-up studies show that both operations are equally effective in relieving pain in approximately 75% of selected patients. In the long term, the PPPD successfully preserves physiologic gastric emptying, but at the cost of a higher marginal ulceration rate. The purported nutritional advantages of the PPPD over the classic Whipple resection have not been clearly established. At present, the PPPD is the procedure of choice for patients with chronic pancreatitis requiring panceraticoduodenectomy. Based on available information, this recommendation appears to arise form the fact that the PPPD is less radical than the regular Whipple procedure, and some surgeons find it technically easier. Our experience fails to show a distinct superiority of the PPPD over the Whipple operation.     

Modification of gastrectomy by the Roux and Ridiger methods

The author recommends a more effective operative method after Roux-Ridiger with an invagination intestinal anastomosis in the management of severe complications of gastric and duodenal ulcer, particularly in duodenostasis and reconstructive operations for a disease of an operated stomach, and in the postvagotomy syndrome. He carried out 340 economical resections of the stomach after Roux-Ridiger with an invagination intestinal anastomosis in various complications of gastric and duodenal ulcer and the post-gastrectomy and postvagotomy syndromes. The immediate and late-term results of the operation were good. Modified gastric resection after Roux and Ridiger with invagination techniques was performed in 26 experimental dose to study the secretory and motor-emptying function of the gastric stump in the immediate and late-term periods after the operation; the results were good.     

Do perforated duodenal ulcers need an acid-decreasing surgical procedure now that omeprazole is available?

If a chronic duodenal ulcer perforates, the choice of operation will depend on the patient's condition. Preoperative shock, concurrent medical diseases, severe generalized peritonitis, or the presence of an intra-abdominal abscess are contraindications to a definitive ulcer operation; hence, simple closure or omental patch closure is performed. Omeprazole can then be used to heal the ulcer in the early postoperative period, with long-term H2-blocker therapy to follow. The patient without a contraindication to a definitive operation should have a proximal gastric vagotomy in addition to an omental patch closure of the perforation. The addition of this procedure does not change the operative mortality rate in properly selected patients, does not cause the gastrointestinal sequelae associated with truncal vagotomy and pyloroplasty or resection, and has a low rate of recurrent ulcer in experienced hands. The presence of a synchronous posterior "kissing" duodenal ulcer would prompt some to choose a vagotomy and pyloroplasty in preference to a proximal gastric vagotomy. The appropriate operation to perform after perforation of an acute duodenal ulcer in a patient with any of the contraindications listed above is simple closure or omental patch closure. In the stable nonseptic patient, the choice is not as clear. Boey and associates noted cumulative recurrent ulcer rates of 37% and 31% at 3 years in separate studies in which omental patch closure was used for perforated acute duodenal ulcers. This may reflect the asymptomatic nature of chronic duodenal ulcers in some patients prior to perforation, the failure of the surgeon to recognize the extent of periduodenal scarring at operation, or differences in the length of postperforation follow-up in series reporting perforations of acute or chronic ulcers. Jordan has suggested that all stable patients with perforated duodenal ulcers should undergo a proximal gastric vagotomy in addition to omental patch closure. In his hands, the addition of proximal gastric vagotomy has an operative mortality rate of 0 to 1%, a recurrent ulcer rate of 3% to 5%, and no adverse postoperative sequelae. He has noted that "this operation gives protection from further ulcer disease to those who need it and will produce no harm to the unidentifiable patients that might not have benefited from definitive surgery." Boey and Wong suggested that omental patch closure is indicated for "acute ulcers associated with drug ingestion or acute stress" in addition to those that occur in patients who are considered to be poor risk, while proximal gastric vagotomy should be added in the remaining patients with perforations of acute ulcers.(ABSTRACT TRUNCATED AT 400 WORDS)     

Postoperative Evaluation of Pylorus-Preserving Procedures Compared with Conventional Distal Gastrectomy for Early Gastric Cancer

We evaluated postoperative function in 98 patients who underwent surgery for early gastric cancer between 1995 and 1998 to compare the results of pylorus-preserving procedures to those of conventional distal gastrectomy with Billroth I (B-I). The pylorus-preserving procedures included endoscopic mucosal resection (EMR), performed in 12 patients; local resection (Local), performed in 14 patients; segmental resection (Seg), performed in 8 patients; and pylorus-preserving gastrectomy (PPG), performed in 19 patients. B-I was performed in 45 patients. The nutritional status and serum albumin (Alb) levels after PPG, the hemoglobin (Hb) levels after EMR, Local, and PPG, and the present/preoperative body weight ratios after EMR, Local, Seg, and PPG were superior to those after B-I. The time before oral intake was recommenced after EMR and Local, the volume of oral intake tolerated after EMR, Local, Seg, and PPG, and the postoperative hospital stay after EMR were all superior to those after B-I. Moreover, significantly fewer patients suffered reflux symptoms after EMR, Local, and PPG, abdominal fullness after EMR, and early dumping syndrome after EMR, Local, and PPG than after B-I. There was also less evidence of gastritis after EMR, Local, and PPG, and of bile reflux after EMR, Local, and PPG, than after B-I. These findings indicate that pylorus-preserving procedures may result in a better postoperative quality of life for selected patients with early gastric cancer. Received: September 28, 2000 / Accepted: March 6, 2001     

扩大壁细胞迷走神经切断术治疗十二指肠溃疡急性穿孔176例

目的探讨扩大壁细胞迷走神经切断术（EPCV）治疗十二指肠溃疡并发急性穿孔的远期临床疗效。方法对1979年以来采用EPCV治疗的176例十二指肠溃疡并发急性穿孔患者的临床资料进行总结,分析评价疗效,评价内容包括术后并发症发生率、溃疡复发率、胃排空功能、胃镜和上消化道钡餐检查结果和营养状态及Visick分级。结果全组患者有153例（86.9%）获得5年随访。无手术死亡者。进食后上腹发生间断性胀痛13例（8.5%）,有时返酸12例（7.8%）,经服用吗叮啉可缓解。出现粘连性肠梗阻行粘连松解术4例（2.6%）,溃疡复发4例（2.6%）,均发生在术后2-3年内。浅表性胃炎21例（13.7%）,十二指肠球部变形31例（20.3%）,胃窦蠕动功能较好,胃排空功能正常。全组无贫血发生,体重增加者116例（75.8%）。Visick改良分级,146例为Ⅰ级和Ⅱ级,优良率占95.4%,Ⅲ级3例（2.0%）,Ⅳ级4例（2.6%）。结论EPCV术具有手术操作简便、术后并发症较少、溃疡复发率低、患者术后远期营养状况良好、生活质量较高的优良疗效,是治疗十二指肠溃疡并发急性穿孔首选的安全有效术式之一。     

Is proximal pancreatoduodenectomy with pyloric preservation superior to total pancreatectomy?

The records of all patients who underwent pylorus-preserving pancreatic resection (29 subtotal and 4 total pancreatectomies) during a 10-year period at the Mayo Clinic were reviewed. Thirty-day operative mortality was 6%. Early postoperative morbidity occurred in 45% of patients and necessitated reoperation in four patients. One patient had a hemorrhage from a marginal ulcer in the early postoperative period. The incidence of late postoperative morbidity was 18%. Marginal ulcers developed in the late postoperative period in three additional patients, for an overall incidence of 13%. One patient underwent vagotomy and pyloroplasty because of intractable bleeding 2 years after initial operation. The 29 patients who underwent pylorus-preserving pancreatoduodenectomy (PPW) were compared (retrospectively) with 200 patients who had undergone standard pancreatoduodenectomy (Whipple operation) during the same 10-year period. The overall incidences of marginal ulcer were 10% in the PPW group and 5% in the Whipple group; the incidences of delayed gastric emptying were similar in these groups. We believe that caution is warranted in the use of PPW, as yet an unproved procedure.     

Treatment of peptic ulcer hemorrhages

The article analyses experience in treatment of 297 patients with gastroduodenal bleeding of ulcerous etiology. Operative interventions after arrest of bleeding and the appropriate preoperative management produce better results (the mortality rate, 3.3%) than those of emergency operations (the mortality rate, 15.7%). It is therefore advisable to start treatment of patients with gastroduodenal bleeding by means of nonoperative measures which proved effective in 61.6% of cases. In doubtful reliability of hemostasis, patients with moderate and severe bleeding should be operated on in the immediate days after hospitalization without waiting for a possible recurrent bleeding. Gastric resection is the main type of operative intervention in bleeding from a gastric ulcer. In a bleeding duodenal ulcer both resection of the stomach and economical operations--vagotomy, excision or closure of the ulcer, pyloroplasty--are equally competent.     

Surgical resection of tumors in the distal duodenum

We present six cases of successfully resected primary tumors of the distal part of duodenum (third and fourth segment). Average age of the four male and two female patients was 59 years (47-80). Distal segmental resection were performed in four, pylorus-preserving pancreatoduodenectomy in two cases. Histologically the tumors were five adenocarcinomas, and one gastrointestinal stromal tumor. This tumor causing massive bleeding. In two patients, local lymph nodes were tumor positive, and in one patient synchronous metastasis of the greater omentum was excised during a palliative resection. There was no operative mortality. During a mean follow-up period of 17 months two patients died. Our results support the fact, that radical surgical resection of these tumors, even by segmental resection, provides a more favorable prognosis for duodenal carcinoma than for pancreatic tumors.     

Early results of pylorus-preserving gastrectomy for duodenal ulcer

Twenty patients with duodenal ulcer were treated by pylorus-preserving gastrectomy. Post operative reduction in maximal acid output was 65%. Gastric emptying was slow without producing stasis.A provocative test showed that dumping was almost completely eliminated and was very mild in the one case in which it did occur.Short-term review between 2 and 3 years postoperatively showed continuing satisfactory results with no gastric stasis and an absence of early recurrence.The results are compared with the results of proximal selective vagotomy, and the mechanism of maintenance of a functioning pylorus is discussed.     

Surgical management of gastroduodenal haemorrhage

We have presented a retrospective study of the surgical management of 299 patients bleeding from duodenal ulcer, gastric ulcer or gastritis. The overall mortality rate was 15%-5% for elective and 25% for emergency operations. The mortality increased with age and reached 50% for emergency operations in patients over the age of 70. Patients with low admission haemoglobin values, who had episodes of hypovolemic shock or who required immediate transfusions were also at risk. A Billroth I gastric resection proved to be the safest operative procedure. Based on our results, we are supporting a program calculated to reduce the mortality attending gastroduodenal bleeding, especially in those patients requiring an emergency operation. The basic principles of this program are constant observation, prompt diagnosis and early surgical intervention.