In-vitro induced histamine liberation from mucous membrane of the stomach and duodenum before and following vagotomy

In 13 patients suffering from duodenal ulcer and undergoing vagotomy biopsies were taken from mucosa of the gastric fundus and of the duodenum. Histamine release from the samples upon challenge to different food was assayed before and after vagotomy. Generally, more histamine was set free from gastric mucosa than from the duodenal one. However, in 11 of 13 subjects there was an alternative shift in the fundus and in the duodenum after vagotomy.     

Various special problems of the treatment of acute peptic ulcer- induced gastrointestinal hemorrhage

The work has analyzed an experience with the treatment of 1336 patients with acute gastrointestinal bleedings of ulcerous etiology, 799 of them were operated upon. All the surgical interventions were divided into 3 categories: emergency operations (immediately after admission of the patient), delayed (within 24 hs) and planned operations (3 weeks later). Operative lethality was 5.2%, 11% and 1.8% correspondingly. Heavy blood loss was most frequent in gastric ulcer (37%) and retrobulbar ulcer of the duodenum (30%), less frequent in ulcer of the duodenum bulb (6.7%) and prepyloric ulcer (4.4%). Urgent fibrogastroscopy was used not only as a diagnostic method, but also as an attempt to control bleeding. Truncular vagotomy with draining operations are thought to be preferable for duodenal ulcers, for gastric ulcer--it is resection of the organ.     

Surgical choices in peptic ulcer associated with duodenal diverticula

The work analyzes surgeon's tactics for associated ulcer disease with duodenal diverticula. Operations were performed on 51 patients with these diseases. The operation of choice is gastric resection after Hofmeister-Finsterer which is sufficiently effective in treatment of ulcer disease and when excluding the duodenum creates conditions for the prevention of inflammation of the diverticulum.     

Massive dissecting intramural duodenal haematoma following endoscopic haemostasis of a bleeding duodenal ulcer

Intramural duodenal haematoma is a rare injury of the duodenum. Most reported cases are secondary to blunt trauma to the abdomen. Such injury following endoscopic intervention is even rarer, and there are no definite guidelines for its management. We report a case where endoscopic haemostasis of a bleeding duodenal ulcer resulted in a massive dissecting intramural duodenal haematoma with gastric outlet obstruction and obstructive jaundice.     

Double gastroenterostomy tube in gastric surgery.

This report describes a new double gastroenterostomy tube. It has been used in patients where delayed oral feedings are anticipated, ie, a perforated duodenal ulcer, suture-plicated, with stenosis of the duodenum; a duodenal ulcer with outlet obstruction treated with vagotomy and gastroenterostomy; and patients with chronic lung disease undergoing gastric surgery and requiring postoperative respiratory assistance. Its use has proved to be beneficial, and it is cheap and allows early enteric feeding.     

Endoscopic diagnosis of masked perforated peptic ulcer]

Fifty eight patients hospitalized with a suspicion to masked perforated ulcer of the stomach and duodenum were subjected to urgent fibrogastroduodenoscopy by means of modern endoscopes with fiber optics. In 8 cases the perforation was diagnosed during endoscopy and subsequently supported intraoperatively. In the remaining patients the diagnosis of perforated ulcer was rejected. An application of urgent endoscopy in patients suspected of masked perforated gastric or duodenal ulcer made it possible to avoid useless laparotomies and shorten the terms of preoperative examination and determination of indications to surgical therapy.     

Gastroduodenoscopy: a routine examination of 2,800 patients before laparoscopic cholecystectomy

Background Unrecognized gastric and duodenal peptic ulcer is a common cause of epigastric pains for patients with cholelithiasis qualified for laparoscopic cholecystectomy. Undiagnosed gastric or duodenal ulcer may be the cause of persistent pains after cholecystectomy. The purpose of the study was to assess the value of a routine preoperative panendoscopy for qualifying patients to undergo laparoscopic cholecystectomy. Methods The study enrolled 2,800 patients treated for cholelithiasis from May 1993 to December 2002. Endoscopic examination was performed for all treated patients 1 to 4 days before their operations. Results Preoperative endoscopy showed pathologic changes in the stomach or duodenum in 1,187 (42%) of 2,800 patients qualified for laparoscopic cholecystectomy. Gastric ulcer was found in 179 patients (6.4%) duodenal ulcer in 127 patients (4.5%), gastritis in 735 patients (26.3%), polyps in 143 patients (5.1%), and cancer in 3 patients (0.1%). The surgery was postponed for patients with ulcer, and antiulcer treatment was started. In 16 patients, the symptoms associated with cholelithiasis subsided after healing of the ulcer. Cholelithiasis in these patients was asymptomatic, and a cholecystectomy was not performed. Conclusions Panendoscopy should be a routine examination performed for each patient qualified to undergo laparoscopic cholecystectomy. For some patients with asymptomatic cholelithiasis, pain in fact is caused by peptic ulcer.     

Effect of intraduodenal acid on the pre- and postvagotomy basal gastric secretion and gastrin.

Acid instillation into the duodenum inhibits basal and stimulated gastric secretion. In man vagotomy suppresses this secretory inhibition. It is postulated that such inhibition responds to a dual mechanism: an hormonal one (enterogastrone) and a nervous one (vagus nerve). This study showed that preoperative duodenal acidification of duodenal ulcer patients results in a decrease in basal gastric secretion and in gastrin levels. On the contrary, in patients submitted to vagal denervation--either through truncal division or highly selective vagotomy--duodenal acidification does not inhibit gastric secretion; however, a drop occurs in basal gastrin levels. An intact gastric vagal innervation therefore, seems necessary for the preservation of the sensitivity of the parietal cell to the effect of hormonal inhibitors, it being immaterial whether duodenal innervation is present or not, as that duodenal acidification provokes a significant fall in serum gastrin levels as determined by radioimmunoassay. This hormonal decrease produced by duodenal acidification can be explained by the inhibition of gastrin release from the antrum. Agreement is expressed with the opinion of other authors that highly selective vagotomy does not appear to carry any advantage over truncal section of the vagus nerves from the standpoint of the inhibitory mechanism of gastric secretion from the duodenum.     

Role of pyloric reflux in experimental stress ulceration during haemorrhagic shock.

The significance of pyloric reflux of bile and duodenal juice in experimental gastric stress ulceration was studied using a swine shock ulcer model. Following a haemorrhagic shock of 3 h duration, nine of the ten control piglets (90%) with normal bile flow have gastric mucosal lesions. None of the five piglets with permanent bile diversion (ligation of common bile duct; cholecystojejunostomy) has gastric lesions. Intragastric instillation of pure bile prior to the shock in piglets with permanent bile diversion induced gastric lesions in only one of the five test animals (20%). If duodenal juice was used instead, four of the six test animals (67%) have lesions. The results indicate that, in the pig, an uninterrupted flow of bile into the duodenum is a prerequisite for the development of gastric mucosal lesions following haemorrhagic shock. They also suggest that duodenal juice containing both bile and pancreatic juice has a stronger ulcerogenic influence on shocked porcine gastric mucosa than bile alone.     

Strategies in surgical treatment of ulcers at present time

Modern state of a problem concerning the ulcer disease (UD) of stomach and duodenum conservative and operative treatment was suggested. Possibilities and perspectives of medicinal therapy were evaluated critically. Indications for surgical treatment of UD were substantiated. Method of choice in duodenal UD is performance of organ preserving intervention, in gastric UD--piloro--and antrumpreserving resection.     

A case of duodenal carcinoma presenting as a submucosal tumor

This paper describes a patient with duodenal carcinoma showing the features of a submucosal tumor, leading to difficulty in making an accurate preoperative diagnosis. A 63-year-old woman was admitted for investigation of a duodenal mass. An examination of the upper gastrointestinal tract revealed a semicircular compression of the stomach and the duodenum. Endoscopy of the stomach and duodenum disclosed a hemispherical tumor with a deep ulcer in the apex. Computer tomography revealed a tumor of about 5 cm in diameter at the same site. Laparotomy was performed under the tentative diagnosis of a submucosal tumor. A tumor was found occupying the duodenum, which compressed the gastric antrum exteriorly, and was also adherent to the head of the pancreas by direct invasion. A curative resection was performed by combining a pancreatoduodenectomy with a transverse colectomy along with regional lymph node clearance. A microscopic examination showed that the tumor contained neoplastic cells growing in a tubular pattern, particularly in its peripheral regions. Thus, this lesion was finally diagnosed as primary adenocarcinoma of the duodenum.     

Results of gastrectomy in uncomplicated duodenal ulcer 10 years after the operation]

An analysis of long-term results of surgical treatment (resection of the stomach) of 92 patients with noncomplicated ulcer of the duodenum has been made 10 years after the operative procedure. Peptic ulcer of the gastroenteroanastomosis was found to develop in 1 of 92 patients. The first group (after Vizik) included 23 patients (25%); the second group--22 patients (23.9%), the third one--44 (47.8%) and the fourth--3 patients (3.3%). As a whole, excellent and good results of gastric resection for noncomplicated duodenal ulcer were noted but in half of the patients.     

Hypo-acidity of gastric juice in chronic gastric ulceration caused by neutralisation.

Samples of gastric juice were aspirated every 15 minutes from 54 normal subjects and 31 patients with chronic gastric ulcers during a maximal histamine infusion test. The known tendency of patients with gastric ulcers to secrete a less acid gastric juice than that of normal subjects was confirmed. However, the hypo-acidity was related to the extent by which the total ionic concentration was less than the isotonic value of 328 mEq/l. On the assumption that such hypo-acidity was produced by the neutralisation of hydrogen ions by bicarbonate ions refluxing into the stomach from the duodenum, the data were corrected and resulted in a normal estimate of the hydrogen ion concentration in the gastric ulcer group. Independent corrections, according to the sodium content of refluxed duodenal juice, yielded similar results for the volume of gastric juice aspirated. It is concluded that while back-diffusion can explain the hypo-acidity of gastric juice in patients with gastric ulcers, duodenal reflux can explain both the hypo-acidity and the hypotonicity, and is therefore more likely to be the correct explanation.     

Mechanical anastomosis on the second duodenum. Value, technics and indications

The authors present 50 anastomoses on the second part of duodenum after gastrectomy, that were done for gastro-duodenal ulcer in 24 patients, gastric carcinoma for 20 patients and post-gastrectomy syndromes in 5 patients. The mechanical procedure provide excellent security (without leakage) and was easy to perform. When it is necessary to make the restoration of duodenal continuity, this device is a good technical solution.     

Maximal gastric secretion and duodenogastric reflux in patients with gastric or duodenal ulcer and in control subjects

Maximal gastric secretion was studied in 41 unoperated patients with gastric ulcer, 201 patients with duodenal ulcer, and 122 control subjects. The patients with a gastric ulcer were divided into high, body and prepyloric, according to the site of the ulcer. Both high and body gastric ulcers secreted significantly less than the controls, and the duodenal ulcer patients secreted significantly more. However, the patients with gastric ulcer were older and lighter than the controls and, since these factors are known to influence maximal gastric secretion, the controls and patients with duodenal ulcer were standardized to the mean weight (and age, for the controls) of the gastric ulcer group. After this standardization, there was no significant difference in secretion between the patients with body ulcers and normal controls. Pyloric loss was a similar percentage of maximal gastric secretion in all groups, but duodenogastric reflux was higher in the gastric ulcer group compared to the controls. The mean volume of duodenogastric reflux was greatest in the patients with a prepyloric gastric ulcer. It is commonly accepted that hyposecretion in patients with a gastric ulcer is due to gastritis consequent upon increased duodenogastric reflux. However, in this study, no gastric hyposecretion was evident in the body and prepyloric gastric ulcer groups, both of whom had greater than normal levels of duodenogastric reflux.     

Surgical treatment of chronic duodenal obstruction after radical operations on the stomach in peptic ulcer

The authors operated on 138 patients with impaired duodenal patency after gastric resection and selective proximal vagotomy. The most substantiated operation is the Roux-en-Y reconstruction. In possible elimination of mechanical obstacles and normal tonicity of the duodenum, the passage through it was restored by means of isoperistaltic jejunal segment. Good long-term results were noted in 83.2%, satisfactory--in 13.6%, bad (ulcer recurrence)--in 3.2% of the patients.     

Specific topographic-anatomical and technical features of resection of the stomach by the Roux method

The topographic-anatomical investigations of the extraorganic part of the arterial and nervous systems of the duodenum and the initial part of the jejunum in combination with the results of the clinical use of gastric resection by the Roux method allowed to draw a conclusion that the development of Roux syndrome can be prevented by a transection of the jejunum with the saved arcades between the first jejunal artery, the duodenal branch and the second jejunal arteries. The rules of gastric resection by the Roux method and indications to this procedures in patients with ulcer disease of the stomach and duodenum are described. Good and excellent long-term results were obtained in 75.8% of the patients operated upon.     

Changes in immune state in patients with duodenal ulcer disease

There were examined 73 patients with giant ulcer (GU) of the duodenum and 62--with the smaller size ulcer of the duodenum. In majority of patients essential disorders of immune state were revealed: reduction of the T-lymphocytes quantity, disbalance of their subpopulation composition, the rise of the circulating immune complexes level, activization of autoimmune reactions. In patients with duodenal GU immune disorders were more pronounced, than in the presence of the smaller size duodenal ulcer. Maximum changes of the immune status were observed in patients with complications of duodenal GU--perforation, penetration, haemorrhage.     

Perforated duodenal ulcer associated with an incarcerated hiatal hernia: report of a case

We report the case of a perforated duodenal ulcer and diffuse peritonitis associated with an incarcerated hiatal hernia. A 77-year-old woman with a 17-year history of rheumatoid arthritis treated with nonsteroidal anti-inflammatory drugs, who had also been receiving treatment for non-Hodgkin's lymphoma over 4 years, was referred to us for investigation of nausea and vomiting. An abdominal compute tomography (CT) scan showed an incarcerated hiatal hernia and free air in the hernia sac. Emergency laparotomy revealed an incarcerated hiatal hernia involving the stomach, transverse colon, and omentum. A perforated ulcer was also found in the posterior wall of the first portion of the duodenum. The combination of these disorders is thought to be rare in patients with a hiatal hernia and free air in its sac. As the reported mortality of perforated gastric ulcer associated with a hiatal hernia is high, early elective surgery should be performed in patients with a duodenal ulcer associated with a hiatal hernia. Received: December 25, 2001 / Accepted: May 7, 2002 Reprint requests to: Y. Otsuka     

Surgical management of acute hemorrhagic postbulbar duodenal ulcer after a previous major surgical procedure

The choice of operation for acute hemorrhagic postbulbar duodenal ulcer after an operation is discussed. Distal partial gastrectomy was performed in six patients. The ulcer was treated by resection, suture, or removal by mucoclasis. Hemostasis was attained in five patients. In another, multiple ulcers were observed in the descending portion of the duodenum and gastrectomy failed to control hemorrhage, resulting in death. Rebleeding was observed in two, one from a newly formed ulcer in the upper part of the papilla of Vater after gastrectomy with truncal vagotomy and which was halted by suture of the ulcer and another was from a newly formed ulcer in the remnant stomach after gastrectomy and which was halted by selective vagotomy and ligation of the left gastric artery. It is recommendable to perform a subtotal gastrectomy and vagotomy combined with removal of the ulcer by mucoclasis or ulcer suture. In some cases, pancreatoduodenectomy may have to be done.