A new intraoperative test for completeness of vagotomy: the PCP-GABA (beta-parachlorophenol-gamma-aminobutyric acid) test

PCP-GABA, an analogue of the neurotransmitter amino acid, GABA, is as effective a stimulant of vagal centers and acid secretion as sham feeding. Insulin hypoglycemia, a test hitherto widely used for the cephalic phase, is unsafe and nonspecific because it also stimulates catecholamine release which affects gastrin secretion. PCP-GABA, unlike insulin, causes no tachycardia or hypoglycemia; however, the major advantage of PCP-GABA is that it can be used safely intraoperatively to assess completeness of vagotomy. Its muscle relaxant action is an additional advantage in this regard. As an intraoperative test, PCP-GABA is given intravenously shortly after induction of anesthesia to stimulate acid secretion and to reduce gastric mucosal pH, which is measured by an intraluminal combination electrode. The electrode can be moved around through the intact gastric wall to take measurements from multiple sites. When vagotomy is complete, gastric mucosal pH increases to over 6. This test works well in the dog. We hope to assess its clinical use in the near future.     

Preparation of the orthotopic autotransplanted pancreas for long-term exocrine studies

The operative technique for the construction of an orthotopically autotransplanted pancreas with a permanent pancreatic fistula has been described. The operation is performed in two stages, with preparation of the transplant based on the gastroduodenal artery and superior pancreaticoduodenal vein in the first stage and construction of a Herrera-type permanent pancreatic fistula in the second stage. Elimination of warm ischemic time by dividing and reanastomosing the vessels on which the transplant will be based during the first stage while the pancreas continues to be perfused by its other vessels resulted in a uniformly successful outcome. The pancreatic transplant functioned well. The dogs were neither diabetic nor exocrine pancreatic deficient. Their responses to stimulation with exogenous secretin and the cholecystokinin analogue, cerulein, were only slightly less than those of dogs without a pancreatic transplant. This preparation should enable studies to be carried out that will better define the interactions of nerves and hormones in the control of pancreatic secretion.     

Occlusion of the superficial femoral artery: What happens without operation

Fifty-three nondiabetic male patients, aged 60 to 81 years (mean 69), with superficial femoral artery occlusion were studied prospectively to determine the outcome of nonoperative treatment. All had intermittent claudication on entry to the study. Patients with rest pain, tissue necrosis or aortoiliac disease were excluded. Patients were coached in walking four times daily to tolerance. Abstinence from tobacco was stressed, but only 15 of the 44 smokers stopped. After 5 years, five patients have died from cerebral and coronary disease. Ten patients required vascular reconstruction for progressive disease. One patient underwent below-knee amputation for gangrene. Although 26 patients had improvement in or stabilization of symptoms and walking distance, only 12 patients had an increase in the ankle to wrist systolic pressure ratio (AWR) from 0.63 ± 0.12 to 0.74 ± 0.13 (p < 0.05). It is concluded that patients over 60 years of age with superficial femoral artery occlusion (1) have a low likelihood of limb loss (1 of 53 patients) if followed up closely on conservative treatment, (2) can expect improvement in symptoms (16 of 21 patients) if the initial AWR is greater than 0.6 and (3) should undergo evaluation for reconstructive surgery if the AWR falls to 0.5.     

Use of secretin in the roentgenologic and biochemical diagnosis of duodenal gastrinoma

The use of secretin in the biochemical and roentgenologic diagnoses of a duodenal gastrinoma has been described. Preoperatively, the secretin test indicated that a gastrinoma and not a retained antrum was the cause of hypergastrinemia in a patient who had previously undergone Billroth II gastrectomy. Intravenous infusion of secretin during selective angiography resulted in greatly enhanced visualization of the tumor which allowed it to be localized to the duodenal stump. Several months postoperatively, the secretin test result had become negative, which presumably suggested that the tumor had been excised completely. Our experience has revealed that intravenous secretin might improve the diagnostic usefulness of selective angiography.     

Intrahepatic stones: The Taiwan experience

From 1970 to 1979, 95 patients with intrahepatic stones were seen. Since 1974, however, the annual rate of cases has been only half that of the previous decades. Patients with this disease are young; onset of symptoms in over a third of the patients occurred before 20 years of age and in 14 patients before 15 years. Average length of time between onset of symptoms and definitive diagnosis was 8.3 years. Southeast Asian stones are multiple, soft, muddy, pigmented, and located in the primary and secondary biliary radicles (particularly in the left hepatic lobe). Transhepatic cholangiography is the best diagnostic maneuver. Many procedures have been tried but no one procedure is entirely satisfactory. Previously unoperated patients (44) had cholecystectomy and exploration of the common bile duct. Patients whose stones recurred after exploration needed reoperation after an average of 2.5 years; patients whose stones recurred after cholecystectomy were seen an average of 5.7 years later, and 11 of 18 were treated medically. The mortality rate was surprisingly low.     

Benign and malignant gastrinoma

The advent of the histamine H2-receptor antagonists and the renewed interest in curative surgery in patients with gastrinoma have made the differentiation between benign and malignant tumors of critical importance. An analysis of 65 patients with gastrinoma followed for an average of 93 months revealed two distinct clinical groups: those with and those without hepatic tumors at initial examination or operation. Among the 14 patients with hepatic tumors, 12 had multiple liver metastases from pancreatic or duodenal primary tumors, and 2 had primary hepatic gastrinomas. Ten of the 14 patients (71 percent) died from tumor progression, and the total tumor-related mortality for this group was 79 percent. In contrast, only 1 of 15 patients (7 percent) with tumor in the lymph nodes died from a tumor-related cause (recurrent ulcer hemorrhage), and none died from tumor progression. Only a single patient with lymph node metastases at initial exploration went on to the development of liver metastases, which was found incidentally at autopsy 313 months later. Among 23 patients with either primary tumors only or no tumors found at laparotomy, there was only one tumor-related death and no deaths from tumor spread. Life-table analysis demonstrated a significantly decreased length of survival for patients with liver tumor compared with those without liver involvement. Multiple endocrine adenopathy syndrome was not a significant factor in survival. Serum gastrin levels were likewise nondiscriminatory. Six of 52 patients (12 percent), including three with tumor in the lymph nodes, were apparently cured by excision of all gastrinoma recognized at laparotomy. The cure rate was 23 percent for patients without multiple endocrine adenopathy syndrome or liver metastases. Hepatic metastases is a definitive marker for clinically malignant disease and portends a poor prognosis. Patients with gastrinoma confined to the lymph nodes uncommonly follow a malignant clinical course. Such patients have at least a 20 percent probability of surgical cure if they do not have multiple endocrine adenopathy syndrome.     

Modern management of anastomotic leak after esophagogastrectomy

From 1970 to 1981, 167 patients, aged 35 to 84 years (mean 61), underwent resection for 94 adenocarcinomas and 73 squamous cell cancers. The operative mortality was 8.9 percent. Anastomotic leaks occurred in 19 patients (11.3 percent), including 18 of 72 (25 percent) after operations for palliation and 1 of 95 (1 percent) after procedures with curative potential (p <0.01). The leakage rate after esophagogastrostomy was 8.5 percent, compared with 43 percent after interposition operations. No leak is attributed to cancer in anastomotic margins. In contrast to previous reports of greater than 50 percent mortality from leaks, only 21 percent of our patients died in the past decade. Four of 19 contained leaks (sinus tract or upper gastrointestinal) were treated nonoperatively; esophagostomy was used only once. Factors responsible for improving results include early diagnosis with routine contrast studies on the fifth to seventh postoperative days, mandatory use of total parenteral nutrition, nonoperative management of contained leaks, accurate, aggressive use of adjuvant chest tubes, and selective esophagostomy for anastomotic disruption.     

Colonic diverticulitis in patients under age 40: Need for earlier diagnosis

Despite a clinical presentation and physical findings consistent with diverticulitis, this diagnosis was considered only in one third of 37 patients under age 40. Barium enema was particularly valuable and presented no risk to the patients with an incorrect diagnosis of acute appendicitis. In the medically treated group, 7 of 17 patients required subsequent operation. Those who had emergency surgery had a high wound infection rate. The need to consider the diagnosis in patients under age 40 years is stressed.     

Failure of histamine H2-receptor antagonist therapy in Zollinger-Ellison syndrome

Review of a 5 year clinical experience with the histamine H2-receptor antagonists metiamide, cimetidine, and ranitidine in 20 patients with Zollinger-Ellison syndrome disclosed a treatment failure rate of 50 percent. The criterion for failure was hemorrhage in four patients, obstruction followed by hemorrhage in one patient, perforation in one, and intractable pain in four. Nine of the 10 patients in whom treatment failed required total gastrectomy for control of complications; the 10th patient refused operation. Retrospective analysis identified hepatic metastases, the multiple endocrine adenomatosis-type I syndrome, refractory diarrhea, and breaks in the medication schedule as being more common in the treatment failure group, but these trends were not statistically significant in our small series of patients. Nonhealing or recurrent ulcers were found in 90 percent of the patients in whom drug therapy failed and in only 10 percent of those patients in whom therapy was successful (p less than 0.01). There were no differences related to age, sex, duration of symptoms, previous gastric operation, ulcer location, presence of diarrhea, or amount of drug prescribed. Basal and peak acid outputs, basal serum gastrin levels, and response to secretin challenge were also nondiscriminatory. The degree of acid inhibition in response to cimetidine was highly variable from one patient to another and on repeat testing in individual patients, and there was no correlation between acid secretory inhibition and clinical course. When severe complications occurred, reinstituting H2-receptor antagonist therapy or increasing the dose did not avert the need for total gastrectomy. Patients refractory to drug treatment who have persistent or recurrent ulcers should be managed with prompt total gastrectomy to prevent life-threatening complications.     

The gastrinoma triangle: operative implications

Operative experience with 45 gastrinoma patients has led to the identification of an anatomic area where occult tumors can be discovered and where excision of these tumors had led to apparent cure. Of 36 patients with histologically confirmed gastrinomas, 27 patients (75 percent) had obvious and 9 patients (25 percent) had occult tumors. All nine occult lesions were found within an anatomic triangle defined by the junction of the cystic and common bile ducts superiorly, the junction of the second and third portions of the duodenum inferiorly, and the junction of the neck and body of the pancreas medially. Although occult tumors from three patients (in the lymph nodes in two patients and in the duodenum in one patient) were removed primarily for histologic diagnosis, postoperative serum gastrin levels have remained within the normal range (follow-up of 86 to 99 months). Two patients had excision of the tumor with intent to cure. One patient with a solitary duodenal tumor was apparently cured but committed suicide 3 months postoperatively. The other patient had both obvious primary and occult metastatic tumors within the triangle and was eugastrinemic 9 months after excision. In all patients in whom tumor was found, it was locally excised, and no patient was subjected to radical pancreatic resection. There were no postoperative complications related to tumor removal. An aggressive approach towards curative tumor excision is now advocated for all gastrinoma patients who are suitable operative risks and have no evidence preoperatively of liver metastases or the multiple endocrine neoplasm-type I syndrome.     

Pros and cons of parietal cell versus truncal vagotomy

The reliability of parietal cell vagotomy as a primary procedure for duodenal ulcer is still questioned by many, and several surgeons advocate pyloroplasty in certain subgroups. Since the opening of our hospital in 1972, a randomized, prospective study has been under way. Sixty-seven patients were randomized into three groups: truncal vagotomy and Jaboulay pyloroplasty (Group 1), parietal cell vagotomy and Jaboulay pyloroplasty (Group 2), and parietal cell vagotomy without drainage (Group 3). The overall operative mortality was zero, with an 18 percent morbidity. Postoperative Congo red testing revealed truncal vagotomy to be a more reliable vagotomy, with 25 percent of Group 1 patients noted to have some degree of incomplete vagotomy compared with 36 percent of patients in Group 3 (p < 0.05). The ulcer recurrence in Group 1 was 4 percent, in Group 2 18 percent, and in Group 3 10 percent. No dumping or diarrhea was noted in Group 3 compared with Group 1 in which 4 percent of patients had dumping and 17 percent had diarrhea and Group 2 in which 14 percent of patients had dumping and 23 percent had diarrhea (p < 0.05). The higher incidences of recurrence and postoperative side effects obviously related to the pyloroplasty made parietal cell vagotomy with pyloroplasty the least desirable operative procedure. Parietal cell vagotomy is technically a more difficult procedure, but if performed satisfactorily, results in greater patient satisfaction, with 81 percent of the patients symptomfree compared with 63 percent of those who had truncal vagotomy and pyloroplasty.     

Arterial embolectomy in the leg: Results in a referral hospital

The clinical characteristics and course of 90 patients in whom 121 arterial emboli occurred from 1968 to 1978 were reviewed. The factor that correlated most significantly with a favorable outcome was the interval from onset of symptoms until arterial embolectomy was performed. The results of embolectomy were excellent in the patients operated on within 6 hours of symptoms (amputation rate 4 percent, mortality rate 15 percent), but less favorable in the patients operated on within 6 to 12 hours of onset of symptoms (amputation rate 27 percent, mortality 40 percent). Mortality (48 percent) and amputation (52 percent) rates in the patients operated on 12 to 48 hours after onset of symptoms were excessive. It is recommended that immediate embolectomy be performed in all potentially viable extremities in patients who present within 12 hours of symptoms, but that after 12 hours only those limbs with obvious viability (not paralyzed or anesthetic) should be operated on. Alternatives for the remainder are high dose intravenous heparinization or expedient amputation. In patients who present greater than 60 hours after the onset of symptoms, embolectomy can be performed with low morbidity and mortality.     

A retroperitoneal cystic leiomyosarcoma spontaneously draining into the stomach.

An unusual case of a retroperitoneal cystic leiomyosarcoma clinically resembling a pancreatic pseudocyst with subsequent spontaneous cystgastrostomy drainage is presented.     

Diagnosis and treatment of gastric emptying disorders: Clinical usefulness of radionuclide measurements of gastric emptying

We studied 53 patients with severe gastrointestinal symptoms thought to be due to a gastric motility disorder. Sixty-six percent had had a previous operation on the stomach, and 21 percent had insuli-ndependent diabetes mellitus. Based on clinical, radiographic, and endoscopic findings, 48 patients were thought to have gastroparesis, 3 were thought to have dumping, and 2 had no diagnosis. Measurement of gastric emptying of solids showed that gastric emptying was normal in 12 patients, rapid in 15 patients, and slow in 26 patients. Further evaluation showed that half of the patients with normal gastric emptying, and one third of those with rapid gastric emptying had other diseases of the gastrointestinal tract that responded well to surgery. Of those patients with dumping, diet modification was effective in 40 percent, and half of those who did not respond to dietary manipulations did well after reoperation. Nineteen patients with delayed gastric emptying were treated with metoclopramide. Sixty percent of those without previous gastric surgery responded, whereas only 25 percent of those with previous gastric surgery had good results. The rate of gastric emptying improved following reoperation in 9 (90 percent) of 10 patients with delayed gastric emptying (4 who had not responded to metoclopramide). Gastric emptying was measured again in 15 patients after treatment. The changes after treatment paralleled the clinical response.These studies indicate that gastroparesis cannot be reliably diagnosed on the basis of clinical findings and standard tests. Gastric emptying studies are essential to diagnose and treat patients thought to have gastric motility disorders, and to evaluate the results of therapy.     

Diagnosis of carotid stenosis by bruit spectral analysis

Bruit spectral analysis provides an improved noninvasive method of quantifying the severity of carotid stenosis, and the method of Lees estimates the residual luminal diameter. Although the analysis required is complex, the test can be easily performed using the Spectraview, a microcomputer-based device which records and processes the sound information. The present study evaluated 44 cervical bruits in patients and found that in 84 percent of the vessels the estimated luminal size was within 1 mm of the angiographic lumen. Although substantial experience is required to obtain the maximum diagnostic accuracy, work with the technique during 18 months indicates that it provides more information from arterial bruits than traditional phonoangiography.     

Experimental gastric carcinogenesis in the rat: Effects of hypergastrinemia and acid secretion

The present experiments examined in rats the influence of chronic hypergastrinemia and the resulting gastric hyperacidity on induction of gastric adenocarcinoma by N-methyl-N′-nitro-N-nitrosoguanidine (MNNG). Three groups of animals were studied: (A) control rats (no operation, normogastrinemia); (B) rats with antrectomy and Billroth II (normogastrinemia); and (C) rats with implantation of the antrum into the colon and Billroth II (hypergastrinemia). All rats were fed MNNG, 83 μg/ml, in drinking water for 6 months and were observed for 6 more months before being killed. The number, location, and histology of malignant gastric neoplasms were recorded.The incidence of tumors in the proximal gastric remnant of the Billroth II antrectomy rats was 88 percent, significantly greater than the incidence in the proximal gastric remnant (excluding the implanted antrum) of Billroth II antral implant rats (50 percent) or in control rats (50 percent). In addition, 19 gastric neoplasms were found in the 12 antra implanted into the transverse colon.Thus antrectomy Billroth II predisposed the animals to tumors, which was at least partially offset by hypergastrinemia. This suggests that gastric mucosa is more vulnerable to carcinogens after antrectomy and Billroth II, and the effects of hypergastrinemia (or acid secretion and mucosal growth) reduce this vulnerability. Hypergastrinemia did not protect the antrum from tumor induction when the antrum was removed from exposure to acid. These data suggest that in rats (1) antrectomy Billroth II predisposes to carcinogenically induced gastric cancer, (2) hypergastrinemia directly or indirectly decreases this predisposition, and (3) in the presence of hypergastrinemia and after removal from the acid stream, the antrum is highly vulnerable to the carcinogenic effects of MNNG.