Effects of duodenogastric bile reflux on gastric mucosal hexosamine concentrations after selective proximal vagotomy or extended distal gastrectomy for duodenal ulcer

Effects of duodenogastric reflux (DGR) of bile on hexosamine concentrations in gastric mucosa were studied in 17 healthy controls and 133 patients with duodenal ulcer patients before and after surgery. Total bile acid concentration in gastric juice was measured using enzyme method to estimate DGR. Mucosal hexosamine concentration of the biopsy specimens taken from the gastric corpus and antrum was measured according to Boas's method. The operative procedures included selective proximal vagotomy (SPV) with or without pyloroplasty, and extended distal gastrectomy with Billroth I(BI) or II(BII) anastomosis. The rate of DGR were significantly higher in cases after gastrectomy, especially in BII cases than in cases after SPV. In the early postoperative period after SPV with or without pyloroplasty, DGR was increased significantly. However, the reflux rate was decreased gradually to the preoperative level thereafter, suggesting that normal function of gastric emptying might be recovered with time. The hexosamine concentration of the antral mucosa showed clearly an inverse relationship to the changes in DGR rate. These results suggested that SPV could be the more physiological procedure than gastrectomy from the point of DGR.     

Pylorus and antroseromuscular flap-preserving gastrectomy--a new type of reconstruction after subtotal gastrectomy for treatment of gastroduodenal ulcer: clinical and experimental study

To avoid motility disturbances after Billroth gastrectomy, the authors designed pylorus and antroseromuscular flap-preserving subtotal gastrectomy (PAFPG). Results showed that gastric motility and emptying time of dogs after PAFPG were close to normal. PAFPG was applied to 125 consecutive patients with gastroduodenal ulcers (gastric ulcer, 15 patients; duodenal ulcer, 94 patients; and combined ulcers, 16 patients) confirmed by barium examination and fibro-gastroendoscopy. All patients recovered smoothly, none of them had postoperative complication. Gastric acid output reduction rates were as follows: basal acid output, 85.05% +/- 8.13%; maximal acid output, 81.76% +/- 10.85%; peak acid output, 81.42% +/- 10.15%. The incidence of postoperative enterogastric reflux (endoscopically) and the concentration of cholic acids in gastric juice were significantly lower in patients after PAFPG than after Billroth I or II gastrectomy. Results suggest that PAFPG reduced gastric acid outputs definitely and overcame adverse motility consequences after Billroth I or II gastrectomy desirably.     

Quantification of duodenogastric reflux in gastroduodenal peptic ulcer and in gastric operation patients, using a 24-h gastric pH measurement as a quantification technique

Twenty-four-hour gastric pH measurement was used to study duodenogastric reflux. To differentiate between gastric hyposecretion and duodenogastric reflux, we also measured bile acid concentrations in the gastric juice, and regarded pH increases to above 4 as possible episodes of reflux. The procedure was used in 60 patients, divided into the following groups: (1) control group (ten patients); (2) duodenal ulcer (ten patients); (3) type 1 gastric ulcer (five patients); (4) type 3 gastric ulcer (five patients); (5) bilateral truncal vagotomy plus pyloroplasty (ten patients); (6) truncal vagotomy plus Billroth I partial gastrectomy (ten patients); and (7) truncal vagotomy plus Billroth II partial gastrectomy (ten patients). The amount of reflux (areas of pH greater than 4) in the type 1 gastric ulcer and Billroth I and Billroth II groups was significantly greater than that found in the control, duodenal ulcer, type 3 gastric ulcer and truncal vagotomy plus pyloroplasty groups. The mean concentration of total bile acids was also greater in the gastrectomized patients than in the rest of the groups studied. In the type 1 gastric ulcer group the mean bile acid concentration was similar to that of the control group.     

An evaluation of segmental gastrectomy for gastric ulcer: one to ten year follow-up.

Of 61 patients with gastric ulcer subjected to an improved technique of segmental gastrectomy, 26 were available for follow-up study for 1 to 10 years; evaluations were made mainly on the postoperative reduction of gastric acid secretion and motor function of the gastric remnant. Results: (1) x-ray observation revealed the gastric remnant to be larger than usually seen following Billroth I or II gastrectomy, with no dilatation or remarkable deformity; sphincteric function of the pylorus and peristaltic activity of the gastric remnant were satisfactory; (2) gastric emptying was usually complete in 60 to 180 minutes in 73 percent of the patients, similar to control patients; (3) no instance of dumping syndrome was recognized; (4) average rates of postoperative acid reduction were 58.3 percent for maximal acid concentration, 67.1 percent for maximal acid output, and 67.6 percent for peak acid output, indicating the reduction of gastric acid secretion to be fairly satisfactory. In none of the patients available for follow-up was identified a recurrence of ulcer. These follow-up results suggest the use of segmental gastrectomy for gastric ulcer and for other benign lesions in the mid portion of the stomach.     

Surgical treatment of complicated ulcer disease of the stomach and duodenum at the health department of a metallurgical factory]

The case records of 419 patients with complicated gastric and duodenal ulcer disease were analysed. Frequent asymptomatic course of the ulcer disease was noted in workers of the metallurgical and engineering industry. Different modifications of Billroth resection of the 2/3 of the stomach were used in 240 patients, selective proximal vagotomy (SPV) with ulcer excision--in 87, transverse gastric resection with preservation of the pyloric sphincter--in 30, closure of a perforative hole--in 60, closure of a perforative hole with excision of the ulcer margins and bilateral truncal vagotomy--in 2. The most favourable long-term result was noted in patients after SPV with ulcer excision and transverse gastric resection with preservation of the pyloric sphincter.     

Highly selective vagotomy with excision of the ulcer compared with gastrectomy for gastric ulcer in a randomized trial.

Fifty-six patients with benign gastric ulcer of the body of the stomach have been entered into a randomized trial of highly selective vagotomy with excision of the ulcer (HSVE) (26 cases) against standard Billroth I partial gastrectomy (BI) (30 cases). The operations were carried out by all grades of surgical staff. No patient died within 1 month of operation. Postoperative morbidity was greater after gastrectomy than after HSVE. At an average follow-up of about 4 years, functional results according to a modified Visick classification were similar in both groups, with about 75 per cent good results. Two recurrent ulcers occurred after gastrectomy (7 per cent) and 4 after HSVE (15 per cent). Neither operation has a distinct advantage at this stage.     

The advantages and disadvantages of a Roux-en-Y reconstruction after a distal gastrectomy for gastric cancer

In Japan, the Billroth I and Billroth II operations have been used for reconstruction after a distal gastrectomy for gastric cancer. However, a Roux-en-Y reconstruction is increasingly performed to prevent duodenogastric reflux. We herein discuss the indications for Roux-en-Y in gastric surgery and review the literature to determine its advantages and disadvantages. Indications for Roux-en-Y reconstruction after a distal gastrectomy are: (a) When the primary lesion has directly invaded the duodenum or head of the pancreas, the Billroth I operation is likely to result in local recurrence near the anastomosis; (b) in addition, the Billroth I operation is not indicated after a subtotal gastrectomy due to an unacceptable anastomotic tension; reconstruction using a nonphysiological route is therefore preferred. The advantages of Roux-en-Y reconstruction after a distal gastrectomy include a reduction of reflux gastritis and esophagitis, a decreased probability of gastric cancer recurrence, and a reduction in the incidence of surgical complications such as ruptured suture lines. The disadvantages of Roux-en-Y reconstruction include the possible development of stomal ulcer, an increased probability of cholelithiasis, increased difficulty with an endoscopic approach to the ampulla of Vater, and the possibility of Roux stasis syndrome. The principal advantage of a Roux-en-Y reconstruction is that it is less likely than the Billroth I operation to result in duodenogastric reflux. Roux-en-Y reconstruction or Billroth I operation can only be selected after considering their respective advantages and disadvantages.     

Bile reflux and degree of gastritis in patients with gastric ulcer: before and after operation

The incidence and degree of bile reflux and gastritis has been measured in normal subjects and in patients with gastric ulcer before operation and after treatment by highly selective vagotomy with ulcer excision, Billroth 1 partial gastrectomy, and truncal vagotomy and drainage. Before operation patients had significantly higher (P less than 0.001) bile acid concentrations in the stomach than normal subjects. Treatment by highly selective vagotomy resulted in significantly lower bile acid concentrations than those before operation and those found after Billroth 1 partial gastrectomy. Antral and body gastritis was significantly less in normal subjects than in the preoperative and all postoperative groups. There was no significant difference in antral or body gastritis between the preoperative gastric ulcer patients and the patients after any of the surgical procedures despite the significant differences in bile acids. Though highly selective vagotomy in the treatment of gastric ulcer results in a reduction in duodenogastric reflux of bile there is no improvement in the gastritis that is present.     

Early detection of gastric remnant carcinoma. The role of gastroscopic screening

Partial gastrectomy for benign ulcer disease has been associated with carcinoma in the gastric remnant. To detect formation of this cancer in patients having undergone this operation, we initiated a screening protocol using barium contrast studies, flexible gastroscopy, and biopsy. Patients were selected from a group of 233 patients who had undergone partial gastrectomy for benign disease between 1960 and 1975. In this group, operations for duodenal ulcer had been performed in 156 patients (83 Billroth I and 73 Billroth II reconstructions) and subtotal gastrectomy in 77 patients with gastric ulcer (17 Billroth I and 60 Billroth II reconstructions). From July 1980 to July 1985, 163 patients underwent gastroscopy and biopsy with a median postoperative interval of 14.6 years. Through screening, three resectable remnant carcinomas were found. We conclude that routine gastroscopy leads to earlier detection and a higher rate of resectability if gastric remnant carcinoma is found; yearly screening should be performed after a ten-year postresection interval; and gastroscopic biopsy is more accurate than upper gastrointestinal tract barium contrast studies and should be used preferentially to identify gastric remnant carcinoma.     

Selective vagotomy plus antrectomy and Roux-en-Y gastrojejunostomy in the treatment of duodenal ulcer]

From 1982 to October 1990, 284 patients with duodenal ulcer were surgically treated. Partial gastrectomy and Billroth anastomosis (PGB) were performed in 92 patients, selective vagotomy plus antrectomy and Billroth anastomosis (VAB) in 92, and selective vagotomy plus antrectomy and Roux-en-Y gastrojejunostomy (VARY) in 98. Follow-up showed that VARY was superior in many respects to PGB and VAB such as in decreasing gastric acidity, long-term complications and Visick grading of I and II (P < 0.05). We conclude that VARY can be used in the treatment of duodenal ulcer.     

Prospective, randomized trial of selective proximal vagotomy with ulcer excision and partial gastrectomy with gastroduodenostomy in the treatment of corporeal gastric ulcer

In a prospective, randomized trial, selective proximal vagotomy with complete ulcer excision was compared with partial gastrectomy with gastroduodenostomy for the treatment of primary corporeal gastric ulcer in 30 patients. The results were evaluated by clinical follow-up examinations at regular intervals, endoscopy, and blood tests. The mean follow-up period was 3 years for both operations. There was no mortality. Postoperative complications, ulcer recurrence rates, the overall clinical results (Visick classification), and blood test results were similar in the two groups. Three of 15 selective proximal vagotomy patients were classified grade IV due to recurrent ulcer (two patients) or dumping (1 patient), and 2 of 14 partial gastrectomy patients as were classified grades III (epigastric pain) and IV (recurrent ulcer). Considering the risk for late symptoms of impaired resorption and gastric cancer after partial gastrectomy, the similar results with selective proximal vagotomy and partial gastrectomy justify further trials of selective proximal vagotomy with ulcer excision for treatment of corporeal gastric ulcer.     

Indication for and outcome of laparoscopy-assisted Billroth I gastrectomy

BACKGROUND: Since 1991, laparoscopy-assisted Billroth I gastrectomy has been used for patients with early gastric cancer. The aim of this study was to clarify the outcome of 40 patients who underwent this operation and to examine the indications based on a retrospective histological study of 248 resected cases of early gastric cancer. METHODS: Operating time, blood loss, length of skin incision, and postoperative hospital stay and complications were examined using the operation records and medical charts. The presence or absence of lymph node metastasis, tumour size, site, gross type, histological type, depth of invasion, presence or absence of ulceration, and status of lymph node metastasis were investigated in 248 early gastric cancers. RESULTS: The mean operating time was 3 h and 48 min and the mean length of skin incision was 5.8 cm. Although one patient who had suffered from chronic bronchitis developed pneumonia and wound dehiscence, no other patients had a postoperative complication. The mean hospital stay after operation was 16 days and all patients were alive without recurrence at a median follow-up of 21 months. The incidence of lymph node metastasis in early gastric cancer was 2 per cent (three of 130) in mucosal cancers and 14 per cent (17 of 118) in submucosal cancers. These lesions could have been completely resected by laparoscopy-assisted gastrectomy. CONCLUSION: All 40 patients were treated successfully by laparoscopy-assisted Billroth I gastrectomy without significant complications and with no recurrences to date. Pathological study of conventionally resected stomach and lymph nodes confirmed that laparoscopy-assisted Billroth I gastrectomy would be a safe and useful operation for most early gastric cancers.     

Billroth-I-Hemigastrektomie beim komplizierten Ulkusrezidiv nach selektiv proximaler Vagotomie

Zusammenfassung In einer retrospektiven Studie wurden die Ergebnisse der Billroth-I-Hemigastrektomie bei komplizierten Rezidivulzera nach selektiv proximaler Vagotomie (SPV) wegen Ulcera duodeni analysiert. Fünfzehn Patienten mit 4 Ulkusblutungen, 5 Stenosen, 3 Penetrationen, einer Perforation und 2 H₂-Blocker refraktären Ulzera wurden 3,8 Jahre (15–81 Monate) postoperativ nachuntersucht. Kein Patient verstarb infolge des Reeingriffes, keiner entwickelte ein neuerliches Rezidivulkus. Bei 4 Patienten wurden 8 frühpostoperative Komplikationen, darunter eine revisionspflichtige Blutung und 3 subhepatische Hämatome, beobachtet. Zwölf Patienten (80%) wiesen im Verlauf ein gutes bis sehr gutes Ergebnis auf (Visick I und II). Die Gründe für eine Visick-III- und Visick-IV-Klassifikation waren in 2 Fällen eine Refluxösophagitis Grad I und II sowie therapierefraktäre dyspeptische Beschwerden in einem Fall. Die alleinige Hemigastrektomie mit Billroth-I-Anastomose ist für das komplizierte Rezidivulkus nach SPV ein probates Verfahren mit niedriger Morbidität und sicherer Rezidivprophylaxe im Langzeitverlauf.

---

Billroth I hemigastrectomy for complicated ulcer recurrence after proximal selective vagotomy

The outcome of Billroth I hemigastrectomy for complicated recurrent ulcers after proximal selective vagotomy (PSV) for duodenal ulcer was analyzed in a retrospective study of 15 patients followed up for 15–81 months (mean 3.8 years) postoperatively. Bleeding was reported in 4, stenosis in 5, penetration in 3, perforation in 1 and refractory ulcer in 2 cases. None of the patients died during revision surgery, and none developed ulcer recurrence. In 4 patients complications were seen, including bleeding requiring relaparotomy (1) and subhepatic hematoma (3). In 12 patients (80%) a good or excellent result (Visick I/11) was seen at follow-up. Reasons for Visick III or Visick IV classification were reflux esophagitis grades I and II in 2 cases and refractory dyspeptic symptoms in 1 case. Distal gastric resection with a Billroth I anastomosis for complicated recurrent ulcer after PSV proved to involve only low morbidity and to effect reliable prophylaxis of ulcer recurrence in the long term.

     

The long-term outcome of Billroth I partial gastrectomy for benign gastric ulcer.

A study was done of 144 patients undergoing Billroth I partial gastrectomy for benign gastric ulcer. At a mean follow-up of 9.4 years, 95 patients were alive. Of 79 patients reviewed, 84% had an excellent or good result on clinical (Visick) grading. Five cases of proven recurrent ulceration were found; two of these patients required subsequent truncal vagotomy. There was one early death after operation, and 48 late deaths, including one from carcinoma of the gastric remnant (at two years), one from a reticulum cell sarcoma of the stomach (at three years), and one from reactivation of pulmonary tuberculosis. The operation was not attended by appreciable nutritional sequelae, although there was a tendency towards iron deficiency anemia.     

Differentiated approach to surgical treatment of patients with perforated duodenal ulcer

From 1995-2001, 264 patients with perforated duodenal ulcer were treated by the Emergency Surgical Service of Azerbaijan State Medical University in Baku. In a time of evolving standards and scientific understanding of acid peptic disease, a treatment formula was applied with excellent results. Treatment was tailored to the stage of peritonitis by time from perforation. This time was objectively evaluated by analysis of the peritoneal exudate. The value of laparoscopy was also assessed. Simple closure was performed in 94 patients (open procedure in 46, laparoscopic suture of perforated ulcer in 48 patients). Resection was performed in 170 patients (partial gastrectomy Billroth I in 118 patients, partial gastrectomy Billroth II in 18 patients and antrectomy vagotomy in 34). Application of the algorithm reduced mortality after simple closure to 6.4% and after resection to 1.2%.     

Jejunal interposition to prevent postgastrectomy syndromes

BACKGROUND: Postgastrectomy syndromes include reflux gastritis and oesophagitis, dumping syndrome, intractable diarrhoea and afferent loop syndrome. To prevent such syndromes, since January 1994 jejunal interposition has been used following distal gastrectomy. The aim of this study was to evaluate the benefit of this procedure. METHODS: A consecutive series of 42 patients who underwent distal gastrectomy for gastric cancer was studied. Twenty-two patients had a Billroth I procedure before January 1994, and 20 patients had isoperistaltic jejunal interposition using a 10-12-cm segment after January 1994. RESULTS: The mean operating time was 260 min for Billroth I and 352 min for jejunal interposition. No serious postoperative complications arose. Reflux gastritis occurred in 19 patients after Billroth I but in none after jejunal interposition. Five patients in the Billroth I group had complaints consistent with dumping syndrome, compared with none after jejunal interposition. The barium gastric emptying time was significantly shorter after Billroth I (mean(s.d.) 269(225)s) than after jejunal interposition (736(479) s) (P < 0.01). CONCLUSION: Jejunal interposition prevented reflux gastritis and inhibited rapid gastric emptying. Postgastrectomy syndromes were effectively prevented by this reconstruction procedure.     

Histological changes in the gastric stump mucosa and late clinical results after Billroth I, Billroth II and Roux-en-Y operations for peptic ulcer disease

To study the morphological alterations and clinical outcome after gastric resection 53 patients operated on for peptic ulcer disease 5 to 7 years earlier were analyzed. The type of reconstruction was either Billroth I (n = 16), Billroth II (n = 19) or Roux-en-Y (n = 18). Vagotomy was combined with Billroth II in 7 (31%) cases and with Roux-en-Y in 8 (44%) cases. According to a modified Visick classification the late functional results were similar after Billroth reconstructions, whereas failures were most often after Roux-en-Y reconstruction (28%). No ulcer recurrences were found. The histological findings were similar in the operative specimens, but biopsies from the gastric stump mucosa 5 to 7 years after surgery showed significantly (P less than 0.05) more atrophic gastritis after Billroth operations than after Roux-en-Y reconstruction. No dysplastic changes were found. It is concluded that Roux-en-Y reconstruction causes least changes in the gastric stump mucosa after gastric resection. The delayed gastric emptying associated with this procedure may, however, cause late functional disturbances.     

The effect of selective proximal vagotomy on mucus production of the stomach in pyloroduodenal ulcer]

Secretion of the main component of gastric juice mucus-fucoglycoproteins (FGP) in uncomplicated and complicated by stenosis of gastric outlet ulcer disease of the stomach and intestine, the effect of selective proximal vagotomy (SPV) and drainage operations on FGP exchange were studied. Dependence of fucose production on severity of the course of ulcer disease has been established. Early after SPV, preservation of FGP concentration in the gastric juice at initial level and significant decrease in their hour production were noted. FGP concentration in patients with its low initial values restored within the first year of follow-up, debit--later on. The data obtained can be used in assessment of the SPV results, and in revealing the patients with high risk for development of ulcer disease recurrence.     

Operative treatment of benign gastric ulcers

Between the years 1953 and 1963, 1,583 patients at the Henry Ford Hospital were recorded as having gastric ulcer. Of this number 150 (9.4 per cent) underwent operative treatment. Failure to respond favorably after medical treatment and suspicion of malignancy prompted surgical intervention most often.Two operative approaches were commonly employed. Gastric resection plus vagotomy with Billroth I reconstruction was utilized in fifty-three patients. Gastric resection with vagotomy and Billroth II reconstruction was the procedure of choice in twenty-nine patients. Thus, eighty-two patients had gastric resection with vagotomy. There were four recurrences in this group (5 per cent). The second largest group of patients were those upon whom gastric resection was performed without vagotomy. The Billroth I reconstruction was performed thirty-one times and the Billroth II procedure was employed twenty-one times. There were nine recurrences in fifty-two patients, a recurrence rate of nearly 17 per cent. Clearly, in this study, gastric resection with vagotomy gave better results (5 per cent recurrence) than did gastric resection alone (17 per cent recurrence). The over-all recurrence rata for 150 patients was approximately 11 per cent.In eight patients the clinical diagnosis was benign ulcer when, in fact, malignancy was present. In two patients, the tumor was lymphoma. Only one of ten patients died of tumor. Excellent follow-up studies were possible in every patient with a malignant lesion. Adequate gastric resection is effective for these small, unsuspected ulcerocarcinomas.There were four postoperative deaths, a mortality rate of 2.7 per cent. Two patients died of myocardial infarction and two died of pulmonary emboli.     

Anastomotic technique influences outcomes after partial gastrectomy for adenocarcinoma

The proper reconstructive technique after partial gastrectomy for adenocarcinoma of the stomach is often debated, but few data exist to clarify the issue. We evaluated outcomes after different anastomoses used during partial gastrectomy for gastric adenocarcinoma. We reviewed the hospital records of all 277 patients who underwent operation for gastric cancer at our institution from 1970 to 1996. Of 118 partial gastrectomies performed with curative intent 57 anastomoses were Billroth II gastrojejunostomies, 22 were Billroth I gastroduodenal reconstructions, and 39 were Roux-en-Y gastrojejunostomies. There was no difference in the incidence of early gastric emptying problems or early or late postoperative obstruction among the groups. Average hospital stay was 14 days for the Billroth I group, 15 days for those with Billroth II reconstructions, and 22 days for the Roux-en-Y cohort. Documented late gastric outlet obstruction occurred in 29 per cent of patients having Billroth I and in 33 per cent of those with Billroth II anastomoses. Antecolic anastomoses represented 30 (53 per cent) and retrocolic 27 (47 per cent) of the 57 Billroth II reconstructions performed. Late gastric outlet obstructions occurred in seven (23 per cent) patients who had antecolic reconstructions and in just one (4 per cent) with a retrocolic anastomosis (P < 0.05). Five-year cumulative survival was lower for patients having Billroth I reconstructions than for those with Billroth II (P < 0.05). Among patients with Billroth II reconstructions, 5-year cumulative survival was lower for those with antecolic reconstructions compared with those with retrocolic anastomoses (P < 0.05). Although conventional teaching dictates otherwise our data indicate that retrocolic Billroth II anastomoses are preferable to antecolic Billroth II reconstructions after partial gastrectomy for adenocarcinoma of the stomach, as there is a diminished risk of late gastric outlet obstruction and a greater 5-year survival among patients having the former procedure. Survival is unacceptably low after Billroth I anastomoses.