Effects of various operations on the electrical activity of the human stomach recorded during the postoperative recovery period.

This study attempts to characterize any changes occurring in the human gastric control electrical rhythm (CER), following a variety of gastric surgical procedures. Pairs of electrodes were implanted in selected specific sites on the stomachs of 57 patients undergoing either antrectomy and vagotomy, proximal gastric vagotomy (PGV), vagotomy and drainage, gastric resection without vagotomy, or fundoplication. Five patients undergoing nongastric operations served as controls. After operation recordings were obtained with differential preamplifiers, an oscilloscope, and a dual-channel tape recorder. An electrical signal compatible with a CER was found almost always in the distal body or antrum, regardless of whether vagotomy was performed. In contrast, a CER was found only occasionally in the fundus, and was never found following PGV. Although there was a difference in the frequency of occurrence of fundic CER in patients with and without vagotomy, it was not statistically significant (p = 0.0668). Patients with prolonged postoperative convalescence because of gastric atony were compared with patients with normal postoperative courses regarding the presence or absence of CER in the gastric antrum or fundus. A statistically significant relationship between abnormal gastric motility and absence of CER was not established.     

Postoperative gastric atony in obstructing peptic ulcers: Inadequate preoperative decompression or vagotomy?

A retrospective study was undertaken in 106 patients operated on for obstructing peptic ulcers to ascertain whether the length of preoperative gastric decompression, the use of preoperative intravenous hyperalimentation, or the type of operative procedure affected the incidence of postoperative gastric atony. Postoperative gastric atony was considered present if the interval between surgery and the resumption of normal oral intake was longer than 2 weeks. Postoperative gastric atony occurred in 2.8 per cent of the patients. There was a significant difference between the patients with and without intravenous hyperalimentation in regard to the average number of preoperative days in the hospital (20 versus 14), but there was no difference in the number of postoperative days in the hospital until fed (8 versus 7). The incidence of postoperative gastric atony was unrelated to either the addition of vagotomy to the operative procedure or the number of preoperative days of gastric decompression. The choice of operation for patients with an obstructing peptic ulcer can only be determined at the time of surgery. Although the widespread use of intravenous hyperalimentation now makes a surgical delay feasible, prolonged preoperative decompression is unwarranted. The additional hospital cost to the patient and the potential morbidity inherent in the use of intravenous hyperalimentation require careful patient selection coupled with intelligent and timely surgical intervention.     

Truncal vagotomy as a possible potentiator of gastric atony

To stimulate ulcer patients undergoing operation for gastric outlet stenosis, pyloric obstruction was created in dogs and repaired with pyloroplasty to which was added truncal vagotomy, proximal gastric vagotomy, or no vagotomy. Gastric antral contractile activity after feeding a solid meal was studied before and after repair (2 week period of study). This activity was correlated with the initial lag and regulated phases of solid meal emptying. Five quantified indices of contractile activity measured during the first postprandial hour indicated variable and inconclusive results in the antrum during the lag phase (first 20 minutes). Consistent percentage changes in these indices after obstruction repair were seen during the subsequent regulated phase. Gastric work was reduced 28 to 35 percent, but not work capability (mean area), by pyloric obstruction in the no vagotomy dogs. Reductions seen in proximal gastric vagotomy dogs were not different from those in the no vagotomy dogs. Higher percentages of reduction in amplitude (70 percent) and mean area of contractions (53 percent) occurred after truncal vagotomy compared with what occurred in the no vagotomy dogs. Mean area was also reduced more compared with what occurred in the proximal gastric vagotomy dogs. These data indicate that the reduced gastric work after feeding and impaired work capability caused by truncal vagotomy when superimposed on that produced by pyloric obstruction may exaggerate gastric atony and contribute to the delayed recovery of gastric emptying seen in the clinical setting.     

Proximal gastric vagotomy in the emergency treatment of bleeding duodenal ulcer

Proximal gastric vagotomy for bleeding duodenal ulcer was performed in 52 low-risk patients between 1973 and 1986. Duodenotomy without violation of the pylorus was done in all patients to allow inspection and control of the bleeding site. The median duration of operation was 3 hours and 20 minutes, although 25% of the procedures required 4 or more hours. There was no postoperative mortality and no early reoperations. Among the six patients with postoperative complications, one rebled from the ulcer and two developed prolonged gastric atony. At the time of follow-up (median, 2.9 years), 48 of the patients were alive and 4 had died of non-ulcer causes. No patient had significant postvagotomy sequelae. Ulcer recurrence was documented in six patients, and three required reoperation. Proximal gastric vagotomy is a safe, effective therapy for bleeding duodenal ulcer. Because of the length of the operation, it should be restricted to low-risk patients who are hemodynamically stable at the time of operation.     

Surgical treatment of patients with perforated peptic ulcers

Results of surgical treatment of 782 patients with perforated gastric and duodenal ulcers are analyzed. Gastric ulcers of I type were diagnosed at 86 (10.9%) patients, prepyloric and pyloric ulcers - at 441 (56.4%), duodenal ulcers - at 255 (32.6%) patients. Perforation was combined with bleeding and stenosis at 24 (3.1%). Palliative operations have been performed at 172 (22.0%) patients, stem vagotomy with ulcer excision and pyloroplasty - at 58 (7.4%), various types of stomach resection - at 54 (6.9%), proximal gastric vagotomy with excision of gastric, pyloric or duodenal ulcer - at 77 (9.8%), proximal gastric vagotomy with excision or suturing of ulcer and pyloro- or duodenoplasty - at 421 (53.8%) patients. The rate of postoperative complications after proximal gastric vagotomy was 3.6%, after stomach resection - 18.2% (p<0.01). Early postoperative complications after vagotomy with ulcer excision and pyloroplasty were diagnosed at 8.3%, after stomach resection - at 18.2% patients (p<0.01). The quality of patients life was higher after organ-saving operations. Proximal gastric vagotomy with excision of ulcer and pyloro- or duodenoplasty should be regarded as operation of choice at perforated duodenal ulcers.     

Treatment of perforated gastroduodenal ulcers

Results of treatment of 751 patients with perforated gastroduodenal ulcers are analyzed. In addition to routine tests, ultrasonography, computed tomography and laparoscopy were used to diagnose difficult cases. The optimum surgical aids are chosen by taking into account the interval between the onset of perforation and admission, a history of peptic ulcerous, the pattern of peritonitis, age, comorbidity, and surgical findings. Organ-saving operations with a vagotomy are preferable. 1% serotonin-adipinate (1 ml dissolved in 200 ml saline solution) was intravenously used to prevent early postvagotomic disorders (gastric atony, dynamic ileus, etc.) in the early postoperative period. Organ-saving operations with vagotomy were found to have some advantage over routine suturing.     

Vagotomy and drainage for obstructing duodenal ulcers: importance of adequate drainage

Sixty patients with gastric outlet obstruction from chronic duodenal ulcer were treated by vagotomy and a variety of drainage procedures including Finney pyloroplasty, Heineke-Mikulicz pyloroplasty, gastrojejunostomy, and gastroduodenostomy (Jaboulay). Postoperative gastric atony or delayed gastric emptying was not a problem when a sufficient period of preoperatiye gastric decompression was employed and an adequate drainage procedure was accomplished. The best long-term results were achieved with vagotomy and Finney pyloroplasty. We believe that surgeons should continue to use vagotomy and drainage in the surgical management of patients with obstructing duodenal ulcers.     

Relief of Acute, Persistent Postvagotomy Atony by Metoclopramide

Seventeen patients with acute, persistent postvagotomy atony after vagotomy with antrectomy or pyrloroplasty for peptic ulcer underwent a doubleblind study of the relief of postvagotomy atony by metoclopramide. All patients had complete, functional gastric obstruction for at least three weeks postoperatively, precluding oral alimentation. Contrast studies and gastroscopy ruled out mechanical obstruction in each patient. Gastric outlet obstruction was confirmed by radioisotope assessment of gastric emptying of a special solid meal labeled with Technetium 99m DTPA. A gamma camera over the epigastrium precisely quantitated the emptying rate of the labeled meals. After baseline scanning an intravenous placebo was given to each patient and all 17 showed gastric retention of the meal after 90 minutes. Gastric emptying rates were restudied 24 hours later after intravenous metoclopramide and all 17 patients then immediately emptied the labeled meals. These patients then received standard postgastrectomy diets. Eight patients received metoclopramide tablets (10 mg 30 minutes a.c., q.i.d.) and nine received placebo tablets. Each of the eight patients receiving metoclopramide ate normally immediately after treatment with no further evidence of gastric atony. The nine patients receiving the placebo were unable to retain any oral feedings and were then given oral metoclopramide which promptly relieved gastric atony. All 17 patients received metoclopramide for one month without side effects after which the drug was discontinued with no recurrence of gastric symptoms during follow-up periods ranging from three to 27 months. Metoclopramide safely and effectively relieves acute, nonmechanical gastric atony when this occurs after surgical treatment of peptic ulcer.     

Idiopathic intermittent gastroparesis and its surgical alleviation

Five otherwise healthy young adults with a syndrome of recurrent intermittent gastric atony have been described. Symptomatic periods characterized by severe nausea, early satiety, and abdominal bloating alternated with asymptomatic intervals. During symptomatic phases upper gastrointestinal barium contrast radiographs demonstrated gastric dilatation with atony but without obstruction. At other times, the symptoms would disappear, and gastric size, motility, and emptying would appear normal. Upper gastrointestinal endoscopy confirmed gastric atony and showed no mucosal abnormalities or gastric outlet obstruction. No pathogenic factors were detected, and the gastroparesis was unassociated with any motility disorder of the esophagus, small bowel, or colon. Thus, it differed from other recognized forms of visceral pseudoobstruction. Because of failed medical treatment, four patients were treated with antrectomy, gastrojejunostomy, and truncal vagotomy to allow passive emptying of the stomach by gravity. All four surgically treated patients improved greatly. Idiopathic intermittent gastroparesis is a distinct clinical syndrome that can be successfully treated by surgical means in severe cases.     

FIVE YEARS‘ EXPERIENCE WITH PROXIMAL GASTRIC (HIGHLY SELECTIVE) VAGOTOMY

In the five-year period 1972 to 1976 the authors' preferred treatment for patients with chronic duodenal or prepyloric peptic ulcer requiring surgery was proximal gastric vagotomy. In spite of this preference, only two-thirds of such patients were so treated. Most patients with bleeding and stenosis were treated by bilateral truncal vagotomy and drainage, and a few by Polya gastrectomy. Proximal gastric vagotomy proved to be a safe elective operation without mortality and with a proven ulcer recurrence rate so far of 6%. Compared with those who had bilateral truncal vagotomy and drainage, the proximal gastric vagotomy patients complained less often of diarrhoea but more often of weight loss and reflux. Two patients have had persistent postprandial non-peptic pain, thought possibly due to upper gastric ischaemia.     

five years' experience with proximal gastric (highly selective) vagotomy.

In the five-year period 1972 to 1976 the author's preferred treatment for patients with chronic duodenal or prepyloric peptic ulcer requiring surgery was proximal gastric vagotomy. In spite of this preference, only two-thirds of such patients were so treated. Most patients with bleeding and stenosis were treated by bilateral truncal vagotomy and drainage, and a few by Pólya gastrectomy. Proximal gastric vagotomy proved to be a safe elective operation without mortality and with a proven ulcer recurrence rate so far of 6%. Compared with those who had bilateral truncal vagotomy and drainage, the proximal gastric vagotomy patients complained less often of diarrhoea but more often of weight loss and reflux. Two patients have had persistent postprandial non-peptic pain, thought possibly due to upper gastric ischaemia.     

Surgical tactics in ulcerous pyloroduodenal stenosis

The authors generalize their experience in the treatment of 528 patients with ulcerous pyloroduodenal stenosis, who accounted for 19.3% of all patients who were operated on and for 29.8% of those with complicated forms of peptic ulcer. All the patients underwent operation after brief (2-3 days) replacement of hydrogen ion deficiencies. Resection of the stomach was carried out in 418 patients, organ-preserving operations-in 102, gastroenteroanastomosis-in 8 patients. Total mortality was 2.5%. There were no fatal outcomes in organ-preserving operations. The incidence of postoperative gastric atony was 6.1% after organ-preserving operations and 4.9% after resection of the stomach.     

Early diagnosis and treatment of a pyloroduodenal ulcer complicated by stenosis of gastric outlet]

Treated were 193 patients with pyloroduodenal ulcer complicated by stenosis of gastric outlet. Compensated stenosis was noted in 14 (7.2%) patients, subcompensated--in 147 (76.2%), decompensated--in 30 (15.5%), gastric tetany--in 2 (1.04%). Studied were the immunologic indices, peripheric blood flow by means of a roentgenologic method under conditions of double contrasting and artificial hypotony, gastric and duodenal function, bioelectric activity--by the method of duodenokinesiography. Gastric resection was performed in 87 patients, vagotomy with drainage operation and without it--in 82, gastroenterostomy--in 14, antrum resection with vagotomy--in 12, Roux resection of the stomach--in 2. The postoperative lethality was 1%. Good and excellent results after gastric resection were noted in 82.1%, after vagotomy--in 88.4% of the patients.     

Post-vagotomy disorders in patients with duodenal ulcer in relation to the method of proximal gastric vagotomy

The article deals with the results of study of the effect of the degree of inhibited gastric acid-producing activity on the frequency of the development of postvagotomy disorders (PVD) in 158 patients with duodenal ulcer after treatment by various methods of proximal gastric vagotomy (PGV) and PGV with a stomach-draining operation. The frequency and severity of PVD were found to correlate intimately with the degree of inhibition of the gastric acid-producing activity by the PGV and the character of the draining operation. PVD were more severe and encountered more frequently in patients in whom HCl secretion was inhibited by 80% and 100% as compared to the initial value, especially in patients who underwent a stomach-draining operation. Organic PVD (stenosis, an indolent or a recurrent ulcer adhesions) are mostly encountered in the late-term postoperative period.     

Stomal obstruction after vagotomy in the treatment of obstructing peptic ulcer

A retrospective evaluation of postoperative gastric atony was made on forty patients operated on for obstructing duodenal ulcer. The incidence of this complication was only 3.1 per cent (one patient in thirty-two) in those undergoing antrectomy and vagectomy, and did not occur in eight treated by subtotal gastrectomy. In light of the pathophysiology of postoperative gastric atony in patients with obstruction and in view of the undesirable side effects of gastrectomy, it is believed that antrectomy with vagotomy is the procedure of choice for this condition.     

Vagotomy and drainage adapted for ulcerous stenosis

The authors have retrospectively studied 56 patients with duodenal ulcer stenosis treated by vagotomy and gastric drainage. They found that there are several types of stenosis needing different drainage and vagotomy procedures. So, they propose an operative policy based on the result of a intra-operative exploration adapting the gastric drainage to the type of stenosis and vagotomy to the selected drainage. If the ideal is to preserve pylorus, then to perform a H.S.V. with dilatation or duodenoplasty, nevertheless, according to the authors, there are still indications for T.V. and drainage.     

Surgeon's strategies in gastroduodenal ulcer hemorrhage

The results of surgical treatment of 1491 patients with gastroduodenal ulcer, complicated by gastrointestinal hemorrhage, were analyzed. Among 757 patients, operated on, there were performed truncal vagotomy, selective proximal vagotomy, pyloroduodenoplasty, duodenoplasty, gastric resection, sectoral gastric resection. Application of elaborated lifesaving active individually-rational tactics have permitted to lower the total and postoperative mortality in occurrence of the ulcer gastroduodenal hemorrhage.     

Bulbantrectomy with truncal vagotomy in the surgical treatment of duodenal ulcer

Duodenal ulcer benefits of very efficient medical treatment. In currently medical practice exist many cases with complicated duodenal ulcer (by stenosis or penetration in neighbor organs like pancreas or biliary tract or painful forms etc.) to which surgical treatment is necessary. Based on the retrospective study of 116 patients operated between 1991-2002 years for gastric or duodenal ulcer, this paper demonstrates that bulbantrectomy associated with bilateral truncal vagotomy (63.7% of cases) is the best surgery in the treatment of duodenal complicated ulcer or resistant to the medical procedures. Provided by correct indication, the intervention is the most pathogenic, offering the best immediate and long term postoperative results. If the bulbantrectomy is contraindicated (critical general status, etc.), the alternative is a bilateral truncal vagotomy associated with a drainage procedure: pyloroplasty (6.9% of cases) or gastroenterostomy. When the vagotomy are contraindicated or cannot be correctly performed, a large gastrectomy (29.3% of cases) followed by gastroduodenal (preferable) or gastrojejunal anastomosis are practiced.     

Roux-Y gastrectomy for chronic gastric atony

The aim of this study was to determine the clinical outcome after Roux-Y gastrectomy for chronic gastric atony. Forty patients (11 men, 29 women; age 47 +/- 12 years) presented with severe chronic gastric atony: 32 patients had postvagotomy atony, 6 had idiopathic atony, and 2 had diabetic gastroparesis. The patients underwent either extensive subtotal or near-total gastrectomy and Roux-Y gastrojejunostomy. No early postoperative mortality occurred. Among the 39 patients followed for a mean of 32 months, 31 patients (79 percent) had fewer symptoms postoperatively than preoperatively, with 26 patients (66 percent) improving at least one Visick grade postoperatively and 22 patients (56 percent) going from grades III and IV preoperatively to grades I and II postoperatively. In contrast, 13 patients (33 percent) did not improve after operation. We concluded that extensive subtotal Roux-Y gastrectomy and near-total Roux-Y gastrectomy were safe procedures that led to improvement in two-thirds of the patients with chronic gastric atony; however, one-third of patients did not have improvement.     

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.