Herbert J. Movius

Vagotomy and pyloroplasty in the treatment of duodenal ulcer

Abstract Experience with pyloroplasty with one-row closure shows it to be a useful adjunct of vagotomy for the surgical treatment of the chronic duodenal ulcer. The special advantages of the combined procedure over procedures involving partial gastric resection or gastro-jejunostomy are its low surgical mortality and morbidity, and the minimal disturbance of the integrity of the digestive function. The operation is successful and has produced healing in 95 per cent of the patients according to long-term follow-up examinations.

Prevention of high flow problems of arteriovenous grafts. Development of a new tapered graft.

Blood flow of 2 to 3 liters/min was measured in polytetrafluoroethylene (PTFE) arteriovenous dialysis grafts. The flow studies were done at the time of graft banding for high output cardiac failure or peripheral steal. Routine tapering of the arterial end of these grafts to a diameter of less than 5 mm has virtually eliminated this problem. Prototype tapered PTFE grafts supplied by the graft manufacturers have been very acceptable during 12 months of use.

Resection of abdominal arteriosclerotic aneurysm

Abstract 1. 1. Ten cases of arteriosclerotic abdominal aortic aneurysm have been reported. There were three deaths in this series, one each from ascending thrombosis and shock, uncontrolled sepsis and uremia, and exsanguination from the proximal suture line. 2. 2. Patients with advanced cardiovascular renal disease in whom the symptoms attributable to the aneurysm were mild were not offered surgery. 3. 3. No patient was refused surgery regardless of his physical status if the symptoms were severe. 4. 4. Protection against embolization and thrombosis by clamping and heparinization are important considerations in the operation. 5. 5. A choice of grafts at the time of operation and sufficient time for their reconstitution is emphasized. 6. 6. Partial thromboendarterectomy is advocated. 7. 7. Continuous through and through silk suture is satisfactory. The graft should be short enough. Careful reperitonization may help prevent delayed leak. 8. 8. Complications included peripheral emboli and thrombosis in two cases and faulty application of the aortic clamp occluding the left renal artery in another two cases. 9. 9. Two patients had coexisting benign rectal strictures requiring later surgical excision. This occurrence appears to be more than coincidental. 10. 10. Six of the patients are now free of symptoms. One patient has disabling residuals of ischemic neuritis.

Prolene sutures are not a significant factor in anastomotic false aneurysms.

Anastomotic false aneurysms have been a significant complication in vascular surgery, and the sutures used have been a major cause. Monofilament sutures have been indicated as contributing to the formation of false aneurysm. However, most of the monofilament sutures operative in the formation of false aneurysms have been made of polyethylene. Polypropylene, although significantly different from polyethylene, has been associated and possibly confused with it. Very few anastomotic aneurysms have resulted from breakage of polypropylene sutures. In this series of 2,400 vascular anastomoses in which polypropylene sutures were used, there were 10 false aneurysms; however, only one resulted from suture failure. In that patient, two Dacron grafts were anastomosed with 5-0 polypropylene suture. Polypropylene is a satisfactory and safe suture material for vascular anastomoses. It does not fragment or break easily when properly handled, and therefore is not a principal cause of false aneurysms.

Comparison of Payne and Scott operations for morbid obesity.

One hundred five patients were operated upon for morbid obesity using accepted criteria for operation. Forty-five patients with the Payne operation (35 cm of jejunum anastomosed end-to-side to 10 cm of ileum) were compared with 45 patients having the Scott operation (30 cm of jejunum anastomosed end-to-end to 15 cm of ileum with the proximal cut end of ileum vented into the transverse colon). The weight loss in the first two years was similar, although the Scott procedure patients lost slightly more weight. Comparison of the two groups by a new grading system also showed little difference in the two procedures. The Scott procedure takes longer and subjects the patient to an additional anastomosis. Study of a smaller group of patients having the Scott operation with varying lengths of jejunum and ileum indicates that there should not be less than 30 cm of jejunum nor more than 15 cm of ileum left in continuity. The length of jejunum is particularly important in the production of weight loss, and accurate intraoperative measurement of intestinal length is crucial. In the postoperative period the length of functional jejunum and ileum can be determined by upper gastrointestinal barium roentgenograms.

The Early and Delayed Phases of Gastric Acid Secretion in Response to Insulin Hypoglycemia: II. The Hypoglycemic Secretory Responses in Duodenal Ulcer Patients after Vagotomy-Pyloroplasty

In a previous communication 1 we reported that duodenal ulcer patients were invariably characterized by sustained gastric acid secretion over a period of 4 hour or longer following insulin stimulation. This response involves an immediate phase (vagal phase) and a delayed phase (pituitary-adrenal phase). In non-ulcer subjects we found two types of responses: one, the sustained response similar to that of duodenal uleer patients, and the other an unsustained response which involved mainly the vagal phase. In this study, we were interested in determining the types of gastrie acid seeretory responses which would follow insulin stimulation in duodenal ulcer patients who had undergone vagotomy with pyloroplasty. The evaluation of methods was similar to that of part I of this artiele. Two sets of data are represented. A set of complete data is represented in terms of an analysis of the pH eurve. Where the exading aspiration teehnique was used, a seeond set of data is represented in terms of milliequivalents of hydrochlorie aeid secretion. As in part I the secretory response is divided into 2 hr. phases, eonsisting of basal seeretion, early phase seeretion and delayed phase secretion. It should be stated that had we not had a large group of patients with vagotomy and pyloroplasty, this study would have been impossible. In our experience, patients having gastroenterostomy or gastrie reseetion give unreliable studies with respect to volumes and pH of gastric secretion, due to the admixture of duodenal and jejunal contents with the gastric aspirates.

Surgical treatment of gastrojejunal stomal ulcer

Abstract From this study we could tentatively assert that vagotomy alone is as effective as other procedures in curing gastrojejunal stomal ulcer and has the advantages of a lower complication rate, and possibly, a lower mortality rate. However, there are not enough patients in the study to draw definite conclusions. Furthermore, ten to twenty years more of follow-up examinations may drastically change the results. Therefore, in the good risk patient, we are not yet prepared to advise vagotomy alone to the exclusion of other procedures. We do believe strongly that it is indicated in the emergency, poor risk patient.

Surgery of the carotid-vertebral system for cerebrovascular insufficiency

Abstract 1. 1. Emphasis is placed upon adequate physical diagnosis to determine if “stroke” patients are suffering from extracranial carotidvertebral occlusive disease. 2. 2. The hazards of routine arteriography are recognized. Suspected arteries only are investigated with angiography with the patient under anesthesia immediately prior to surgery. 3. 3. Moderate hypothermia, prevention of hypotension and routine use of the internal shunt are measures taken to provide maximal safety for the patient. 4. 4. Clinical experience with thirty-five patients and twenty-nine arterial reconstructions is presented. 5. 5. Surgical technic and conduct of the operative procedure are outlined.

Aortoiliac thromboendarterectomy: Technic and results

Summary One-hundred and five patients who underwent aortoiliac thromboendarterectomy are presented. The operative mortality was 4.7 per cent. Four patients died in the early postoperative period. Of ninety-six patients available for analysis ninety-two (95.8 per cent) have had a satisfactory result (87.6 per cent of the total series). Operative deaths, surgical failures necessitating reoperation, and unsatisfactory results are analyzed, and the technic of the operation is described.

A technic for carotid thromboendarterectomy

An exacting technic for carotid thromboendarterectomy is described. Certain anatomic features and pitfalls are discussed along with specific instrumentation. Intraoperative use, insertion, and removal of the inlying carotid shunt are described.