John H. Landor

Results of surgical management in 92 consecutive patients with Zollinger-Ellison syndrome.

Hospital records and follow-up information on 92 patients with surgically proven Zollinger-Ellison syndrome have been reviewed, and data relating to symptomatology, age and sex incidence, pathologic findings, and early and late results of surgical procedures have been summarized. The postoperative mortality rate was 15%, and was adversely affected by previous peptic ulcer surgery, by the necessity of urgent operation for complications of peptic ulcer, and by employment of a procedure that failed to control acid secretion. Thirteen patients were found to have primary gastrinomas of the duodenum and an additional 13 patients had islet cell hyperplasia without evidence of frank neoplasm; prognosis in these two groups appears to be particularly favorable. Despite the current availability of effective nonoperative measures for control of gastric hypersecretion, surgical exploration is warranted in all patients to determine location and extent of tumor and to attempt to control the ulcer diathesis by resection of tumor. Long-term therapy with H2 receptor antagonists is advised for patients whose hypersecretory state has not been alleviated by tumor resection or whose gastrinoma cannot be removed. Total gastrectomy is still indicated in patients whose tumors are not amenable to resection and who are resistant to, or cannot follow, a rigid medical regimen.

GASTRIC HYPERSECRETION PRODUCED BY MASSIVE SMALL BOWEL RESECTION IN DOGS.

Summary Marked increases in Heidenhain pouch secretion were observed in 4 dogs immediately following removal of the major portion of the small intestine. A similar increase in secretion was seen in 2 dogs after small intestinal bypass, with prompt return to the control level of gastric secretion after restoration of normal intestinal continuity. Only 1 of 4 dogs with antrectomy exhibited a rise in pouch secretion after massive intestinal resection. Possible causes for the gastric hypersecretion observed are discussed.

THE EFFECT OF EXTRAGASTRIC VAGOTOMY ON HEIDENHAIN-POUCH SECRETION IN DOGS.

SummaryThree of 4 dogs with antrectomy and Heidenhain pouches exhibited an increase in pouch secretion after extragastric vagotomy. Further increases in secretion were observed following transthoracic vagotomy. The elevation in gastric secretion induced by extragastric vagotomy is believed to result from changes in biliary, pancreatic, and/or intestinal function secondary to parasympathetic denervation. The additional increases in pouch secretion after transthoracic (gastric) vagotomy were most likely related to the lowered production of acid by the stomach.

Control of the Zollinger-Ellison syndrome by excision of primary and metastatic tumor

In a patient with Zollinger-Ellison syndrome, control of the peptic ulcer diathesis was attempted by excision of a small duodenal gastrinoma and removal of three lymph nodes containing metastases. The patient has been asymptomatic for 2.5 years with basal achlorhydria, a normal serum gastrin level and a negative gastrin response to secretin. Our experience with this patient emphasizes the fact that the presence of metastatic disease does not preclude the possibility of long-term control of hypergastrinemia by resection of the tumor. Attempts to cure the Zollinger-Ellison syndrome by tumor resection alone, however, should only be made in patients whose hypersecretion is adequately controlled by antisecretory drugs.

Oestrus and gastric secretion in the dog

Marked decreases in 24-hour Heidenhain pouch secretion, lasting from nine to 18 days, were observed in five mongrel bitches during periods of naturally occurring oestrus. Neither oophorectomy nor control celiotomy caused significant change in Heidenhain pouch secretion in bitches who were not experiencing oestrus. The oral administration of diethyl stilboestrol, in doses ranging between 5 mg and 70 mg per day, had no clear-cut effect on Heidenhain pouch secretion.

Postenterectomy gastric hypersecretion in dogs: The relative importance of proximal versus distal resection

Abstract In mongrel dogs with Heidenhain pouches, resection of the proximal one-third of the small intestine led to marked and significant gastric hypersecretion, resection of the distal one-third of the bowel was followed by less marked increase in secretion, and sham resection resulted in no change in secretion. Subsequent resection of the middle one-third of the intestine brought about further significant increases in gastric secretion whether preceded by proximal or distal resection. The possible significance of these findings in relation to the etiology of postenterectomy gastric hypersecretion is discussed.

The effect of enterectomy on gastric secretion in dogs with biliary fistulas

Bile was excluded from the gastrointestinal tract of 5 dogs with Heidenhain pouches by total external biliary fistulas. After a major portion of the jejunum and the ileum was resected Heidenhain pouch secretions increased in all instances. The results indicate that the increase in gastric secretion which regularly follows small-bowel resection is independent of the presence or absence of bile in the gastrointestinal tract.

Examination of the mechanism involved in antral inhibition of gastric secretion

Summary1. The transplantation of approximately half of the gastric antrum into a Heidenhain pouch, where it was exposed to an acid environment, resulted in no significant depression of gastric secretion.2. This experiment failed to provide evidence in favor of the existence of a gastric inhibitory hormone originating in the antrum.

Relationship between amino acid dose and gastric secretory response.

Gastric secretory dose-response studies, using an 8.5% mixed L-amino acid solution as the agonist, were carried out in three dogs with Heidenhain pouches and gastric fistulae. Secretory responses of the Heidenhain pouches were measured during two hour infusions of amino acids given at rates of 0, 0.05, 0.1, 0.2, 0.4, 0.8, and 1.6 g/kg/h and plasma amino nitrogen was measured before and during the infusion. Three separate studies at each dose level were made in each dog. The maximum secretory response occurred at the dose of 0.4 g/kg/h and amounted to approximately 20% of the maximal histamine response. Larger doses produced no additional increase in secretion or an actual decrease in secretory rate. It is concluded that the solution of amino acids used acts as a modest gastric agonist and that increases in plasma amino nitrogen such as may be observed after a protein meal are capable of eliciting a slight, but definite, gastric secretory response.

Effect of an intravenous fat preparation on canine gastric secretion

The effect of intravenous administration of a fat emulsion on canine gastric secretion stimulated by intravenous infusion of amino acids, pentagastrin or insulin was studied. The fat preparation was given at a rate of 30 ml/hour for 2 hours, and its effects were compared with those of a comparable amount of saline solution, each given on three separate occasions in each dog. Fat did not alter the Heidenhain pouch secretion stimulated by intravenous amino acids (1.10 versus 1.11 mmol of hydrogen ion, p greater than 0.9) or the gastrostomy secretion stimulated by intravenous insulin (9.22 versus 9.54 mmol of hydrogen ion, p greater than 0.7) but had a modest inhibitory effect on Heidenhain pouch secretion stimulated by pentagastrin (2.75 versus 3.54 mmol of hydrogen ion, p less than 0.05). These data provide indirect support for the contention that the inhibition of gastric secretion by fat in the gut is mediated by the release of an enterogastrone rather than by a direct effect of absorbed fat. Because gastric stimulation by intravenous fat was not observed in the dog, it seems likely that intravenous fat emulsion can be given to seriously ill patients without fear of an increased likelihood of peptic ulceration due to induced gastric hypersecretion.