Paul H. Jordan

Unresolved problems of pancreatic pseudocysts.

The treatment of 54 patients with pancreatic pseudocysts was reviewed. The operative mortality was 11% and after an average followup of 3 years the recurrence rate was 3.8%. Hemorrhage was the most significant complication of pseudocysts and occurred in 4 patients preoperatively and three patients postoperatively. The patients who developed recurrence or died had been operated within one day after the diagnoses of pseudocysts were made. The deaths were due to the conditions that necessitated the emergency operations rather than to the fact that the cyst wall had not adequately matured.Ideally, operation should be performed when the patient has reached an optimal clinical condition and the walls of the cyst are sufficiently thick. Currently there is no guide for estimation of the state of cyst maturation, although this may develop with the use of ultrasound. Since complications can develop during a prolonged observation period it was our policy to proceed with surgery as soon after diagnosis as the patient was in satisfactory clinical condition. It is evident from this study that internal drainage can be performed safely in less time than the 6 weeks frequently recommended. Morbidity and mortality were not adversely affected by a short interval between diagnosis and operation if the timing was a matter of election rather than a condition of emergency.

Perforated pyloroduodenal ulcers. Long-term results with omental patch closure and parietal cell vagotomy.

OBJECTIVE The authors evaluated parietal cell vagotomy and omental patch closure as treatment for perforated pyloroduodenal ulcers. BACKGROUND DATA Since the beginning of the century, there has been a difference of opinion as to whether perforated pyloroduodenal ulcers are best managed with nonoperative treatment, simple closure, or definitive treatment, i.e., a procedure that handles the emergency problem and simultaneously provides protection against further ulcer disease. The criticism of using definitive treatment at the time of perforation has been that some patients who might not have recurrent ulcer, if a definitive operation was not performed, would be at risk of adverse postoperative sequelae, including death. Parietal cell vagotomy as treatment of intractable duodenal ulcer disease was shown to be almost without complications. The objective of this study was to determine if the operation was equally applicable to perforated pyloroduodenal ulcers. METHODS A group of 107 selected patients with perforated pyloroduodenal ulcers underwent definitive treatment by omental patch closure and parietal cell vagotomy. The patients were evaluated prospectively on an annual basis up to 21 years. Gastric analyses were performed on each visit for which the patient gave his/her consent. Patients suspected of a recurrent ulcer were examined endoscopically for verification. RESULTS There was one death (0.9%). Ninety-three patients were observed for follow-up for 2 to 21 years. The recurrent ulcer rate by life table analysis was 7.4%. The reoperative rate was 1.9%. Postoperative gastric sequelae were insignificant. All but four patients were graded Visick I or II at the time of their last evaluation. CONCLUSION This study confirms that the combination of parietal cell vagotomy and omental patch closure is an excellent choice for treatment of patients with perforated pyloroduodenal ulcers, who, by virtue of their age, fitness, and status of the peritoneal cavity are candidates for definitive surgery. Virtually none of the morbidity that occurs with other forms of definitive treatment is inflicted on patients who might never have needed a definitive operation if simple closure was performed. At the same time, it provides definitive therapy for the larger number of patients who subsequently would have required a second operation for continued ulcer disease if simple closure alone was performed. Whether this operation is performed at the time of perforation should depend on the presence or absence of risk factors, rather than whether the ulcer is acute or chronic.

A Prospective Study of Parietal Cell Vagotomy and Selective Vagotomy-antrectomy for Treatment of Duodenal Ulcer

A prospective, randomized, study involving 92 patients who required elective operation for treatment of duodenal ulcer was performed to compare the results of Parietal Cell Vagotomy (PCV) and selective vagotomy-antrectomy Billroth I (SV-A-BI). The protocol was broken twice. One patient was unable to undergo PCV because of pyloric stenosis and one patient underwent Billroth II anastomosis instead of Billroth I because of post-bulbar stenosis. Performance of PCV was never aborted because a patient was obese. There were no deaths. Diarrhea, dumping and other gastric complaints were less frequenct after PCV than after SV-A-BI for all time periods studies up to two years. Two months after operation, the Hollander tests were negative in 59% of patients after PCV and in 100% after SV-A-BI. Inhibition of BAO and MAO were also significantly less after PCV than after SV-A-BI. Since vagotomy of the parietal cell mass was identical in both groups of patients it was concluded that the differences in the secretory rates and the fewer negative Hollander tests in the PCV group than in the SV-A-BI group were due to retention of the antrum irrespective of its innervation. There was no explanation for the gradual increase in the BAO in the PCV group. One recurrent ulcer occurred in the PCV group in a patient who overindulged in alcohol and aspirin. After 4 days of medical management, this superficial ulcer healed as demonstrated by endoscopy. There were no recurrent ulcers after SV-A-BI. As a result of this study, it is concluded that PCV is superior to SV-A-BI because of the lower frequency of postoperative complications, diarrhea, dumping and other symptoms associated with gastric surgery. PCV may be the operation of choice for the elective treatment of duodenal ulcer; however, it remains undetermined whether the recurrent ulcer rate following PCV will be sufficiently low that the procedure can retain a position of superiority over SV-A-BI.

Obstructive jaundice in patients with pancreatitis without associated biliary tract disease.

Jaundice occurring in patients with pancreatitis is usually due to hepatocellular injury or to associated biliary tract disease. Common duct obstruction is occasionally caused by pancreatic fibrosis, edema or pseudocyst in patients who have neither hepatocellular injury nor biliary tract disease. We have studied 7 patients with obstructive jaundice due to pancreatitis who demonstrated no other known cause for jaundice. The difficulty in making the differential diagnosis between benign and malignant disease in these patients, particularly when no pain is associated with obstructive jaundice, is discussed. In view of the fact that the terminal common duct traverses the pancreas, it is uncertain why obstructive jaundice associated with chronic pancreatitis does not occur more often unless the condition is sometimes transient and overlooked. Operative intervention is required in those patients in whom jaundice is persistent. Operation is intended to decompress the biliary tract and the pancreas. The approach used will be dictated by the operative findings in each patient.

A Followup Report of a Prospective Evaluation of Vagotomy-Pyloroplasty and Vagotomy-Antrectomy for Treatment of Duodenal Ulcer

A prospective randomized study of 200 consecutive patients who required elective operation for treatment of duodenal ulcer was conducted. Truncal vagotomy and drainage (V-D) was done in 108 patients with a 2% mortality and truncal vagotomy and antrectomy (V-R) were performed in 92 patients with no mortality. Ninety-four per cent of these patients were followed 5-8 years after operation or until their death if that preceded the termination of the study. The immediate postoperative morbidity including stomal dysfunction and reoperation was greater after V-D than after V-R. In the opinion of the patients and independent investigators, the number of gastrointestinal complaints was similar throughout the study for the two groups of patients. In the opinion of the author, however, more gastrointestinal complaints occurred in patients from the V-R group than from the V-D group. Because of the subjectivity involved in the evaluation of these complaints, it is unknown whether a real difference existed between the two groups of patients. No patient in either group was symptomatically disabled after operation. There were nine recurrent ulcers requiring reoperation after V-D and one after V-R. The insulin test was positive in 58% of patients after V-D and 14% after V-R. These figures were essentially unchanged from those in the first report made three to five years after operation. The basal acid output and the response to histalog stimulation also remained unchanged in the two groups of patients during the same period. This study suggests that if one abstains from resection in patients where technical difficulties with the duodenum can be expected, V-R can be performed in the remaining patients with a mortality rate equally as low as that usually reported for V-D. It is concluded that V-R is superior to V-D for the majority of patients because it is associated with fewer recurrent ulcers without a significant difference in the severity of other postoperative gastrointestinal complaints.

Evaluation of the Nissen Fundoplication for Treatment of Hiatal Hernia

Twenty-nine patients who underwent Nissen fundoplication of the treatment of symptomatic, sliding, esophageal hiatal hernia are reported. Foiurteen of these patients also underwent parietal cell vagotomy (PCV) without a drainage procudure. Simultaneous cineradiography and manometric studeis, esophagoscopy and gastric analysis were performed pre- and postoperatively, Esoplhageal acid clearing and pH reflux tudies were performed postoperatively. All but 3 patients had reflux and/or esophagitis preoperatively. All but 3 patients had reflux and/or esophagitis preoperatively, Cineradiography and the pH reflux test were teh most reliable tests for diagnosis of reflux. There was no operative mortality. The mean followup period was 20 months. Dysphagfia occured in 5 patients. Correction of dyphagia in one patient required reoperation. The dysphagia in the remaining patients was temporary and mild, responding to dilatation. Two patients had mild diarrhea. One patient who had had a pervious gastric resectin developed severe diarrhea after bilateral truncal vagotomy. No patient developed the “bloat syndrome.” A close correlation did not exist betwen reflux and peroperative sphincter perssure. The mean LES pressure incerased 10 mmH2O postoperatively and the two patients with persitent reflux postoperatively had normal LES pressure. Correction of reflux after Nissen fundoplicatin is probably due to some mechanism other than increased LES pressure. Recurrent or persistent hiatal hernia was diagnosed in 4 patients by cinradiography. Two of these patients had reflux but only the patient who had undergone PCV was without symptoms or esophagitis. The techinical performance of the Nissen hiatal repair was greatly facilitated by PCV. This procedure, was not associated with increased moerbidity, mortality or the adverse effects usually attributed to vagotomy. In the events of recuurrent hernia and reflux, PCV may pervent the development of esophagitis.

An interim report on parietal cell vagotomy versus selective vagotomy and antrectomy for treatment of duodenal ulcer.

This is an interim report of a prospective, randomized study involving 194 consecutive patients who underwent elective operation for treatment of duodenal ulcer. The results of parietal cell vagotomy without drainage (PCV) and selective vagolomy-antrectomy and Billroth I anastomosis (SV-A-B I) were compared. There was no mortality. Postoperatively patients were examined at two, six, 12 months and every 12 months thereafter. The two operations showed no statistical difference in the frequency of diarrhea. Dumping was less (p < .01) after PCV than after SV-A-B I. Weight loss was less (p < .01) after PCV than after SV-A-B I. There were no recurrent ulcers after SV-A-B I and five after PCV. In each instance but one the recurrent ulcer healed on withdrawal of an ulcerogenic drug. One patient required reoperation. Re-operations in the PCV group consisted of one for recurrent ulcer, one for gastric outlet obstruction and three for intestinal obstruction. The reoperations after SV-A-B I consisted of four for gastric outlet obstruction, three for intestinal obstruction, one for ruptured spleen and two for incisional hernia. PCV was technically feasible and practical to perform except in the occasional patient with severe pyloric stenosis. Obesity was never a deterrent. After PCV it is reasonable to assume that a recurrent ulcer rate in the range of 5–10% can be expected by surgeons who have been properly trained. This recurrence rate is higher than that after SV-A-B I but no higher than that encountered with TV-P. The recurrence rate is acceptable and is a fair exchange for the avoidance of dumping and weight loss that accompany SV-A-B I with significantly greater frequency and which on occasion can produce gastric crippling, although this did not occur in this study. All recurrent ulcers after PCV do not require reoperation but when operative treatment is required the patient has all the options that he had prior to PCV.

Indications for parietal cell vagotomy without drainage in gastrointestinal surgery.

Parietal cell vagotomy (PCV) was used for a variety of gastrointestinal conditions in 658 patients. Operative and late related deaths after PCV were 1.1% (3/273) in patients with intractable duodenal ulcers, 1.1% (1/91) in perforated ulcers, 0% (0/43) in Type I gastric ulcers, 0% (0/45) in pyloric and prepyloric ulcers, 3.2% (6/188) when combined with fundoplication, 8.7% (2/23) when combined with vascular surgery, and 4.2% (1/24) in ulcer patients with acute bleeding. The recurrent ulcer rate after PCV was 8.4% in patients operated on for duodenal ulcer, 6.4% for perforated ulcer, 5.3% for bleeding ulcers, 10% for Type I gastric ulcers, and 31% for pyloric and prepyloric ulcers. PCV was preferred to total gastrectomy in four patients in whom a gastrinoma could not be located. PCV was used in 188 patients with reflux esophagitis and in 12 patients with achalasia to facilitate fundoplication and placement of the myotomy, respectively. Based on the results of the study, PCV is contraindicated in patients with pyloric and prepyloric ulcers. PCV is not recommended when traumatic dilatation of the pylorus is required to overcome obstruction. PCV may have limited application in patients with bleeding ulcers and Type I gastric ulcers. In our experience PCV is not contraindicated in patients with ulcers resistant to H2 receptor antagonists. PCV may be contraindicated when acid hypersecretion exceeds an as-yet undetermined level. PCV is an ideal procedure for intractable duodenal ulcers and perforated ulcers.