Stephen J. Stempien

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.

Insulin gastric analysis: Technic and interpretations

T HE STIMULATING EFFECT Of i n s u l i n i n d u c e d hypoglycemia upon gastric acid secretion has been known for a long time. T h e prompt secretory response in intact animals and human subjects is a l t r ibuted to stimulation of vagal centers in the brain since it can be abolished by vagotomy. In recent years, an impor tant extension of knowledge concerning insulin-induced gastric secretion has resulted from the work of Porter 1 and French 2 and their associates. They have shown that electrode stimulation of the anterior hypothalamus in monkeys produces a prompt gastric acid secretion which can be abolished by vagotomy, whereas electrode stimulation of the posterior hypothalamus produces a delayed gastric acid response which can be abolished by adrenalectomy. Further, the gastric secretory response to insulin was shown to be a composite of the two responses, the early and the delayed phases. T h e existence of these two phases of gastric acid secretion following insulin-induced hypoglycemia has been confirmed by the author and his associates in two separate studies of vagotomized subjects, a, 4 Also, in a prior prel iminary report on the effect of phentolamine (Regitine) on insulininduced gastric secretion, Shay and Sun 5 concluded that these two phases were demonstrated because of the blocking effect of phentolamine on the delayed phase of secretion. However, this remains to be confirmed. 7Fhe exact mechanism of the total gastric acid secretory response to insulin-induced hypoglycemia is not fully understood. T h e early response is more readily understandable as a st imulation of vagal centers by their direct communicat ion with the anterior hypothalanms. T h e delayed response is assumed to be a neurohumora l effect from the posterior hypothalamus to the anterior pi tui tary via the portal circulation to the pi tui tary body. s Stimulation of the anterior pituitary produces in turn stimulation of the adrenal cortex, releasing hormones responsible for a

The Mallory-Weiss syndrome and lesion: A study of 30 cases

SummaryThirty cases of the Mallory-Weiss synrome were encountered at one hospital during a 6-year period. Although one is often alerted to the presence of this lesion by a history indicating the syndrome, its diagnosis depends upon visualization of the mucosal laceration in the gastric fund us by early endoscopic examination, surgical exploration, or autopsy.Since in the majority of instances the bleeding is of a minor nature or is controlled by medical supportive therapy, and since it is not always possible to develop a historical sequence of events characteristic of the syndrome, a more widespread use of the early endoscopic diagnostic approach in the bleeding patient will more accurately succeed in revealing the frequency with which this lesion occurs.Alcoholism, inflammatory disease of the gastric mucosa, and the presence of an esophageal hiatus sliding hernia are important predisposing factors in the creation of this lesion by forceful efforts which acutely raise intra-abdominal pressure.Gastroscopy is much more successful than esophagoscopy in demonstrating the lesion; X-ray is of value only in ruling out other possible sources of bleeding.This disorder occurs more frequently than is generally appreciated, and the possibility of its presence should be considered in every patient bleeding from the upper gastrointestinal tract.

THE SOURCES OF UPPER GASTROINTESTINAL BLEEDING IN LIVER CIRRHOSIS

Excerpt INTRODUCTION The occurrence of upper gastrointestinal hemorrhage in patients suffering from hepatic cirrhosis represents a serious complication of this disease. Prognosis in this situation ...

Clinical appraisal of insulin gastric analysis

ConclusionInsulin gastric analysis, properly performed and interpreted, is a reliable indicator of postoperative clinical status of patients with peptic ulcer. It can be used to assess the adequacy of vagotomy or antrectomy.Clinical experience with insulin gastric analysis confirms the findings of animal studies which indicate that cephalic secretion is essentially an integrated neurohumoral response, involving a vagal release of antral gastrin. The profound depression of basal acid in the negative-response group also indicates that basal secretion is largely under cephalic control.

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.

Tolbutamide gastric analysis

ConclusionWith rare exception, the tolbutamide gastric analysis has been shown to be a reliable indicator of clinical status in postsurgical peptic ulcer patients. In this group the side effects were rare and, when present, were very mild. Bad risk patients, considered unacceptable for an insulin gastric analysis, tolerated the entire tolbutamide test procedure without any ill effects. Only one serious reaction was observed in a patient in whom unexpected fasting hypoglycemia was overlooked.Our experience strongly suggests that tolbutamide is a useful supplementary test for evaluating the adequacy of vagotomy and/or antrectomy. In poor risk patients and the aged, the tolbutamide test is the procedure of choice.

Endoscopic aspects of the gastric mucosa ten years or more after vagotomy-pyloroplasty

Three large age-matched groups were comparatively examined to evaluate the endoscopic appearance of the gastric mucosa. The authors contend that vagatomy-pyloroplasty leads to pregressive degeneration and inflamation that eventuate in gastric mucosal atrophy.

Symptomatic esophageal hiatus sliding hernia

Summary and conclusions1. The clinical, endoscopic, and radiologic findings in 100 patients with symptomatic sliding esophageal hiatus hernia have been presented and correlated.2. The symptomatology in this disorder appears to be the result of organic changes in the distal esophagus or herniated gastric pouch, or of motor and mechanical disturbances in the involved esophagogastric segment3. Symptoms usually ascribed to inflammatory-ulcerative changes may be present without these findings being noted on careful endoscopic examination. Conversely, pathologic changes of the mucosa may be present in patients without such symptoms.4. The most common symptoms noted were epigastric and/or sub-sternal pain or distress, heartburn and/or regurgitation, dysphagia, and upper gastrointestinal bleeding.5. The complications encountered were esophagitis, esophageal ulcer, esophageal stricture, gastritis of the mucosa lining the hernial sac, and gastric ulcer in the sac.6. The frequent and serious manifestation of apper gastrointestinal bleeding is again emphasized and its relationship to dietary and alcoholic indiscretion noted.7. Esophagoscopy and/or gastroscopy are indispensable for the proper diagnostic and prognostic evaluation of this common clinical entity.

Intractable Duodenal Ulcer" Objective Evaluation as a Basis for Surgical Selection

Conclusion1. The objectively determined intractable duodenal ulcer is in reality a complicated ulcer.2. The complications constitute a well-defined triad of:a.Advanced organic changes of pyloroduodenal segmentb.Extraordinarily high basal gastric acid secretionc.Associated benign hypertrophic hypersecretory gastropathy 3. The complete triad, or any two of its constituent factors associated with demonstrable duodenal ulcer, offers reliable objective data in support of intractability with surgical implications. Only one factor, standing alone, can be used as supportive evidence for such intractability, namely, advanced organic changes of pyloroduodenal segment.4. It is our opinion, that surgery for intractability shouldnot be recommended if none of these three factors is present.