Gastric incontinence and post-vagotomy diarrhoea

All disease begins in the gut: Influence of gastrointestinal disorders and surgery on oral drug performance

The term "disease" conjures a plethora of graphic imagery for many, and the use of drugs to combat symptoms and treat underlying pathology is at the core of modern medicine. However, the effects of the various gastrointestinal diseases, infections, co-morbidities and the impact of gastrointestinal surgery on the pharmacokinetic and pharmacodynamic behaviour of drugs have been largely overlooked. The better elucidation of disease pathology and the role of underlying cellular and molecular mechanisms have increased our knowledge as far as diagnoses and prognoses are concerned. In addition, the recent advances in our understanding of the intestinal microbiome have linked the composition and function of gut microbiota to disease predisposition and development. This knowledge, however, applies less so in the context of drug absorption and distribution for orally administered dosage forms. Here, we revisit and re-evaluate the influence of a portfolio of gastrointestinal diseases and surgical effects on the functionality of the gastrointestinal tract, their implications for drug delivery and attempt to uncover significant links for clinical practice.

Postgastrectomy nutrition

Gastric resection, whether partial or total gastrectomy, often results in nutrition-related complications including weight loss, diet intolerances, and micronutrient deficiencies. The physiology of normal and postgastrectomy digestion is the basis for most of the current diet recommendations after gastric surgery. A careful review reveals that there is not sufficient literature to support a standard postgastrectomy diet. Rather, individualized diet manipulation for symptom relief is recommended. This review highlights the physiology behind common postgastrectomy complications, provides guidelines for the medical and nutrition management of these complications, and presents a basic approach to postgastrectomy gastrointestinal symptoms.

Short bowel syndrome: amelioration of diarrhea after vagotomy and pyloroplasty for peptic hemorrhage

Acute mesenteric ischemia is a rare symptomatic manifestation of arteriosclerosis. Prognosis crucially depends on rapid diagnosis and surgical management to prevent or at least minimize the bowel infarction. The length of the small bowel is considered to be between 3 and 8 m, and a normal bowel function can be maintained even after resection of its one third. But loss of a major part (> 60%) can lead to malnutrition and death. However, patients, who survived an extended intestinal resection due to improved postoperative care (intensive care unit and parenteral nutrition), develop short bowel syndrome. This phenomenon is a medical problem, and several surgical techniques have been used to slow down intestinal transit time or to increase the area of absorption. All these procedures have controversial outcomes and are still on different experimental levels; namely, they cannot be recommended for routine use. In our report of a patient suffering from short bowel syndrome, vagotomy and pyloroplasty were performed to repair a sudden peptic hemorrhage. This operation cured bleeding peptic ulcer and also palliated the diarrhea, a main clinical manifestation of short bowel syndrome. In this study, our aim is to emphasize the favorable clinical outcome of vagotomy concerning a principal manifestation of short bowel syndrome, such as diarrhea. To the best of our knowledge, the present study is the first report showing the vagotomy as a possible procedure for the treatment of diarrhea, although this occurrence has no clear explanation. We also discuss the management of short bowel syndrome.

Dumping Syndrome

The dumping syndrome consists of early postprandial abdominal and vasomotor symptoms, resulting from osmotic fluid shifts and release of vasoactive neurotransmitters, and late symptoms secondary to reactive hypoglycemia. Effective relief of symptoms of dumping syndrome can be achieved with dietary modifications to minimize ingestion of simple carbohydrates and to exclude fluid intake during ingestion of the solid portion of the meal. More severely affected individuals may respond to agents such as pectin and guar, which increase the viscosity of intraluminal contents, or to drugs such as the alpha-glucosidase inhibitor acarbose, which blunts the rapid absorption of glucose, and the somatostatin analog octreotide, which alters gut transit and impairs release of vasoactive mediators into the bloodstream.

Antral compensation after proximal gastric vagotomy

Proximal gastric vagotomy (PGV) has little impact on the normal pattern of solid gastric emptying, despite denervation of the proximal two thirds of the stomach and loss of the proximal gastric pump. In four healthy volunteers and four patients with PGV, we investigated the possible compensatory mechanisms that may come into play after proximal denervation of the stomach. We measured antropyloroduodenal motility with a 10-lumen sleeve/side-hole catheter for 180 minutes after ingestion of a dual-isotope radiolabeled mixed liquid/solid meal. Patients with PGV exhibited faster liquid emptying, but the rate of solid emptying was similar to that in healthy volunteers. The frequency of propagated antropyloric pressure wave was similar between the two groups, but patients with PGV exhibited less isolated pressure waves in the proximal antrum. The amplitude and duration of pressure waves recorded in the distal antrum were significantly increased in the PGV patients as compared to healthy volunteers. Although the pattern of propagated antral contractions and solid gastric emptying remains unchanged after PGV, there is an increase in the amplitude and duration of distal antral contractions, which may compensate for loss of proximal gastric pumping mechanisms.

Preservation of normal gastric emptying following gastric surgery by use of a muscle bridge

BACKGROUND

Maintenance of descending antral intramural pathways may be important in normal functioning of the pylorus after pylorus-preserving gastrectomy.

METHODS

We examined the effect of a 1-cm bridge of muscle as a means of maintaining pyloric connection to antral intramural motor control pathways in 10 pigs. Antropyloroduodenal pressures and transpyloric flow were measured during gastric emptying of saline before and after either total or subtotal transection and reanastomosis of antrum.

RESULTS

Complete antral transection shortened the time interval between antral and subsequent pyloric lumen occlusion, significantly reducing total gastric emptying and volume of transpyloric flow pulses. Subtotal transection maintained pre-transection timing and was associated with normal patterns of transpyloric flow and emptying.

CONCLUSIONS

Our results indicate that a muscle bridge is capable of maintaining normal gastric emptying and the coordination of antral with pyloric contractions. We propose that antropyloric coordination is maintained by transmission of neural signals through the muscle bridge.

Roux-limb motility after total gastrectomy and Roux-en-Y anastomosis in patients with Zollinger-Ellison syndrome

The Roux-en-Y syndrome was defined as chronic nausea, intermittent vomiting, and chronic abdominal pain worsened by eating in patients who have undergone a gastrojejunostomy Roux-en-Y reconstruction for peptic ulcer. When these patients fasted, the Roux limb showed striking abnormalities in motor function; when postprandial, they failed to convert to normal fed-state motor activity. In contrast, patients with Zollinger-Ellison syndrome do well after similar surgery; they can eat most foods and maintain their body weight. We studied the motility of the Roux limb and jejunum in six patients with Zollinger-Ellison after an esophagojejunostomy Roux-en-Y anastomosis. Roux-limb motor activity in these patients, as characterized by the migrating motor complex, was more frequent, well organized, and in synchrony with the remaining jejunum; most subjects also converted to the fed state after a liquid meal. We suggest that the enteric nervous system is intact and functions normally in patients who have had a Roux-en-Y reconstruction for ulcer disease secondary to Zollinger-Ellison, but not in patients with idiopathic peptic ulcer disease.

Preoperative and postoperative motility disorders of the stomach

Improved technology has expanded the study and understanding of gastrointestinal motility. Although no clear cause and effect relation has been demonstrated, altered motility has been found in association with a variety of nonsurgical and postoperative settings. As this relation is better defined, perhaps patients who are at risk to develop complications of surgery can be better identified so that treatment can be tailored toward their specific defect. Technological advances can also be expected to provide new and more effective interventions in this expanding field.

Highly selective vagotomy combined with cholecystectomy: is there an increased risk of diarrhea?

The addition of cholecystectomy to truncal vagotomy and a drainage procedure increases the incidence and severity of postvagotomy diarrhea. This study attempts to establish whether diarrhea is more common after highly selective vagotomy (HSV) and cholecystectomy than after HSV alone. The incidence of diarrhea in 729 patients who underwent HSV without cholecystectomy was found to be 8.8% whereas, in 66 patients in whom HSV was combined with cholecystectomy, the incidence of diarrhea was 9.3%. In most patients, the diarrhea was very mild and in none was it severe. We conclude that the addition of cholecystectomy to HSV does not result in an increased incidence of diarrhea.

Drug absorption in gastrointestinal disease and surgery

It is well recognized that drug absorption from the gastrointestinal tract is influenced by gastric and intestinal motility, surface area available for absorption, and physicochemical properties of the drug. Disease and surgery have been shown to alter these factors. Consequently, drug absorption can be altered as well, and these affect drug therapy. Apparently this effect is variable, but the variability may be due in part to the complexities of performing studies in this area. For example, many patient factors as well as drug characteristics must be considered. In addition, appropriate interpretation of results requires that intravenous data be collected if changes in absorption are based on bioavailability. At this time, the alterations in drug absorption due to gastrointestinal disease and surgery are of unknown or little clinical significance; nevertheless, clinicians should be aware that the possibility of malabsorption exists and anticipate any monitoring of or alterations in therapy that may have to be made.

The mechanism of vagotomy-induced acute gastric mucosal injury in the rat

The present study investigated the integrity of the rat gastric mucosa after 6 hours of vagotomy without drainage. Transection vagotomy was employed to ensure complete gastric vagal denervation. Vagotomy without drainage produced gastric distension and mucosal injury confined to the glandular part. Anterior truncal vagotomy produced injury in 70% of rats, whereas truncal or transection vagotomy produced injury in all rats. The injury score with transection vagotomy was significantly higher than that with anterior truncal (21.2 mm2 +/- 1.6 vs. 8 mm2 +/- 2.7, mean +/- SEM, n = 10, p less than .01) or truncal vagotomy (21.2 mm2 +/- 1.6 vs. 15.6 mm2 +/- 1.4, mean +/- SEM, n = 10, p less than .05). Histologic examination of the mucosal injury revealed necrosis involving the epithelium and lamina propria. Cholestyramine, pyloroplasty, or gastric diversion protected the stomach against the vagotomy-induced mucosal injury. The results demonstrate in the rat that vagotomy without drainage produces within 6 hours injury of the gastric mucosa, which increases as vagal denervation is rendered more complete. Because cholestyramine protects the rat stomach against vagotomy-induced acute gastric mucosal injury, reflux of duodenal contents appears to be the principal factor behind this injury. Pyloroplasty prevents gastric distension but probably not duodenal contents refluxing, suggesting that this distention also may have a role in the mechanism of the said injury.

Current status of proximal gastric vagotomy

Proximal gastric vagotomy is nearing its twentieth year in clinical use as an operation for peptic ulcer disease. No other acid-reducing operation has undergone as much scrutiny or study. At this time, the evidence of such studies and long-term follow-up strongly supports the use of proximal gastric vagotomy as the treatment of choice for chronic duodenal ulcer in patients who have failed medical therapy. Its application in treating the complications of peptic ulcer disease, which recently have come to represent an increasingly greater percentage of all operations done for peptic ulcer disease, is well-tested. However, initial series suggest that it should probably occupy a prominent role in treating some of these complications, particularly in selected patients, in the future. The operation has the well-documented ability to reduce gastric acid production, not inhibit gastric bicarbonate production, and also minimally inhibit gastric motility. The combination of these physiologic results after proximal gastric vagotomy, along with preservation of the normal antropyloroduodenal mechanism of gastrointestinal control, serve to allow patients with proximal gastric vagotomy the improved benefits of significantly fewer severe gastrointestinal side effects than are seen after other operations for peptic ulcer disease.

Relationship between gastric emptying of liquid and postvagotomy diarrhoea

Gastric emptying of liquid was studied in 10 normal volunteers and in 27 patients previously treated with truncal vagotomy and drainage. Thirteen of the twenty-seven patients complained of persistent postvagotomy diarrhoea. For each study 300 ml 15 per cent dextrose, labelled with 99mTc-diethylene triamine penta-acetic acid (DTPA), was ingested at a standard rate by subjects who sat facing a gamma camera. Imaging proceeded for 30 min. Gastric area activity curves were corrected for emptying of the test meal during ingestion, and for movement using a new image alignment technique. Gastric emptying at 15 min was 10 +/- 2.6 per cent (mean +/- s.e.m.) in healthy volunteers, 48 +/- 7.3 per cent in patients without diarrhoea, and 84 +/- 2.3 per cent in those with diarrhoea (P less than 0.001, ANOVA). Gastric emptying from 15 min onwards was slower than normal in both patient groups (P less than 0.001). These results show that initial gastric emptying is rapid following truncal vagotomy and drainage, and this change is greater in patients with postvagotomy diarrhoea. No patient with diarrhoea had normal initial gastric emptying.

Effect of codeine and loperamide on upper intestinal transit and absorption in normal subjects and patients with postvagotomy diarrhoea

Patients with chronic severe diarrhoea after truncal vagotomy and pyloroplasty are often difficult to treat using conventional antidiarrhoeal drugs and remain severely disabled. We examined the effect of two drugs, codeine phosphate and loperamide, on upper intestinal transit and carbohydrate absorption, measured non-invasively by serial exhaled breath hydrogen monitoring, in patients with postvagotomy diarrhoea who had previously failed to gain relief from drug therapy. Orocaecal transit was consistently faster in these patients than a group of controls and was associated with malabsorption of glucose. Codeine phosphate 60 mg significantly delayed transit in patients and controls and was associated with a reduction in glucose malabsorption and improvement in symptoms. Loperamide also delayed transit and improved symptoms, but the doses required for this effect (12-24 mg) were higher than usually considered necessary in secretory diarrhoea. These studies indicate that rapid intestinal nutrient transit and associated malabsorption is a factor in the development of diarrhoea postvagotomy and that symptomatic relief can be achieved in most patients by more rational use of existing drugs.

Effects of osmoreceptor stimulation on human duodenal motor activity

The motor responses of the human duodenum to saline solutions of varying osmolality were examined in order to investigate the possible role played by the upper intestine in the control of gastric efflux of hyperosmolar material. During fasting, delivery of the solutions into the duodenum increased duodenal motor activity and intraduodenal pressure, the magnitude of the response increasing with osmolality. At the highest osmolalities, a regular duodenal motor pattern was induced in some individuals which was indistinguishable from fasting phase III activity. After feeding, hyperosmolar saline again increased motor activity. In addition, the transit of an intraduodenal marker to the caecum was accelerated. These findings support the concept that the duodenum is both sensitive and responsive to its intraluminal content. The motor responses additionally appear to function to clear excessively stimulating intraluminal material from the duodenal lumen and may also contribute to the 'postpyloric' resistance which is known to exert control of normal gastric emptying.

Surgical management of severe intractable postvagotomy diarrhoea

Experience with the surgical management of 23 patients with postvagotomy diarrhoea is outlined. The most common pre-operative abnormalities are rapid gastric emptying (14/23) and fast small bowel transit (23/23). Three patients were found to have steatorrhoea due to organic disease. Peptic ulcer surgery performed at a young age (means = 29 years, range 21-37) appears to be the only identifiable risk factor. The results of medical treatment with bile salt binding agents were disappointing in the long term. In 10 out of 13 patients treated with antiperistaltic segments, the procedure had to be reversed because of episodes of severe postprandial colic, intestinal obstruction and bacterial overgrowth. A good result with relief of the explosive diarrhoea was obtained by the distal onlay reversed ileal graft in six out of seven patients. This procedure creates a passive non-propulsive segment, and has no undesirable sequelae. It should be considered in those patients in whom the diarrhoea is not controlled by conservative measures.

Vagotomy inhibits the effect of neurotensin on gastrointestinal transit in the rat

Neurotensin has previously been shown to delay gastric emptying, gastrointestinal transit and ileo-caecal emptying in the rat. To investigate the vagal influence on these effects of neurotensin, separate groups of rats were operated with combined vagotomy and pyloroplasty or with pyloroplasty alone and compared to a group of normal rats. All animals were supplied with a permanent gastrointestinal catheter and a venous catheter. After operation the rats were allowed to recover for 7 days, and were fasted for 24 h prior to the experiments. A radioactive marker of 1.0-0.5 ml Na2(51)CrO4 in isotonic polyethylene glycol 400 was instilled intraluminally in the stomach, proximal or distal the small intestine. Saline (control animals) or neurotensin (test animals) was given i.v. in each group studied. The animals were killed at 15, 30, 60, and 120 min after administration of the marker. The distribution of the marker in the gastrointestinal tract was registered with a scintillation detector and quantitative analysis of the amount of radioactivity retained in separate gastrointestinal segments was carried out. Gastric emptying was delayed by combined vagotomy and pyloroplasty (P less than 0.01) compared to pyloroplasty alone and normals. Neurotensin at doses of 6 (P less than 0.05) and 12 (P less than 0.01) pmol kg-1 min-1 retarded gastric emptying dose-dependently in normals and rats with pyloroplasty alone, but did not further slow the gastric emptying in rats with vagotomy and pyloroplasty. However, at a dose of 24 pmol kg-1 min-1 neurotensin delayed gastric emptying (P less than 0.01) compared to controls. Gastrointestinal transit was slowed down by neurotensin at a dose of 6 pmol kg-1 min-1 in normals (P less than 0.01) and rats with pyloroplasty alone (P less than 0.05). In rats with vagotomy and pyloroplasty, neurotensin at doses of 6 and 12 pmol kg-1 min-1 had no effect on gastrointestinal transit.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastric emptying after anterior lesser curve seromyotomy and posterior truncal vagotomy

Anterior lesser curve seromyotomy with posterior truncal vagotomy (ASPTV) provides a simple, safe and expeditiously performed method of denervating the parietal cell mass, whilst preserving the pylorus. Dumping and diarrhoea are uncommon after this procedure. Gastric emptying has been assessed after ASPTV and other elective operations for duodenal ulcer. Liquid and solid phase gastric emptying studies were performed in control subjects (17), patients before and at least six months after ASPTV (14), vagotomy and pyloroplasty both without (8) and with (6) diarrhoea, vagotomy and gastroenterostomy (11), and Polya gastrectomy (7). There was no delay in emptying time for liquids or solids between ASPTV patients and controls. With the exception of an increase in the early emptying of liquids (P = 0.02) after ASPTV, gastric emptying was not different from normal. After truncal vagotomy and pyloroplasty in patients without diarrhoea the gastric emptying of solids, but not of liquids, was markedly increased (P = 0.00001), whereas in those with diarrhoea both liquid and solid phase emptying were markedly increased (P less than 0.001). When gastroenterostomy was used as the drainage procedure both phases of emptying were increased. After Polya gastrectomy, both early and late emptying of liquids and solids were increased (early phase P less than 0.05, overall emptying P less than 0.001).

Nausea, vomiting, and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb

The Roux-en-Y anastomosis is a surgical procedure performed to divert the pancreaticobiliary juices from the gastric pouch in patients who have alkaline reflux gastritis or esophagitis, or both, that develop after vagotomy and Billroth I or II operations. After the Roux-en-Y procedure the inflammation subsides but is often replaced by a characteristic group of symptoms--chronic abdominal pain, nausea, and vomiting worsened by eating. Using a semiconductor recording probe, we investigated the Roux limb in 7 subjects who were fasted and then fed (liquid and solid meals). In the fasted state the migrating motor complex was either completely absent or grossly disrupted. Only 1 subject converted to a fed-state motility pattern in the Roux limb after a liquid meal (Osmolite), and all 7 subjects failed to convert to a fed state after a solid meal. These studies suggest that the Roux-en-Y syndrome of pain, nausea, and vomiting is secondary to a defect in motor function and that the Roux limb is acting as an area of functional obstruction.

The effect of a segmental gastrectomy with proximal gastric vagotomy on gastric secretion and gastric emptying

Gastric acid secretory responses to graded doses of pentagastrin were measured in duodenal ulcer patients before and after either proximal gastric vagotomy (17 patients) or proximal gastric vagotomy associated with a segmental gastrectomy (11 patients). Calculated maximal output of acid and responsiveness of the acid-secreting cells to pentagastrin were reduced by both operations; after surgery, maximal acid output was lower in the proximal gastric vagotomy plus segmental gastrectomy group than in the proximal gastric vagotomy group. Gastric emptying of a liquid meal was assessed before and after either proximal vagotomy (13 patients) or proximal gastric vagotomy plus segmental gastrectomy (9 patients). The early phase of emptying was equally accelerated by both operations, and at later stages the emptying was only slightly, but not significantly, faster following proximal gastric vagotomy associated with segmental gastrectomy.

Preference for proximal gastric vagotomy combined with cholecystectomy

The incidence and severity of postvagotomy diarrhoea has been studied in 32 patients who had undergone both vagotomy and cholecystectomy. Sixteen of these patients had had a proximal gastric vagotomy and 16 a truncal vagotomy and pyloroplasty. Diarrhoea was present in 68 per cent of patients in whom the vagotomy was truncal and in 31 per cent of those in whom it was proximal gastric. Matched groups of patients with truncal vagotomy with pyloroplasty and proximal gastric vagotomy without cholecystectomy were also compared. The possible mechanisms of this diarrhoea following combined vagotomy and cholecystectomy have been discussed.

Novel approach to quantify duodenogastric reflux in healthy volunteers and in patients with type I gastric ulcer

A new method is described which allows simultaneous measurement of gastric emptying and duodenogastric reflux and avoids transpyloric intubation. After intragastric instillation of a liquid lipid meal in six healthy volunteers the fractional gastric emptying rate was 2.9 +/- 0.3 in the upright and 2.5 +/- 0.6 SEM X 10(-2)/min in the supine position, respectively (p greater than 0.5). The duodenogastric reflux rate (expressed as fraction of the intraduodenal amount of duodenal marker) was 0.30 (range 0.03-0.81) and 0.22 (0.01-0.55) X 10(-2)/min, respectively (p greater than 0.2). Atropine (40 micrograms/kg) decreased the supine gastric emptying rate to 1.1 +/- 0.2 (p less than 0.05) and increased the supine duodenogastric reflux rate to 2.74 (0.04-9.80) X 10(-2)/min (p less than 0.05). Fasting duodenogastric reflux rate was similar in the supine and upright position, 0.49 (0.04-0.89) and 0.42 (0.06-0.97) X 10(-2)/min, respectively (p greater than 0.5). Fractional gastric emptying rate was similar in 10 volunteers and 17 patients with type I gastric ulcer (2.1 +/- 0.4 vs 1.7 +/- 0.2 SEM X 10(-2)/min, p greater than 0.2). Their duodenogastric reflux rates were also similar, 0.65 (0.01-5.24) vs 1.10 (0.01-10.83) X 10(-2)/min (p greater than 0.5). We conclude therefore that (1) gastric emptying and both fasting and postprandial duodenogastric reflux are independent of the posture; (2) fasting and postprandial reflux are of similar magnitude; (3) atropine shows gastric emptying and increases duodenogastric reflux; and (4) patients with type I gastric ulcer have neither slowed gastric emptying nor increased duodenogastric reflux.

Bile acids and post-vagotomy diarrhoea

Cholecystectomy increases the risk of post-vagotomy diarrhoea and bile acid binding agents may relieve it, suggesting a role for bile acids in its pathogenesis. The faecal bile acid loss in 15 patients with episodic diarrhoea after vagotomy and drainage was not raised when compared with 12 normal subjects, except on days when diarrhoea occurred. This elevation was caused by an increase in stool weight rather than bile acid concentration, suggesting that the increased bile acid loss during attacks was not causally related. Asymptomatic vagotomy patients excreted normal amounts of bile acids. Seven patients with episodic diarrhoea after vagotomy and drainage with cholecystectomy continuously excreted excessive amounts of bile acids when compared with normal subjects and asymptomatic patients. The concentration of bile acid in their stools was higher than that observed in symptomatic patients after vagotomy and drainage alone. The continuous presence of excess bile acid may prime the colon to react more readily to stimuli caused by disturbed gastric emptying and rapid small bowel transit, without being the main factor in causing the condition. These findings may explain the increased risk of diarrhoea when cholecystectomy is combined with vagotomy.

Effect of truncal vagotomy and pylorotomy on gastric emptying

The effect of transthoracic vagotomy and a conventional pylorotomy on gastric emptying of a hyperosmolar glucose meal was evaluated in four dogs by means of an isotope technique. The measurements were made preoperatively and 1 month and 3-6 months after each operation. Vagotomy significantly increased the initial rate of gastric emptying, whereas the total fraction of the meal emptied in 60 min was the same as before operation. The pylorotomy did not alter the emptying. Approximately 50% of the meal was still retained in the stomach at the end of the tests. The abnormal gastric emptying of the glucose meal after vagotomy was normalized by drinking an 'aperitif' of 20% soya bean oil 15 min before the ingestion of the glucose meal. It is concluded that a vagotomy alters the pattern but not the 60-min fraction of gastric emptying of a liquid meal, whereas a pylorotomy alters neither the pattern nor the 60-min fraction of gastric emptying. The vagally denervated gastrointestinal tract has maintained mechanisms for control of the gastric emptying.

Gastric mycosis following gastric resection and vagotomy

In a prospective five-year follow-up study of 289 consecutive patients subjected to antrectomy and gastroduodenostomy with or without vagotomy, 130 patients underwent gastroscopy. Gastric mycosis was present almost exclusively in patients subjected to combined antrectomy and vagotomy (36%). Gastric acidity seemed to be of only minor or no importance in the development of the mycosis. The residual volume in the gastric remnant was significantly higher in patients with gastric mycosis. The impaired emptying of the gastric remnant is most likely a vagotomy effect and may be the main reason for the development of gastric mycosis. A simple but effective method was developed to evacuate gastric yeast cell aggregates. Gastric mycosis seems to give rise to only slight symptoms, mainly nausea and foul-smelling belching, whereas the reflux of duodenal contents that often occurred in combination with gastric mycosis was more likely to cause gastritis and substantial discomfort.

Postvagotomy and cholecystectomy syndrome

Seventy-five patients with unsatisfactory results following vagotomy, drainage and cholecystectomy have been reviewed. The operations were performed together in 45 patients, vagotomy preceded cholecystectomy in 16 patients and cholecystectomy was performed before vagotomy in 14 patients. The interval between the two operations when cholecystectomy was performed first was 7.1 +/- 1.66 SE years, whereas when vagotomy was performed first this was 3.1 +/- 1.03 SE years (p less than 0.05). Forty-three patients had symptomatic bile reflux gastritis and 59 had postvagotomy diarrhea. Dumping, bilious vomiting and recurrent peptic ulceration occurred in 11 patients, nine and five patients, respectively, and were no more frequently encountered than would have been expected after vagotomy and drainage alone. In the light of the information derived from the addition of cholecystectomy to vagotomy and drainage a pathophysiology of postvagotomy diarrhea without dumping, and bile reflux gastritis without bilious vomiting or recurrent chronic peptic ulceration is postulated.

Reconstructive gastric surgery

Among 173 patients undergoing reconstructive gastric operations, including 115 patients who received Roux-en-Y gastrojejunostomy, 25 with jejunal interpositions, 11 with conversion of Billroth II to Billroth I, 8 with closure of gastroenterostomy, 5 with pyloric reconstruction and 9 with other operations, only 2 immediate postoperative mortalities occurred. A perfect or good result was obtained in 108 of 156 patients (69 per cent) at long term follow-up, while a fair result was achieved in 35 patients (22 per cent) and a poor result in 13 patients (9 per cent). We concluded that reconstructive gastric operations were safe and had clearly improved 7 of 10 patients in this series.

Gastric emptying after oesophagectomy as assessed by plasma paracetamol concentrations

Gastric emptying after oesophagogastrectomy may be affected by opposing influences. Truncal vagotomy of the orthotopic stomach, as used by surgeons for peptic ulcer, results in delayed gastric emptying. The emptying of such a denervated stomach is affected by position and posture and may result in gastric "incontinence", particularly if associated with drainage procedures. It is possible that postural effects may outweigh the reduced motility if the vagotomised stomach is transplanted into the chest as after oesophagogastrectomy. Despite the effect that disturbed gastric emptying may have on nutrition and drug absorption there have been few studies concerning patients who have had oesophageal resection or bypass. We report our preliminary experience of an indirect method to estimate gastric emptying after oesophageal resection and bypass, using the absorption profile of paracetamol (acetaminophen). This technique is safe and has been shown to reflect gastric emptying accurately in the innervated stomach. With this technique we have shown that, even in the absence of a concomitant drainage procedure, oesophageal resection, or bypass, using the denervated stomach to restore alimentary continuity does not result in any detectable delay in gastric emptying.

The measurement of gastric emptying: a comparison of fixed scintillation detection and the double-sampling technique

The gastric emptying of a fluid meal was measured simultaneously by fixed scintillation detection and the double-sampling technique in 14 normal subjects and 15 patients who had a vagotomy and drainage procedure. In the normal subjects good correlation was obtained between the two methods but in the operated group there was poor correlation owing to difficulty in measuring the initial rapid emptying phase by fixed scintillation detection. Modification of the fixed scintillation method allows it to be used accurately in postoperative patients. The radioactivity of the meal is measured in vitro before ingestion and this reading is converted, using a constant derived from normal subjects, to a baseline value to which the subsequent in vivo readings are related. This modified technique permits the investigation of gastric emptying of fluid meals in patients with postvagotomy syndromes without the discomfort of a nasogastric tube. The equipment required is inexpensive.

Does osmotic control of gastric emptying persist after truncal vagotomy?

Gastric emptying of 5 per cent and 10 per cent glucose test meals has been measured in 43 patients with a duodenal ulcer prior to surgery and in 52 patients with an unsatisfactory result following truncal vagotomy and a drainage procedure. Seventeen patients had a recurrent ulcer and incomplete vagotomy while 35 patients were symptomatic with complete vagotomy. In both the preoperative and postoperative patients the 10 per cent glucose test meal emptied significantly more slowly than the 5 per cent glucose test meal regardless of the completeness of vagotomy. Thus, osmotic control of gastric emptying persists after vagotomy.

Impaired gastric accommodation to distension and rapid gastric emptying in patients with Chagas' disease

In order to evaluate the contribution of the myenteric plexuses to the control of gastric accommodation to distension and to the rate of gastric emptying of a saline solution in man, we have evaluated these functions in patients with Chagas' disease, which is known to be associated with extensive lesions of the myenteric plexuses. Intragastric pressure was significantly higher (P < 0.05) in Chagas patients (N = 15) than in normal controls (N = 15) for air distension volumes of 100-700 ml. In the range 300-700 ml, the difference between the groups was approximately twofold (P < 0.001). The gastric emptying rate of 500 ml 154 mM NaCl in a second group of Chagas' disease patients (N = 13) was significantly faster than that of the control group (N = 17) at 5 min (P < 0.005) and at 15 min (P < 0.005) after the test meal, but at 25 min the volumes remaining in the stomach were not statistically significant for the two groups (P > 0.10). The impairment of gastric accommodation to distension and consequent rapid gastric emptying demonstrated for chagasic patients emphasizes the role of the myenteric plexuses in gastric reservoir function in man and complements previous evidence obtained in animal studies.

The measurement of gastric transit time in obese subjects using 24Na and the effects of energy content and guar gum on gastric emptying and satiety

1. A new method has been used to measure mean gastric transit time. 2. This method, based on the absorption of 24Na from the proximal small bowel, is simple, non-invasive and can be used at the bedside. 3. The mean transit time was increased by adding guar gum to a test meal. 4. There was a significant correlation between mean gastric emptying time and a subjective measure of satiety.

Postvagotomy diarrhoea and dumping treated with reconstruction of the pylorus

The results of reconstruction of the pylorus in 12 patients with disabling diarrhoea and/or dumping after vagotomy and pyloroplasty are reported. Eight patients, primarily operated on with a truncal vagotomy and pyloroplasty, all indicated frequent diarrhoea as their principal symptom. After the reconstruction operation the stools were normalized in five, and the frequency of diarrhoea was reduced considerably in two patients. Three of four patients who had had a selective vagotomy and pyloroplasty complained of severe dumping after all kinds of food; after the reconstruction these symptoms were milder and provoked by sweets and milk only. The fourth patient with heavy diarrhoea as the principal symptom had postoperatively a slight reduction of the frequency. The operation is easy to perform, and no complication was encountered. The pathogenesis of the symptoms is discussed, and it is recommended that patients with disabling diarrhoea and/or dumping after vagotomy and pyloroplasty undergo a reconstruction of the pylorus.

The albatross syndrome--how to prevent it

While no single test or historical feature will allow the physician to predict the patients who will have poor results from ulcer surgery, certain factors may alert the physician to a possible poor result and encourage careful re-evaluation of the need for surgery. Any patient with intractable pain should be assessed carefully in an attempt to establish the cause of the intractability, and this assessment should include endoscopy. The endoscopist may help to identify those patients with structural disease that is too minimal to explain the intractable complaints. Careful attention should also be given to the evaluation of the patient's personality, work record, and relationship to spouse, family, and friends. Patients who have previously been disabled by other medical problems such as low back injury should be approached with caution. While newer procedures in ulcer surgery may alter the incidence of standard postgastrectomy complications it will not alter the incidence of the albatross syndrome, which is more directly related to the selection of the patient rather than the selection of the surgeon or surgical procedure.

Interrelations between serum gastrin levels, gastric emptying and acid output before and after proximal gastric vagotomy and truncal vagotomy and antrectomy

In a prospective study of proximal gastric vagotomy and truncal vagotomy and antrectomy measurements were made, before and after operation, of acid output, gastrin output and gastric emptying of a solid and a liquid meat extract meal. No relationships were demonstrable between acid output and gastrin output. Truncal vagotomy and antrectomy (TVA) produced rapid early emptying of both meals combined with gross prolongation of the overall emptying of the solid meal. Truncal vagotomy and antrectomy reduced the intergrated gastrin output after either meal. Proximal gastric vagotomy (PGV) produced rapid early emptying of the liquid meal with no alteration in the early emptying of the solid meal; however, overall solid meal emptying was delayed. Proximal gastric vagotomy increased basal, peak and integrated gastrin output. In preoperative patients slow solid meal emptying was associated with higher gastrin output but after PGV the reverse was found, the slowest emptiers having the lowest gastrin output. These findings do not support the contention that a pyloroplasty should be added to PGV to reduce the hypergastrinaemia produced by the operation.

Highly selective vagotomy or truncal vagotomy and pyloroplasty for chronic duodenal ulceration: a randomized, prospective clinical study

The results of a randomized, prospective clinical trial of highly selective vagotomy (HSV) versus truncal vagotomy and pyloroplasty (TVP) in 126 male patients undergoing elective surgery for chronic duodenal ulceration are presented. The operations were performed by surgeons of all grades of experience. At a mean follow-up time of just over 3 years a satisfactory result was obtained in 93 per cent of patients following HSV and 78 per cent of patients following TVP, the difference being probably statistically significant (P less than 0.05). The incidence of early and late dumping, bile vomiting, flatulence, post-prandial epigastric discomfort and wound infection was statistically significantly less after HSV than after TVP. Three patients have developed a recurrent duodenal ulcer after each type of operation (5.4 per cent). At this early stage HSV has advantages over TVP; it will be interesting to see if these are maintained with the passage of time.

The role of IgA in the prevention of bacterial colonization of the jejunum in the vagotomized subject

The efficacy of three mechanisms of defence against jejunal bacterial colonization (i.e. gastric acid, vagal and pyloric integrity and intestinal IgA) has been investigated. Only in subjects with disturbance of all three mechanisms did significant jejunal colonization occur, and this was invariably associated with severe diarrhoea. Clearly normal intestinal IgA is of critical importance in the prevention of jejunal bacterial colonization in the vagotomized subject.

Should cholecystectomy be combined with vagotomy and pyloroplasty?

Duodenal ulcers and gallstones, two of the commonest surgical conditions, affect respectively 10% of men and up to 20% of the population. Although many detailed studies of the treatment of these conditions have been conducted, there is no report of the results of surgery when the conditions coexist. 60 patients who had undergone vagotomy, pyloroplasty, and cholecystectomy were compared with age and sex matched controls who had undergone vagotomy and pyloroplasty alone or cholecystectomy alone. In the early postoperative period after the combined procedure there was a very high incidence of post-vagotomy diarrhoea (48.3%, P equal to 0.00013) and bile-reflux gastritis. The findings implicate bile-acids--their excretion and handling by the small intestine--in the aetiology of post-vagotomy diarrhoea. Where the conditions coexist truncal vagotomy and pyloroplasty should be avoided in the treatment of the duodenal ulcer because of the risk of post-vagotomy diarrhoea and bile-reflux gastritis.