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Gastric Mycosis Following Gastric Resectionand Vagotomy

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Gastric Mycosis Following Gastric Resectionand Vagotomy Gastric Mycosis Following Gastric Resection and Vagotomy 0. REHNBERG, M.D., A. FAXEN, M.D., U. HAGLUND, M.D., J. KEWENTER, M.D., B. STENQUIST, M.D., L. OLBE, M.D. In a prospective five-year follow-up study of 289 consecutive From the Department of Surgery 11 and 111, University of patients subjected to antrectomy and gastroduodenostomy with Gffteborg, Sahigen's Hospital, GMteborg, Sweden or without vagotomy, 130 patients underwent gastroscopy. Gastric mycosis was present almost exclusively in patients sub- jected to combined antrectomy and vagotomy (36%). Gastric acidity seemed to be of only minor or no importance in the ach is unknown, macroscopically apparent gastric my- development of the mycosis. The residual volume in the gastric remnant was significantly higher in patients with gastric my- cosis has been claimed to be responsible for such symp- cosis. The impaired emptying of the gastric remnant is most toms as nausea, belching, vomiting, and epigastric likely a vagotomy effect and may be the main reason for the pain.7"' development of gastric mycosis. A simple but effective method The purpose of the present investigation was to study was developed to evacuate gastric yeast cell aggregates. Gastric significance of gastric mycosis in terms of mycosis seems to give rise to only slight symptoms, mainly the clinical nausea and foul-smelling belching, whereas the reflux of duo- subjective symptoms and ordinary nutritional param- denal contents that often occurred in combination with gastric eters in a series of patients subjected to surgery for mycosis was more likely to cause gastritis and substantial dis- peptic ulcer disease and to evaluate the occurrence of comfort. gastric mycosis as related to postoperative acid secre- tion, gastric emptying, and bile reflux. y EAST FUNGI are common saprophytes in the oral Material and Methods cavity in the healthy adult' and are probably pres- ent in small quantities in the entire gastrointestinal The study comprised 130 patients, including all those tract.2 The presence of yeasts has been demonstrated undergoing postoperative gastroscopy in a series of 289 in ulcerations of the stomach and the duodenum.3'5 patients consecutively subjected to antrectomy with Sch6nebeck6 showed that yeasts were particularly com- gastroduodenostomy for duodenal or gastric ulcer. In mon in the gastric juice of patients with gastric ulcer patients with preoperative maximal acid response to or carcinoma, and after partial gastrectomy. Achylia betazole (Histalog®) exceeding 20 mmol/30 min (51 and/or impairment of gastric motility have been con- patients), a selective or truncal vagotomy was per- sidered the most important factors favoring overgrowth formed in addition to the antrectomy. All 94 patients of yeast,6 possibly in combination with reflux of duo- with complaints of any gastrointestinal nature received denal contents into the stomach.7 gastroscopy in the follow-up period. In addition, 36 In excessive amounts, yeast fungi may form huge asymptomatic patients were subjected to gastroscopy intraluminal colonies, appearing as filling defects at as controls. barium meal examinations.8-'0 They are often impres- The follow-up study included examination of the pa- sively demonstrated at gastroscopy as white or slightly tients at one month, and three and five years after op- bile-colored amorphous aggregates, either scattered eration. The postoperative state of the patient was over the entire mucosal surface, or appearing as a gruel graded according to the Visick scale.'2 The body weight or porridge-like substance. They may also be present five years after operation was compared with the usual as more or less homogeneous boluses. This condition is preoperative weight. The changes from three to five referred to as gastric mycosis and is often associated years after operation of blood hemoglobin and folate with obvious signs of gastritis. Although the clinical concentrations, and serum concentrations of iron, vi- significance of microscopic yeast infection in the stom- tamin B,2, albumin, calcium, and alkaline phosphatases were recorded. These assays were carried out at the Department of Clinical Chemistry at Sahlgren's Hos- Supported by grants from the Swedish Medical Research Council, routine The half-hour acid numbers 1 7X-760 and B77-1 7X-00577- 130. pital using procedures. peak Reprints will not be available from the author. output following stimulation by pentagastrin or beta- Submitted for publication: December 1, 1981. zole (PAOG) and by insulin (PAO,n,) was determined. 0003-4932/82/0700/0021 $00.75 © J. B. Lippincott Company 21 22 REHNBERG AND OTHERS Ann. Surg. - July 1982 Pentagastrin was given as an intravenous infusion of 90 were 30-day treatments by nystatin (500 000 IU X 3) and 300 ug/hr, betazole as subcutaneous injection of or metoclopramid (10 mg X 3) in six of seven patients 2 mg/kg BW, and insulin as an intravenous injection as checked by gastroscopy (unpublished observation). of 0.2 U/kg BW. Acid response to insulin was judged An effective method was designed taking advantage of positive or negative according to the Hollander cri- the low specific weight of the yeasts. Patients with gas- teria.'3 tric mycosis drank a large volume (750 ml) of ordinary The presence or absence of macroscopic yeast ag- fruit syrup (1 part syrup and 4 parts water, about 800 gregates was noted at gastroscopy after an overnight mOsm/kg), then laid on the left side for two hours, fast. If macroscopic aggregates were found, samples thus providing optimal conditions for the floating yeasts were taken for yeast culturing and microscopy. Positive to empty into the duodenum. This procedure was re- findings indicated gastric mycosis. peated four times during the day. The residual content of the stomach was aspirated at the beginning of the gastroscopy and thus did not Statistics include, for instance, regurgitations from the duodenum Statistical methods used were during the gastroscopy. In 20 antrectomized and va- chi-square, Fischer's gotomized patients, the fasting liquid gastric volume exact, Mann Whitney U, and Wilcoxon's matched pairs was determined in connection with gastroscopy, involv- signed-rank tests. ing eight consecutive and unselected patients without and 12 patients with gastric mycosis. In eight of the Results patients with gastric mycosis, the fasting liquid gastric At gastroscopy, gastric mycosis was found in 19 of volume was determined before and after evacuation of the 130 patients. On culture, ten patients had growth the mycosis. of Candida and nine patients of Torulopsis. Five pa- In five patients with gastric mycosis and Candida tients with gastric mycosis and growth of C. albicans albicans growth in the culture, serum was tested for on culture were tested for Candida antibodies in serum, Candida antibodies by complement-binding and im- with negative results in all cases. Among the yeasts, munodiffusion tests.'4 scattered fibers of fruits and vegetables were often seen Gastric emptying of a liquid meal-750 ml of 10% at microscopy. glucose solution-was studied according to George.'5 There were no significant differences in body weight Twenty-three patients were investigated following an- or blood chemistry between patients with and without trectomy and vagotomy (five patients without and 18 mycosis, provided the Visick score was taken into ac- patients with mycosis). Nine of the patients with my- count. cosis were restudied after evacuation of the gastric yeasts as checked by gastroscopy. At an in vitro control Gastric Mycosis in Relation to Operative Procedure experiment, phenol red solution was added to a mixture and of yeasts and gastric juice. Thirty minutes later, all of Postgastrectomy Complaints the dye was found in the liquid and none in the yeast Gastric mycosis was observed in one of 79 patients phase after centrifugation. in whom antrectomy without vagotomy had been per- The volume of the liquid gastric content following 12 formed. This patient had a stomal ulcer with stenosis. hours of fasting was determined by nasogastric tube Mycosis was demonstrated in 18 of the 51 patients suction in randomly chosen duodenal ulcer patients af- (36%) who had been subjected to antrectomy and va- ter antrectomy and gastroduodenostomy with (19 pa- gotomy (p < 0.001). No stenosis was found in any of tients) or without (18 patients) vagotomy. these patients. Eight patients originally operated on by The concentration of conjugated bilirubin in the fast- antrum resection and later reoperated on by vagotomy ing liquid gastric content was photometrically deter- because of a stomal ulcer were all free from gastric mined in 33 patients subjected to combined antrectomy mycosis at gastroscopic examination after the first op- and vagotomy. Immediately after aspiration of gastric eration, and four of them displayed mycosis after the juice, 2.5 mol/l sodium hydroxide were added to the vagotomy (Table 1). sample until pH 6 was reached. Following antrum resection and vagotomy, nausea and diarrhea occurred with significantly higher fre- Procedure for Evacuation of Mycosis quency (p < 0.001 and 0.025, respectively) in patients with gastric mycosis (Table 2). Epigastric pain, pyrosis, As a rule, evacuation of visible yeasts could not be and dumping had the same frequency in patients with successfully performed by repeated gastric lavage and and without mycosis. suction through a wide gastric tube. Equally inefficient Evacuation of gastric mycosis by the "float-away" VOL. I196 . NO. I GASTRIC MYCOSIS 23 method was complete in all 12 patients tested, according TABLE 1. Incidence of Gastric Mycosis in Relation to Operative to gastroscopy before and after the procedure. The Procedure and Postoperative Complaints mycosis had reappeared at gastroscopy from one to 12 Operative months later in five of six evacuated patients who did Procedure GI Symptoms Asymptomatic Total not proceed with the "float-away" method on their own. Antrectomy 1/55 = 2% 0/24 1/79 Complete evacuation of all visible yeasts did not alter Antrectomy the symptoms, including vomiting and/or nausea, in plus vagotomy 13/39 = 33% 5/12 = 40% 18/51 = 36% five of eight patients.
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