Gut, 1969, 10, 366-374 Gut: first published as 10.1136/gut.10.5.366 on 1 May 1969. Downloaded from Gastroenterostomy and vagotomy for chronic duodenal ulcer A. W. DELLIPIANI, I. B. MACLEOD1, J. W. W. THOMSON, AND A. A. SHIVAS From the Departments of Therapeutics, Clinical Surgery, and Pathology, The University ofEdinburgh The number of operative procedures currently in Kingdom answered a postal questionnaire. Eight had vogue in the management of chronic duodenal ulcer died since operation, and three could not be traced. The indicates that none has yet achieved definitive status. patients were questioned particularly with regard to Until recent years, partial gastrectomy was the eating capacity, dumping symptoms, vomiting, ulcer-type dyspepsia, diarrhoea or other change in bowel habit, and favoured operation, but an increasing awareness of a clinical assessment was made based on a modified its significant operative mortality and its metabolic Visick scale. The mean time since operation was 6-9 consequences, along with Dragstedt and Owen's years. demonstration of the effectiveness of vagotomy in Thirty-five patients from this group were admitted to reducing acid secretion (1943), has resulted in the hospital for a full investigation of gastrointestinal and widespread use of vagotomy and gastric drainage. related function two to seven years following their The success of duodenal ulcer surgery cannot be operation. Most were volunteers, but some were selected judged only on low stomal (or recurrent) ulceration because of definite complaints. There were more females rates; the other sequelae of gastric operations must than males (21 females and 14 males). The following be considered. Thus the metabolic consequences investigations were carried out on these patients: that may attend partial gastrectomy are now well ROUTINE HAEMATOLOGICAL INDICES (35 PATIENTS) Male recognized (Glaxo Symposium, 1967) and diarrhoea patients with a haemoglobin level of less than 13.5 g is known to be a frequent complication ofvagotomy, per 100 ml, and females with a level of less than 11.5 g though estimates of its incidence in a severe form per 100 ml were considered to be anaemic (Dacie and http://gut.bmj.com/ vary (McKelvie, 1963; Burge, 1964; Cox and Bond, Lewis, 1963). 1964). More complete studies after vagotomy have been infrequent, though Cox, Bond, Podmore, and SERUM VITAMIN B12 (35 PATIENTS) This was measured Rose (1964) have contributed an metabolic microbiologically using Lactobacillus leichmannii as important the test organism (Girdwood, 1956, 1960)( normal range study of patients following vagotomy and gastro- = 170 to 1,000 ,u,ug/ml). enterostomy. The present communication reviews our results in SERUM FOLATE (33 PATIENTS) This was measured micro- on September 24, 2021 by guest. Protected copyright. patients who have undergone truncal vagotomy and biologically using Lactobacillus casei as the test organ- gastroenterostomy for duodenal ulceration. A ism (Kershaw and Girdwood, 1964; Girdwood, Williams, group of these patients has been subjected to more McManus, Dellipiani, Delamore, and Kershaw, 1966) detailed metabolic studies. (normal range = 2-2 to 18-5 m,ug/ml). MATERIALS AND METHODS VITAMIN B12 ABSORPTION (35 PATIENTS) Measured by the Schilling test (1953), a urinary output of less than 7-5% During the years 1957 to 1961, 151 patients (112 males of the orallyadministered dose of 0.5 gC of 58Co-labelled and 39 females) were submitted to gastroenterostomy vitamin in the subsequent 24 hours was considered to be and vagotomy for chronic duodenal ulceration. The abnormal. In some patients the test was repeated after operations were elective, and though a number of the five days of tetracycline therapy or with 50 mg of patients had bled from their ulcers shortly before intrinsic factor. admission they were not bleeding at the time of surgery. One patient died postoperatively of a staphylococcal chest infection giving an operative mortality of 0.7%. FIGLU TEST (35 PATIENTS) Formiminoglutamic acid was The clinical status of these patients five to 10 years measured in the urine using conventional electrophoresis following surgery has been assessed. It was possible to after a 15 g loading dose of histidine (Kohn, Mollin, and interview 121 patients personally in hospital or at home, Rosenbach 1961; Kershaw and Girdwood, 1964). and 19 who lived overseas or elsewhere in the United FIVE-DAY FAECAL FAT EXCRETION (29 PATIENTS) The fat 'Please address requests for reprints to I. B. Macleod, Department of Clinical Surgery, University Medical School, Teviot Place, Edinburgh was measured by the method of van de Kamer, Huinink, 8. ten Bokkel, and Weyers (1949). A faecal fat excretion of 366 Gastroenterostomy and vagotomy for chronic duodenal ulcer 367 Gut: first published as 10.1136/gut.10.5.366 on 1 May 1969. Downloaded from seven or more g per day was considered abnormal (Doig TABLE I and Girdwood, 1960). OVERALL CLINICAL ASSESSMENT OF PATIENTS FIVE OR MORE YEARS POSTOPERATIVELY GASTRIC AND JEJUNAL MUCOSAL BIOPSY (GASTRIC 25 Clinical No. of Percentage PATIENTS, JEJUNAL 24 PATIENTS) Biopsies were taken Grade' using the Crosby-Kugler capsule (1957) under fluoro- Patients of Patients scopic control. The gastric biopsies were assessed by I 55 39 observing variation in the total mucosal depth, the extent II 36 26 III 33 23-6 of lymphocytic and plasma cell infiltration, and loss of IV 16 specialized cells from the deeper parts of the glands 11-4 (intestinal metaplasia). They were consequently graded Total 140 100 as showing 'mild', 'moderate', and 'severe' changes I' = no symptoms (Figs. 1 to 3). Jejunal biopsies were examined by II = mild symptoms, no treatment required dissection and by light microscopy. Our criteria for III = moderate symptoms, requiring treatment normality have been described elsewhere (Girdwood IV = severe symptoms, failures et al, 1966). Patients in clinical grades I and 11 (65 %) were MAXIMAL HISTAMINE-STIMULATED GASTRIC SECRETION regarded as having had a good result. Patients in (32 PATIENTS) The test was carried out as described by grade III (23.6%) were improved by operation and Kay (1953), and the total secretion in the post-histamine hour on the whole were pleased by the result: though determined. handicapped to some degree by symptoms, they INSULIN-STIMULATED GASTRIC SECRETION (35 PATIENTS) preferred these to their preoperative dyspepsia. Twenty units of soluble insulin administered intra- venously was used as the stimulant (Hollander, 1946), LONG-TERM SEQUELAE OF GASTROENTEROSTOMY AND and an assessment of completeness of vagotomy was VAGOTOMY The incidence of the major unpleasant made on multiple criteria (Bank, Marks, and Louw, sequelae in this series is given in Table II. 1967). SERUM IRON (35 PATIENTS) The method of Ramsay TABLE II (1953) was used, and a level of less than 60 ,ug per SEQUELAE OF ALL DEGREES OF SEVERITY IN 140 PATIENTS 100 ml considered indicative of iron deficiency. Symptom No. of Percentage Patients ofPatients http://gut.bmj.com/ SERUM ELECTROLYTES, SERUM CALCIUM, PHOSPHORUS, AND ALKALINE PHOSPHATASE Routine determinations were Dumping 56 40 Diarrhoea 24 17 made. Vomiting 32 23 Proven stomal ulcer 6 4.3 ANTIBODIES TO PARIETAL CELLS AND INTRINSIC FACTOR Residual dyspepsia 15 11 (22 PATIENTS) Serum determinations of these auto- (without proven stomal ulcer) antibodies were made using the method of Irvine (1966). Hypoglycaemic attacks 5 on September 24, 2021 by guest. Protected copyright. RESULTS In many patients, these symptoms were of minor degree but their incidence in a form sufficiently severe OVERALL CLINICAL ASSESSMENT OF PATIENTS FIVE OR to handicap normal activities was higher than we MORE YEARS POSTOPERATIVELY Only 39 % ofpatients had anticipated: this is noted in Table III, which were completely symptom free at this stage (Table I). excludes the stomal ulcer patients. In 11 .4% of patients the operation was regarded as It was possible to compare preoperative haemo- a failure (clinical grade IV) because of recurrent or globin levels with haemoglobin levels at review in stomal ulcer, severe dumping, diarrhoea, or only 95 patients, and the results are indicated in vomiting. Table IV. TABLE III SEVERE SIDE EFFECTS OF OPERATION Symptom No. of Percentage Comments Patients ofPatients Dumping' 15 10-7 Weakness, flushing, sweating ± vomiting or diarrhoea after main meals Diarrhoea 7 5.0 Liquid stools. Episodes of diarrhoea lasting 48 hr and occurring more than once a month Vomiting2 6 4-2 Vomiting occurring more frequently than once a month 'Two patients with very severe dumping had associated severe diarrhoea and are also included in the diarrhoea group. 'Vomiting usually bilious. Three patients required reoperation for this symptom. 368 A. W. Dellipiani, L B. Macleod, J. W. W. Thomson, and A. A. Shivas Gut: first published as 10.1136/gut.10.5.366 on 1 May 1969. Downloaded from FIG. 1. FIG. 3. FIG. 1. Gastritic change, grade L There is some degree of lymphocytic and plasma cell infiltration but little reduction in total thickness ofthe mucosa and minimal loss of specialized epithelial cells from the glands. Mucosal thickness is measured from the superficial edge of the muscularis mucosae to the free margin of the epithelium. http://gut.bmj.com/ (Haematoxylin and eosin x 50.) FIG. 2. Gastritic change, grade I. Considerable loss of specialized epithelial cells is evident in the deeper parts of the glands which are pale-staining due to replacement by mucus-secreting cells. The mucosa is moderately reduced in thickness and chronic inflammatory infiltration is more marked than in grade I (Haematoxylin and eosin x 50.) on September 24, 2021 by guest. Protected copyright. FIG. 3. Gastritic change, grade II. The mucosa is con- siderably reduced in thickness, there is almost complete loss ofspecialized epithelial cells and chronic inflammatory infiltration is a conspicuous feature (Haematoxyline and eosin x 50.) FIG. 2. Fifteen male patients were anaemic (Hb < 13-5 patients remained at the same weight or gained g%) and 11 female patients (Hb < 115 g%).