Bleeding duodenal ulceration: the results of emergency treatment with highly selective vagotomy.

We report the results of a prospective study of all patients undergoing highly selective vagotomy (HSV) for bleeding duodenal ulceration (BDU) at Concord Hospital between 1979 and 1989. Highly selective vagotomy was undertaken in 63 patients (58 male, 5 female) with a median age of 69 years (range: 16-89). Fifty-five patients were reviewed, 7 patients having died in the peri-operative period and one being lost to follow-up. The mean period to review was 50 months (range: 1-120). Thirty-six patients have been followed-up for more than 24 months. Thirty-day postoperative mortality was 11% (7 patients). Combined major and minor morbidity was 41%. Postoperative rebleeding occurred in four patients (6.3%), three of whom died. Ulceration had recurred in two of 55 patients (4%). Symptoms have been evaluated in 55 patients since operation and 93% have been graded as Visick I or II. We conclude that HSV is effective in the emergency treatment of BDU and has few long-term sequelae.

Carcinoma of the stomach: a review with special reference to total gastrectomy.

Five hundred and eleven patients with adenocarcinoma of the stomach were reviewed. Weight loss and abdominal pain were the most common symptoms. One-third of patients were found to have proximal gastric lesions with dysphagia being a major symptom in 23% of all patients. Laparotomy was performed on 88% of patients with 56% of the entire series undergoing gastric resection. The overall 5-year survival rate was 12.3% and for curative resection 43%. The 5-year survival rate of patients undergoing total gastrectomy was 53% and for patients undergoing subtotal or partial gastrectomy the 5-year survival rate was 42%. The operative mortality, similar in both groups, was 8.1% versus 5.6%. Palliation was better achieved by resection than bypass. Total gastrectomy for palliation was undertaken in 48 patients. This group of patients has achieved a good quality of life and a mean survival rate of 12.5 months.

Highly selective vagotomy in the treatment of complicated duodenal ulcer.

Highly selective vagotomy has been utilized urgently in 33 patients with bleeding duodenal ulcer, 16 patients with pyloric stenosis and six patients presenting with perforated ulcer. Five patients died after surgery for bleeding duodenal ulcer, and two patients rebled after surgery. Forty-eight patients were reviewed at a mean of 28 months with an excellent outcome being obtained in 45 patients. Two of the three patients with poor results had proven ulcer recurrence while the third patient required reoperation for recurrent pyloric stenosis. No patient has suffered diarrhoea after vagotomy. Highly selective vagotomy is an effective treatment for urgent management of complicated duodenal ulceration and is without troublesome post-vagotomy symptoms.

Major hepatic resection for neoplasia. The Concord Hospital experience.

In a major hepatic resection one, or more, of the eight major anatomical segments of the liver is removed. Such procedures are a recent development and during 1972-1982, 22 such resections were performed for neoplasia at Concord Hospital, with a mortality rate of 5%. The indications for elective hepatic resection for neoplasia are discussed. Of particular importance is the excellent palliation and survival that is achieved when localized metastases of colorectal origin are resected.

Fine bore jejunostomy feeding following major abdominal surgery: a controlled randomized clinical trial.

A randomized controlled prospective clinical trial has been undertaken to examine the efficacy of the technique of early postoperative feeding using a fine bore catheter jejunostomy. Fifty patients undergoing surgery for gastrointestinal malignancy were randomly allocated into treatment and control groups. A low residue liquidized diet (Isocal) was administered to the patients in the treatment group. Control patients received routine intravenous therapy. Nutritional parameters (serum albumin, serum transferrin, serum prealbumin, weight, body fat and fat free mass) were measured pre-operatively and on the tenth postoperative day. Postoperative surgical complications were similar in both groups. There were 20 catheter complications and one death directly attributable to the jejunal catheter feeding. Postoperative stay was significantly longer (P less than 0.01) in the treatment group patients. Evaluation of the nutritional parameters showed no advantage for either the treatment group or a selected complication-free, 'successful treatment', subgroup. It is concluded that no significant clinical or nutritional advantage for jejunal catheter feeding has been demonstrated and because of the related complications, its routine use cannot be recommended.

Hypergastrinemia develops within 24 hours of truncal vagotomy in dogs.

Postvagotomy hypergastrinemia may result from withdrawal of tonic vagal inhibitory mechanism(s) or from G-cell hyperplasia secondary to diminished acid secretion. Early development of hypergastrinemia, after vagotomy, would favor the first mechanism, whereas delayed development would favor the second. We sought to distinguish between these two mechanisms and to determine whether alterations in somatostatin release might mediate postvagotomy hypergastrinemia. We measured plasma concentrations of gastrin and somatostatinlike immunoreactivity basally and in response to meal (pH controlled at 5.5) and to insulin hypoglycemia before and after truncal vagotomy in 11 dogs. Basal and postprandial hypergastrinemia were established within 24 and 48 h after vagotomy, respectively. Basal and meal-stimulated plasma somatostatinlike immunoreactivity concentrations were unaltered by vagotomy, although insulin hypoglycemia-induced rises in plasma somatostatinlike immunoreactivity were abolished by vagotomy. Our data suggest that neither G-cell hyperplasia nor alterations in somatostatin release explain postvagotomy hypergastrinemia in the dog. The observations support the hypothesis that postvagotomy hypergastrinemia results from the withdrawal of a tonic vagal inhibitory mechanism of gastrin release that is independent of somatostatin. Whether the tonic vagal inhibition of gastrin is direct or indirect is unknown.

A new intraoperative test for completeness of vagotomy: the PCP-GABA (beta-parachlorophenol-gamma-aminobutyric acid) test.

PCP-GABA, an analogue of the neurotransmitter amino acid, GABA, is as effective a stimulant of vagal centers and acid secretion as sham feeding. Insulin hypoglycemia, a test hitherto widely used for the cephalic phase, is unsafe and nonspecific because it also stimulates catecholamine release which affects gastrin secretion. PCP-GABA, unlike insulin, causes no tachycardia or hypoglycemia; however, the major advantage of PCP-GABA is that it can be used safely intraoperatively to assess completeness of vagotomy. Its muscle relaxant action is an additional advantage in this regard. As an intraoperative test, PCP-GABA is given intravenously shortly after induction of anesthesia to stimulate acid secretion and to reduce gastric mucosal pH, which is measured by an intraluminal combination electrode. The electrode can be moved around through the intact gastric wall to take measurements from multiple sites. When vagotomy is complete, gastric mucosal pH increases to over 6. This test works well in the dog. We hope to assess its clinical use in the near future.