Longterm results of esophageal myotomy for achalasia.

BACKGROUND: Achalasia is a progressive, noncurable, motor disorder of the esophagus. Myotomy of the distal esophagus is the principal method of providing palliation. A major controversy is the necessity for a complementary antireflux procedure. STUDY DESIGN: Forty-two patients were studied by clinical history manometrically, roentgenographically, and endoscopically. Transabdominal Heller myotomy is the preferred approach. Nine patients had Nissen fundoplication and parietal cell vagotomy (group 1), and 16 had posterior gastropexy and parietal cell vagotomy (group II). Initially 16 of 17 patients underwent transthoracic Heller myotomy without fundoplication (group III). Twenty-five patients were followed a mean of 10 years (range 5 to 26 years). RESULTS: One postoperative death was from adult respiratory distress. Results in group I were excellent in five, good in three, and fair in one. The patient with a fair result developed a diverticulum at the myotomy site and significant reflux at 9 years. Results in group II patients were excellent in 2, good in 11, there was 1 operative death, and no followup in 1. Of the 17 patients in group III, 3 had resection of an esophageal diverticulum, and 3 had closure of esophageal perforation caused by pneumatic dilatation. Results in the 13 patients followed were excellent in 6, good in 5, and poor in 2. CONCLUSIONS: There is no statistical difference in results by chi-square analysis between transthoracic Heller myotomy without fundoplication and transabdominal Heller myotomy with parietal cell vagotomy and Nissen fundoplication or posterior gastropexy.

Operative treatment for chronic pancreatitis pain.

BACKGROUND: Management of pain is the most frustrating problem associated with chronic pancreatitis. Pain is progressive and difficult to quantify. Uncontrolled, it eventually destroys the patient's quality of life, leading to drug addiction. STUDY DESIGN: This study reports the results of 258 operations on 239 consecutive patients treated for pain related to chronic pancreatitis between 1969 and 1999. The operations performed were 42 pancreaticoduodenectomies, 48 side-to-side pancreaticojejunostomies, 68 distal pancreatectomies, 21 85% to 95% distal pancreatectomies, 70 cystenterostomies and 9 sphincteroplasties. Efforts were made to choose the operation most appropriate for the pathological conditions encountered in each patient. Results of treatment were satisfactory if patients were entirely relieved of pain and unsatisfactory if there was any residual pain. Presence or absence of pain was based on patient's own evaluation at the time of their last followup examination. RESULTS: Results were overall satisfactory in 71% of patients after pancreaticoduodenectomy, 68% after side-to-side pancreaticojejunostomy, 69% after distal pancreatectomy; 69% after 85% to 95% distal pancreatectomy, 51% after cystenterostomy, and 44% after sphincteroplasty. The mean followup of patients was 4 y (range 0 to 23 y). CONCLUSIONS: The cause of chronic pancreatitis is obscure. As a consequence, there have been few advances in the treatment of this condition. There are new techniques to resect the pancreas, but the results are little better than those obtained with older methods. Advances in the treatment of chronic pancreatic pain will come from knowledge concerning its cause. Discovery of mechanisms stimulating the pathways that lead to the perception of pain and methods for interruption of these mechanisms may provide new treatments.

A personal experience with pancreatic and duodenal neuroendocrine tumors.

BACKGROUND: Since the concept of hormones was proposed in 1901, numerous gastrointestinal hormones and neuroendocrine tumors that can produce these hormones have been identified. The most common tumors are gastrinomas and insulinomas. STUDY DESIGN: During a 35-year experience, there were 82 neuroendocrine tumors, including 37 gastrinomas, 11 insulinomas, 16 nonfunctioning tumors, 11 gastrinomas suspected but not found, 3 tumors arising in lymph nodes, 1 somatostatinoma, 1 glucagonoma, and 2 amphicrine tumors. MEN I syndrome coexisted with three pancreatic gastrinomas, two pancreatic and duodenal gastrinomas, four suspected gastrinomas, one nonfunctioning tumor, two insulinomas, and no duodenal gastrinomas. RESULTS: Of the nine patients with pancreatic gastrinoma without MEN I, three had lymph node, three had liver metastases, and one had both. The mean survival time was 4.8 years. Three patients with pancreatic gastrinoma and MEN I were alive at 2, 17, and 20 years, respectively. Of the 20 patients with duodenal gastrinoma, none had MEN I; 13 had lymph node metastases and 1 had liver metastases. The overall followup was 7.0 years. Ten patients were biochemically cured. Nonfunctioning tumors, with one exception, originated in the pancreas. Of the three gastrinomas potentially arising in lymph nodes, two, and possibly three, were cured by node removal. Eleven patients had an insulinoma. No patient had recurrence of hypoglycemia after removal of an insulinoma. CONCLUSIONS: Patients with duodenal gastrinoma with lymph node metastases were curable, and cures were achieved occasionally after resection of liver metastases. Results of operation were similar for those with and without MEN I. MEN I and metastases were not contraindications to operation; instead, these patients should be operated on aggressively. Gastrinomas not found at operation were likely to be small duodenal gastrinomas. Gastrinomas can arise in a lymph node and can be cured by its removal. Parietal cell vagotomy is recommended after operation for gastrinomas in the event of residual tumor. With the exception of patients with MEN I or microadenomata, insulinomas were treated best by tumor enucleation. Otherwise, Whipple operation or distal pancreatectomy and enucleation of tumor in the remaining pancreas was indicated.

New look at epiphrenic diverticula.

Twenty-five patients with epiphrenica diverticula were studied to clarify the mechanism for esophageal regurgitation and to evaluate methods of treatment. Esophagogastroduodenoscopy, esophageal motility, and cineradiographic studies were performed. With probes in the tubular esophagus and diverticula of two patients, motility and cineradiographic studies were performed simultaneously to correlate symptoms and pressure changes with movement of diverticular and esophageal contents. Nineteen patients were operated, and six relatively asymptomatic patients were not. There was no operative mortality, and the one esophageal fistula that occurred healed spontaneously. Results were excellent or good in 10 operated patients followed long term after resection or imbrication of the diverticula. Eight patients did not undergo myotomy. Results in four of these patients followed long term were excellent. Retrograde movement of diverticular contents into the esophagus depends on pouch volume and a pressure gradient between the pouch and the tubular esophagus after an esophageal contraction wave in the tubular esophagus has dissipated. The height of esophageal reflux and resulting symptoms depend on these factors and the lower esophageal sphincter pressure (LESP). Asymptomatic patients with an epiphrenic diverticulum do not require operation. Resection or imbrication of a diverticulum are the operative methods of treatment. We prefer the abdominal approach when this is possible. Myotomy in contraindicated when gastroesophageal reflux exists or the LESP is below normal.

Parietal cell vagotomy performed with fundoplication for esophageal reflux.

BACKGROUND: Reduction of acid secretion is an important aspect of medical treatment of reflux esophagitis. Truncal vagotomy and drainage procedures used in conjunction with antireflux procedures to reduce acid secretion in patients with gastroesophageal reflux were unsatisfactory. This study reviews the results of parietal cell vagotomy used in conjunction with a 360-degree fundoplication to determine if reduction of acid by this form of vagotomy was beneficial to patients with gastroesophageal reflux. METHODS: Between March 1973 and May 1993, 94 private and 64 Veterans Administration patients underwent parietal cell vagotomy and Nissen type fundoplication for esophageal reflux. Esophagogastroduodenoscopy (EGD), gastric analysis, cine-esophagogram, and 24-hour esophageal pH and motility studies were performed preoperatively on VA patients. Private patients underwent EGD, cine-esophagogram, and sometimes pH and motility studies. Similar studies were performed postoperatively if the patient permitted. The major technical alteration made during the study was the addition of posterior gastropexy to the operations performed between March 1978 and January 1987. Patients were considered failures if dysphagia and reflux symptoms were moderate but operation not contemplated (Visick III) or symptoms were severe and reoperation had been performed or was contemplated (Visick IV). RESULTS: There were no operative deaths. There were 25 operative failures; dysphagia contributed to failure in 4, reflux in 11, and dysphagia and reflux in 10 patients. Reoperation was required in 6 patients. There was no statistical difference in acid secretion inhibition for patients with or without postoperative reflux symptoms. The cumulative probability for operative failure was 9.3 +/- SE 4.2% for patients who underwent posterior gastropexy and 22.9 +/- SE 4.6% (P <0.02) for those who did not. CONCLUSIONS: Parietal cell vagotomy with Nissen fundoplication is a safe operation. The exposure created by PCV protected the vagi from injury. The study design made it impossible to determine whether PCV improved the results of fundoplication but the failure rate was significantly (P <0.02) reduced by the addition of posterior gastropexy. This may have lessened the risk of disintegration of the wrap that might be more likely to occur after PCV.

Type I gastric ulcer treated by parietal cell vagotomy and mucosal ulcerectomy.

BACKGROUND: Type I gastric ulcers occur at the gastric incisura and do not coexist with duodenal or pyloric ulcers. Antrectomy and Billroth I anastomosis are the most frequent operations used for treatment of patients with this lesion. STUDY DESIGN: Postoperative results, including recurrence, were evaluated in 48 patients with a Type I gastric ulcer who were treated by parietal cell vagotomy and mucosal excision of the ulcer and had a mean follow-up of eight years. RESULTS: There was no operative mortality and no major operative complications occurred. The patients have had follow-up examination for a mean of eight years. All but four patients were in Visick I and II categories when last examined. Four patients were in category IV because they required a second gastric operation. The cumulative probability of recurrent ulcer rate calculated by life table analysis was 6.5 plus or minus 9.5 (standard error of the mean) percent at nine years. CONCLUSIONS: Parietal cell vagotomy and ulcerectomy is an excellent operation for patients with Type I gastric ulcers and provides an alternative to antrectomy for patients with this lesion.

Percutaneous needle biopsy of the pancreas: when should it be performed?

Is it appropriate for a good risk patient with a clinical history or imaging studies suggestive of an operable pancreatic neoplasm to undergo a percutaneous fine-needle aspiration biopsy (FNAB) prior to operation? A group of 118 patients who underwent percutaneous FNAB of the pancreas between 1987 and 1993 were evaluated retrospectively. The initial readings of the biopsies were positive for neoplasm in 78 patients and negative in 32. Four suspicious biopsies were included with the positive biopsies for analysis, and four unsatisfactory biopsies were added to the negative biopsies. Operation was performed on 57 of the 118 patients; 39 of these patients had a positive and 18 a negative FNAB. Of the 18 patients with a negative biopsy, 12 were proved to have neoplasia at operation. No operation was performed on 61 patients; 43 of these patients had a positive and 18 a negative FNAB. Three patients with a negative biopsy were treated with chemotherapy, and three subsequently died of pancreatic cancer. It was concluded that because the sensitivity of percutaneous FNAB is only 84% the procedure should be limited to patients suspected of having pancreatic cancer deemed technically inoperable or medically unsuitable for operation.

A comprehensive characterization of lymphoepithelial cyst associated with the pancreas.

BACKGROUND: Lymphoepithelial cyst of the pancreas is a rare but distinctive cystic lesion lined by a mature, keratinizing squamous epithelium and surrounded by lymphoid tissue. METHODS: To gain more insights into this entity, we describe 5 examples of lymphoepithelial cyst of the pancreas (2 of which were briefly described before) and compare them with similar cases in the literature for a total of 19 cases. RESULTS: The male:female ratio was 16:3; patients' ages ranged from 32 to 73 years (mean and median 51). The lymphoepithelial cyst was incidentally found at autopsy in 4 patients (21%) or during evaluation for unrelated diseases in another 4 patients (21%). In the remaining 11 patients, the cyst was associated with abdominal pain in 9 (47% of all patients), nausea/vomiting in 3 (16%), diarrhea in 1 (5%), and nonspecific systemic symptoms in 6 (32%) (some patients had more than 1 associated symptom). Computed axial tomography scan, with or without ultrasonographic study, was done in 16 cases and uniformly displayed a single, well-circumscribed, cystic mass protruding beyond the surface of the pancreas; the rest of the pancreas was normal. Intraoperatively, the cyst was readily apparent once the lesser sac was entered and the surface of the pancreas exposed; the cyst was located at the head (3 cases), neck (1 case), body (6 cases), and tail (9 cases). Surgery was done for all 15 clinical cases and included local excision of the cyst with a thin rim of attached, underlying pancreas (6 cases), or distal pancreatectomy with (4 cases) or without (3 cases) splenectomy. Follow-up information, available in 7 cases, showed that all symptoms disappeared and the patients were alive and well up to 6 years after surgery. CONCLUSIONS: This rare cyst of the pancreas has a uniform and characteristic clinicopathologic profile, enabling easy and accurate diagnosis. Although the histogenesis of lymphoepithelial cysts is not known, they are benign and can be cured by local excision.

Perforated pyloroduodenal ulcers. Long-term results with omental patch closure and parietal cell vagotomy.

OBJECTIVE: The authors evaluated parietal cell vagotomy and omental patch closure as treatment for perforated pyloroduodenal ulcers. BACKGROUND DATA: Since the beginning of the century, there has been a difference of opinion as to whether perforated pyloroduodenal ulcers are best managed with nonoperative treatment, simple closure, or definitive treatment, i.e., a procedure that handles the emergency problem and simultaneously provides protection against further ulcer disease. The criticism of using definitive treatment at the time of perforation has been that some patients who might not have recurrent ulcer, if a definitive operation was not performed, would be at risk of adverse postoperative sequelae, including death. Parietal cell vagotomy as treatment of intractable duodenal ulcer disease was shown to be almost without complications. The objective of this study was to determine if the operation was equally applicable to perforated pyloroduodenal ulcers. METHODS: A group of 107 selected patients with perforated pyloroduodenal ulcers underwent definitive treatment by omental patch closure and parietal cell vagotomy. The patients were evaluated prospectively on an annual basis up to 21 years. Gastric analyses were performed on each visit for which the patient gave his/her consent. Patients suspected of a recurrent ulcer were examined endoscopically for verification. RESULTS: There was one death (0.9%). Ninety-three patients were observed for follow-up for 2 to 21 years. The recurrent ulcer rate by life table analysis was 7.4%. The reoperative rate was 1.9%. Postoperative gastric sequelae were insignificant. All but four patients were graded Visick I or II at the time of their last evaluation. CONCLUSION: This study confirms that the combination of parietal cell vagotomy and omental patch closure is an excellent choice for treatment of patients with perforated pyloroduodenal ulcers, who, by virtue of their age, fitness, and status of the peritoneal cavity are candidates for definitive surgery. Virtually none of the morbidity that occurs with other forms of definitive treatment is inflicted on patients who might never have needed a definitive operation if simple closure was performed. At the same time, it provides definitive therapy for the larger number of patients who subsequently would have required a second operation for continued ulcer disease if simple closure alone was performed. Whether this operation is performed at the time of perforation should depend on the presence or absence of risk factors, rather than whether the ulcer is acute or chronic.

Twenty years after parietal cell vagotomy or selective vagotomy antrectomy for treatment of duodenal ulcer. Final report.

OBJECTIVE: This study was a prospective, randomized evaluation of parietal cell vagotomy (PCV) and selective vagotomy-antrectomy (SV-A) in the treatment of duodenal ulcer. BACKGROUND DATA: Operative treatment of duodenal ulcer is associated with mortality and mechanical and metabolic morbidity. At the time that surgeons appear to have succeeded in developing operations with low morbidity and mortality, the number of patients requiring elective operation has decreased partly because of the simultaneous, dramatic improvement in medical therapy. Nevertheless, surgical therapy still is important, especially in certain socioeconomic environments. METHODS: After a pilot study of PCV, 200 patients with duodenal ulcers were randomized to PCV or SV-A. One surgeon was responsible for the operations and follow-up studies. An attempt was made to evaluate all patients annually in the hospital. Gastric analyses were performed on each visit, for which the patient gave his/her consent. RESULTS: There was no operative mortality. The recurrence rate-by-life table analysis was less (p < 0.003) after SV-A than PCV. Dumping was greater (p < 0.001), and there was no difference in the frequency of diarrhea after SV-A compared with PCV. The percentage of patients with grades Visick I or Visick II was not different for the two operations, but more patients were graded Visick I after PCV than after SV-A. CONCLUSIONS: Selective vagotomy-antrectomy and parietal cell vagotomy are effective and safe operations, when used appropriately. Selective vagotomy-antrectomy is preferable for patients with pyloric and prepyloric ulcers and pyloric obstruction. Parietal cell vagotomy is the authors' choice for duodenal ulcer patients because of the occasional patient who becomes disabled by SV-A.

Determination of 25-hydroxyvitamin D3 in human serum by fluorescence labelling and high-performance liquid chromatography.

A method is described for the determination of 25-hydroxyvitamin D3 in human blood serum. The problems of sensitivity and selectivity encountered with previous techniques were avoided by the formation of a highly fluorescent Diels-Alder adduct following solid-phase extraction of the vitamin. After excess of reagent had been eliminated, quantification was achieved by high-performance liquid chromatography. The recovery of the vitamin from serum was 76.4 +/- 1.76%. The precision of the method was determined, and the relative standard deviations were 8.38% at a concentration of 47.0 x 10(-9) mol dm-3, 6.74% at a concentration of 99.8 x 10(-9) mol dm-3 and 3.79% at a concentration of 146.8 x 10(-9) mol dm-3. The detection limit for the adduct was 2.93 x 10(-14) mol injected, for a signal-to-noise ratio of 3:1, and serum concentrations of 0.25 x 10(-9) mol dm-3 could easily be quantified. No interference from endogenous or exogenous substances was observed.

Voltammetric behaviour of morphine at a glassy carbon electrode and its determination in human serum by liquid chromatography with electrochemical detection under basic conditions.

The electrochemical oxidation of morphine was studied at pH values of between 7.00 and 12.00 by cyclic voltammetry and chronoamperometry at a planar glassy carbon electrode. The peak potential was dependent on pH over the range 7.00-9.75; it was independent of pH above the latter value, indicating a pKa value of 9.75. The peak current was found to be independent of pH, ionic strength of phosphate buffer (0.02-0.1 mol dm-3) and percentage of acetonitrile (0-40% v/v). The oxidation was found to occur in three steps; these are considered to result from a one-electron oxidation of the phenoxide group, followed by a one-electron loss from the oxidation product, pseudomorphine, and finally a two-electron loss from a tertiary amine group. A simple method of analysis by high-performance liquid chromatography was developed which employed a column packed with a reversed-phase, pH-stable, octadecylsilane-modified silica. Separation was achieved with a mobile phase containing 20% v/v acetonitrile in 0.05 mol dm-3 phosphate buffer, pH 11.0. Amperometric detection was carried out with an applied potential of +0.45 V versus Ag-AgCl. The detection limit was 1.24 x 10(-13) mol of morphine injected. The detector gave a linear response from 1.2 x 10(-12) to 4.0 x 10(-10) mol of morphine injected. The extraction method required 0.5 ml of serum, and no solvent evaporation was needed. The recovery of morphine was 80.9%. The method gave a linear response to at least 15.0 x 10(-7) mol dm-3.(ABSTRACT TRUNCATED AT 250 WORDS)

Indications for parietal cell vagotomy without drainage in gastrointestinal surgery.

Parietal cell vagotomy (PCV) was used for a variety of gastrointestinal conditions in 658 patients. Operative and late related deaths after PCV were 1.1% (3/273) in patients with intractable duodenal ulcers, 1.1% (1/91) in perforated ulcers, 0% (0/43) in Type I gastric ulcers, 0% (0/45) in pyloric and prepyloric ulcers, 3.2% (6/188) when combined with fundoplication, 8.7% (2/23) when combined with vascular surgery, and 4.2% (1/24) in ulcer patients with acute bleeding. The recurrent ulcer rate after PCV was 8.4% in patients operated on for duodenal ulcer, 6.4% for perforated ulcer, 5.3% for bleeding ulcers, 10% for Type I gastric ulcers, and 31% for pyloric and prepyloric ulcers. PCV was preferred to total gastrectomy in four patients in whom a gastrinoma could not be located. PCV was used in 188 patients with reflux esophagitis and in 12 patients with achalasia to facilitate fundoplication and placement of the myotomy, respectively. Based on the results of the study, PCV is contraindicated in patients with pyloric and prepyloric ulcers. PCV is not recommended when traumatic dilatation of the pylorus is required to overcome obstruction. PCV may have limited application in patients with bleeding ulcers and Type I gastric ulcers. In our experience PCV is not contraindicated in patients with ulcers resistant to H2 receptor antagonists. PCV may be contraindicated when acid hypersecretion exceeds an as-yet undetermined level. PCV is an ideal procedure for intractable duodenal ulcers and perforated ulcers.

Hepatocellular carcinoma metastatic to the stomach presenting as bleeding multiple craterogenic ulcers.

A patient with previous resection of primary hepatocellular carcinoma developed upper intestinal bleeding. Pinch biopsy and needle aspiration biopsy of a submucosal antral lesion seen at endoscopy yielded metastatic hepatoma. We believe this to be the first report of the endoscopic appearance of a submucosal tumor. Currently available methods of tissue diagnosis are discussed.

Operations for duodenal ulcer disease.

Operative treatment of duodenal ulcer has been restricted to the small proportion of ulcer patients who have complications of ulcers or to those patients who do not respond to medical treatment. The principal surgical procedures that have been used include different types of gastric drainage, gastric resection, gastric denervation, or various combinations of these principles. Initially, the primary objective of ulcer surgery was to prevent recurrent ulcer. Currently, the objectives of operation are to cure an ulcer without a recurrent ulcer or any undesirable sequelae developing as a result of altered gastric physiology. Perhaps no operation will satisfy each of these conditions for every patient. Parietal cell vagotomy without a drainage procedure, the latest contribution to ulcer surgery, has been intensively studied for 19 years. The operative mortality of 0.26%, the recurrence rate of 4 to 11%, and virtually no significant side effects have caused the operation to become the procedure of choice for an increasingly large number of gastric surgeons.

Perforated peptic ulcer.

Peptic ulcer disease has declined significantly since 1950 in industrialized nations. However, the number of patients with perforated and bleeding ulcers has been constant or has declined only slightly, except for older patients, in whom the frequency has increased. In patients with perforated ulcers, operative management is preferable to non-operative treatment. The operative choices are simple closure of the perforation or definitive surgery. Patients who have significant risk factors should undergo simple closure. Closure of the ulcer with parietal cell vagotomy is the author's first choice for definitive operative treatment when this procedure can be performed.