Evaluation of benzalkonium chloride chemoneurolytic proximal gastric vagotomy.

BACKGROUND: Transmucosal chemoneurolytic injection of benzalkonium chloride (BAC) has previously been shown to duplicate operative proximal gastric vagotomy (PGV) in controlling gastric acid secretion. In this study, BAC was evaluated as to efficacious dose, methods of delivery, and systemic toxicities. METHODS: Sham celiotomy, operative PGV controls, transmucosal injections through a gastrotomy, and transserosal injections of BAC (saline controls, 0. 625, 1.25, 2.5, 5.0, 10 mg BAC/kg body wt) were administered to Sprague-Dawley rats. After 3 months the rats underwent Congo red testing (CRT), horseradish peroxidase (HRP) neuronal staining, and necropsy. The color density change of the gastric mucosa from basic to acidic demonstrated by the CRT at the time of necropsy was used to calculate the residual anatomic acid-secreting area. Prior to necropsy, subserosal HRP injections into the anterior and posterior stomach walls assayed vagal neuronal viability via retrograde axonal flow. Results were compared by an ANOVA. RESULTS: The results demonstrated that 1.25-10 mg/kg transmucosal BAC replicated the results of operative PGV; 2.5 mg/kg was found to be the most effective dose. All injection groups including saline controls demonstrated similar diminished vagal retrograde axonal flow by HRP testing consistent with local BAC chemoneurolytic effects. No systemic toxic symptoms were observed after tail vein intravenous BAC 1.25, 2.5, and 5.0 mg/kg. CONCLUSIONS: These efficacy studies have demonstrated BAC's potential utility in the performance of endoscopic transmucosal chemoneurolytic PGV.

A reappraisal of total pancreatectomy for pancreatic cancer: results from U.S. Veterans Affairs hospitals, 1987-1991.

BACKGROUND: After enthusiasm for total pancreatectomy for pancreatic adenocarcinoma peaked in the 1970s, a failure to improve outcomes in the 1980s led to fewer reports of this procedure. METHODS: We retrieved records from 252 Whipple and 47 total pancreatectomies for pancreatic cancer performed at U.S. Department of Veterans Affairs hospitals from 1987 to 1991. RESULTS: Thirty-day mortality was 8% with both procedures. There was no significant difference in morbidity at 30 days (Whipple 36%, total pancreatectomy 39%). The mean survival after total pancreatectomy was 526 days compared to 376 days following Whipple (P = 0.03). Staging information was retrieved from tumor registrars for 117 patients with pancreatic adenocarcinoma, 21 of whom underwent total pancreatectomy and 96 the Whipple procedure. In patients with stage I and stage II localized pancreatic adenocarcinoma, mean survival was 772 days in 11 patients after total pancreatectomy, and 446 days in 55 patients after Whipple resection (P = 0.057). CONCLUSION: The type of resection did not affect the mean survival of patients with stage III (nodal metastases) or stage IV (distant metastases) cancer.

Pancreatic cancer palliation: using tumor stage to select appropriate operation.

To assess the effect of tumor stage on the surgical palliation of pancreatic cancer, 350 cancers from 74 U.S. Department of Veterans Affairs (DVA) hospitals from 1987 to 1991 were staged from pathologic and operative data, then grouped by initial surgery: biliary bypass only (BO), gastric bypass only (GO), or combined biliary and gastric bypass (BG). Re-operations were recorded as later gastric and/or biliary bypass: Stages I-II (local disease): BO (n = 52)--6 later gastric (12%), 3 later biliary (6%); BG (n = 60)--3 later gastric (5%); 3 later biliary (5%). Stage III (positive nodes): BO (n = 26)--1 later gastric (4%); BG (n = 35)--1 later gastrobiliary bypass (3%). Stage IV (metastases): BO (n = 71)--3 later gastric (4%), 3 later biliary (4%); BG (n = 70)--2 later gastrobiliary bypass (3%). GO (all stages): (n = 41)--1 later gastric (2%), 4 later biliary (10%). Using a two-factor ANOVA comparing survival by stage and original surgery, we found that stage had a significant effect on survival (p = 0.0001), but the type of initial bypass operation had no effect. Re-operation after palliative pancreatic cancer surgery was necessary in less than 5% of patients with BG. Initial BG reduced the incidence of re-operation for patients with jaundice and without metastatic disease, and may also benefit patients with gastric obstruction alone. Patients with jaundice who have peritoneal or liver metastases can be treated effectively with BO if they have no symptoms of gastric outlet obstruction.

Palliative operations for pancreatic cancer in the hospitals of the U.S. Department of Veterans Affairs from 1987 to 1991.

A total of 1,180 patients underwent palliative surgery for pancreatic cancer in the 158 hospitals of the U.S. Department of Veterans Affairs from 1987 to 1991. Using computerized data files, we analyzed these procedures according to type of procedure (gastric bypass only [GO], biliary bypass only [BO], or combined biliary and gastric bypass [BG]), survival, reoperation and complication rates, patient age, and operative (30-day) mortality. Survival after GO (208 days) was significantly shorter than after BO or BG (279 days and 259 days, respectively; p < or = 0.05 by analysis of variance). The reoperation rate after BO (12%) was higher than after BG (5%; p < or = 0.001 by chi 2 analysis) and was due to the higher incidence of reoperative gastric bypass in the BO group. Complication rates were similar after all bypass types. Reoperations had a 25% 30-day mortality. The 32 gastric bypasses performed after an initial BO were done at a mean of 193 days after the original BO bypass, whereas other reoperations were undertaken at a mean of 73 days after the first operation. This first national study of palliative operations for pancreatic cancer supports combined biliary/gastric bypass as the initial procedure, thus minimizing reoperations and their attendant morbidity.