Vagotomy.

Peptic ulcer disease was for years a common indication for surgery in Danish hospitals and considerable experience in partial gastrectomy was gained. In spite of an unquestionable mortality rate and a number of patients having postgastrectomy complaints, results were generally recognized as acceptable. Danish surgeons were for long reluctant to take up vagotomy and drainage as a primary ulcer operation, but when they did start a large number of procedures were performed. In fact, the use of this treatment culminated during two to three decades. However, on a basis of experiences from these years, Danish research contributed actively to the international evolution of the surgical vagotomy technique, the evaluation of clinical results and the studies of postoperative alterations in gastric physiology. References are selected from an extensive literature and are in no way complete.

Controlled clinical trial with sucralfate in the treatment of macroscopic gastritis.

The efficacy of sucralfate in the treatment of patients with dyspepsia and macroscopic signs of gastritis was assessed in a double-blind, placebo-controlled study. Treatment was 2 g sucralfate or placebo taken 1/2 h before breakfast and at bedtime. Clinical and endoscopic examinations were performed after 6 weeks' treatment, and if mucosal changes and/or symptoms persisted, medication was continued for another 6 weeks. Cumulative healing rates at 6 and 12 weeks were 43% (13 of 30) and 62% (18 of 29) in the sucralfate group verus 37% (11 of 30) and 62% (18 of 29) in the placebo group. Corresponding rates for symptomatic improvement were 80% and 83% for those receiving sucralfate and 73% and 79% for placebo-treated patients. None of the differences between sucralfate and placebo were significant, and sucralfate does not seem to be superior to placebo in the treatment of macroscopic gastritis.

The fasting and food-stimulated serum gastrin concentration in 151 duodenal ulcer patients compared to 41 healthy subjects.

The basal and postprandial serum gastrin concentrations (SGC) were compared between 151 duodenal ulcer (DU) patients and 41 non-dyspeptic volunteers. All DU patients had an eventful history and were submitted to us for surgery. The basal SGC was significantly higher in DU patients (40 +/- 30 vs 17 +/- 8 pg/ml). The peak post-prandial SGC was also significantly higher (123 +/- 83 vs 52 +/- 28 pg/ml) and the integrated gastrin output twice as high as in healthy subjects (5311 +/- 3879 vs 2554 +/- 1995 pg/ml x min; P less than 0.01). A statistically significant linear correlation for fasting and maximal postprandial SGC was found. No statistically significant interrelation between gastrin and acid parameters existed. In the DU patients no differences in SGC were found according to age. Fifteen patients complained of nonalimentary vomiting as part of their ulcer symptoms. They had significantly higher SGC although no differences in acid secretion were found. No significant differences in gastrin or acids were related to ulcer complications.

Surgery is preferable in patients with severe chronic peptic ulcer disease.

Conservative treatment given as interrupted courses is easy and successful for the majority of patients with peptic ulcer disease. For those plagued for years and years by severe chronic complaints the choice will be maintenance treatment or surgery. Maintenance treatment possibly spares the patient for an operation but includes a risk of stenosis claiming the necessity of a drainage operation with risk of sequels. The taking of the pill means a daily remembrance of the disease. Relapse rate is high. The economic problem is not unimportant for the patient. When contra indications are taken seriously into consideration modern ulcer surgery is not dangerous. There are no sequels if the pyloric function can be left intact. The cured patients feel fit and will usually forget the disease. Recurrence rate is lower than that during maintenance therapy but if occurring early they may be difficult to treat. The young patient with severe chronic duodenal ulcer disease should not wait eternally for a parietal cell vagotomy. When the ulcer is located to the pyloric channel prolonged conservative treatment may be advisable. Treatment policy for the gastric ulcer is debatable. No treatment is yet ideal. The advice to the individual patient should be based upon a non-prejudiced evaluation of the advantages and disadvantages of the therapeutic possibilities necessitating that the gastroenterologist and the surgeon have a thorough knowledge of the results of the other speciality.

Antral hypergastrinemia--a report of three cases.

Three patients with juxtapyloric ulcers and hypergastrinemia are presented. Fasting and food-stimulated serum gastrin concentration (SGC) were measured in 1970, 1972 and 1973 before the primary ulcer operation (selective gastric vagotomy and Jaboulay gastroduodenostomy; SGV + GD). Fasting SGC were 105, 149 and 158 pg/ml and the postprandial concentrations were 400, greater than 800 and greater than 800 pg/ml, respectively. The pentagastrin-stimulated acid secretion was within the normal range. After SGV + GD, only a slight decrease in acid secretion was observed. The hypergastrinemia persisted unchanged or decreased slightly in 1 patient. A recurrent ulcer developed and a precise antrectomy was carried out. Postoperatively, the fasting SGC was markedly reduced and the postprandial gastrin response abolished. The resected specimens were subjected to immunocytochemical gastrin cell quantitation. The number of gastrin cells was elevated in all 3 patients and the gastrin cell topography was distorted, with cells being present both in the lower and upper thirds of the antropyloric glands.

Sucralfate in gastritis.

Gastritis has a wide spectre of definition modalities. Most previous studies have compared symptomatology with histologic gastritis with negative results. We believe that this may be due to inadequate definition criteria and emphasize this point by comparing gastroesophageal reflux with duodenogastric reflux. A prospective randomized trial has been conducted for half a year comparing Sucralfate with a placebo in patients with symptomatological and macroscopical gastritis. Although approximately one hundred patients met the endoscopic criteria, the vast majority could not be included due to well-defined interfering diseases, and thus the material is still too sparse to give any indication of the influence of Sucralfate on endoscopic gastritis, although the preliminary overall results seem promising.

Fasting and food-stimulated serum gastrin concentration in 151 duodenal ulcer patients and 41 non-dyspeptic volunteers. Significant sex differences.

In 41 non-dyspeptic volunteers (18 females and 23 males) the fasting and food-stimulated serum gastrin concentration was investigated. No significant sex differences were found in the basal serum gastrin concentration. The integrated postprandial gastrin output, however, was significantly higher in females than in males. In 151 duodenal ulcer patients (31 women and 120 men) significant sex differences were found in both the fasting and the food-stimulated serum gastrin concentration. Women had values approximately 60% higher than men. In 116 of the patients (27 women and 89 men) the basal and pentagastrin-stimulated gastric acid concentrations were investigated. In the basal state no significant sex differences in acid output were found. After stimulation women had significantly lower gastric acidity and gastric acid output than men.

Canine gastric ulcer produced by hemorrhagic shock and aspirin.

Ischemia of the gastric mucosa, for example during hemorrhagic shock, appears to be an important pathogenetic factor in acute bleeding from the upper gastrointestinal tract. In the present experiment the effects on the canine gastric mucosa of hemorrhagic shock (ischemia) and intragastric aspirin in acid and neutral solution were studied. The combination of hemorrhagic shock, aspirin, and acid caused pronounced mucosal lesions, whereas only minor lesions were seen with aspirin and acid alone. It is concluded that the ischemic gastric mucosa is more susceptible to aspirin solution than normal mucosa. This may have important bearings on clinical practice.

The type of anastomosis after selective gastric vagotomy and precise antrectomy is of no importance for basal and postprandial serum gastrin concentration.

Twenty-six patients were treated for duodenal or recurrent ulcer with selective gastric vagotomy plus precise antrectomy--that is, complete removal of the entire antrum. Sixteen had a gastroduodenal anastomosis and 10 a gastrojejunal anastomosis. Fasting and protein meal-stimulated serum gastrin concentration was measured in 10 patients before antrectomy and in all after the operation. Fasting serum gastrin concentration was reduced and food-stimulated gastrin response abolished irrespective of the type of the anastomosis. It is concluded that a postprandial gastrin rise means retained antral tissue in the gastric remnant and that neither protein nor mechanical stimulation of the passage of food through the duodenum stimulates the duodenal G-cells to gastrin release.

Possible mechanism of hemostasis effected by electrocoagulation.

Forty acute gastric ulcers were created in 10 rabbits. The bleeding was controlled by monopolar electrocoagulation in 20 ulcers, the remaining ulcers were left untreated as controls. Spontaneous intravascular thrombosis was precluded by heparinization. A histological assessment in the acute stage revealed significant morphological alterations in electrocoagulated ulcers, with fibrin deposition, decreased tissue stainability and swelling of the vessel walls, indicating heat-induced damage including cells of the vessel walls. An intravascular occlusive fibrin thrombosis demonstrated in all coagulated ulcers is suggested to be the probable mechanism of hemostasis.

A predictor analysis of patients' assessment of outcome after operation for duodenal ulcer. A one-year prospective study.

During a period of one year data were obtained concerning life events, non-specific psychological symptoms, individual social history and ulcer history in consecutive cases of patients about to undergo elective surgical treatment for duodenal ulcer. At a one-year follow-up, a blind clinical evaluation was performed, and information concerning the patients' assessment of outcome was obtained. Those patients who at the one-year follow-up stated no improvement due to the operation could be predicted to some extent from postoperative complications, partly from a long ulcer history. The patients who stated that the result did not come up to their expectations were predicted from older age, and from certain symptoms, especially severe headache. It is suggested that it is relevant to apply the patients' assessment of outcome for the purpose of evaluation, supplementing the clinical assessment of the more biomedical aspects of outcome.

A predictor analysis of clinical assessment of outcome among patients operated on for duodenal ulcer. A 1-year prospective study.

During a period of 1 year, data concerning life events, non-specific psychological symptoms, individual social history, and ulcer history were obtained for consecutive cases of patients about to have elective surgical treatment for duodenal ulcer. At the 1-year follow-up examination a blind, clinical evaluation was performed (dumping, dyspepsia, recurrence, and Visick grading), and information concerning the 94 patients' assessment of outcome was obtained. A multivariate predictor analysis was performed. Most patients (85%) benefited from treatment. The excess rate of non-specific psychological symptoms indicating impairment remained unchanged. The patients assessments of outcome were correlated with the clinical assessment. A positive correlation was found for women to have dumping and poor Visick grade and for unmarried persons to have postoperative dyspepsia and a poor Visick grade. A negative correlation between a long ulcer history and postoperative dyspepsia and a positive correlation between pyloroplasty and dumping were found. Non-specific psychological symptoms predicted poor clinical assessments. It is suggested that it is relevant to apply the patients' assessments for the purpose of evaluation, supplementing the clinical assessment of the more biomedical aspects of outcome.

Arhus County Vagotomy Trial: gastric secretory alterations during the first year after selective gastric and parietal cell vagotomy.

Changes in gastric acid secretion during the 1st year after selective gastric (SGV) and parietal cell (PCV) vagotomy for duodenal ulcer disease were studied. Pentagastrin tests were performed preoperatively and 3 months and 1 year after surgery in 383 SGV and 302 PCV patients. Resting juice pH showed after both operations a trend towards the preoperative distribution from 3 months to 1 year. Basal acid output showed a similar pattern. The initial reduction in pentagastrin-stimulated peak acid output (PAOpg) was most pronounced after SGV, but an increase occurred for both operations during the 1st postoperative year. An exception from this was the minority of patients who had a less than 20% initial reduction. They had a further decrease in their PAOpg. No sex difference and no influence of the duration of symptoms could be demonstrated. The patients with less than 20% initial reduction were younger than the other groups, and this applied for both SGV and PCV. The patterns of change in gastric acid secretion during the first year after vagotomy suggest that biologic factors are active, in addition to the effect of the surgical technique.

Arhus County Vagotomy Trial: ulcer recurrence rate related to alterations in gastric acid secretion after selective gastric and parietal cell vagotomy.

Clinical and secretory data were analysed with respect to the recurrence rate for 685 patients treated with either selective gastric vagotomy (SGV) or parietal cell vagotomy (PCV) for duodenal ulcer disease. The duration of ulcer history before surgery was of no importance for the recurrence risk. Men with recurrence after SGV were significantly younger than men without recurrence, but no difference was found for women with SGV or for men and women with PCV. The recurrence rate was not higher for hypersecretors (pentagastrin-stimulated peak acid output (PAOpg) greater than 45 mmol/h) than for patients with lower PAOpg. Resting, basal, and stimulated secretion 3 months after surgery were higher for the patients with recurrence than for the patients without, but only a few of the secretion values were significantly different. A higher recurrence rate was found for the patients with the lowest initial acid reduction, and this trend was more pronounced in the PCV group. With regard to the change in gastric secretion during the first year after vagotomy a significant rise was seen for the PCV patients who developed recurrence in spite of initial reduction of more than 60%. For all SGV patients and the PCV patients with an initial reduction on the average or less, the change in secretion capacity had no influence on the recurrence rate. The findings are in accordance with reports about anatomical limitations for a sufficient PCV in about 20% of the patients.