Pyloric and duodenal motor contributions to duodenogastric reflux.

The motor mechanisms of duodenogastric reflux were identified in 4 healthy, conscious dogs using electromyographic and fluoroscopic recordings of stomach, duodenum and upper jejunum. A barium suspension was injected via a pre-placed cannula in the orad jejunum, during the interdigestive period. Under normal conditions, reflux was uncommon. It was produced by duodenal segmental contractions occurring when the pylorus was open, or forced open by the duodenal contractions. Reflux was more common during retrograde electrical pacing of the duodenal pacesetter potential. It was then also produced by duodenal segmental contractions associated with an open, or opening, pylorus. During intravenous administration of apomorphine, reflux occurring early in the vomiting complex, was again produced by duodenal segmental contractions associated with an open, or opening, pylorus. The major apomorphine reflux event, however, occurred later when an emetic antiperistaltic contraction, originating in the duodenum or orad jejunum swept the contents before it into the stomach.

Nonsurgical pneumoperitoneum.

Free intraperitoneal air is not necessarily caused by a perforated viscus. The present study reviews the causes of pneumoperitoneum that do not necessitate laparotomy, and emphasizes the importance of obtaining a complete clinical history.

Proximal gastric vagotomy: effects of two operative techniques on clinical and gastric secretory results.

PGV performed in 39 patients by separating the lesser omentum from the stomach beginning 6 or 7 cm proximal to the pylorus and skeletonizing the distal 1 to 2 cm of esophagus was followed by 15.4% of proven and 10.2 of suspected recurrent ulcers. Insulin tests were done during the first 3 months postoperatively on 31 of the patients, including the 6 with proven and the 4 with suspected recurrent ulcers. The peak acid output to insulin minus tha basal acid output (PAOI-BAO) was less than 5 mEq/hr in 16 cases (52%) and from 5 to 25 mEq/hr in the remaining 15 cases. In 6 patients with proven recurrent ulcer, PAOI-BAO averaged 21.9 mEq/hr (range, 11.3 to 41.8); in the 4 patients with suspected recurrence, 9.5 (range, 4.4 to 11.8). The operative technique was changed in one respect; the distal 5 to 7.5 cm of the esophagus was skeletonized. In 14 patients, the mean PAOI-BAO +/- S.E. within 3 months of PGV was 1985 +/- 0.7 mEq/hr, and 13 of 14 values were less than 5 mEq/hr. One patient developed recurrent ulcer and required re-operation; this patient's value for PAO-BAO was 1.8 mEq/hr. The results show quantitatively that great differences in the completeness of PGV result from differences in the periesophageal dissection and emphasize its importance if optimal results are to be obtained and, especially, if the efficacy of the operation is to be judged.

Gastric emptying of liquids after different vagotomies and pyloroplasty.

Gastric emptying of five liquid meals which differ in their physicochemical properties have been measured in control dogs and dogs that have received a Heinecke-Mikulicz pyloroplasty alone, proximal gastric vagotomy without drainage, selective gastric vagotomy and pyloroplasty and truncal vagotomy and pyloroplasty. The first two phases of emptying have been computed by the method of least squares to obtain a logarithmic-linear pattern and are expressed as relative rates: The initial post-ingestion process is characterized by beta or the average relative rate of emptying in the first ten minutes, the basic or exponential rate as beta and the change in rate from the initial to basic pattern as deltabeta. Each measure of gastric emptying was statistically analyzed to determine specific differences in rates between the operations studied. We confirmed the earlier claims that pyloroplasty alone does not change the emptying rate of liquid meals. Each measure or phase of emptying varies consistently across the operations from meal to meal tested. Initial emptying after all three vagotomies is significantly faster than control with progressive rate increases as proximal gastric vagotomy is compared with selective gastric vagotomy with pyloroplasty and with truncal vagotomy with pyloroplasty, probably indicative of gastric fundal loss of accommodation to volume distention after denervation. The basic exponential pattern of emptying is not lost after any of the operations studied. The basic rate after proximal gastric vagotomy and selective gastric vagotomy with pyloroplasty is nearly identical, slightly delayed from the control rate and significantly slower than the more rapid rate after truncal vagotomy with pyloroplasty. Possible explanations for these are discussed and imply a particular importance of the hepatic and celiac vagal fibers, sectioned only with truncal vagotomy, in the regulation of gastric emptying of liquids.

What is the best elective operation for duodenal ulcer?

During the past 40 years, after gastroenterostomy and pyloroplasty for duodenal ulcer had been replaced by partial gastrectomy in many centres, partial gastrectomy itself gave way to combinations of vagotomy with gastroenterostomy, pyloroplasty or antrectomy. Opinions differ concerning the procedure of choice and in this paper the author examines the causes of this diversity of opinion and assesses the reliability of conclusions that can be drawn about the elective treatment of duodenal ulcer today. Most reports of results from various operations have come from retrospective studies, and the causes of variability among such reports are analyzed to point out the great difficulty in making a valid judgment about the relative worth of the various operations used to treat duodenal ulcer. Results of some of the few prospective studies with randomized operations assessed blindly are then presented and note is taken of the surprising observation that greatly different operations appear to give remarkably similar results. From the data available the author develops a logical way of approaching the choice of operation for the various problems related to duodenal ulcer that require elective surgical treatment.