FROM THE DEPARTMENTS OF RADIOLOGY AND SURGICAL GASTROENTEROLOGY, KOMMUNEHOSPITALET, UNIVERSITY OF AARHUS, DK-8000 AARHUS, DENMARK.
GASTRIC MOTILITY AND EMPTYING FOLLOWING PARIETAL CELL VAGOTOMY AND SELECTIVE GASTRIC VAGOTOMY Experimental investigation KIRSTEN MIKKELSEN, P. O. ERIKSEN and J. BONE In recent years, selective gastric vagotomy and parietal cell vagotomy (also called highly selective vagotomy or proximal gastric vagotomy) have been increasingly used in the treatment of duodenal ulcer. By the former method, reduction of acid secretion is achieved by cutting all branches of the vagal nerves to the stomach keeping the extragastric vagus intact. This procedure is ordinarily combined with pyloroplasty. By parietal cell vagotomy, only the parietal cell mass is denervated, and the innervation of the muscular gastric antrum is preserved. The clinical results in some series (AMDRUP & GRIFFITH 1969, AMDRUP & JENSEN 1970, WILBUR & KELLY 1973) seem to indicate that a drainage is not a necessary supplement to parietal cell vagotomy while other authors (KLEMPA 1971, HOLLE et coll. 1972) claim that this has to be added. As the drainage procedure may result in dumping symptoms, the question of its necessity is important. The present animal experiments aim at assessing the influence of the two methods and a drainage procedure upon gastric motility of a meal normally taken by the experimental animals. The intention was also to examine the influence of the operations on the hormonal phase of gastric secretion. Therefore, a denervated fornix pouch, i.e. a Heidenhain pouch, was constructed in all dogs and the influence of this operation on gastric emptying and motility was also assessed. Supported by grant from Statens Lregevidenskabelig Forskningsrad, No. 512-4235. Submitted for publication 23 October 1975. Acta Radiologica Diagnosis 17 (1976) Fasc. 5 September
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Fig. I. Technique of parietal cell vagotomy in a dog with a Heidenhain pouch. Dotted line indicates the border between corpus and antrum.
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Fig. 2. Technique of selective gastric vagotomy in a dog with a Heidenhein pouch and gastroduodenostomy.
Material and Methods Adult, healthy mongrel dogs were used and the gastric motility was recorded: (1) before and after application of a Heidenhain pouch, (2) after parietal cell vagotomy without drainage, (3) after application of a gastroduodenal anastomosis (method of Jaboulay) and (4) after altering the parietal cell vagotomy into a selective gastric vagotomy by cutting the antral nerves. Another series of dogs with a Heidenhain pouch was investigated before and after selective gastric vagotomy without a drainage operation. All procedures were performed under pentobarbital (Nembutal) anaesthesia (30 rug/kg intravenously). In all the dogs a Heidenhain pouch was first constructed according to the method of DE VITO & HARKINS (1959). On performing the parietal cell vagotomy, an intragastric pH electrode was used to determine the border between the corpus and the antrum after stimulation of acid secretion with 0.25 mg pentagastrin (Peptavlon) administered intramusculary 20 min before operation. The branches of the anterior and posterior gastric nerves were then sectioned from the border between the corpus and antrum to the gastroesophageal junction which was carefully 'skeletonized' circumferentially of all small vagal branches (Fig. 1). In selective gastric vagotomy the anterior and posterior gastric nerves were cut just below the left gastric artery. The remaining part of the stomach was denervated by the technique used in parietal cell vagotomy (Fig. 2). The gastroduodenal anastomosis was constructed between the distal part of the antrum and the upper part of the duodenum. The stoma was placed I to 2 cm from the pylorus and was 4 cm wide. Examinations were not started until 3 to 4 weeks following surgery. The gastric emptying rate was recorded by fluoroscopy 3 times for each dog after
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KIRSTEN MIKKELSEN, P. O. ERIKSEN AND J. BONE
Table 1 Gastric emptying and motility before and after application of a Heidenhain pouch. In this and in the following tables gastric emptying time is the mean of 3 experiments in each dog
Dog No.
Waves per min
Strength
Peristaltic waves
Emptying time (min)
Before operation
AIO All A12 A13 A14 A15
5-6 5 5 5-6 6 6
3 3 3 3 3 2
+ + + + + +
217 200 147 199 260 297 220 ± 52.36 (mean)
After operation
A10 All A12 A13 A14 A15
? 4 4-5 6 6 4-5
3 3 2 2 3 2
+ +
279 175 162 126 133 179 176 ± 55.06 (mean)
+ + + +
+ All effective
Table 2 Gastric empyting and motility before and after application of partial cell vagotomy (PC V)
Operation
Dog No.
Waves per min
Strength
Heidenhain pouch
All A14 A24 A25 A26 A28
4 6 5 5 ? 5
3 3 3 3 2 3
All A14 A24 A25 A26 A28
5 6 5 4 ? 5
3 3 3 2 2 3
Heidenhain pouch +PCV
Peristaltic waves
Emptying time (min)
+
175 133 130 163 155 150 151±17.33 (mean)
+ + + + + + + +
+ +
+ All effective - Some ineffective
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170 148 192 222 158 152 173 ± 28.80 (mean)
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PARIETAL CELL VAGOTOMY
Table 3 Gastric emptying and motility before and after application ofparietal cell vagotomy (PC V) and Jaboulay anastomosis (GD) Operation
Dog No.
Waves per min
Strength
Peristaltic waves
Emptying time (min)
Heidenhain pouch
A24 A25 A26 A28 A29 A31 A32 A33
5 5 ? 5 5 6 5 5
3 3 3 3 3 3 3 3
+
130 163 155 150 143 133 135 117 141 ± 14.99 (mean)
A24 A25 A26 A28 A29 A31 A32 A33
18 20 15 ? 10 8 10 20
1 1 1 0 2 1 1 1
+
PCV+GD
+ + + + +
+ +
+ + + + ?
+
122 110 117 147 110 115 110 215 131 ±35.96 (mean)
+ All effective - Some ineffective
each of the mentioned operations. After 18 hours of fasting the dogs were given 200 g of standard dog food (in 100 g: 9 g of protein, 3 g of fat, and 7 g of carbohydrate) with 75 ml barium sulphate added. The stomach was considered empty when only a slight mucosal coating persisted. At the first examination the dogs were placed on the screening couch, 5, 15, 30, 45, 60, 90 and 120 min after the meals and a videotape was recorded. At the two following examinations they were screened at 60, 90, 120 min and until the moment of emptying. Evaluation of motility was later made by replaying the videotape (method of LAGEMANN & HOFFMANN 1971). Assessments were made according to the following scheme: (1) frequency of peristaltic contractions measured as waves per min; (2) intensity of the peristaltic waves, equalling the superficial contraction as force 1, medium deep as force 2, and the extra deep hour-glass shaped contractions as force 3, no peristalsis as 0; and (3) effect of the peristalsis indicated by the number of contractions emptying some of the gastric content into the duodenum. Results of the emptying rate are given in min as mean ± SD. The significance of mean differences was estimated with Student's t-test for paired values. 46 - 765833
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KIRSTEN MIKKELSEN, P. O. ERIKSEN AND J. BONE
Table 4 Gastric emptying time before and after altering the parietal cell vagotomy and anastomosis (PCV-+ G D) into a selective gastric vagotomy and anastomosis (SG V -+ G D). Gastric motility ceased completely after selective gastric vagotomy Dog N:).
Emptying time (min) rCV+GD
SGV+GD
A24 A25 A26 A28 A29 A31 A32 A33
122 ItO 117 147 110 115 110 215
lIS 100 95 112 60 152 147 202
Mean
131 ±35.96
123±43.30
Results Generally the peristalsis started about IS min after the meal. The behaviour of the stomach remained unaltered within the first hour, then the peristalsis tapered slowly. As in man, the fornix of the stomach only made slight movements, whereas peristalsis occurred in the intact antrum propelling the gastric content into the duodenum. After application of a Heidenhain pouch. Six dogs were used (Table I). Only a slight alteration of the force of the contractions occurred in 2 of the dogs (A 12 and A 13). The mean emptying time for the group decreased, but insignificantly from 226±S2.36 to 176±SS.06 min. After parietal cell vagotomy. Six dogs were used (Table 2). The stomach appeared as before the operation. The strength of the contraction of the peristaltic waves was unchanged except in dog A 2S. A non-significant increase in the mean emptying time from lSI ± 17.33 to 173± 28.80 min occurred in this group. After parietal cell vagotomy and gastroduodenal anastomosis. Eight dogs were used (Table 3). Previously, 4 of them had a parietal cell vagotomy without anastomosis (A24, A2S, A26, A28). After the operation the barium passed mainly through the anastomosis and only to a small degree through the pylorus. The strength of the contractions decreased in all of the dogs while the number of peristaltic contractions increased. However, as compared to the control group, mean emptying time for the whole group decreased insignificantly from 141 ± 14.99 to 131 ±3S.96 min. Even if
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Table 5 Gastric emptying time in dogs with a Heidenhain pouch be/ore and after application 0/ selective gastric vagotomy without anastomosis. Gastric motility ceased completely after the uagitomy
Dog No.
Empyting time (min) Before operation
After operation
A7 A34 A36 A43
225 153 207 140
480 460 440 350
Mean
181 ±41.13
433±57.37
the dogs with previous parietal cell vagotomy are considered separately, no significant alteration occurred.
After selective gastric vagotomy and gastroduodenal anastomosis. The same 8 dogs as in the last section were used (Table 4). After cutting the antral nerves the stomach in all the dogs appeared like a big, slack bag, emptying through the anastomosis only. No peristalsis was observed. The emptying time decreased insignificantly from 131 ±35.96 to 123±43.30 min. After selective gastric vagotomy without drainage. Four dogs were used (Table 5). After the operation the stomach appeared big, slack and atonic as in the foregoing group but the emptying time was significantly delayed from 181±41.13 to 433± 57.37 min (p < 0.005). Discussion
The methods for investigation of the gastric emptying rate are numerous: plastic spheres were used by WILBUR & KELLY (1973), liquid meals with contrast medium added by AMDRUP & GRIFFITH (1969), scintigraphy by WICKBOM et colI. (1971) and aspiration by BUCKLER (1967). The results differ widely, however. The examining conditions must be as identical as possible to the normal. The contrast medium added to the meal should not interfere with the determinations of the various parameters under assessment. The contrast medium used seems to fulfil these requirements. Less physiologic contrast meals have been used in some previous investigations. There seems to be no report available on the significance of a Heidenhain pouch on gastric motility and emptying. The present results indicate that the pouch does not alter the emptying rate or motility. Following selective gastric vagotomy the stomach became dilated and slack with complete atony. The meal was propelled only passively and slowly through the pylorus, resulting in a protracted retention of the meal in the stomach. Following a Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 14, 2015
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KIRSTEN MIKKELSEN, P. O. ERIKSEN AND J. BONE
gastroduodenostomy, the emptying time was reduced as the contrast passively passed through the anastomosis. After parietal cell vagotomy, the size and shape of the stomach were normal, the strength and number of the contractions were unaltered and the emptying time was insignificantly delayed. On the other hand, AMDRUP & GRIFFITH in dogs with a Heidenhain pouch using a homogeneous mixture of evaporated milk, barium sulphate and water observed a non-significant increase in the stomach emptying rate. Similar results were reported by WILBUR & KELLY who in dogs without a Heidenhain pouch employed solid plastic spheres. If a difference exists between the present results and the two reports mentioned, this may be explained by the difference of the type of meal used, in the present experiments being a normal dog meal, non-homogeneous and semisolid. The present results agree with those of clinical examinations, in which similar types of physiologic meal and added contrast medium were employed (BRANDSBORG et coIl. 1975). Contrary to this, KLEMPA et coIl. (1971) using colloidal barium SUlphate found a significantly prolonged gastric emptying after parietal cell vagotomy in dogs with a Heidenhain pouch. This discrepancy may be explained by differences in the operative procedure. In the present experiments the pH electrode was used for the determination of the border between the antrum and the corpus. It was in all dogs identified about 2 em proximal to the border indicated by the anatomy of the nerves and used by KLEMPA et coIl. It is likely that the prolonged gastric emptying time after their operation was caused by the more extensive denervation of the antrum. With reference to the results of KLEMPA et coIl., HOLLE et coIl. claim that a drainage procedure always has to be performed together with parietal cell vagotomy. The present results indicate that emptying is normal after parietal cell vagotomy while the addition of a drainage procedure changes the motility with a considerable reduction in the intensity of the gastric contractions, presumably because the meal is passively transported through the anastomosis. This results in a more rapid emptying which in man may lead to 'dumping'. In conclusion it may be said that parietal cell vagotomy does not affect the gastric motility and emptying but that this procedure with drainage and selective gastric vagotomy with or without drainage affect both the motility and emptying. The results achieved in animal experiments indicate that parietal cell vagotomy without drainage is the procedure of choice.
SUMMARY After parietal cell vagotomy in dogs antral motility and gastric emptying time is unaffected. Addition of a drainage procedure changed the motility considerably by decreasing the force of contractions and diminishing the number of peristaltic waves. After cutting the antral nerves complete atony occurred, but emptying rate was unaltered as the contrast meal passed passively through the anastomosis. Selectivegastric vagotomy without drainage caused atony and significantly prolonged emptying time.
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ZUSAMMENFASSUNG Nach parietaler Zellvagotomie war die Motilitat des Antrums und die Entleerungszeit des Magens von Hunden nicht beeinflusst. Ein zusatzliches Drainageverfahren veranderte die Motilitat durch einen Abfall der Kraft der Kontraktionen und eine verminderte Zahl von peristaltischen Wellen betrachtlich, Nach Abschneiden der Nerven des Antrums trat eine vollstandige Atonie auf. Jedoch war die Entleerungsgeschwindigkeit unverandert, wenn die Kontrastmahlzeit passiv durch die Anastomose befOrdert wurde. Eine selektive Vagotomie des Magens ohne Drainage verursachte eine Atonie und eine signifikant verlangerte Entleerungszeit.
RESUME La rnotilite antrale et la duree de l'evacuation gastrique ne sont pas modif'iees apres vagatomie cellulaire parietale chez des chiens. L'association d'une technique de drainage modifie considerablernent la motilite en diminuant la force des contractions et en diminuant Ie nombre des ondes peristaltiques. Apres section des nerfs antraux apparait une atonie complete mais la vitesse d'evacuation est inchangee car Ie repas baryte passe passivement a travers I'anastomose. La vagotomie gastrique selective sans drainage entraine une atonie et une prolongation importante de la duree d'evacuation.
REFERENCES AMDRUP B. M. and GRIFFITH C. A.: Selective vagotomy of the parietal cell mass. Part I. With preservation of the innervated antrum and pylorus. Ann. Surg. 170 (1969), 207. AMDRUP E. and JENSEN H. E.: Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum. Gastroenterology 59 (1970), 522. BRANDSBORG 0., BRANDSBORG M., MIKKELSEN K. and LOVGREEN N. A.: Selective gastric vagotomy and parietal cell vagotomy by duodenal ulcer. Influence upon gastric motility and serum-gastrin-concentration. Gastroenterology (1975), in press. BUCKLER K. G.: Effect of gastric surgery upon gastric emptying in cases of peptic ulceration. Gut 8 (1967), 137. BURGE H., MACLEAN c., STEDEFORD R., PINN G. and HOLLANDERS D.: Selective vagotomy without drainage, an interim report. Brit. med. J. 3 (1969), 690. CLARKE R. J. McFARLAND J. B. and WILLIAMS J. A.: Gastric stasis and gastric ulcer after selective gastric vagotomy without a drainage procedure. Brit. med. J. 1 (1972), 538. COBB J. S., BANK S., MARKS I. N. and Louw J. T.: Gastric emptying after vagotomy and pyloroplasty. Relation to some postoperative sequelae. Amer. J. dig. Dis. 16 (1971), 207. DOZOIS R. P., KELLY K. A. and CODE C. F.: Effect of distal antrectomy on gastric emptying of liquids and solids. Gastroenterology 61 (1971), 5. HOLLE F., BAUER H., KLEMPA I., KONZ B., LISSNER J. und POETSCH H.: Zur Theorie und Praxis der selektiven proximalen Vagotomie (S.P.V. und Pyloroplastik). Bull. Soc. Int. Chir. 2 (1972), 90. KLEMPA J., HOLLE F., BRUCKNER W., WELSCH K. H., HANDLE H. and WOLFF A.: The effect of selective proximal vagotomy and pyloroplasty on gastric secretion and motility in dog. Arch. Surg. 103 (1971), 713. LAGEMANN K. und HOFFMANN K.: Magenmotilitat in Ruhe und bei korperlicher Belastung. Fortschr. Rontgenstr, 115 (1971), 817.
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SYMBAS P. N., KILLEN D. A. and SCOTT H. W.: An experimental study of effect of altering size of gastric pouch and integrity of pyloric sphincter on gastric emptying. Surg. Gynec. Obstet. 116 (1963), 643. WEDDLE C. 0., SPRINGFIELD A., ORMSBEE H. S. and BASS P.: Parietal cell vagotomy and gastric emptying of liquids in the dog. Arch. Surg. 108 (1974), 83. DE VITO R. V. and HARKINS H. N.: Techniques in Heidenhain pouch experiments. J. appl. Physiol. 14 (1959), 138. WICKBOM G., CHRISTOFFERSSON E., PERSSON J. E. and WALLENSTEN S.: Studier av ventrikeltornningen med 51Cr-markt Ioda i normalfall och hos patienter med duodenal- och ventrikelsar, (In Swedish.) Nord. Med. 86 (1971), 1285. WILBUR B. G. and KELLY K. A.: Effect of proximal gastric and truncal vagotomy on canine gastric electric activity, motility and emptying. Ann. Surg. 178 (1973), 295. WILKINSON A. R. and JOHNSON D.: Effect of truncal, selective and highly selective vagotomy on gastric emptying and intestinal transit of a food-barium meal in man. Ann. Surg. 178 (1973), 190.
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GASTRIC MOTILITY AND EMPTYING FOLLOWING PARIETAL CELL VAGOTOMY AND SELECTIVE GASTRIC VAGOTOMY Experimental investigation KIRSTEN MIKKELSEN, P. O. ERIKSEN and J. BONE In recent years, selective gastric vagotomy and parietal cell vagotomy (also called highly selective vagotomy or proximal gastric vagotomy) have been increasingly used in the treatment of duodenal ulcer. By the former method, reduction of acid secretion is achieved by cutting all branches of the vagal nerves to the stomach keeping the extragastric vagus intact. This procedure is ordinarily combined with pyloroplasty. By parietal cell vagotomy, only the parietal cell mass is denervated, and the innervation of the muscular gastric antrum is preserved. The clinical results in some series (AMDRUP & GRIFFITH 1969, AMDRUP & JENSEN 1970, WILBUR & KELLY 1973) seem to indicate that a drainage is not a necessary supplement to parietal cell vagotomy while other authors (KLEMPA 1971, HOLLE et coll. 1972) claim that this has to be added. As the drainage procedure may result in dumping symptoms, the question of its necessity is important. The present animal experiments aim at assessing the influence of the two methods and a drainage procedure upon gastric motility of a meal normally taken by the experimental animals. The intention was also to examine the influence of the operations on the hormonal phase of gastric secretion. Therefore, a denervated fornix pouch, i.e. a Heidenhain pouch, was constructed in all dogs and the influence of this operation on gastric emptying and motility was also assessed. Supported by grant from Statens Lregevidenskabelig Forskningsrad, No. 512-4235. Submitted for publication 23 October 1975. Acta Radiologica Diagnosis 17 (1976) Fasc. 5 September
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Fig. I. Technique of parietal cell vagotomy in a dog with a Heidenhain pouch. Dotted line indicates the border between corpus and antrum.
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Fig. 2. Technique of selective gastric vagotomy in a dog with a Heidenhein pouch and gastroduodenostomy.
Material and Methods Adult, healthy mongrel dogs were used and the gastric motility was recorded: (1) before and after application of a Heidenhain pouch, (2) after parietal cell vagotomy without drainage, (3) after application of a gastroduodenal anastomosis (method of Jaboulay) and (4) after altering the parietal cell vagotomy into a selective gastric vagotomy by cutting the antral nerves. Another series of dogs with a Heidenhain pouch was investigated before and after selective gastric vagotomy without a drainage operation. All procedures were performed under pentobarbital (Nembutal) anaesthesia (30 rug/kg intravenously). In all the dogs a Heidenhain pouch was first constructed according to the method of DE VITO & HARKINS (1959). On performing the parietal cell vagotomy, an intragastric pH electrode was used to determine the border between the corpus and the antrum after stimulation of acid secretion with 0.25 mg pentagastrin (Peptavlon) administered intramusculary 20 min before operation. The branches of the anterior and posterior gastric nerves were then sectioned from the border between the corpus and antrum to the gastroesophageal junction which was carefully 'skeletonized' circumferentially of all small vagal branches (Fig. 1). In selective gastric vagotomy the anterior and posterior gastric nerves were cut just below the left gastric artery. The remaining part of the stomach was denervated by the technique used in parietal cell vagotomy (Fig. 2). The gastroduodenal anastomosis was constructed between the distal part of the antrum and the upper part of the duodenum. The stoma was placed I to 2 cm from the pylorus and was 4 cm wide. Examinations were not started until 3 to 4 weeks following surgery. The gastric emptying rate was recorded by fluoroscopy 3 times for each dog after
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Table 1 Gastric emptying and motility before and after application of a Heidenhain pouch. In this and in the following tables gastric emptying time is the mean of 3 experiments in each dog
Dog No.
Waves per min
Strength
Peristaltic waves
Emptying time (min)
Before operation
AIO All A12 A13 A14 A15
5-6 5 5 5-6 6 6
3 3 3 3 3 2
+ + + + + +
217 200 147 199 260 297 220 ± 52.36 (mean)
After operation
A10 All A12 A13 A14 A15
? 4 4-5 6 6 4-5
3 3 2 2 3 2
+ +
279 175 162 126 133 179 176 ± 55.06 (mean)
+ + + +
+ All effective
Table 2 Gastric empyting and motility before and after application of partial cell vagotomy (PC V)
Operation
Dog No.
Waves per min
Strength
Heidenhain pouch
All A14 A24 A25 A26 A28
4 6 5 5 ? 5
3 3 3 3 2 3
All A14 A24 A25 A26 A28
5 6 5 4 ? 5
3 3 3 2 2 3
Heidenhain pouch +PCV
Peristaltic waves
Emptying time (min)
+
175 133 130 163 155 150 151±17.33 (mean)
+ + + + + + + +
+ +
+ All effective - Some ineffective
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170 148 192 222 158 152 173 ± 28.80 (mean)
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PARIETAL CELL VAGOTOMY
Table 3 Gastric emptying and motility before and after application ofparietal cell vagotomy (PC V) and Jaboulay anastomosis (GD) Operation
Dog No.
Waves per min
Strength
Peristaltic waves
Emptying time (min)
Heidenhain pouch
A24 A25 A26 A28 A29 A31 A32 A33
5 5 ? 5 5 6 5 5
3 3 3 3 3 3 3 3
+
130 163 155 150 143 133 135 117 141 ± 14.99 (mean)
A24 A25 A26 A28 A29 A31 A32 A33
18 20 15 ? 10 8 10 20
1 1 1 0 2 1 1 1
+
PCV+GD
+ + + + +
+ +
+ + + + ?
+
122 110 117 147 110 115 110 215 131 ±35.96 (mean)
+ All effective - Some ineffective
each of the mentioned operations. After 18 hours of fasting the dogs were given 200 g of standard dog food (in 100 g: 9 g of protein, 3 g of fat, and 7 g of carbohydrate) with 75 ml barium sulphate added. The stomach was considered empty when only a slight mucosal coating persisted. At the first examination the dogs were placed on the screening couch, 5, 15, 30, 45, 60, 90 and 120 min after the meals and a videotape was recorded. At the two following examinations they were screened at 60, 90, 120 min and until the moment of emptying. Evaluation of motility was later made by replaying the videotape (method of LAGEMANN & HOFFMANN 1971). Assessments were made according to the following scheme: (1) frequency of peristaltic contractions measured as waves per min; (2) intensity of the peristaltic waves, equalling the superficial contraction as force 1, medium deep as force 2, and the extra deep hour-glass shaped contractions as force 3, no peristalsis as 0; and (3) effect of the peristalsis indicated by the number of contractions emptying some of the gastric content into the duodenum. Results of the emptying rate are given in min as mean ± SD. The significance of mean differences was estimated with Student's t-test for paired values. 46 - 765833
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Table 4 Gastric emptying time before and after altering the parietal cell vagotomy and anastomosis (PCV-+ G D) into a selective gastric vagotomy and anastomosis (SG V -+ G D). Gastric motility ceased completely after selective gastric vagotomy Dog N:).
Emptying time (min) rCV+GD
SGV+GD
A24 A25 A26 A28 A29 A31 A32 A33
122 ItO 117 147 110 115 110 215
lIS 100 95 112 60 152 147 202
Mean
131 ±35.96
123±43.30
Results Generally the peristalsis started about IS min after the meal. The behaviour of the stomach remained unaltered within the first hour, then the peristalsis tapered slowly. As in man, the fornix of the stomach only made slight movements, whereas peristalsis occurred in the intact antrum propelling the gastric content into the duodenum. After application of a Heidenhain pouch. Six dogs were used (Table I). Only a slight alteration of the force of the contractions occurred in 2 of the dogs (A 12 and A 13). The mean emptying time for the group decreased, but insignificantly from 226±S2.36 to 176±SS.06 min. After parietal cell vagotomy. Six dogs were used (Table 2). The stomach appeared as before the operation. The strength of the contraction of the peristaltic waves was unchanged except in dog A 2S. A non-significant increase in the mean emptying time from lSI ± 17.33 to 173± 28.80 min occurred in this group. After parietal cell vagotomy and gastroduodenal anastomosis. Eight dogs were used (Table 3). Previously, 4 of them had a parietal cell vagotomy without anastomosis (A24, A2S, A26, A28). After the operation the barium passed mainly through the anastomosis and only to a small degree through the pylorus. The strength of the contractions decreased in all of the dogs while the number of peristaltic contractions increased. However, as compared to the control group, mean emptying time for the whole group decreased insignificantly from 141 ± 14.99 to 131 ±3S.96 min. Even if
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719
Table 5 Gastric emptying time in dogs with a Heidenhain pouch be/ore and after application 0/ selective gastric vagotomy without anastomosis. Gastric motility ceased completely after the uagitomy
Dog No.
Empyting time (min) Before operation
After operation
A7 A34 A36 A43
225 153 207 140
480 460 440 350
Mean
181 ±41.13
433±57.37
the dogs with previous parietal cell vagotomy are considered separately, no significant alteration occurred.
After selective gastric vagotomy and gastroduodenal anastomosis. The same 8 dogs as in the last section were used (Table 4). After cutting the antral nerves the stomach in all the dogs appeared like a big, slack bag, emptying through the anastomosis only. No peristalsis was observed. The emptying time decreased insignificantly from 131 ±35.96 to 123±43.30 min. After selective gastric vagotomy without drainage. Four dogs were used (Table 5). After the operation the stomach appeared big, slack and atonic as in the foregoing group but the emptying time was significantly delayed from 181±41.13 to 433± 57.37 min (p < 0.005). Discussion
The methods for investigation of the gastric emptying rate are numerous: plastic spheres were used by WILBUR & KELLY (1973), liquid meals with contrast medium added by AMDRUP & GRIFFITH (1969), scintigraphy by WICKBOM et colI. (1971) and aspiration by BUCKLER (1967). The results differ widely, however. The examining conditions must be as identical as possible to the normal. The contrast medium added to the meal should not interfere with the determinations of the various parameters under assessment. The contrast medium used seems to fulfil these requirements. Less physiologic contrast meals have been used in some previous investigations. There seems to be no report available on the significance of a Heidenhain pouch on gastric motility and emptying. The present results indicate that the pouch does not alter the emptying rate or motility. Following selective gastric vagotomy the stomach became dilated and slack with complete atony. The meal was propelled only passively and slowly through the pylorus, resulting in a protracted retention of the meal in the stomach. Following a Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 14, 2015
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gastroduodenostomy, the emptying time was reduced as the contrast passively passed through the anastomosis. After parietal cell vagotomy, the size and shape of the stomach were normal, the strength and number of the contractions were unaltered and the emptying time was insignificantly delayed. On the other hand, AMDRUP & GRIFFITH in dogs with a Heidenhain pouch using a homogeneous mixture of evaporated milk, barium sulphate and water observed a non-significant increase in the stomach emptying rate. Similar results were reported by WILBUR & KELLY who in dogs without a Heidenhain pouch employed solid plastic spheres. If a difference exists between the present results and the two reports mentioned, this may be explained by the difference of the type of meal used, in the present experiments being a normal dog meal, non-homogeneous and semisolid. The present results agree with those of clinical examinations, in which similar types of physiologic meal and added contrast medium were employed (BRANDSBORG et coIl. 1975). Contrary to this, KLEMPA et coIl. (1971) using colloidal barium SUlphate found a significantly prolonged gastric emptying after parietal cell vagotomy in dogs with a Heidenhain pouch. This discrepancy may be explained by differences in the operative procedure. In the present experiments the pH electrode was used for the determination of the border between the antrum and the corpus. It was in all dogs identified about 2 em proximal to the border indicated by the anatomy of the nerves and used by KLEMPA et coIl. It is likely that the prolonged gastric emptying time after their operation was caused by the more extensive denervation of the antrum. With reference to the results of KLEMPA et coIl., HOLLE et coIl. claim that a drainage procedure always has to be performed together with parietal cell vagotomy. The present results indicate that emptying is normal after parietal cell vagotomy while the addition of a drainage procedure changes the motility with a considerable reduction in the intensity of the gastric contractions, presumably because the meal is passively transported through the anastomosis. This results in a more rapid emptying which in man may lead to 'dumping'. In conclusion it may be said that parietal cell vagotomy does not affect the gastric motility and emptying but that this procedure with drainage and selective gastric vagotomy with or without drainage affect both the motility and emptying. The results achieved in animal experiments indicate that parietal cell vagotomy without drainage is the procedure of choice.
SUMMARY After parietal cell vagotomy in dogs antral motility and gastric emptying time is unaffected. Addition of a drainage procedure changed the motility considerably by decreasing the force of contractions and diminishing the number of peristaltic waves. After cutting the antral nerves complete atony occurred, but emptying rate was unaltered as the contrast meal passed passively through the anastomosis. Selectivegastric vagotomy without drainage caused atony and significantly prolonged emptying time.
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PARIETAL CELL VAGOTOMY
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ZUSAMMENFASSUNG Nach parietaler Zellvagotomie war die Motilitat des Antrums und die Entleerungszeit des Magens von Hunden nicht beeinflusst. Ein zusatzliches Drainageverfahren veranderte die Motilitat durch einen Abfall der Kraft der Kontraktionen und eine verminderte Zahl von peristaltischen Wellen betrachtlich, Nach Abschneiden der Nerven des Antrums trat eine vollstandige Atonie auf. Jedoch war die Entleerungsgeschwindigkeit unverandert, wenn die Kontrastmahlzeit passiv durch die Anastomose befOrdert wurde. Eine selektive Vagotomie des Magens ohne Drainage verursachte eine Atonie und eine signifikant verlangerte Entleerungszeit.
RESUME La rnotilite antrale et la duree de l'evacuation gastrique ne sont pas modif'iees apres vagatomie cellulaire parietale chez des chiens. L'association d'une technique de drainage modifie considerablernent la motilite en diminuant la force des contractions et en diminuant Ie nombre des ondes peristaltiques. Apres section des nerfs antraux apparait une atonie complete mais la vitesse d'evacuation est inchangee car Ie repas baryte passe passivement a travers I'anastomose. La vagotomie gastrique selective sans drainage entraine une atonie et une prolongation importante de la duree d'evacuation.
REFERENCES AMDRUP B. M. and GRIFFITH C. A.: Selective vagotomy of the parietal cell mass. Part I. With preservation of the innervated antrum and pylorus. Ann. Surg. 170 (1969), 207. AMDRUP E. and JENSEN H. E.: Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum. Gastroenterology 59 (1970), 522. BRANDSBORG 0., BRANDSBORG M., MIKKELSEN K. and LOVGREEN N. A.: Selective gastric vagotomy and parietal cell vagotomy by duodenal ulcer. Influence upon gastric motility and serum-gastrin-concentration. Gastroenterology (1975), in press. BUCKLER K. G.: Effect of gastric surgery upon gastric emptying in cases of peptic ulceration. Gut 8 (1967), 137. BURGE H., MACLEAN c., STEDEFORD R., PINN G. and HOLLANDERS D.: Selective vagotomy without drainage, an interim report. Brit. med. J. 3 (1969), 690. CLARKE R. J. McFARLAND J. B. and WILLIAMS J. A.: Gastric stasis and gastric ulcer after selective gastric vagotomy without a drainage procedure. Brit. med. J. 1 (1972), 538. COBB J. S., BANK S., MARKS I. N. and Louw J. T.: Gastric emptying after vagotomy and pyloroplasty. Relation to some postoperative sequelae. Amer. J. dig. Dis. 16 (1971), 207. DOZOIS R. P., KELLY K. A. and CODE C. F.: Effect of distal antrectomy on gastric emptying of liquids and solids. Gastroenterology 61 (1971), 5. HOLLE F., BAUER H., KLEMPA I., KONZ B., LISSNER J. und POETSCH H.: Zur Theorie und Praxis der selektiven proximalen Vagotomie (S.P.V. und Pyloroplastik). Bull. Soc. Int. Chir. 2 (1972), 90. KLEMPA J., HOLLE F., BRUCKNER W., WELSCH K. H., HANDLE H. and WOLFF A.: The effect of selective proximal vagotomy and pyloroplasty on gastric secretion and motility in dog. Arch. Surg. 103 (1971), 713. LAGEMANN K. und HOFFMANN K.: Magenmotilitat in Ruhe und bei korperlicher Belastung. Fortschr. Rontgenstr, 115 (1971), 817.
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SYMBAS P. N., KILLEN D. A. and SCOTT H. W.: An experimental study of effect of altering size of gastric pouch and integrity of pyloric sphincter on gastric emptying. Surg. Gynec. Obstet. 116 (1963), 643. WEDDLE C. 0., SPRINGFIELD A., ORMSBEE H. S. and BASS P.: Parietal cell vagotomy and gastric emptying of liquids in the dog. Arch. Surg. 108 (1974), 83. DE VITO R. V. and HARKINS H. N.: Techniques in Heidenhain pouch experiments. J. appl. Physiol. 14 (1959), 138. WICKBOM G., CHRISTOFFERSSON E., PERSSON J. E. and WALLENSTEN S.: Studier av ventrikeltornningen med 51Cr-markt Ioda i normalfall och hos patienter med duodenal- och ventrikelsar, (In Swedish.) Nord. Med. 86 (1971), 1285. WILBUR B. G. and KELLY K. A.: Effect of proximal gastric and truncal vagotomy on canine gastric electric activity, motility and emptying. Ann. Surg. 178 (1973), 295. WILKINSON A. R. and JOHNSON D.: Effect of truncal, selective and highly selective vagotomy on gastric emptying and intestinal transit of a food-barium meal in man. Ann. Surg. 178 (1973), 190.
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