Br. J. Surg. Vol. 62 (1975) 879-881
The effect of the size of the gastric outlet on gastric emptying after vagotomy for duodenal ulcer W. D. G E O R G E , D. J . C O W L E Y , C. M . R O Y S T O N , H. I. G L A S S AND J. S P E N C E R * SUMMARY
Gastric emptying of isotopically labelled solid meals was studied in normal human subjects and in 30 patients who had had an operation for chronic duodenal ulcer. Each patient had a vagotomy of the whole stomach combined with either a Finney pyloroplasty to produce a large gastric outlet or a Heineke-Mikulicz pyloroplasty to produce a relatively small outlet. At 10-22 days after operation gastric emptying was equally and significantly slowed in both groups when compared with the normal controls. This delay occurred regardless of whether the vagotomy was complete or incomplete. At 4-6 months after operation emptying had returned to normal in the patients who had had a Finney pyloroplasty but remained significantly slowed after HeinekeMikulicz pyloroplasty. Mild symptoms of gastric stasis frequently occurred in both groups in the early postoperative period, but were rare 4-6 months afier operation. There was no correlation between the incidence of these early symptoms of stasis and the size of the gastric outlet constructed. SYMPTOMS of gastric stasis are a well-recognized complication of vagotomy and drainage operations (Williams and Barnes, 1969), and may occasionally be severe and prolonged (Hermann and Johnson, 1970). Cowley et al. (1972) found that gastric emptying of solid meals was slower than that of a normal control group, both at 1 4 weeks and later at 1 4 months after vagotomy and pyloroplasty. However, emptying had returned to normal in patients tested more than 1 year after operation. This early delay in emptying occurred regardless of whether the vagotomy was complete or incomplete, and it was postulated that a factor other than vagal denervation was responsible. One possible factor which the investigators considered was that the pyloroplasty could actually reduce the size of the gastric outlet and thus lead to temporary retention of solids. To resolve this question in patients undergoing total gastric vagotomy it was decided to compare the effects on gastric emptying of two different types of pyloroplasty, one of which would produce a large and the other a relatively small gastric outlet.
Materials and methods Subjects and surgical procedures Thirty patients who had had an operation for chronic duodenal ulcer were studied; there were 5 women and 25 men of mean age 46.3 years (range 24-68). These were compared with a control group of 17 healthy 64*
volunteers; 4 women and 13 men of mean age 42.5 years (range 26-65). The surgically treated group all had a total gastric vagotomy by the method of the surgeon’s choice: 17 had a selective vagotomy and 13 a truncal vagotomy. If considered suitable for a pyloroplasty they were then randomly allocated to have one of two forms of pyloroplasty (Fig. 1). Sixteen patients had a 12-cm long incision over the pylorus and duodenum closed by Finney’s method to produce a large gastric outlet, and 14 had a 5-cm long incision Finney pyloroplasty
Heineke-Mikulicz pyloroplasty
Fig. 1 . Operations employed : total gastric vagotomy with either a large Finney or small Heineke-Mikulicz pyloroplasty.
over the pylorus closed transversely in the HeinekeMikulicz fashion to produce a relatively small gastric outlet. Either pyloroplasty was closed with two layers of continuous catgut. No patient with preoperative or operative evidence of pyloric stenosis was included in the study. Gastric emptying tests in 26 of these patients (15 Finney, I 1 Heineke-Mikulicz) were carried out 10-22 days after operation, and were (repeated 4-6 months postoperatively in 24 patients 13 Finney, 11 Heineke-Mikulicz). The latter group
* Departments of Surgery and Medical Physics, Royal Postgraduate Medical School, Hammersmith Hospital, London. Present address of W. D. George and D. J. Cowley: University Department of Surgery, University Hospital of South Manchester. Manchester. 879
W. D. George et al. included 20 patients who had had early postoperative tests, and 4 in whom the early test had been a technical failure. Measurement of gastric emptying The method used was the modified gamma camera technique described by Cowley et al. (1972). After an overnight fast the patient ate a meal of two scrambled eggs, two slices of buttered bread and 300 ml of milk; 1OOpCi lz@Csbound to zirconium phosphate were stirred into the milk, which was drunk intermittently throughout the meal. Immediately after finishing the meal the patient was positioned supine beneath the gamma camera, and counts of radioactivity from the stomach area were recorded continuously on magnetic tape for 90 minutes. After correction for background radioactivity the integrated counts for each 5-minute period from the delineated stomach area were printed out by a computer. Analysis of results Gastric emptying has been expressed as the percentage emptying in each 5-minute period against time. The total radioactivity count for each 5-minute period of the test was calculated and expressed as a percentage of the initial 5-minute count. Emptying as expressed by this percentage was calculated for seventeen 5-minute periods after the initial count. The mean percentage gastric emptying of each group at these time intervals was compared with that in the other groups in the study, and submitted to statistical analysis using Student’s t-test for unpaired data to compare group means. The conventional half-emptying times were not used, as in the patients after vagotomy and pyloroplasty the emptying pattern was seldom monoexponential.
Results The mean time between starting the meal and beginning the recording was 10.1 minutes for the control
group, 11.5 minutes for patients with a Finney pyloroplasty and 11.9 minutes for those with a Heineke-Mikulicz pyloroplasty. There was no significant difference between the groups. The mean percentage emptying patterns of the two operated groups at both times of testing are shown in Fig. 2, and are compared with the emptying pattern of the control group. At 10-22 days after operation the mean gastric emptying following either form of pyloroplasty was equally and significantly slowed when compared with the control group (P
The effect of the size of the gastric outlet on gastric emptying after vagotomy for duodenal ulcer W. D. G E O R G E , D. J . C O W L E Y , C. M . R O Y S T O N , H. I. G L A S S AND J. S P E N C E R * SUMMARY
Gastric emptying of isotopically labelled solid meals was studied in normal human subjects and in 30 patients who had had an operation for chronic duodenal ulcer. Each patient had a vagotomy of the whole stomach combined with either a Finney pyloroplasty to produce a large gastric outlet or a Heineke-Mikulicz pyloroplasty to produce a relatively small outlet. At 10-22 days after operation gastric emptying was equally and significantly slowed in both groups when compared with the normal controls. This delay occurred regardless of whether the vagotomy was complete or incomplete. At 4-6 months after operation emptying had returned to normal in the patients who had had a Finney pyloroplasty but remained significantly slowed after HeinekeMikulicz pyloroplasty. Mild symptoms of gastric stasis frequently occurred in both groups in the early postoperative period, but were rare 4-6 months afier operation. There was no correlation between the incidence of these early symptoms of stasis and the size of the gastric outlet constructed. SYMPTOMS of gastric stasis are a well-recognized complication of vagotomy and drainage operations (Williams and Barnes, 1969), and may occasionally be severe and prolonged (Hermann and Johnson, 1970). Cowley et al. (1972) found that gastric emptying of solid meals was slower than that of a normal control group, both at 1 4 weeks and later at 1 4 months after vagotomy and pyloroplasty. However, emptying had returned to normal in patients tested more than 1 year after operation. This early delay in emptying occurred regardless of whether the vagotomy was complete or incomplete, and it was postulated that a factor other than vagal denervation was responsible. One possible factor which the investigators considered was that the pyloroplasty could actually reduce the size of the gastric outlet and thus lead to temporary retention of solids. To resolve this question in patients undergoing total gastric vagotomy it was decided to compare the effects on gastric emptying of two different types of pyloroplasty, one of which would produce a large and the other a relatively small gastric outlet.
Materials and methods Subjects and surgical procedures Thirty patients who had had an operation for chronic duodenal ulcer were studied; there were 5 women and 25 men of mean age 46.3 years (range 24-68). These were compared with a control group of 17 healthy 64*
volunteers; 4 women and 13 men of mean age 42.5 years (range 26-65). The surgically treated group all had a total gastric vagotomy by the method of the surgeon’s choice: 17 had a selective vagotomy and 13 a truncal vagotomy. If considered suitable for a pyloroplasty they were then randomly allocated to have one of two forms of pyloroplasty (Fig. 1). Sixteen patients had a 12-cm long incision over the pylorus and duodenum closed by Finney’s method to produce a large gastric outlet, and 14 had a 5-cm long incision Finney pyloroplasty
Heineke-Mikulicz pyloroplasty
Fig. 1 . Operations employed : total gastric vagotomy with either a large Finney or small Heineke-Mikulicz pyloroplasty.
over the pylorus closed transversely in the HeinekeMikulicz fashion to produce a relatively small gastric outlet. Either pyloroplasty was closed with two layers of continuous catgut. No patient with preoperative or operative evidence of pyloric stenosis was included in the study. Gastric emptying tests in 26 of these patients (15 Finney, I 1 Heineke-Mikulicz) were carried out 10-22 days after operation, and were (repeated 4-6 months postoperatively in 24 patients 13 Finney, 11 Heineke-Mikulicz). The latter group
* Departments of Surgery and Medical Physics, Royal Postgraduate Medical School, Hammersmith Hospital, London. Present address of W. D. George and D. J. Cowley: University Department of Surgery, University Hospital of South Manchester. Manchester. 879
W. D. George et al. included 20 patients who had had early postoperative tests, and 4 in whom the early test had been a technical failure. Measurement of gastric emptying The method used was the modified gamma camera technique described by Cowley et al. (1972). After an overnight fast the patient ate a meal of two scrambled eggs, two slices of buttered bread and 300 ml of milk; 1OOpCi lz@Csbound to zirconium phosphate were stirred into the milk, which was drunk intermittently throughout the meal. Immediately after finishing the meal the patient was positioned supine beneath the gamma camera, and counts of radioactivity from the stomach area were recorded continuously on magnetic tape for 90 minutes. After correction for background radioactivity the integrated counts for each 5-minute period from the delineated stomach area were printed out by a computer. Analysis of results Gastric emptying has been expressed as the percentage emptying in each 5-minute period against time. The total radioactivity count for each 5-minute period of the test was calculated and expressed as a percentage of the initial 5-minute count. Emptying as expressed by this percentage was calculated for seventeen 5-minute periods after the initial count. The mean percentage gastric emptying of each group at these time intervals was compared with that in the other groups in the study, and submitted to statistical analysis using Student’s t-test for unpaired data to compare group means. The conventional half-emptying times were not used, as in the patients after vagotomy and pyloroplasty the emptying pattern was seldom monoexponential.
Results The mean time between starting the meal and beginning the recording was 10.1 minutes for the control
group, 11.5 minutes for patients with a Finney pyloroplasty and 11.9 minutes for those with a Heineke-Mikulicz pyloroplasty. There was no significant difference between the groups. The mean percentage emptying patterns of the two operated groups at both times of testing are shown in Fig. 2, and are compared with the emptying pattern of the control group. At 10-22 days after operation the mean gastric emptying following either form of pyloroplasty was equally and significantly slowed when compared with the control group (P
