Influence of subtotal gastrectomy on bile acid concentration, total bacterial counts in the gastric juice, and histologic changes in the gastric mucosa

The concentrations of bile acids, PH and total bacterial counts in the gastric juice were measured among 44 patients with peptic ulcer before and after subtotal gastrectomy (Billroth II in 14 cases, Billroth I in 10 cases, and PAFPG in 20 cases). Thirty three patients were studied by endoscopy and gastric mucosa biopsy one year after the surgery. The results showed that the fasting gastric bile acids concentrations in both B-II and B-I groups were significantly higher than in PAFPG group, when examined 3 weeks and 1 year postoperatively. The PH and total bacterial counts in gastric juice were increased significantly after B-II and B-I reconstruction compared with PAFPG. The abnormal histology of gastric remnant mucosa was more common in B-II or B-I groups than in PAFPG (P less than 0.05). Our data demonstrated that B-II and B-I gastrectomy caused considerably enterogastric reflux, while PAFPG prevented it effectively by keeping the gastric physiology in a relatively stable status. It is the authors' belief that the results provide objective basis for selecting surgical procedure and evaluating operative effects.     

Postprandial plasma secretin and CCK release in patients with gastrectomy and pancreatoduodenectomy]

Postprandial plasma secretin and CCK release were investigated in patients with gastrectomy and pancreatoduodenectomy reconstructed by Billroth-I, Billroth-II, Roux-en-Y and Child's methods. Plasma secretin response were significantly decreased in patients with B-I and B-II reconstruction after gastrectomy, especially in total gastrectomized patients with Roux-en-Y reconstruction, which might be resulted from the reduced gastric acid secretion following gastrectomy. CCK release was not significantly changed in patients with various reconstructions after gastrectomy compared with control group. In patients with pancreatoduodenectomy reconstructed by Child's method plasma secretin and CCK release were significantly decreased as compared with normal controls.     

Bone lesions and dental caries after gastrectomy

We investigated the development of bone lesions and dental caries in 350 patients who had undergone gastrectomy during the 11 year period from 1968 to 1978, on the basis of bone mineral content (BMC), decayed missing and filled (DMF) teeth and urinary c-AMP. We found that patients with low BMC and incidence of DMF teeth increased in number during the postoperative years; These abnormalities were, in comparison to the Billroth-I (B-I) and milk intake groups, significant in the Billroth-II (B-II) and non-milk intake groups. Among the gastrectomized patients, those with increased DMF teeth had significantly higher contents of urinary c-AMP. The possibility that secondary hyperparathyroidism resulting from gastrectomy contributes to the development and incidence of dental caries has to be given consideration.     

Quantification of duodenogastric reflux in gastroduodenal peptic ulcer and in gastric operation patients, using a 24-h gastric pH measurement as a quantification technique

Twenty-four-hour gastric pH measurement was used to study duodenogastric reflux. To differentiate between gastric hyposecretion and duodenogastric reflux, we also measured bile acid concentrations in the gastric juice, and regarded pH increases to above 4 as possible episodes of reflux. The procedure was used in 60 patients, divided into the following groups: (1) control group (ten patients); (2) duodenal ulcer (ten patients); (3) type 1 gastric ulcer (five patients); (4) type 3 gastric ulcer (five patients); (5) bilateral truncal vagotomy plus pyloroplasty (ten patients); (6) truncal vagotomy plus Billroth I partial gastrectomy (ten patients); and (7) truncal vagotomy plus Billroth II partial gastrectomy (ten patients). The amount of reflux (areas of pH greater than 4) in the type 1 gastric ulcer and Billroth I and Billroth II groups was significantly greater than that found in the control, duodenal ulcer, type 3 gastric ulcer and truncal vagotomy plus pyloroplasty groups. The mean concentration of total bile acids was also greater in the gastrectomized patients than in the rest of the groups studied. In the type 1 gastric ulcer group the mean bile acid concentration was similar to that of the control group.     

Pylorus-preserving gastrectomy: Effect on resistance through the sphincter of Oddi compared to conventional distal gastrectomy in dogs

Bile stasis is an important etiologic factor in the high incidence of postgastrectomy gallstone disease (PGGD). Our previous study showed that duodenal, but not prepyloric, transection disturbed the motility of the sphincter of Oddi (SO) in anesthetized dogs. We had developed pylorus-preserving gastrectomy (PPG), in which the anal margin of the resected stomach is the prepyloric portion, not the duodenum. The present study evaluated the usefulness of PPG for reducing bile stasis, which may induce PGGD. We examined the resistance of bile flow through the SO using dogs that had undergone either PPG (n = 5) or conventional distal gastrectomy ( B-I) (n = 5). Four weeks after gastrectomy we anesthetized the animals and compared the basal and volume load-induced pressure in the common bile duct (CBD) between groups with or without administration of cholecystokinin-8 (CCK8). Flow resistance of the SO was evaluated by measuring flow volume through the SO following a graded pressure load to the CBD. The basal pressure and the threshold pressure to open the SO were significantly lower in PPG dogs than in B-I dogs independent of CCK8 administration. There were no significant differences between groups in regard to volume load-induced pressure elevation or the resistance of the SO. These results indicate that PPG may be more useful for reducing the incidence of PGGD than conventional distal gastrectomy, possibly through attenuating resistance to bile flow.     

Contractile function of the gallbladder after gastrectomy

Gallbladder contractile function was observed by B-mode ultrasonography on patients with radical gastrectomy for gastric carcinoma (20 cases), with subtotal gastrectomy for peptic ulcer (36 cases), and with highly selective vagotomy (7 cases). Thirty-one preoperative patients with peptic ulcer were used as control. It was found that within one month after radical or subtotal gastrectomy the average area and the volume of the gallbladder became much larger than that found in control group. The empty rate of the gallbladder was found decreased and the remainder bile increased. Early stage gallstones were found in two cases 11 and 13 months after gastrectomy. The inner diameter of the common bile duct was increased after radical gastrectomy. No definite relationship was found between gallbladder contractile disfunction and the mode of gastroenterostomy. It was also found that highly selective vagotomy had only slight influence on the biliary tract. These results suggest that gastrectomy has significant influence on the function of biliary tract and plays an important role in the formation of gallstones.     

Delayed gastric emptying of liquids and solids following Roux-en-Y biliary diversion.

Recent reports cite an increased incidence in delayed gastric emptying following Roux-en-Y biliary diversion for alkaline reflux gastritis. The effect of Roux-en-Y diversion on the gastric emptying of liquids and solids was evaluated following vagotomy and antrectomy and vagotomy and subtotal gastrectomy. Twenty dogs underwent placements of large Thomas cannula in the stomach. Four dogs with intact stomachs served a controls. Eight dogs each with vagotomy and antrectomy were subdivided into Roux-en-Y gastrojejunostomy (RYA) and a Billroth II (B-IIA) group. Eight dogs each with vagotomy and subtotal gastrectomy were subdivided into similar groups. Four dogs - Roux-en-Y (RSTG) and four dogs - Billroth II (B-IISTG). Gastric emptying of solid food, normal saline and 25% dextrose was evaluated. RYA dogs demonstrated a significant delay in gastric emptying of solids compared with corresponding B-IIA animals. RYA dogs had 76, 61 and 42% of solid food retained at three, five and eight hours while B-II animals retained 56, 41 and 20%, respectively. The results are highly significant at all time intervals (p less than 0.001 at five and eight hours). Control animals retained 34, 17 and 3% of solid food at three, five and eight hours. RSTG animals had 73, 52 and 28% retained solids at three, five and eight hours, while B-IISTG animals had 55, 42 and 13% retention, respectively (p less than 0.05 at eight hours). Normal saline was significantly delayed in both Roux-en-Y subgroups compared with B-II dogs (p less than 0.02 in V/A, p less than 0.05 in V/STG). There was a trend toward delayed emptying of 25% dextrose in the Roux-en-Y groups, but significance was achieved only in the RYA compared with B-IIA groups (p less than 0.02 at 30 minutes). Delayed gastric emptying following Roux-en-Y gastrojejunostomy is documented in the experimental animals which underwent vagotomy and appears greater in magnitude than that observed following vagotomy and B-II gastrectomy. These data corroborate the clinical observations of severe delayed gastric emptying in patients undergoing Roux-en-Y diversions for alkaline gastritis.     

Intestinal microflora and bile acids following biliary tract reconstruction

The purpose of this study was to evaluate the intestinal microflora and the composition of various bile acids in jejunal fluid following B-I and B-II types of biliary reconstruction in dogs. B-1 type reconstruction, in which the biliary tract was directly anastomosed to the food passing tract, was performed in 8 dogs, which received cholecystoduodenostomy (group C-D) and in 8 which received cholecystojejunostomy (group C-J). B-II type reconstruction by Roux-Y cholecystojejunostomy, in which bile flowed into the jejunal limb, was performed in 8 dogs (group R-Y). Incidences of detection of gram-positive, gram-negative and anaerobic bacteria were as follows: 33%, 33% and 6% in the jejunal fluid obtained at initial operation, 67%, 67% and 33% in group C-D, 83%, 67% and 33% in group C-J, and 75%, 88% and 75% in group R-Y. In six dogs in group R-Y, unconjugated or secondary bile acids in the jejunal fluid increased, while these increases were observed in only two dogs in group C-J and in no dogs in C-D. Unconjugated and secondary bile acids were more likely to increase following B-II type reconstruction than following B-I type reconstruction. These findings are thought to be associated with bacterial overgrowth in the jejunal loop. These results suggest that B-II type reconstruction, in which bilio-enterostomy is exposed with infected intestinal fluid and unconjugated and secondary bile acids, is inferior in preventing ascending cholangitis.     

Canine gallbladder bile. Effects of proximal gastric vagotomy, truncal vagotomy, and truncal vagotomy with pyloroplasty on volume and composition.

Three groups of four dogs each underwent proximal gastric vagotomy, truncal vagotomy, or truncal vagotomy with pyloroplasty. Two dogs had sham operations. Gallbladder bile was aspirated and measured. Aliquots were cultured and assayed for cholesterol, phospholipid, and bile salts initially and at subsequent laparotomies. Both truncal vagotomy groups showed marked increases in aspirate volume at subsequent laparotomies. The sham and proximal gastric vagotomy groups showed a small initial decrease in mean aspirate volume without further significant changes. When the bile assay data were plotted on triangular coordinates, all point for all groups remained well within the area of cholesterol solubility. Nevertheless, two dogs in each truncal vagotomy group were found to have gallstones. No stones were found in the sham and proximal gastric vagotomy groups. Proximal gastric vagotomy appears to preserve fasting gallbladder bile volume and does not alter bile composition in the dog.     

Absorption of amino acids in patients after partial gastrectomy (B II) and truncal vagotomy with pyloroplasty or antrectomy (author's transl)

After surgery for gastric or duodenal ulcer the resorption of amino acids is changed due to alteration of morphology and function of stomach, bile system, pancreas and small bowel. We used the stable isotope labelled amino acid 15N-glycine in patients after partial gastrectomy (B II), truncal vagotomy with pylorplasty as well as antrectomy and in healthy persons. It could be shown that in contrast to the control group the absorption of the amino acid in the surgical group took place more rapid and more intensive.     

Effect of bile acid gavage or vagotomy and pyloroplasty on gastrointestinal carcinogenesis

Possible promotion of MNNG-induced gastrointestinal carcinogenicity was evaluated in male Wistar rats exposed to unconjugated bile acid given as gavage or as obtained through truncal vagotomy plus pyloroplasty. No significant difference was found compared with the relevant control groups. Even though gastroduodenal erosions were found more frequently in the bile acid gavage and MNNG groups than in MNNG-treated controls, secondary deconjugated bile acids apparently did not reach optimal promoting concentrations. In contrast to partial gastrectomy, vagotomy and pyloroplasty does not increase the tumor yield in the rat.     

残胃癌贲门胃底切除余胃食管再吻合的实验研究和临床应用

１９８０年以来作者对残胃贲门癌的治疗问题进行了实验和临床研究。作者选用杂种犬６０只,先以Ｂ－Ⅰ式及Ｂ－Ⅱ式行胃大部切除。２０周后残胃行贲门胃底切除,余胃食管吻合。病理见余胃血液循环良好,食管余胃吻合口愈合良好。在实验研究基础上,对收治的残胃贲门癌２５例,１７例行残胃贲门胃底切除,余胃食管吻合,术后恢复良好。实验和临床均证实残胃贲门胃底切除余胃食管再吻合的方法是安全可行的,既符合器官保存的手术原则,也符合肿瘤切除原则。     

Bone lesions and dental caries after gastrectomy--evaluation of milk intolerance and operative procedure

We investigated the development of bone lesions and dental caries in 350 patients who had undergone gastrectomy during the 11 year period from 1968 to 1978, on the basis of bone mineral content (BMC), decayed missing and filled (DMF) teeth and urinary c-AMP. We found that patients with low BMC and incidence of DMF teeth increased in number during the postoperative years; These abnormalities were, in comparison to the Billroth-I (B-I) and milk intake groups, significant in the Billroth-II (B-II) and non-milk intake groups. Among the gastrectomized patients, those with increased DMF teeth had significantly higher contents of urinary c-AMP. The possibility that secondary hyperparathyroidism resulting from gastrectomy contributes to the development and incidence of dental caries has to be given consideration.     

Bile reflux and degree of gastritis in patients with gastric ulcer: before and after operation

The incidence and degree of bile reflux and gastritis has been measured in normal subjects and in patients with gastric ulcer before operation and after treatment by highly selective vagotomy with ulcer excision, Billroth 1 partial gastrectomy, and truncal vagotomy and drainage. Before operation patients had significantly higher (P less than 0.001) bile acid concentrations in the stomach than normal subjects. Treatment by highly selective vagotomy resulted in significantly lower bile acid concentrations than those before operation and those found after Billroth 1 partial gastrectomy. Antral and body gastritis was significantly less in normal subjects than in the preoperative and all postoperative groups. There was no significant difference in antral or body gastritis between the preoperative gastric ulcer patients and the patients after any of the surgical procedures despite the significant differences in bile acids. Though highly selective vagotomy in the treatment of gastric ulcer results in a reduction in duodenogastric reflux of bile there is no improvement in the gastritis that is present.     

Effects of vagotomy and gastrectomy on pancreatic glucagon release.

The effects of gastrectomy and vagotomy on pancreatic glucagon release were investigated clinically. The study included 20 men and eight women, who ranged in age from 28 to 69 years, and who were divided into the following four groups: 1) patients with gastroduodenal ulcers treated with partial gastrectomy, by the Billroth I method, whose hepatic branch was preserved (n = 7). 2) Patients with gastroduodenal ulcers treated with partial gastrectomy, by the Billroth II method, whose hepatic branch was preserved (n = 7). 3) Patients with gastric carcinoma treated with subtotal gastrectomy, by the Billroth I method. In these cases lymphadenectomy required section of the hepatic branch (n = 7). 4) Patients with gastric carcinoma treated with subtotal gastrectomy, by the Billroth II method. In these cases lymphadenectomy required section of the hepatic branch (n = 7). Oral glucose tolerance tests were performed in 10 patients, before operation, and in 28 gastrectomized and vagotomized patients. In the preoperative patients and in the first group, oral glucose (50g) suppressed pancreatic glucagon release, but in the other groups pancreatic glucagon levels were markedly increased.     

The effect of vagotomy on gallbladder function and bile composition in man.

Vagotomy and gastric surgery have been implicated in gallstone formation, although the association remained unproven. Gallbladder function was investigated in 11 patients with a pyloroplasty and truncal vagotomy, 5 with a subtotal gastrectomy, and 16 healthy controls. Gallbladder filing and emptying in response to cholecystokinin (CCK 0.01 U/kg min), when quantitated by 99m-Tc-HIDA cholescintigraphy, did not show any differences between the control and the surgical groups. In each group, over 70% of hepatic activity partitioned into the gallbladder rather than the duodenum, filing the gallbladder at 2.1%/min. Gallbladder emptying began five minutes after initiating the CCK infusion and ejected half of its contents during the next 12 minutes. Biliary lipid compositions was determined in 20 patients who underwent elective pyloroplasty and vagotomy for duodenal ulcer disease. Gallbladder bile collected at surgery was compared to bile-rich duodenal fluid aspirated eight months after recovery from surgery. Cholesterol saturation decreased significantly (p less than 0.05) both in terms of the relative cholesterol content (6.9% leads to 5.2%) and the lithogenic index (1.24 leads to 0.84). To determine if a selective increase in one of the conjugated bile salts could explain this improvement, bile salt composition was analyzed by high pressure liquid chromatography in eight patients and showed no change after surgery. Thus, vagotomy does not adversely affect gallbladder function, but instead improves cholesterol solubility.     

Bile composition and bile acid pool size. Comparison after truncal, selective, and highly selective vagotomy

We studied biliary lipid composition and bile acid pool size in 29 patients surgically treated for duodenal ulcer. Fourteen were examined both before and after surgery, the rest postsurgically only. They were divided into three groups according to type of vagotomy. With duodenal fluid obtained via nasogastric tube, we determined bile acid pool size, bile concentrations, and lithogenic index. We found no significant differences in bile composition and bile acid pool size among the three types of vagotomy, postsurgically. However, patients studied before surgery, compared with the entire post-vagotomy group, had a significant increase in relative cholesterol content and lithogenic index, most pronounced in the truncal vagotomy group. Bile acid pool size was also increased postsurgically. Vagotomy may predispose to gallstone development by increasing the bile's relative cholesterol concentration and thus the lithogenic index. However, the slightly expanded bile acid pool size may improve cholesterol solubility in certain patients.     

Alterations in gastrointestinal emptying of 99m-technetium-labeled solids following sequential antrectomy, truncal vagotomy and Roux-Y gastroenterostomy

Recent reviews have documented significant delayed gastric emptying following Roux-Y biliary diversion for alkaline gastritis. This study establishes the use of radionuclide imaging in the experimental model and evaluates the following: (1) gastric emptying following antrectomy with and without vagal denervation; (2) the effect of Roux-Y diversion on gastric and upper gastrointestinal emptying using animals as their own controls; and (3) the role of truncal vagotomy in the "Roux-Y delayed emptying syndrome." Upper gastrointestinal emptying was evaluated in 8 dogs using the radionuclide technetium 99 labeled egg white method with continuous visualization by gamma camera. Eight dogs underwent B-II antrectomy without vagotomy and were divided into two groups. Four underwent vagotomy, re-evaluation, and Roux-Y diversion. Four underwent Roux-Y diversion first, re-evaluation, then truncal vagotomy. Control dogs retained 65% +/- 4% (SEM) and 45% +/- 6% of ingested food at 2 and 4 hours, respectively. Following antrectomy only, rapid gastric emptying of radionuclide solid is observed with 35% +/- 7%, 16% +/- 4% and 7% +/- 4% retention and 2, 3, and 4 hours, respectively. Roux-Y antrectomy without vagotomy results in similar rapid gastric emptying. Truncal vagotomy following B-II antrectomy delays gastric emptying compared to antrectomy only. Truncal vagotomy and Roux diversion results in varied patterns of gastrointestinal emptying. Significant gastric retention and gastric and Roux limb retention are observed in 25% of trials. Significant Roux limb retention is observed in 45% of the group. Prior to vagotomy there is no retention or altered transit in the Roux limb. In general, no delay in gastrointestinal emptying is observed in the absence of vagal denervation. These data corroborate our clinical experience in observing both Roux and gastric retention following radionuclide evaluation in Roux-Y patients.     

Ectopic jejunal pacemakers and enterogastric reflux after Roux gastrectomy: effect of intestinal pacing

The aims of this study were to determine whether ectopic pacemakers are present in the Roux limb of dogs after vagotomy and Roux gastrectomy, whether these pacemakers lead to enterogastric reflux, and whether abolishing the pacemakers with electric pacing might correct such reflex, were it to occur. In five dogs that had undergone gastric vagotomy and Roux gastrectomy and five dogs that had undergone gastric vagotomy and Billroth I gastrectomy (controls), myoelectric activity of the Roux limb or duodenum was recorded during saline infusion (154 mmol/L NaCl) or nutrient (Meritene) infusion into the limb or the duodenum. Reflux of infusate into the stomach was determined via a gastric cannula. Tests in Roux dogs were done with and without limb pacing. Roux dogs showed ectopic pacemakers in the Roux limb that drove the pacesetter potentials of the limb in a reverse, or orad, direction during 76% of the recordings; Billroth dogs rarely had such pacemakers (p less than 0.001). Enterogastric reflux occurred in both groups of dogs but was greater during phase III of the interdigestive migrating myoelectric complex in Roux dogs (12% +/- 6%) than in Billroth dogs (3% +/- 1%; p less than 0.05). Pacing abolished the ectopic pacemakers in the Roux dogs and reduced enterogastric reflux from 12% +/- 6% to 3% +/- 2% when phase III was present (p less than 0.05). In conclusion, the Roux limb was driven by ectopic pacemakers that contributed to, but were not solely responsible for, jejunogastric reflux. Pacing abolished the ectopic pacemakers and decreased reflux when phase III was present in the limb.     

Gastric emptying of solids after Roux-en-Y gastrectomy: is extragastric vagal innervation important?

Truncal vagotomy, antrectomy with Roux-en-Y gastrojejunostomy is frequently complicated by poor gastric emptying. The aim of this study was to determine whether the vagal denervation beyond the stomach (extragastric vagal denervation) contributes to this delay in gastric emptying. Three groups of six female mongrel dogs underwent antrectomy, Roux-en-Y gastrojejunostomy, and either truncal vagotomy, gastric vagotomy, or no vagotomy. After operation each dog underwent two separate radioisotope gastric-emptying studies with a small volume solid meal. The dogs were scanned by a gamma-camera continuously for 4 hours, and images of the gastric remnant were summed by computer every 6 minutes. Radioactivity in the gastric remnant region of interest was compared to overall activity and plotted as a function of time. The half-emptying times (X +/- SEM) for each group were truncal vagotomy 164 +/- 24 minutes, gastric vagotomy 79 +/- 23 minutes, and no vagotomy 117 +/- 10 minutes. Animals with a gastric vagotomy had a significantly faster rate of gastric emptying than did those with truncal vagotomy (p = 0.02, Scheffe's test). Therefore the extragastric vagal innervation appears to play a role in determining the rate of emptying of solids after antrectomy and Roux-en-Y gastrojejunostomy.