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Demonstration of the functional anatomy of the canine gastric antrum II.Operative technics not requiring gastrotomy
Demonstration
II.
of the Functional
Anatomy
of the Canine
Gastric Antrum
Operative
Not Requiring
Technics
Gastrotomy
ROGER E. MOE, M.D., Seattle, Washington, AND P. J. KLOPPER, M.D., Amsterdam, The Netherlands
From the Laboratory for Ex@erimental Surgery, Surgical Clinic, Wilhelmina Gasthuis, University of Amsterdam, The Netherlands. This study was aided in part by funds accruing from National Institutes of Health Grants No. A M-04010 and No. A M-03898, and Research Training Grant No. GM-325.
acetic acid, as in the Landboe-Christensen method, is not adaptable to in viva observation. 1n situ transillumination of the stomach can effectively reveal the gastric antrum when light transmission of the antrum and corpus is altered by Congo red stain on gastric mucosa. With this stain the corpus area is darkened, thus retarding transillumination, while the antrum, which is not darkened, transilluminates very well. When Congo red is sprayed intragastrically by way of the esophagus, and the stomach is transilluminated by a light source placed against the stomach wall, an observer can see a corpus-antrum boundary without performing a gastrotomy. The second technic used in this study, intragastric pH measurement, has also been previously used for a variety of reasons. Indwelling pH electrodes were used by early workers to study pH changes in the stomach after administration of food and drugs [ll-151. Many observations were made with an antimony electrode; with this electrode, however, accuracy may be lost as the period of observation progresses. More recent work with antimony or glass electrodes has been reported by Hoffstetter [16], Kreitner and Pantlitschko [17,18], Schmid [19], Rovelstad [Z&22], and Grieve [23]. Some of those studies dealt with intragastric pH value comparisons in cases of gastric or duodenal ulcers. Klopper measured intragastric pH changes with a glass electrode in cats and dogs during electrical stimulation of the cerebral cortex and during the course of experiments on conditioned reflexes to study the influence of the cerebral
TIS NOW possible to see boundaries
of the gastric antrum in a completely intact stomach in situ. All methods previously described for demonstrating the gastric antrum during surgery have required exposure of gastric mucosa through a gastrotomy. Those methods can be found elsewhere [l-5]. To detect the corpusantrum boundary without gastrotomy, two technics can be used : (1) transillumination, showing color differences over the gastric corpus and antrum after intragastric spraying with Congo red dye via an esophageal route, and (2) intragastric detection of pH differences over corpus and antrum mucosa by means of an esophagogastric pH electrode. Each of these technics is an extension of older methods. The f%rst, transillumination of the stomach, has been used for various purposes [G-9]. In 1944 Landboe-Christensen reported his studies on the extent of the Vpylorus zone” or antrum in excised stomachs. After treating each stomach with acetic acid, he found that the pylorus zone was translucent while the “fundus” or corpus was not. Using transillumination, he was thus able to show the area of the antrum in comparison with the area of the corpus [7]. Payne in 1963 used a similar method for showing limits of the human antrum in relation to gastric vasculature [JO]. However, prerequisite treatment of the stomach with
I
80
American Joumal of Surgery
Demonstration
of Canine Gastric Antrum
A
1. A, hand pump with plastic tube, spray nozzle, and glass bottle. B, detail of nozzle. FIG.
cortex on gastric secretion [Z&25]. Vollmar and Nijller studied intragastric pH for diagnosis of gastric carcinoma, employing a tiny pH-sensitive radio transmitter which is swallowed like a pill [26]. While all the previously mentioned researchers have measured the pH of mucosa or free fluid in intact stomachs, Capper and coworkers measured pH values over gastric mucosa through a gastrotomy [2]. Capper’s work showed that differences in pH between corpus and antrum mucosa can be detected during surgery in patients with peptic ulcer and that direct pH measurement can reveal a boundary between the corpus and antrum. The present study involves an esophagogastric pH glass electrode for measuring pH differences over gastric mucosa in an attempt to reveal characteristics of the corpus and antrum without opening the stomach. Distribution natterns and continuous tracings of pH have heen made with far greater detail of mucosal pH than has ever been available. Furthermore, a method is described for labeling the corpus-antrum boundary in gastric arteriograms to show the relation of the boundary to gastric vasculature. Finally, planar patterns of dog stomachs were made and marked to indicate the distribution of the corpus and antrum, permitting quantitative comparison of relative areas. Vol. 111, January 1966
FIG. 2.
Detail
81
2 of light.
3
FIG. 3. Glass electrode (Philips 240 Ingold). MATERIALS
AND METHODS
Thirty fasting dogs of both sexes, weighing between 10 and 22 kg., were used in this experiment. Different anesthetics were employed, none of which prevented delineation of the corpus-antrum boundary. These anesthetics were: (1) intravenous alpha-chloralose (50 mg./kg. body weight) and urethan (500 mg./kg.) in propylene glycol; (2) intravenous thiopental sodium or Kemithal@; (3) nitrous oxide and oxygen with and without Fluothane@; and (4) nitrous oxygen and oxygen with curare or succinylcholine. Atropine and similar agents were avoided. All animals were intubated endotracheally. Gastric secretion was stimulated with histamine in the same way as reported in a previous article [5]. Tramillumination with Dyestuff. After induction of anesthesia a Levin tube was inserted via the esophagus into the stomach for lavage and drainage. An esophagogastric spray tube was then introduced. This plastic tube was fitted with a spray nozzle at the distal end which was introduced into the stomach, while a small hand pump was attached to the proximal end. The spray nozzle and hand pump (Fig. 1) are inexpensive components taken from an ordinary household flower sprayer. This nozzle had a single hole through which a fine spray could emerge. The hand pump fitted into an ordinary glass bottle containing 6 to 7 per cent aqueous Congo red dye dissolved with moderate warming. Along the side of the spray tube a small plastic cannula was fixed, which was open at the distal end and connected to an air tank at the proximal end and permitted the necessary inflation and deflation of the stomach. After the stomach was approached through a mid-
82
Moe and Klopper
FIG. 4. The pH tracing of a normal stomach; different pH values in the parts of the stomach are evident.
line laparotomy incision, it was palpated to ascertain the location of the intragastric tubes. The surgeon then guided the distal end of the Levin tube into the gastric antrum for lavage to remove acid from the antrum. Through the Levin tube 150 cc. of 0.05 per cent sodium bicarbonate with a pH of between 7.5 and 8 was rapidly injected, followed by a similar amount of tepid tap water with a pH of 7. With the lavage tube in the antrum rinsing fluid could flow from the antrum posteriorly into the corpus, after which the Levin tube was pulled back into the corpus to withdraw the fluid. With the small cannula on the spray tube the stomach was inflated to an approximate pressure of 15 to 20 cm. of water, a pressure far below the danger level for rupturing a stomach [27]. After inflation the stomach was transilluminated by a light held against the gastric serosa. The best sites for transillumination proved to be the posterior wall or the lesser curvature. The light used here (Fig. 2) was a 6 volt bulb fixed in a locally constructed handle and connected to a rheostat. Both this light and electric cord were sterilized in boiling water. For better visualization, the overhead surgical light was turned off, but it was not necessary to darken the room. The spray tube within the stomach was held so that both the antrum and posterior mucosal surfaces could be well covered with dye. If intragastric pressure is too high, the stomach wall cannot be invaginated easily for the surgeon to grasp the spray tube. A gentle fine spray of Congo red was delivered to the gastric mucosa. This sprayed area, which included the entire antrum and nearby corpus, could be easily seen during transillumination. It is not necessary to spray the entire corpus. With a 7 per cent solution of dye, 30 to 50 cc. in most cases, color intensity was optimal for transillumination. The corpus-antrum border was marked by insertion of through and through interrupted sutures at the lesser and greater curvatures and on the anterior and posterior walls. One to four biopsy specimens at the marker sutures were taken from each stomach for correlation with the histologic corpus antrum border. Finally, the stomach was lavaged with water to remove excess dye. In&gastric Mucosal pH Detection. A glass pH electrode (Philips type 240 Ingold) was introduced via the esophagus into the stomach. Although the diameter of this electrode (Fig. 3) is 6 mm., the pHsensitive area in the tip is only about 1 mm. wide. A reference electrode (Philips type 340-2 Ingold) was placed against buccal mucosa and kept moist with a wet gauze pack. The electrodes were then connected to Philips direct-reading pH meters (type 9400/01). In four dogs pH values were traced continuously on a Honeywell Electronic 17 pen recorder. After laparotomy the intragastric pH electrode was easily palpated and controlled by the surgeon’s American
Journal of Surgery
Demonstration of Canine Gastric Antrum
83
CORPUS
7.5 PYLORUS
i-i/ 5
7
6
FIG. 5 and 6. Distribution diagrams of pH of gastric mucosa. In the region of the boundary the three parallel rows of values are 1 cm. above, directly upon, and 1 cm. below the border.
fingers. The electrode was held perpendicularly to the gastric mucosa and was slowly moved longitudinally from the esophagus into the stomach and duodenum to locate areas of differing pH. (Fig. 4.) Spot checks at various sites on the mucosa were also made and recorded on distribution diagrams. (Fig. 5 and 6.) Detection of pH differences was facilitated by mild finger pressure on the stomach wall over the electrode and by moderate inflation of the stomach. In each specimen interrupted through and through marker sutures were placed where corpus-antrum pH changes existed; the relation of these marker sutures to the histologic border was subsequently studied. In five animals the pH boundary noted by direct measurement was compared with a transilluminated corpus-antrum color boundary. Arteriography. In four animals with corpusantrum boundaries previously marked, a colloidal 50 per cent supension of barium sulfate (Micropaque@) was injected through a retrograde aortic cannula. Total gastric excision was performed and each stomach was opened along the greater curvature. Vitallium wire was threaded between the boundarymarker sutures, X-ray films of these specimens demonstrated gastric vasculature as well as the corpus-antrum boundary marked by radiopaque wire. (Fig. 7.) Gastric Planar Patterns. With the use of sterile sheets of filter paper planar patterns were made of the outline of ten stomachs in situ and of ten stomachs immediately after total excision. The corpus-antrum boundary was marked on each pattern. In addition, each boundary was checked for histologic accuracy. The area of each antrum was then compared with the area of each corresponding total stomach using a weighing method reported by Olch and Harkins [28]. (Fig. 8.) Vol. 111, January 1966
Arteriograrnsof stomach with marked boundary. Top, lateral view with A, antrum; B, boundary; Co, corpus; C, cardia; P, pylorus; LC, lesser curvature; LGA, left gastric artery. Arrow indicates junction of left and right gastroepiploic arteries. Bottom, view with stomach opened by incision along the greater curvature. A longitudinal wire appears along the lesser curvature. FIG. 7.
RESULTS
Transillumination with Dyestuff. After an intragastric dye spray a corpus-antrum color boundary was immediately visible when high acid secretion existed. (Fig. 9.) In the presence of low acid secretion, however, it was necessary to wait several minutes for corpus dye to become darkened at the boundary. Grossly, the boundary in stomachs of normal dogs was either a straight line or was gently curvilinear; it was not ragged. With no acid secretion the entire gastric mucosa stained red, and no color boundary appeared. One dog exhibited this state. Marker sutures which had been inserted were proved by endoscopy to be at the color boundary. In addition, these color boundaries
Moe and Klopper
84 NU
BER %
70 ANTRUM pattern
of total
in STOMACH
FIG. 8. Extent of antrum in twenty dogs. in intact
stomachs
were proved
to correspond
to pH differences by direct measurements with an intragastric pH electrode moved back and forth longitudinally over marker sutures (Fig. 10.). Moreover, color boundaries were located within f 1 cm. of the histologic border of the corpus-a&rum on each biopsy. Intragastric Mucosal pH Detection. The pH differences existed over mucosa in different regions of the stomach, as demonstrated by the varied pH values in different animals when corresponding sites in each stomach were compared. Furthermore, pH values at any site were found to change with time in each animal, depending upon the relative amount and persistence of acid secretion. However, each animal did exhibit regional pH differences over gastric mucosa. When pH measurements were taken on resected or excised specimens, regional pH differences rapidly disappeared. Within
fifteen minutes after resection the entire gastric mucosa revealed pH values of 6 to 7.5. For detecting a corpus-antrum boundary, the accuracy of intragastric pH detection proved similar to the transillumination method, as shown by biopsy comparison and by use of both methods together in the same animals. Arteriography. The corpus-antrum boundary can be conveniently compared to the course of the right and left gastric arteries and to the right and left gastroepiploic arteries. The antrum receives branches from both the right and left gastric arteries and from the right gastroepiploic artery. In three of four dogs proximal antrum limits were well below vascular landmarks reported for human subjects by Payne [IO], and in no dogs did the antrum extend above those landmarks. Gastric Planar Patterns. With the stomach in situ or after gastric excision, the mean area of gastric antrum was found to occupy 20 per cent of the total gastric area, with a range from 10 to 30 per cent and a standard error of 4.6. (Fig. 8.) COMMENTS This investigation indicates that the functional anatomy of the canine gastric antrum can
FIG. .9. Boundary between antrum and corpus after Congo red spraying and transillumination of the inflated stomach. Corpus is black and antrum is red when visualized at operation.
FIG. 10. Tracing of pH values in the corpus-antrum region by moving electrode back and forth over a marking suture placed after spraying with Congo red dye; tracing made in intact stomach. American
Journal
of Surgery
Demonstration of Canine Gastric Antrum be demonstrated during surgery without opening the stomach. These technics, transillumination or pH detection, seem to be practical in many respects. Simplicity, speed, lack of toxicity, and low cost all serve to recommend either or both methods. They can also be applied through a gastrotomy of 1 cm. if desired. Transillumination with Congo red dye effectively shows the location of black stain (acid) inside the stomach. Hence, a source of technical error appears if acid in the antral lumen is not removed or minimized by gastric lavage. Another source of error appears if dye is sprayed from a nozzle, which creates a profuse coarse spray; in such a case, black dye from the corpus can be washed into the antrum. A tine gentle spray as used in this study can prevent this error. Still a third source of error can appear if the stomach walls are pushed and rubbed together during transillumination. Such .actions will smear the boundary, but can be prevented by insufflation and gentle manipulation of the stained stomach. Unlike the transillumination technic, pH detection of a corpus-antrum boundary is not prevented by free acid in the antral lumen. Relatively high pH values for antrum mucosa can be detected despite free fluid of low pH in the antral lumen. Gentle finger pressure on the stomach wall against the electrode minimizes the amount of free fluid between mucosa and electrode. The distribution of canine mucosal pH conforms roughly to what might be expected from information on the number of parietal cells which exist in different parts of normal human stomachs [29-321. Mucosal pH in an acidsecreting stomach is low where most parietal cells are located in the corpus, with somewhat higher pH values where fewer parietal cells exist in the fundus; pH is highest in the antrum in which few if any parietal cells are found. The average area of the antrum compared to total planar area of the stomach in this study was 20 per cent. In preserved human stomachs area of the antrum averaged 11.5 per cent of total stomach area [7]. It is not known if this difference is related to the species or is due to technic. According to Ruding and Hirdes the extent of the gastric antrum in human subjects may vary considerably in pathologic conditions 1331. This present study supports the concept that complete resection of the antrum can be Vol. 111. January 1966
85
achieved by a small distal gastric resection in many instances as demonstrated by Palumbo and Sharpe [34]. Landmarks proposed by Payne [IO] and Ruding and Hirdes [33] for partial gastric resection were selected to include exceptionally large areas of gastric antrum, thereby removing a larger distal segment than is necessary for complete antrectomy in many stomachs. By using technics reported here, a line of resection 1 cm. proximal to a color boundary or a pH boundary can provide complete antrectomy while leaving the largest practicable gastric remnant; either “closed” or “open” methods of anastomosis can be used. In dogs there was no special “tongue” of antrum extending high up the lesser curvature, although the apex of the antrum extended proportionately higher on the lesser than the greater curvature. Can the apex of the antrum be shown on the lesser curvature when the lesser omentum is thick and fat? With pH detection the lesser curvature presents no problems of this type. With dye transillumination, however, a thick omentum could make it difficult to see the highest part of the antrum on the lesser curve. This problem can be readily obviated by transilluminating the stomach after partially mobilizing the greater and lesser curvatures and resecting the pylorus from the duodenum. With a clamp on the pylorus the stomach can be kept inflated. Hence, with the lesser omentum removed to a point just below the left gastric artery, the apex of a color boundary is easily visible. Proximal resection can then be completed. At the same time a question can be raised about the significance of a small slip of residual antrum remaining on the proximal gastric remnant after antrectomy with vagotomy in the treatment of duodenal ulcer. It has never been conclusively proved that a small bit of antrum on the proximal remnant leads to a recurrent ulcer. Evidence for this hypothesis has been purely circumstantial. Indeed, the recurrence rate of ulcers after incomplete antrectomy and vagotomy should, at most, not exceed the recurrence rate after vagotomy and pyloroplasty in which the entire antrum is left in situ. Biologically, removal of the vast majority of a gland or organ drastically curtails its function. Similarly, removal of the vast majority of the antrum by subtotal antrectomy should curtail the antral phase of gastric secretion drastically, providing the conditions of
Moe and Klopper
86
Nyhus and co-workers [35] are met: vagotomy, no occurrence of stasis, and no exclusion of antrum from the acid stream. It is believed that some of the alarm concerning a tiny piece of antrum remaining on the proximal gastric remnant is generated by the poor results of the von Eiselsberg type of antral exclusion, which is quite another matter [36]. The following clinical and experimental procedures may be facilitated by in situ demonstration of limits of the gastric antrum without gastrotomy : (1) antrectomy with vagotomy [34,37-391; (2) high gastric resection without vagotomy, intended to include complete antrectomy [40,41]; (3) supra-antral resection, if the entire antrum is to be left in situ [42]; (4) construction of experimental gastric pouches which include only the gastric corpus or the gastric antrum; (5) experiments in which the corpus-antrum boundary is marked for studies of corpus-antrum relations over an extended time period. In our clinic this technic of transillumination has already been used to demonstrate the corpus-antrum boundary in patients with peptic ulcer, a technic readily accomplished without opening the stomach. These clinical results will be published elsewhere.
Harkins, and Professor Lloyd M. Nyhus for valuable assistance and support. REFERENCES 1. LOWICKI, E. and LITTLEFIELD, J. B. An
2.
3.
4.
5.
6.
7.
8.
9.
SUMMARY
The corpus-antrum boundary was demonstrated in dogs during laparotomy without performing a gastrotomy. This boundary was demonstrated by : (1) transillumination of the stomach to show color differences in the gastric corpus and antrum after intragastric spraying with Congo red dye via the esophagus; (2) intragastric detection of pH differences in the corpus and antrum via an esophagogastric pH electrode. These technics reveal similar corpus-antrum boundaries which correlate satisfactorily with histologic boundaries. Further data are presented on gastric mucosal pH distribution. Gastric arteriography was performed to show the relation of the corpus-antrum boundary to gastric vasculature. In twenty dogs relative planar area occupied by the antrum as compared to total gastric area was found to average 20 per cent. Possible applications of technics used here are mentioned. Acknowledgment: We are greatly indebted to Professor Dr. I. Boerema, Professor Henry N.
10.
11.
12.
13.
14.
15.
16.
17. 18.
experimental method of precisely defining the dimensions of the gastric antrum. S. Forum, 12: 308, 1961. CAPPER, W. M., LAIDLAW, C. D’A., BUCKLER, K., and RICHARDS, D. The pH fields of the gastric mucosa. Lance& 2: 1200, 1962. MOE, R. E., NYHUS, L. M., and HARKINS, H. N. The use of dye for differentiating the gastric antrum from the gastric corpus. Bull. Sot. Internat. Chir., 22: 424, 1963. SMITH, G. V. and HOWES, E. L. Absence of histamine reserpine ulcers in pyloric pouches free of acid. Surgery, 55: 262, 1964. MOE, R. E., KLOPPER, P. J., and NYHUS, L. M. Demonstration of the functional anatomy of the canine gastric antrum. I. Operative technics requiring gastrotomy. Am. J. Surg., 110: 277, 1965. VISSCHER, M. B. The secretion of dyestuffs by the gastric glands and the pancreas. Fed. Proc., 1: 246, 1942. LANDBOE-CHRISTENSEN,E. Extent of the pylorus zone in the human stomach. Acta path. et microbiol. stand. (suppi.), 54: 671, 1944. MOE, R. E. and TILLY, D. A. In vivo demonstration of the gastric vasculature by transillumination. J. Biol. Photographic A., 31: 59, 1963. PALMER, E. D. Clinical Gastroenterology. New York, 1963. Hoeber Medical Division, Harper and Row. PAYNE, J. T. The significance of vascular landmarks in gastric resection. West. J. Slrrg., 71: 161, 1963. MCCLENDON, J. F. Acidity curves in the stomach and duodenums of adults and infants, plotted with the aid of improved methods measuring hydrogen ion concentration. Am. J. Physiol., 38: 191, 1915. SARRE, H. Cited in Rein, H. Einfiihrungen in die Physiologie des Menschen, p. 194. Berlin, 1940. Springer Verlag. FLEXNER, J. and KNIAZUK, M. Method for the continuous recording of gastric pH in situ. II. Experimental details. Am. J. Digest. Dis., 7: 138, 1940. EYERLY, J. B. Comparative pH values within the stomach, pylorus and duodenum in antacid therapy. Am. J. Digest Dis., 7: 431, 1940. HAGGARD. H. W. and GREENBERG, L. A. An antimony electrode for the continuous recording of the acidity of human gastric contents. Science, 93: 479, 1941. HOFFSTETTER, F. pH Messungen mit der Glaselektrode im Magensaft. Gustroenterologiu, 72: 201, 1947. KREITNER, H. Eine neue Magensonde zur Saurabestimmung. Wien. klin. Wchnschr., 61: 32, 1949. KREITNER, H. and PANTLITSCHKO, M. Untersuchungen der Magenfunktion durch direkte Wien. Bestimmungen im lebenden Magen. Wschr. inn. Med., 30: 160, 1949. American
Journal
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Demonstration
of Canine Gastric Antrum
19. SCHMID, J. pH-Messung im Magen-Darmtrakt. Wien. klin. Wchnschr., 61: 945, 1949. 20. ROVELSTAD, R. A., OWEN, C. A., JR., and MAGATH, T. B. Factors influencing continuous recording of in situ pH of gastric and duodenal contents. Gastroenterology, 20: 609, 1952. 21. ROVELSTAD,R. A. Continuously recorded in situ pH of gastric and duodenal contents in patients with and without duodenal ulcers. Gastroenterology, 31: 530, 1956. 22. ROVELSTAD,R. A. Gastric analysis. Gastroenterology, 45: 90, 1963. 23. GRIEVE, J. Continuous records of gastric pH in situ and their possible use in pre-operative assessment of peptic ulcer patients. &it. J. Surg., 49: 189, 1961. 24. KLOPPER, P. J. De invloed van de schors van de grote hersenen op enige autonoom geinnerveerde organen. Thesis. Amsterdam, 1954. 25. KLOPPER, P. J. Les variations du pH de l’estomac pendant la phase cephalique de la secretion du sue gastrique chez le chien. J. physiol., (Paris), 47: 621, 1955. 26. VOLLMAR, J. and NGLLER, H. G. Die elektronische Magensaftbestimmung und ihre Bedeutung fiir die Chirurgie; demonstriert am Beispiel des Magencarcinoms. Arch. klin. Chir., 294: 287, 1960. 27. BURT, C. A. V. Pneumatic rupture of the intestinal canal with experimental data showing the mechanism of perforation and the pressure required. Arch. Surg., 22: 875, 1931. 28. OLCH, P. D. and HARKINS, H. N. Quantitative assessment of extent of gastric resection. Comparison of pattern-planimeter and pattern weight methods. Surgery, 48: 655, 1960. 29. BERGER, E. H. The distribution of parietal cells in the stomach: a histotopographic study. Am. J. Anat., 54: 87, 1934. 30. 01, M., HOSHIKO, S., and FUNATSU, S. A study of the distribution of parietal cells in human stomach. Cited in Surgery of the Stomach and Duodenum, p. 182. Edited by Harkins, H. N. and Nyhus, L. M. Boston, 1962. Little, Brown & co. 31. GROSSMAN, M. I. and MARKS, I. N. Secretion of pepsinogen by the pyloric glands of the dog, with some observations on the histology of gastric mucosa. Gastroenterology, 38: 343, 1960. 32. POLACEK, M. A. and ELLISON, E. H. A comparative study of parietal cell mass and distribution in normal stomachs, in stomachs with duodenal ulcer, and in stomachs of patients with pancreatic adenoma. S. Forum, 14: 313, 1963. 33. RUDING, R. and HIRDES, W. H. Extent of the gastric antrum and its significance. Surgery, 53: 743, 1963. 34. PALUMBO, L. T. and SHARPE, W. S. Distal antrectomy with vagectomy for duodenal ulcer. Review of 450 cases. Arch. Surg., 87: 1040, 1963. 35. NYHUS, L. M., CHAPMAN, N. D., DEVITO, R. V., and HARKINS, H. N. The control of gastrin release. An experimental study illustrating a new concept. Gastroenterology, 39: 582, 1960. 36. VON EISELSBERG, A. Zur unilateralen Pylorausschaltung. Wien. med. Wchnschr., 23: 44, 1910. Vol. 111, Januavy 1966
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37. HARKINS, H. N., JESSEPH, J. E., STEVENSON, J. K., and NYHUS, L. M. The “combined” operation for peptic ulcer. Arch. Surg., 80: 743, 1960. 38. HERRINGTON, J. L., JR. Antrectomy-vagotomy for duodenal ulcer. A fifteen-year appraisal. New York J. Med., 63: 2489, 1963. 39. EDWARDS, L. W., HERRINGTON,J. L., JR., STEPHENSON, S. E., JR., CARLSON, R. I., PHILLIPS, R. J., JR., CATE, W. R., JR., and SCOTT, H. W., JR. Duodenal ulcer: treatment by vagotomy and removal of the gastric antrum. Ann. Surg., 145: 738, 1957. 40. HARKINS, H. N. Duodenal ulcer. In: Surgery of the Stomach and Duodenum, p. 189. Edited by Harkins, H. N. and Nyhus, L. M., Boston, 1962. Little, Brown & Co. 41. HARKINS, H. N. and NYHUS, L. M. Surgery of the Stomach and Duodenum, p. 418. Boston, 1962. Little, Brown & Co. 42. BERNE, C. J. Vagotomy, pyloroplasty and supraantral resection for duodenal ulcer. In: Surgery of the Stomach and Duodenum, p. 456. Edited by Harkins, H. N. and Nyhus, L. M. Boston, 1962. Little, Brown & Co. DISCUSSION MELVIN P. OSBORNE (Boston, Mass.) : The importance of this paper is obvious. It is probably luck that makes possible a good guess as to the identification of the boundaries of a dog’s antrum. There is a little change in the appearance of the mucosa. In the human subject this is really not possible and the application of a pH indicator paper strip to the open stomach reveals that the antrum extends all the way up to the esophagus in some patients. In others it is only a very small little section, no more than 3 cm. in length.
We have also found that in all patients with marginal ulcers and who were operated on, there was residual antrum in the fundic pouch. Every surgeon must try some of these methods for mapping the antrum. If resection of the antrum is necessary in gastric surgery it is necessary to know what and where it is. LLOYD M. NYHUS (Seattle, Wash.): Much of this early work was done in our laboratory in Seattle. I wish to recognize that Dr. Moe and Dr. Klopper did this work primarily with Professor Boerema in Amsterdam. We have believed for some time the importance of complete antrectomy. We are beginning to wonder, however, whether a complete antrectomy is necessary, if certain rules are followed. To perform a complete antrectomy one must resect essentially the entire gastric lesser curvature. However, I wonder if it is necessary to perform a complete antrectomy if a Billroth operation is also carried out, leaving the antrum in continuity with the acid inhibitory mechanisms. If there is no stasis in the antrum and if the remaining antrum is vagotomized, there should be little trouble. We have
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Moe and Klopper
some evidence in this regard; Palumbo recently reported excellent results with a so-called 15 to 20 per cent distal gastrectomy in which these three conditions were maintained. There is another consideration. A technic as per. formed by Drs. Moe and Klopper has great importance in the field of experimental surgery. In the
preparation of an isolated antral pouch, it is important to be sure there is no acid “cuff” on it. Extra antrum is excised to be certain that the acid-secreting cells were removed. Physiologically, an acid cuff on an excluded antrum completely negates all experimental results obtained from that preparation.
Am&can
Journal
of Surgery
II.
of the Functional
Anatomy
of the Canine
Gastric Antrum
Operative
Not Requiring
Technics
Gastrotomy
ROGER E. MOE, M.D., Seattle, Washington, AND P. J. KLOPPER, M.D., Amsterdam, The Netherlands
From the Laboratory for Ex@erimental Surgery, Surgical Clinic, Wilhelmina Gasthuis, University of Amsterdam, The Netherlands. This study was aided in part by funds accruing from National Institutes of Health Grants No. A M-04010 and No. A M-03898, and Research Training Grant No. GM-325.
acetic acid, as in the Landboe-Christensen method, is not adaptable to in viva observation. 1n situ transillumination of the stomach can effectively reveal the gastric antrum when light transmission of the antrum and corpus is altered by Congo red stain on gastric mucosa. With this stain the corpus area is darkened, thus retarding transillumination, while the antrum, which is not darkened, transilluminates very well. When Congo red is sprayed intragastrically by way of the esophagus, and the stomach is transilluminated by a light source placed against the stomach wall, an observer can see a corpus-antrum boundary without performing a gastrotomy. The second technic used in this study, intragastric pH measurement, has also been previously used for a variety of reasons. Indwelling pH electrodes were used by early workers to study pH changes in the stomach after administration of food and drugs [ll-151. Many observations were made with an antimony electrode; with this electrode, however, accuracy may be lost as the period of observation progresses. More recent work with antimony or glass electrodes has been reported by Hoffstetter [16], Kreitner and Pantlitschko [17,18], Schmid [19], Rovelstad [Z&22], and Grieve [23]. Some of those studies dealt with intragastric pH value comparisons in cases of gastric or duodenal ulcers. Klopper measured intragastric pH changes with a glass electrode in cats and dogs during electrical stimulation of the cerebral cortex and during the course of experiments on conditioned reflexes to study the influence of the cerebral
TIS NOW possible to see boundaries
of the gastric antrum in a completely intact stomach in situ. All methods previously described for demonstrating the gastric antrum during surgery have required exposure of gastric mucosa through a gastrotomy. Those methods can be found elsewhere [l-5]. To detect the corpusantrum boundary without gastrotomy, two technics can be used : (1) transillumination, showing color differences over the gastric corpus and antrum after intragastric spraying with Congo red dye via an esophageal route, and (2) intragastric detection of pH differences over corpus and antrum mucosa by means of an esophagogastric pH electrode. Each of these technics is an extension of older methods. The f%rst, transillumination of the stomach, has been used for various purposes [G-9]. In 1944 Landboe-Christensen reported his studies on the extent of the Vpylorus zone” or antrum in excised stomachs. After treating each stomach with acetic acid, he found that the pylorus zone was translucent while the “fundus” or corpus was not. Using transillumination, he was thus able to show the area of the antrum in comparison with the area of the corpus [7]. Payne in 1963 used a similar method for showing limits of the human antrum in relation to gastric vasculature [JO]. However, prerequisite treatment of the stomach with
I
80
American Joumal of Surgery
Demonstration
of Canine Gastric Antrum
A
1. A, hand pump with plastic tube, spray nozzle, and glass bottle. B, detail of nozzle. FIG.
cortex on gastric secretion [Z&25]. Vollmar and Nijller studied intragastric pH for diagnosis of gastric carcinoma, employing a tiny pH-sensitive radio transmitter which is swallowed like a pill [26]. While all the previously mentioned researchers have measured the pH of mucosa or free fluid in intact stomachs, Capper and coworkers measured pH values over gastric mucosa through a gastrotomy [2]. Capper’s work showed that differences in pH between corpus and antrum mucosa can be detected during surgery in patients with peptic ulcer and that direct pH measurement can reveal a boundary between the corpus and antrum. The present study involves an esophagogastric pH glass electrode for measuring pH differences over gastric mucosa in an attempt to reveal characteristics of the corpus and antrum without opening the stomach. Distribution natterns and continuous tracings of pH have heen made with far greater detail of mucosal pH than has ever been available. Furthermore, a method is described for labeling the corpus-antrum boundary in gastric arteriograms to show the relation of the boundary to gastric vasculature. Finally, planar patterns of dog stomachs were made and marked to indicate the distribution of the corpus and antrum, permitting quantitative comparison of relative areas. Vol. 111, January 1966
FIG. 2.
Detail
81
2 of light.
3
FIG. 3. Glass electrode (Philips 240 Ingold). MATERIALS
AND METHODS
Thirty fasting dogs of both sexes, weighing between 10 and 22 kg., were used in this experiment. Different anesthetics were employed, none of which prevented delineation of the corpus-antrum boundary. These anesthetics were: (1) intravenous alpha-chloralose (50 mg./kg. body weight) and urethan (500 mg./kg.) in propylene glycol; (2) intravenous thiopental sodium or Kemithal@; (3) nitrous oxide and oxygen with and without Fluothane@; and (4) nitrous oxygen and oxygen with curare or succinylcholine. Atropine and similar agents were avoided. All animals were intubated endotracheally. Gastric secretion was stimulated with histamine in the same way as reported in a previous article [5]. Tramillumination with Dyestuff. After induction of anesthesia a Levin tube was inserted via the esophagus into the stomach for lavage and drainage. An esophagogastric spray tube was then introduced. This plastic tube was fitted with a spray nozzle at the distal end which was introduced into the stomach, while a small hand pump was attached to the proximal end. The spray nozzle and hand pump (Fig. 1) are inexpensive components taken from an ordinary household flower sprayer. This nozzle had a single hole through which a fine spray could emerge. The hand pump fitted into an ordinary glass bottle containing 6 to 7 per cent aqueous Congo red dye dissolved with moderate warming. Along the side of the spray tube a small plastic cannula was fixed, which was open at the distal end and connected to an air tank at the proximal end and permitted the necessary inflation and deflation of the stomach. After the stomach was approached through a mid-
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FIG. 4. The pH tracing of a normal stomach; different pH values in the parts of the stomach are evident.
line laparotomy incision, it was palpated to ascertain the location of the intragastric tubes. The surgeon then guided the distal end of the Levin tube into the gastric antrum for lavage to remove acid from the antrum. Through the Levin tube 150 cc. of 0.05 per cent sodium bicarbonate with a pH of between 7.5 and 8 was rapidly injected, followed by a similar amount of tepid tap water with a pH of 7. With the lavage tube in the antrum rinsing fluid could flow from the antrum posteriorly into the corpus, after which the Levin tube was pulled back into the corpus to withdraw the fluid. With the small cannula on the spray tube the stomach was inflated to an approximate pressure of 15 to 20 cm. of water, a pressure far below the danger level for rupturing a stomach [27]. After inflation the stomach was transilluminated by a light held against the gastric serosa. The best sites for transillumination proved to be the posterior wall or the lesser curvature. The light used here (Fig. 2) was a 6 volt bulb fixed in a locally constructed handle and connected to a rheostat. Both this light and electric cord were sterilized in boiling water. For better visualization, the overhead surgical light was turned off, but it was not necessary to darken the room. The spray tube within the stomach was held so that both the antrum and posterior mucosal surfaces could be well covered with dye. If intragastric pressure is too high, the stomach wall cannot be invaginated easily for the surgeon to grasp the spray tube. A gentle fine spray of Congo red was delivered to the gastric mucosa. This sprayed area, which included the entire antrum and nearby corpus, could be easily seen during transillumination. It is not necessary to spray the entire corpus. With a 7 per cent solution of dye, 30 to 50 cc. in most cases, color intensity was optimal for transillumination. The corpus-antrum border was marked by insertion of through and through interrupted sutures at the lesser and greater curvatures and on the anterior and posterior walls. One to four biopsy specimens at the marker sutures were taken from each stomach for correlation with the histologic corpus antrum border. Finally, the stomach was lavaged with water to remove excess dye. In&gastric Mucosal pH Detection. A glass pH electrode (Philips type 240 Ingold) was introduced via the esophagus into the stomach. Although the diameter of this electrode (Fig. 3) is 6 mm., the pHsensitive area in the tip is only about 1 mm. wide. A reference electrode (Philips type 340-2 Ingold) was placed against buccal mucosa and kept moist with a wet gauze pack. The electrodes were then connected to Philips direct-reading pH meters (type 9400/01). In four dogs pH values were traced continuously on a Honeywell Electronic 17 pen recorder. After laparotomy the intragastric pH electrode was easily palpated and controlled by the surgeon’s American
Journal of Surgery
Demonstration of Canine Gastric Antrum
83
CORPUS
7.5 PYLORUS
i-i/ 5
7
6
FIG. 5 and 6. Distribution diagrams of pH of gastric mucosa. In the region of the boundary the three parallel rows of values are 1 cm. above, directly upon, and 1 cm. below the border.
fingers. The electrode was held perpendicularly to the gastric mucosa and was slowly moved longitudinally from the esophagus into the stomach and duodenum to locate areas of differing pH. (Fig. 4.) Spot checks at various sites on the mucosa were also made and recorded on distribution diagrams. (Fig. 5 and 6.) Detection of pH differences was facilitated by mild finger pressure on the stomach wall over the electrode and by moderate inflation of the stomach. In each specimen interrupted through and through marker sutures were placed where corpus-antrum pH changes existed; the relation of these marker sutures to the histologic border was subsequently studied. In five animals the pH boundary noted by direct measurement was compared with a transilluminated corpus-antrum color boundary. Arteriography. In four animals with corpusantrum boundaries previously marked, a colloidal 50 per cent supension of barium sulfate (Micropaque@) was injected through a retrograde aortic cannula. Total gastric excision was performed and each stomach was opened along the greater curvature. Vitallium wire was threaded between the boundarymarker sutures, X-ray films of these specimens demonstrated gastric vasculature as well as the corpus-antrum boundary marked by radiopaque wire. (Fig. 7.) Gastric Planar Patterns. With the use of sterile sheets of filter paper planar patterns were made of the outline of ten stomachs in situ and of ten stomachs immediately after total excision. The corpus-antrum boundary was marked on each pattern. In addition, each boundary was checked for histologic accuracy. The area of each antrum was then compared with the area of each corresponding total stomach using a weighing method reported by Olch and Harkins [28]. (Fig. 8.) Vol. 111, January 1966
Arteriograrnsof stomach with marked boundary. Top, lateral view with A, antrum; B, boundary; Co, corpus; C, cardia; P, pylorus; LC, lesser curvature; LGA, left gastric artery. Arrow indicates junction of left and right gastroepiploic arteries. Bottom, view with stomach opened by incision along the greater curvature. A longitudinal wire appears along the lesser curvature. FIG. 7.
RESULTS
Transillumination with Dyestuff. After an intragastric dye spray a corpus-antrum color boundary was immediately visible when high acid secretion existed. (Fig. 9.) In the presence of low acid secretion, however, it was necessary to wait several minutes for corpus dye to become darkened at the boundary. Grossly, the boundary in stomachs of normal dogs was either a straight line or was gently curvilinear; it was not ragged. With no acid secretion the entire gastric mucosa stained red, and no color boundary appeared. One dog exhibited this state. Marker sutures which had been inserted were proved by endoscopy to be at the color boundary. In addition, these color boundaries
Moe and Klopper
84 NU
BER %
70 ANTRUM pattern
of total
in STOMACH
FIG. 8. Extent of antrum in twenty dogs. in intact
stomachs
were proved
to correspond
to pH differences by direct measurements with an intragastric pH electrode moved back and forth longitudinally over marker sutures (Fig. 10.). Moreover, color boundaries were located within f 1 cm. of the histologic border of the corpus-a&rum on each biopsy. Intragastric Mucosal pH Detection. The pH differences existed over mucosa in different regions of the stomach, as demonstrated by the varied pH values in different animals when corresponding sites in each stomach were compared. Furthermore, pH values at any site were found to change with time in each animal, depending upon the relative amount and persistence of acid secretion. However, each animal did exhibit regional pH differences over gastric mucosa. When pH measurements were taken on resected or excised specimens, regional pH differences rapidly disappeared. Within
fifteen minutes after resection the entire gastric mucosa revealed pH values of 6 to 7.5. For detecting a corpus-antrum boundary, the accuracy of intragastric pH detection proved similar to the transillumination method, as shown by biopsy comparison and by use of both methods together in the same animals. Arteriography. The corpus-antrum boundary can be conveniently compared to the course of the right and left gastric arteries and to the right and left gastroepiploic arteries. The antrum receives branches from both the right and left gastric arteries and from the right gastroepiploic artery. In three of four dogs proximal antrum limits were well below vascular landmarks reported for human subjects by Payne [IO], and in no dogs did the antrum extend above those landmarks. Gastric Planar Patterns. With the stomach in situ or after gastric excision, the mean area of gastric antrum was found to occupy 20 per cent of the total gastric area, with a range from 10 to 30 per cent and a standard error of 4.6. (Fig. 8.) COMMENTS This investigation indicates that the functional anatomy of the canine gastric antrum can
FIG. .9. Boundary between antrum and corpus after Congo red spraying and transillumination of the inflated stomach. Corpus is black and antrum is red when visualized at operation.
FIG. 10. Tracing of pH values in the corpus-antrum region by moving electrode back and forth over a marking suture placed after spraying with Congo red dye; tracing made in intact stomach. American
Journal
of Surgery
Demonstration of Canine Gastric Antrum be demonstrated during surgery without opening the stomach. These technics, transillumination or pH detection, seem to be practical in many respects. Simplicity, speed, lack of toxicity, and low cost all serve to recommend either or both methods. They can also be applied through a gastrotomy of 1 cm. if desired. Transillumination with Congo red dye effectively shows the location of black stain (acid) inside the stomach. Hence, a source of technical error appears if acid in the antral lumen is not removed or minimized by gastric lavage. Another source of error appears if dye is sprayed from a nozzle, which creates a profuse coarse spray; in such a case, black dye from the corpus can be washed into the antrum. A tine gentle spray as used in this study can prevent this error. Still a third source of error can appear if the stomach walls are pushed and rubbed together during transillumination. Such .actions will smear the boundary, but can be prevented by insufflation and gentle manipulation of the stained stomach. Unlike the transillumination technic, pH detection of a corpus-antrum boundary is not prevented by free acid in the antral lumen. Relatively high pH values for antrum mucosa can be detected despite free fluid of low pH in the antral lumen. Gentle finger pressure on the stomach wall against the electrode minimizes the amount of free fluid between mucosa and electrode. The distribution of canine mucosal pH conforms roughly to what might be expected from information on the number of parietal cells which exist in different parts of normal human stomachs [29-321. Mucosal pH in an acidsecreting stomach is low where most parietal cells are located in the corpus, with somewhat higher pH values where fewer parietal cells exist in the fundus; pH is highest in the antrum in which few if any parietal cells are found. The average area of the antrum compared to total planar area of the stomach in this study was 20 per cent. In preserved human stomachs area of the antrum averaged 11.5 per cent of total stomach area [7]. It is not known if this difference is related to the species or is due to technic. According to Ruding and Hirdes the extent of the gastric antrum in human subjects may vary considerably in pathologic conditions 1331. This present study supports the concept that complete resection of the antrum can be Vol. 111. January 1966
85
achieved by a small distal gastric resection in many instances as demonstrated by Palumbo and Sharpe [34]. Landmarks proposed by Payne [IO] and Ruding and Hirdes [33] for partial gastric resection were selected to include exceptionally large areas of gastric antrum, thereby removing a larger distal segment than is necessary for complete antrectomy in many stomachs. By using technics reported here, a line of resection 1 cm. proximal to a color boundary or a pH boundary can provide complete antrectomy while leaving the largest practicable gastric remnant; either “closed” or “open” methods of anastomosis can be used. In dogs there was no special “tongue” of antrum extending high up the lesser curvature, although the apex of the antrum extended proportionately higher on the lesser than the greater curvature. Can the apex of the antrum be shown on the lesser curvature when the lesser omentum is thick and fat? With pH detection the lesser curvature presents no problems of this type. With dye transillumination, however, a thick omentum could make it difficult to see the highest part of the antrum on the lesser curve. This problem can be readily obviated by transilluminating the stomach after partially mobilizing the greater and lesser curvatures and resecting the pylorus from the duodenum. With a clamp on the pylorus the stomach can be kept inflated. Hence, with the lesser omentum removed to a point just below the left gastric artery, the apex of a color boundary is easily visible. Proximal resection can then be completed. At the same time a question can be raised about the significance of a small slip of residual antrum remaining on the proximal gastric remnant after antrectomy with vagotomy in the treatment of duodenal ulcer. It has never been conclusively proved that a small bit of antrum on the proximal remnant leads to a recurrent ulcer. Evidence for this hypothesis has been purely circumstantial. Indeed, the recurrence rate of ulcers after incomplete antrectomy and vagotomy should, at most, not exceed the recurrence rate after vagotomy and pyloroplasty in which the entire antrum is left in situ. Biologically, removal of the vast majority of a gland or organ drastically curtails its function. Similarly, removal of the vast majority of the antrum by subtotal antrectomy should curtail the antral phase of gastric secretion drastically, providing the conditions of
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Nyhus and co-workers [35] are met: vagotomy, no occurrence of stasis, and no exclusion of antrum from the acid stream. It is believed that some of the alarm concerning a tiny piece of antrum remaining on the proximal gastric remnant is generated by the poor results of the von Eiselsberg type of antral exclusion, which is quite another matter [36]. The following clinical and experimental procedures may be facilitated by in situ demonstration of limits of the gastric antrum without gastrotomy : (1) antrectomy with vagotomy [34,37-391; (2) high gastric resection without vagotomy, intended to include complete antrectomy [40,41]; (3) supra-antral resection, if the entire antrum is to be left in situ [42]; (4) construction of experimental gastric pouches which include only the gastric corpus or the gastric antrum; (5) experiments in which the corpus-antrum boundary is marked for studies of corpus-antrum relations over an extended time period. In our clinic this technic of transillumination has already been used to demonstrate the corpus-antrum boundary in patients with peptic ulcer, a technic readily accomplished without opening the stomach. These clinical results will be published elsewhere.
Harkins, and Professor Lloyd M. Nyhus for valuable assistance and support. REFERENCES 1. LOWICKI, E. and LITTLEFIELD, J. B. An
2.
3.
4.
5.
6.
7.
8.
9.
SUMMARY
The corpus-antrum boundary was demonstrated in dogs during laparotomy without performing a gastrotomy. This boundary was demonstrated by : (1) transillumination of the stomach to show color differences in the gastric corpus and antrum after intragastric spraying with Congo red dye via the esophagus; (2) intragastric detection of pH differences in the corpus and antrum via an esophagogastric pH electrode. These technics reveal similar corpus-antrum boundaries which correlate satisfactorily with histologic boundaries. Further data are presented on gastric mucosal pH distribution. Gastric arteriography was performed to show the relation of the corpus-antrum boundary to gastric vasculature. In twenty dogs relative planar area occupied by the antrum as compared to total gastric area was found to average 20 per cent. Possible applications of technics used here are mentioned. Acknowledgment: We are greatly indebted to Professor Dr. I. Boerema, Professor Henry N.
10.
11.
12.
13.
14.
15.
16.
17. 18.
experimental method of precisely defining the dimensions of the gastric antrum. S. Forum, 12: 308, 1961. CAPPER, W. M., LAIDLAW, C. D’A., BUCKLER, K., and RICHARDS, D. The pH fields of the gastric mucosa. Lance& 2: 1200, 1962. MOE, R. E., NYHUS, L. M., and HARKINS, H. N. The use of dye for differentiating the gastric antrum from the gastric corpus. Bull. Sot. Internat. Chir., 22: 424, 1963. SMITH, G. V. and HOWES, E. L. Absence of histamine reserpine ulcers in pyloric pouches free of acid. Surgery, 55: 262, 1964. MOE, R. E., KLOPPER, P. J., and NYHUS, L. M. Demonstration of the functional anatomy of the canine gastric antrum. I. Operative technics requiring gastrotomy. Am. J. Surg., 110: 277, 1965. VISSCHER, M. B. The secretion of dyestuffs by the gastric glands and the pancreas. Fed. Proc., 1: 246, 1942. LANDBOE-CHRISTENSEN,E. Extent of the pylorus zone in the human stomach. Acta path. et microbiol. stand. (suppi.), 54: 671, 1944. MOE, R. E. and TILLY, D. A. In vivo demonstration of the gastric vasculature by transillumination. J. Biol. Photographic A., 31: 59, 1963. PALMER, E. D. Clinical Gastroenterology. New York, 1963. Hoeber Medical Division, Harper and Row. PAYNE, J. T. The significance of vascular landmarks in gastric resection. West. J. Slrrg., 71: 161, 1963. MCCLENDON, J. F. Acidity curves in the stomach and duodenums of adults and infants, plotted with the aid of improved methods measuring hydrogen ion concentration. Am. J. Physiol., 38: 191, 1915. SARRE, H. Cited in Rein, H. Einfiihrungen in die Physiologie des Menschen, p. 194. Berlin, 1940. Springer Verlag. FLEXNER, J. and KNIAZUK, M. Method for the continuous recording of gastric pH in situ. II. Experimental details. Am. J. Digest. Dis., 7: 138, 1940. EYERLY, J. B. Comparative pH values within the stomach, pylorus and duodenum in antacid therapy. Am. J. Digest Dis., 7: 431, 1940. HAGGARD. H. W. and GREENBERG, L. A. An antimony electrode for the continuous recording of the acidity of human gastric contents. Science, 93: 479, 1941. HOFFSTETTER, F. pH Messungen mit der Glaselektrode im Magensaft. Gustroenterologiu, 72: 201, 1947. KREITNER, H. Eine neue Magensonde zur Saurabestimmung. Wien. klin. Wchnschr., 61: 32, 1949. KREITNER, H. and PANTLITSCHKO, M. Untersuchungen der Magenfunktion durch direkte Wien. Bestimmungen im lebenden Magen. Wschr. inn. Med., 30: 160, 1949. American
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19. SCHMID, J. pH-Messung im Magen-Darmtrakt. Wien. klin. Wchnschr., 61: 945, 1949. 20. ROVELSTAD, R. A., OWEN, C. A., JR., and MAGATH, T. B. Factors influencing continuous recording of in situ pH of gastric and duodenal contents. Gastroenterology, 20: 609, 1952. 21. ROVELSTAD,R. A. Continuously recorded in situ pH of gastric and duodenal contents in patients with and without duodenal ulcers. Gastroenterology, 31: 530, 1956. 22. ROVELSTAD,R. A. Gastric analysis. Gastroenterology, 45: 90, 1963. 23. GRIEVE, J. Continuous records of gastric pH in situ and their possible use in pre-operative assessment of peptic ulcer patients. &it. J. Surg., 49: 189, 1961. 24. KLOPPER, P. J. De invloed van de schors van de grote hersenen op enige autonoom geinnerveerde organen. Thesis. Amsterdam, 1954. 25. KLOPPER, P. J. Les variations du pH de l’estomac pendant la phase cephalique de la secretion du sue gastrique chez le chien. J. physiol., (Paris), 47: 621, 1955. 26. VOLLMAR, J. and NGLLER, H. G. Die elektronische Magensaftbestimmung und ihre Bedeutung fiir die Chirurgie; demonstriert am Beispiel des Magencarcinoms. Arch. klin. Chir., 294: 287, 1960. 27. BURT, C. A. V. Pneumatic rupture of the intestinal canal with experimental data showing the mechanism of perforation and the pressure required. Arch. Surg., 22: 875, 1931. 28. OLCH, P. D. and HARKINS, H. N. Quantitative assessment of extent of gastric resection. Comparison of pattern-planimeter and pattern weight methods. Surgery, 48: 655, 1960. 29. BERGER, E. H. The distribution of parietal cells in the stomach: a histotopographic study. Am. J. Anat., 54: 87, 1934. 30. 01, M., HOSHIKO, S., and FUNATSU, S. A study of the distribution of parietal cells in human stomach. Cited in Surgery of the Stomach and Duodenum, p. 182. Edited by Harkins, H. N. and Nyhus, L. M. Boston, 1962. Little, Brown & co. 31. GROSSMAN, M. I. and MARKS, I. N. Secretion of pepsinogen by the pyloric glands of the dog, with some observations on the histology of gastric mucosa. Gastroenterology, 38: 343, 1960. 32. POLACEK, M. A. and ELLISON, E. H. A comparative study of parietal cell mass and distribution in normal stomachs, in stomachs with duodenal ulcer, and in stomachs of patients with pancreatic adenoma. S. Forum, 14: 313, 1963. 33. RUDING, R. and HIRDES, W. H. Extent of the gastric antrum and its significance. Surgery, 53: 743, 1963. 34. PALUMBO, L. T. and SHARPE, W. S. Distal antrectomy with vagectomy for duodenal ulcer. Review of 450 cases. Arch. Surg., 87: 1040, 1963. 35. NYHUS, L. M., CHAPMAN, N. D., DEVITO, R. V., and HARKINS, H. N. The control of gastrin release. An experimental study illustrating a new concept. Gastroenterology, 39: 582, 1960. 36. VON EISELSBERG, A. Zur unilateralen Pylorausschaltung. Wien. med. Wchnschr., 23: 44, 1910. Vol. 111, Januavy 1966
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37. HARKINS, H. N., JESSEPH, J. E., STEVENSON, J. K., and NYHUS, L. M. The “combined” operation for peptic ulcer. Arch. Surg., 80: 743, 1960. 38. HERRINGTON, J. L., JR. Antrectomy-vagotomy for duodenal ulcer. A fifteen-year appraisal. New York J. Med., 63: 2489, 1963. 39. EDWARDS, L. W., HERRINGTON,J. L., JR., STEPHENSON, S. E., JR., CARLSON, R. I., PHILLIPS, R. J., JR., CATE, W. R., JR., and SCOTT, H. W., JR. Duodenal ulcer: treatment by vagotomy and removal of the gastric antrum. Ann. Surg., 145: 738, 1957. 40. HARKINS, H. N. Duodenal ulcer. In: Surgery of the Stomach and Duodenum, p. 189. Edited by Harkins, H. N. and Nyhus, L. M., Boston, 1962. Little, Brown & Co. 41. HARKINS, H. N. and NYHUS, L. M. Surgery of the Stomach and Duodenum, p. 418. Boston, 1962. Little, Brown & Co. 42. BERNE, C. J. Vagotomy, pyloroplasty and supraantral resection for duodenal ulcer. In: Surgery of the Stomach and Duodenum, p. 456. Edited by Harkins, H. N. and Nyhus, L. M. Boston, 1962. Little, Brown & Co. DISCUSSION MELVIN P. OSBORNE (Boston, Mass.) : The importance of this paper is obvious. It is probably luck that makes possible a good guess as to the identification of the boundaries of a dog’s antrum. There is a little change in the appearance of the mucosa. In the human subject this is really not possible and the application of a pH indicator paper strip to the open stomach reveals that the antrum extends all the way up to the esophagus in some patients. In others it is only a very small little section, no more than 3 cm. in length.
We have also found that in all patients with marginal ulcers and who were operated on, there was residual antrum in the fundic pouch. Every surgeon must try some of these methods for mapping the antrum. If resection of the antrum is necessary in gastric surgery it is necessary to know what and where it is. LLOYD M. NYHUS (Seattle, Wash.): Much of this early work was done in our laboratory in Seattle. I wish to recognize that Dr. Moe and Dr. Klopper did this work primarily with Professor Boerema in Amsterdam. We have believed for some time the importance of complete antrectomy. We are beginning to wonder, however, whether a complete antrectomy is necessary, if certain rules are followed. To perform a complete antrectomy one must resect essentially the entire gastric lesser curvature. However, I wonder if it is necessary to perform a complete antrectomy if a Billroth operation is also carried out, leaving the antrum in continuity with the acid inhibitory mechanisms. If there is no stasis in the antrum and if the remaining antrum is vagotomized, there should be little trouble. We have
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some evidence in this regard; Palumbo recently reported excellent results with a so-called 15 to 20 per cent distal gastrectomy in which these three conditions were maintained. There is another consideration. A technic as per. formed by Drs. Moe and Klopper has great importance in the field of experimental surgery. In the
preparation of an isolated antral pouch, it is important to be sure there is no acid “cuff” on it. Extra antrum is excised to be certain that the acid-secreting cells were removed. Physiologically, an acid cuff on an excluded antrum completely negates all experimental results obtained from that preparation.
Am&can
Journal
of Surgery