Effect of preservation of the pyloric sphincter during antrectomy on postoperative gastric emptying

Effect of Preservation of the Pyloric Sphincter During Antrectomy on Postoperative Gastric Emptying DUNCAN A. KILLEN, M.D. AND PANACIOTIS N. SYMBAS, M.D., Nusbville, Tennessee From tbe S. R. Ligbt Laboratory for Surgical Research and tbe Department of Surgery, Vanderbilt University Medical Center, Nasbville, Tennessee.

METHOD AduIt heaIthy mongre1 dogs were used as test animaIs. Three groups of animaIs were prepared, according to the operative procedure empIoyed, as foIIows: (I) no gastric operation, (2) conventiona hemigastrectomy with remova1 of the distaI40 per cent of the stomach incIuding the pyIorus and (3) pyIoric muscIe preserving dista1 hemigastrectomy with removaI of the distaI50 per cent of the stomach except the terminaI 2 cm. of the seromuscuIar Iayers. AI1 operative procedures were performed under steriIe conditions and veterinary nembutal (30 mg. per kg.) anesthetization. The technic of performance of the sphincter preserving hemigastrectomy is depicted in Figure I. CompIete removal of the antra1 mucosa was verified by microscopic examination of the termina1 portion of the excised mucosa.

OMPLETE remova of the antraI mucosae during gastric resection for peptic uker is desirable in order to insure abolition of the gastric or “gastrin” phase of acid production [1,2]. However, antrectomy performed in the conventiona manner necessitates remova of the phyIoric sphincter. Loss of the pyIoric sphincter resuIts in abnormaIIy rapid gastric emptying and the postprandia1 “dumping” of gastric contents into the intestine [3-51. DistaI hemigastrectomy has been performed in dogs by an operative technic which permits compIete remova of the antra1 mucosa and preservation of the pyIoric sphincter. The postoperative gastric emptying in this anima1 preparation has been assessed, and the resuIts obtained form the basis for this report.

C

a C d e FIG. I. Drawing of the technicaI steps in performance of the pyIoric sphincter preserving antrectomy. (a) The limits of gastric resection are outIined. (b) The area outIined in a has been excised and the Iesser curvature portion of the gastric pouch cIosed. Note that the mucosa of the gastric pouch has been advanced, and the suture Iine extended into a mucosal funne1 which forms a smaI1 mucosa1 stoma. The dista1 antra1 mucosa is grasped with an AIIis cIamp, and the mucosa dissected from the everted muscuIaris. (c) The dista1 antra1 mucosa has been compIeteIy mobiIized by eversion of the dista1 seromuscuIar Iayers of the dista1 antrum incIuding the pyIoric sphincter. The first suture between the mucosa1 funne1 of the gastric pouch and the duodena1 mucosa is being placed. (d) The mucosal suture Iine has been compIeted using interrupted catgut stitches. (e) The everted portion of the distal gastric seromuscular Iayers is repIaced, and the seromuscuIar suture Iine compIeted. Accepted American Journal of Surgery.

for pubIication June

Volume IOI, December 1962

836

12,

1962.

Effect of Preservation

of PyIoric

Sphincter

During

Antrectomy

FIG. 2. Duodenum (D) and gastric pouch (S) of an anima1 which died of inanition one and one-half months foIlowing performance of a sphincter preserving antrectomy. The arrows indicate mucosal and seromuscular suture lines.

FolIowing each gastric resection, gastrointestina continuity was effected by the performance of a gastroduodenostomy. Each animaI was maintained on a regimen of nothing by mouth, parentera fIuids procaine peniciIIin and streptomycin for the first four or five postoperative days. After the fifth postoperative day, no specia1 precautions were taken; the animaIs were offered standard kennel rations. The animals were observed postoperativeIy for at Ieast a six month period during which time monthly body weight measurements were recorded. After a postoperative period of one to seven months had passed, a standardized gastrointestinal series was performed in each anima1 in order to measure the rate of gastric emptying. Nothing by mouth was given during the twenty-four hours prior to performance of this procedure. The unanesthetized anima1 was secured in the prone position and a mixture of barium suIfate and 30 per cent gIucose was instiIIed via a Iong rubber catheter in the stomach. A voIume of 25 cc. per kg. body weight of this hypertonic mixture was pIaced in the gastric pouch. This contrast mea1 was used in order to ampIify any roentgenoIogic changes occurring in the smaI1 bowe1 in response to the “dumping” of a Iarge voIume of hypertonic soIution into the duodenum [3,6]. AbdominaI roentgenograms were obtained

one, four and eight hours after ingestion of the test mea1. The rate of transit of the contrast mea1 through the stomach and intestine was assessed in each anima1 from radiographic observations. RESULTS

A tota of twenty animaIs were used in this study. Five normal animaIs served as controIs. Fifteen animaIs were operated upon in the manner described. The two operative deaths were in animaIs which had undergone a sphincter preserving hemigastrectomy. One of these deaths resuIted from intra-operative bronchia aspiration and asphyxiation. The other anima1 was found dead in his cage on the first postoperative day; the cause of death couId not be determined with certainty, but was presumed to be a rcsuIt of a deep anesthetic narcosis. Three Iate deaths occurred one and a half, one and a haIf and five and a half months after operation. Of these animaIs, two had unciergone the sphincter preserving resection, and one had undergone the conventional resection. These deaths foIIowed a period of continued weight Ioss and were thought to have resuIted from inanition. In each of the three animals the suture Iines were we11 heaIed, and no evidence of stoma1 obstruction was observed at autopsy. (Fig. 2.) The stomach of one anima1 contained a Iarge trichobezoar. 837

KiIIen and Symbas

FIG. 3. AbdominaI roentgenograms one hour foIIowing ingestion of hypertonic barium sulfate meal in: A, normal animaIs, B, animals which had undergone a conventiona hemigastrectomy and C, animaIs which had undergone the sphincter preserving hemigastrectomy. Note the large amount of smaI1 bowe1 opacification present in B and C as compared to that present in A.

consistent differences between the postoperative weight changes of the two groups of animaIs were noted. The resuIts obtained by performance of the gastrointestina1 series are shown in Figures 3, 4 and 5. The reIative amounts of contrast medium present in the stomach and smaI1 bowe1 one, four and eight hours foIIowing the barium mea1 are tabuIated in TabIe I. There was an abnormaIIy rapid passage of the hypertonic contrast mea1 into the smaI1 bowel in the animaIs which had undergone the conventiona1 (sphincter destroying) hemigastrectomy. The rate of gastric emptying in the animaIs which had undergone the sphincter preserving hemigastrectomy was more rapid than gastric emptying in the contro1 or norma

The postoperative body weight in each animal that survived the operative period was caIcuIated in terms of percentage of the preoperative weight. The mean (and range) of the minimum postoperative weights of the animaIs of the conventiona hemigastrectomy and the sphincter preserving hemigastrectomy groups were 70 per cent (41 to 93 per cent) of the preoperative weight and 67 per cent (42 to 86 per cent) of the preoperative weight, respectiveIy. The mean (and range) of the anima1 weights six months postoperative in the conventiona1 hemigastrectomy and sphincter preserving hemigastrectomy groups were g5 per cent (87 to 102 per cent) of the preoperative weight and 87 per cent (58 to 106 per cent) of the preoperative weight, respectiveIy. No 838

Effect of Preservation

of Pyloric

Sphincter

During

Antrectomy

FIG. 4. AbdominaI roent; genograms four hours folIowing ingestion of hypertonic barium suIfate meal in: A, normal _ animals, B, animak which had undergone a conventional hemigastrectomy and C, animaIs which had undergone .1 I.. 1 ~I ~1 ?.TI_ -1~. ~’ : ~.I --.L..~- _ -:C..r:._ __..___A:_ D _.___.._...IA__

that in A and C.

animals, emptying ventiona1

but was less rapid than the gastric in those animaIs subjected to a conhemigastrectomy.

various procedures evaIuated have been: (I) the construction of a purposefuIIy smaI1 gastroduodenostomy or gastroenterostomy [6], the interposition of a segment of smaI1 bowe1, iIeocecum or coIon [7-91 and (3) the preservation of the dista1 antrum and/or pyIorus by performance of a “sIeeve” type of gastric resection [~,ro]. Construction of a purposeIy small anastomotic stoma and the gastroduodena1 interposition of a segment of bowe1 have not proved suffIcientIy satisfactory to justify universa1 application of such methods of gastrointestina1 reconstruction folIowing gastric resection. A “sleeve” gastric resection preserves the pyIoric sphincter mechanism, but the retained antral mucosa comes in contact with ingested food so that the likelihood of a per-

COMMENTS

An operative procedure which incorporates complete removal of the antra1 mucosa seems essentia1 for maxima1 suppression of gastric acid production in the peptic uIcer patient [r,z]. Antrectomy, as usuaIIy performed, resuIts in a Ioss of the pyIoric sphincter mechanism causing the postoperative syndrome of “dumping” of gastric contents into the smaI1 bowe1

[?Fd SeveraI operative maneuvers produce a sIower gastric emptying resection have been devised.

designed to after gastric Among the

839

KilIen

and Symbas

FIG. 3. AbdominaI roentgenograms eight hours folIowing ingestion of hypertonic barium sulfate meal in: A, norma animals, B, animats which had undergone a conventional hemigastrectomy and C, animaIs which had undergone the sphincter preserving hemigastrectomy. Note greater residual gastric opacification present in A compared to that present in B and C, especially to that present in B.

stomach through the prepyIoric area, as performed in the sphincter preserving “sIeeve” gastric resection, does not destroy the sphincteric reguIatory function of the pyIorus [.J]. However, in performing the sphincter preserving resection which permits compIete antra1 mucosa excision, the mucosa and submucosa of the pyIoric area are stripped from the antra1 muscuIaris and the pyIoric sphincter. The effect of this maneuver upon the intrinsic reguIatory function of the pyIorus is not known. The deIayed gastric emptying observed in the presence of the preserved pyIoric sphincter in this study tends to support the concept that the sphincter to some extent stiI1 controIs the rate of gastric emptying after such a resection. (Figs. 3, 4 and 5 and TabIe I.) The cIinica1 appIication of a sphincter pre-

sistent “gastrin” phase of acid stimulation exists. FIynn and Longmire [IO] devised an operative technic of gastric resection which permitted compIete excision of the antraI mucosa and preservation of the transected pyloric sphincter [ro]. They evaIuated the effect of such a sphincter preserving resection on postoperative gastric emptying in a smaI1 number of animaIs. Their findings were suggestive but not concIusive that postoperative gastric emptying was beneficiaIIy effected by this type of resection. The operative technic empIoyed in the present study is essentiaIIy the same as that which they used except that no pyIoric sphincterotomy was performed in the series of animaIs herein anaIysed. It has been shown that division of the dista1 840

Effect

of Preservation

of Pyloric

Sphincter

TABLE RELATIVE

OPACIFICATION

OF STOMACH AFTER

AND

During

Antrectomy

I*

SMALL

HYPERTONIC

BOWEL,

BARIUM

ONE,

FOUR

Group

EIGHT

HOURS

SmalI Bowel

Stomach

_

AND

MEAL

i

(>ne Hour

/I
Four Hours

Hours

-I-

+++ +++ +++ +++ +++

Control

Conventiona

++-+ +++ +++ +++

hemigastrectomy

Sphincter preserving trectomy

+++ +++ +++ +++ +++

hemigas-

+++ +++ +++ +++ +++

/ ~

t:: ++ ++

i

++ ++ +-+ + -- + t -- + ++

+ + + + +

t++++ ++ +:+

:

I

+I;

++ +‘)+ +++ ++ tt ++ + ~ -t

++t

z ++ ++

-

Key

+

:

o + + + + + +

No opacification Slight opacification Moderate opacification Marked opacification

antrectomy is more norma than that which foIIows the conventiona (sphincter destroying) antrectomy. 3. Such a sphincter preserving antrectomy wouId seem feasibIe in certain clinical situations.

serving gastric resection wouId not be practica1 in most peptic ulcer patients. The inflammatory changes and scarring associated with a peptic ulcer of the pylorus or the first portion of the duodenum wouId make the intrapyroric mucosal stripping and anastomosis diffIcuIt if not impossibIe. AIso, preservation of the pyIoric sphincter wouId cause gastric retention if a vagotomy were performed in combination with the antrectomy. However, when the uIcer is situated in the stomach and the tissues of the pyIoric area are normaI, gastric resection (without vagotomy) with preservation of the pyIoric sphincter by the technic described wouId be feasible.

REFERENCES I. DRAGSTEDT, L. R. The

2.

3.

SUMMARY

In a dog, it is possibIe to perform gastric antrectomy in such a manner as to completely excise the antra1 mucosa yet preserve the pyIoric sphincter. 2. The gastric emptying of hypertonic SOIUtions folIowing such a sphincter preserving

4.

I.

841

5.

6.

physiology of the gastric antrum. Arch. Surg., 75: 552, 1957. SCOTT, H. W., JR., HERRINGTON,J. L., EDWARDS, W. H. and SHULL, H. J. The hazards of antra1 exclusion with vagotomy in the surgical treatment of duodenal uIcer. Ann. Surg., rg I : 181, 1960. ABBOTT, W. E., KRIEGER, H. and LEVEY, S. TechnicaI surgical factors which enhance or minimize postgastrectomy abnormalities. Ann. Surg., 148: 567, 1938. FISHER, J. A., TAYLOR, W. and CANNON, J. A. The dumping syndrome: correlation between its experimenta production and clinical incidence. Surg. Gynec. v Obst., IOO: 559, 1955. FRIESEN, S. R. and RIEGER, E. A study of the role of the pyIorus in the prevention of the “dumping syndrome.” Ann. Surg., I 5 I : 5 17. 1960. AMDRL.P, E., HJORTH, P. and JORGENSEN, J. B.

KiIIen and Symbas RadioIogicaI demonstration of variations in the Auid content of the smaI1 intestine during dumping attacks. Brit. J. Radiol., 31: 542, 1958. 7. KILLEN, D. A., SYMBAS, P. N., BURRUS, G. and Scorn,, H. W., JR. Use of the transposed iIeoceca1 vaIve for sphincteric controI of gastric emptying after ablation of the pyIorus. Surgery, 48: 838, 1960.

842

8. POTH, E. J. The dumping syndrome and its surgica1 treatment. Am. Surgeon, 23: 1097, 1957. g. WATKINS, D. H. and WHITTENSTEIN, G. SubtotaI gastric resection with coIon substitution. Arch. Surg., 70: 843, 1935. IO. FLYNN, P. J. and LONGMIRE, W. P., JR. SubtotaI gastrectomy with pyIoric sphincter preservation. S. Forum, IO: 185, 1960.