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Role of the gastric antrum in gastric hypersecretion after jejunal reversal
Role of the Gastric Antrum in Gastric Hypersecretion after Jejunal Reversal
Donald J. Lulu, MD, Des Moines,
Iowa
Previous reports from our laboratory have demonstrated that gastric hypersecretion occurs after reversal of an 8 cm jejunal segment in continuity, after massive small bowel resection, or after both [l--3]. We also demonstrated that this hypersecretion increases with the distance of the reversed segment from the pylorus but can be diminished, although not to pre-reversal levels, by the addition of truncal vagotomy and pyloroplasty [I]. Although the beneficial effects of vagotomy and pyloroplasty in diminishing this hypersecretion were anticipated, the increasing hypersecretion related to the distance of the reversed segment from the pylorus was not. If, however, as has been assumed, the gastric antrum were responsible for the hypersecretion, it would be reasonable to predict that the closer the reversed segment was placed to the stomach, the greater the delay in gastric emptying and, therefore, the greater the antral stimulation. Since exactly the opposite was found, the presence of an augmented intestinal phase of secretion independent of the gastric antrum was suspected. In an attempt to delineate the mechanism of gastric stimulation, the following experimental models were created. From the Surgical Service, Veterans Administration Hospital, Des Moines, Iowa. Reprint requests should be addressed to Dr Lulu, Surgical Service, Veterans Administration Hospital, 30th and Euclid, Des Moines, Iowa 50310.
240
Material and Methods Five adult female dogs were selected after routine examination and devocalization by our veterinarian. After the dogs were dewormed and were acclimated to laboratory conditions, a standard daily diet of 1,200 gm of commercial dog food supplemented with 10 gm of salt, vitamins, and two tablespoons of bone meal was fed each dog. After recovery from the surgical procedures previously described, complete vagally denervated Heidenhain pouches that contained no antral mucosa were constructed and the secretions were externally drained via plastic cannulas. Twenty-four hour specimens were collected for a minimal period of thirty days after recovery from this surgical procedure. The volumes were recorded and averaged for each of the five dogs and an aliquot was titrated for free hydrochloric acid with 0.1 N sodium hydroxide using the color change and point of Tbpfer’s reagent. The milliequivalents of free hydrochloric acid were computed and recorded for each dog. Finally, gastric emptying times were determined using the standard meal mixed with barium. Since our earlier studies had shown that of three levels of reversal of an 8 cm segment of jejunum in continuity, namely, an immediate postpyloric level, 45 cm from the ligament of Treitz, and 100 cm from the ligament of Treitz, the maximal hypersecretion occurred at the 100 cm level, all five dogs were subjected to an 8 cm jejunal reversal at the 100 cm level. After complete recovery, gastric volumes, free hydrochloric acid production, and gastric emptying times were again recorded over a thirty day collection period and averaged.
The American
Journal of Surgery
Gastric
TABLE I
Gastric Volume, Post Heidenham
Secretory,
Pouch Construction Free HCI
Dog Number
Volume (ml)
D26 D35 D37 D42 D48
64 167 127 126 163
and Emptying
(mEq) 53.3 17.9 14.7 13.7 19.9
Emptying Time (hr) 2 2 1 2 2
Post Reversal at 100 Cm Level
Volume (ml)
(mW
Emptying Time (hr)
Volume (ml)
rree HC,I (ink)
102 212
93.7 24.1 38.2 26.3 41.8
2 1 2 2 2
39 44 104 36 143
Y5.4 1.; 7.” 1 9 17.2
Free HCI
286 211 303
The collected data showed that total gastric antrectomy did indeed effectively reduce the hypersecretion and hyperacidity produced by jejunal reversal as well as generally reducing the gastric emptying time. (Table I.) Summary and Conclusions The mechanism by which gastric secretory volume and acidity are increased after jejunal reversal is apparently related to antral stimulation and
1974
Jejunal
Reversal
Post Anlrectclmy
____
Results
127, March
after
Data
Finally, complete antral resection was carried out utilizing the 1 per cent’ Congo red-histamine diphosphate technic to delineat,e the exact extent of the gastric antrum. This was accomplished by injecting intravenously 1 cc of histamine diphosphate at the time of the operation to induce hypersecretion of free hydrochloric acid and by painting the mucosa of the stomach with the 1 per cent Congo red solution through a generous gastrotomy. The acid-producing portion of the stomach was thus colored deep blue due to the presence of free acid whereas the nonacid-producing areas remained deep red. After total gastric antrectomy, gastrointestinal continuity was restored by an antecolic Polya type of gastrojejunostomy. After complete recovery of the dogs, gastric volume, acid, and emptying times were again studied as described.
Volume
Secretion
Emptying Time (hr)
_
subsequent overactivity. This finding is supported by previously reported data indicating that vagotomy and pyloroplasty have an ameliorating effect [I]. and this effect is even further enhanced markedly by total gastric antrectomy. The intestinal phase of gastric secretion is apparently responsible for the remaining stimulation which is relatively small. In practical terms, when bowel reversal is employed because of undesirable sequelae from adequate peptic ulcer operations, if the operation has achieved its goal of reducing free hydrochloric acid, no further procedure aimed at t.he ulcer diathesis is necessary. If, however, bowel reversal is used as a mechanism for slowing intestinal transit time in patients in whom ulcer surgery has not been carried out, the addition of t,otal gastric antrectomy rather than vagotomy and pyl.oroplasty is advocated. References 1. Lulu DJ, Dragstedt RL I I: The effect of the level of small bowel reversal on gastric hypersecretion. Am J Surg 124: 322, 1972. 2. Kimura S, Dragstedt LR II: Reversed jejunal segments and gastric hypersecretion. Arch Surg 98: 713, 1969. 3. Grundberg AB, Lopez AS, Dragstedt LR II: Effect of intestinal reversal and massive resection on gastric secretion. Arch Surg 94: 326, 1967.
249
Donald J. Lulu, MD, Des Moines,
Iowa
Previous reports from our laboratory have demonstrated that gastric hypersecretion occurs after reversal of an 8 cm jejunal segment in continuity, after massive small bowel resection, or after both [l--3]. We also demonstrated that this hypersecretion increases with the distance of the reversed segment from the pylorus but can be diminished, although not to pre-reversal levels, by the addition of truncal vagotomy and pyloroplasty [I]. Although the beneficial effects of vagotomy and pyloroplasty in diminishing this hypersecretion were anticipated, the increasing hypersecretion related to the distance of the reversed segment from the pylorus was not. If, however, as has been assumed, the gastric antrum were responsible for the hypersecretion, it would be reasonable to predict that the closer the reversed segment was placed to the stomach, the greater the delay in gastric emptying and, therefore, the greater the antral stimulation. Since exactly the opposite was found, the presence of an augmented intestinal phase of secretion independent of the gastric antrum was suspected. In an attempt to delineate the mechanism of gastric stimulation, the following experimental models were created. From the Surgical Service, Veterans Administration Hospital, Des Moines, Iowa. Reprint requests should be addressed to Dr Lulu, Surgical Service, Veterans Administration Hospital, 30th and Euclid, Des Moines, Iowa 50310.
240
Material and Methods Five adult female dogs were selected after routine examination and devocalization by our veterinarian. After the dogs were dewormed and were acclimated to laboratory conditions, a standard daily diet of 1,200 gm of commercial dog food supplemented with 10 gm of salt, vitamins, and two tablespoons of bone meal was fed each dog. After recovery from the surgical procedures previously described, complete vagally denervated Heidenhain pouches that contained no antral mucosa were constructed and the secretions were externally drained via plastic cannulas. Twenty-four hour specimens were collected for a minimal period of thirty days after recovery from this surgical procedure. The volumes were recorded and averaged for each of the five dogs and an aliquot was titrated for free hydrochloric acid with 0.1 N sodium hydroxide using the color change and point of Tbpfer’s reagent. The milliequivalents of free hydrochloric acid were computed and recorded for each dog. Finally, gastric emptying times were determined using the standard meal mixed with barium. Since our earlier studies had shown that of three levels of reversal of an 8 cm segment of jejunum in continuity, namely, an immediate postpyloric level, 45 cm from the ligament of Treitz, and 100 cm from the ligament of Treitz, the maximal hypersecretion occurred at the 100 cm level, all five dogs were subjected to an 8 cm jejunal reversal at the 100 cm level. After complete recovery, gastric volumes, free hydrochloric acid production, and gastric emptying times were again recorded over a thirty day collection period and averaged.
The American
Journal of Surgery
Gastric
TABLE I
Gastric Volume, Post Heidenham
Secretory,
Pouch Construction Free HCI
Dog Number
Volume (ml)
D26 D35 D37 D42 D48
64 167 127 126 163
and Emptying
(mEq) 53.3 17.9 14.7 13.7 19.9
Emptying Time (hr) 2 2 1 2 2
Post Reversal at 100 Cm Level
Volume (ml)
(mW
Emptying Time (hr)
Volume (ml)
rree HC,I (ink)
102 212
93.7 24.1 38.2 26.3 41.8
2 1 2 2 2
39 44 104 36 143
Y5.4 1.; 7.” 1 9 17.2
Free HCI
286 211 303
The collected data showed that total gastric antrectomy did indeed effectively reduce the hypersecretion and hyperacidity produced by jejunal reversal as well as generally reducing the gastric emptying time. (Table I.) Summary and Conclusions The mechanism by which gastric secretory volume and acidity are increased after jejunal reversal is apparently related to antral stimulation and
1974
Jejunal
Reversal
Post Anlrectclmy
____
Results
127, March
after
Data
Finally, complete antral resection was carried out utilizing the 1 per cent’ Congo red-histamine diphosphate technic to delineat,e the exact extent of the gastric antrum. This was accomplished by injecting intravenously 1 cc of histamine diphosphate at the time of the operation to induce hypersecretion of free hydrochloric acid and by painting the mucosa of the stomach with the 1 per cent Congo red solution through a generous gastrotomy. The acid-producing portion of the stomach was thus colored deep blue due to the presence of free acid whereas the nonacid-producing areas remained deep red. After total gastric antrectomy, gastrointestinal continuity was restored by an antecolic Polya type of gastrojejunostomy. After complete recovery of the dogs, gastric volume, acid, and emptying times were again studied as described.
Volume
Secretion
Emptying Time (hr)
_
subsequent overactivity. This finding is supported by previously reported data indicating that vagotomy and pyloroplasty have an ameliorating effect [I]. and this effect is even further enhanced markedly by total gastric antrectomy. The intestinal phase of gastric secretion is apparently responsible for the remaining stimulation which is relatively small. In practical terms, when bowel reversal is employed because of undesirable sequelae from adequate peptic ulcer operations, if the operation has achieved its goal of reducing free hydrochloric acid, no further procedure aimed at t.he ulcer diathesis is necessary. If, however, bowel reversal is used as a mechanism for slowing intestinal transit time in patients in whom ulcer surgery has not been carried out, the addition of t,otal gastric antrectomy rather than vagotomy and pyl.oroplasty is advocated. References 1. Lulu DJ, Dragstedt RL I I: The effect of the level of small bowel reversal on gastric hypersecretion. Am J Surg 124: 322, 1972. 2. Kimura S, Dragstedt LR II: Reversed jejunal segments and gastric hypersecretion. Arch Surg 98: 713, 1969. 3. Grundberg AB, Lopez AS, Dragstedt LR II: Effect of intestinal reversal and massive resection on gastric secretion. Arch Surg 94: 326, 1967.
249