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Effects of gastric surgery upon gastric emptying in cases of peptic ulceration
... The results of the few studies which have been undertaken have been conflicting. Buckler (1967) observed that the total emptying time of the stomach was prolonged after operation. Madsen and Pederson (1968), George et al. (1968), andMcKelvey (1970) noted that after operation the stomach emptied more rapidly, particularly in patients with postoperative diarrhoea. ...
Emptying of liquids from the stomach was studied in 19 patients who had had a vagotomy and pyloroplasty and the results compared with 12 patients with duodenal ulcers and 9 patients with normal upper gastrointestinal tracts. The patterns of gastric emptying after vagotomy and pyloroplasty was found to consist of a very rapid initial emptying phase followed by emptying at a rate rather faster than in the other two groups. There was no difference in the gastric emptying of patients with duodenal ulcer and those with a normal gastrointestinal tract. Patients who complained of postprandial fullness and dumping after vagotomy and pyloroplasty had extremely rapid initial gastric emptying, more than half the test solution leaving the stomach almost immediately. Three patients who had postoperative gastric ulcers, 2 patients with vomiting since operation and 1 with postvagotomy persistent diarrhea showed a starting index and half-life similar to those of asymptomatic postoperative patients and only minor differences in the emptying time.
Serial tests at varying intervals during the weeks after operation showed the gastric emptying of liquids was faster than normal from the earliest postoperative test. Over the succeeding weeks, emptying became still faster and probably reached a static state in 2 or 3 months.
... Disturbances of alimentary movements are well recognized side-effects of surgical vagotomy, and many patients note increased bowel frequency after vagotomy (Cox and Bond, 1964). There is also good evidence of an altered pattern of gastric emptying (Goodall, 1966; Griffith, Owen, and Shields, 1966; Buckler, 1967; McKelvey, 1970). These phenomena have been investigated fairly intensively but agreement is still lacking on their precise characteristics. ...
The effect of a subthreshold dose of carbachol on alimentary transit of a radioisotopically labelled fluid test meal was measured before and after vagotomy and pyloromyotomy in rats. Vagotomy itself had a transient slowing effect on the rates of gastric emptying and transit in the upper small intestine. Subthreshold carbachol had no effect before vagotomy but accelerated gastric emptying and small intestinal transit after vagotomy. These findings might explain the increased bowel frequency which is common after vagotomy.
... This is probably not the explanation, however, as our findings in model 1 dogs with no bypass and an intact pylorus show that different instillations into the stomach do empty at different rates. Emptying time following vagotomy and drainage is disputed (Buckler, 1967). Tinker et al (1970), who used meals of a more solid nature, showed delayed emptying after vagotomy and drainage. ...
It has been suggested that an intact vagal supply is essential for the normal function of the recptors in the duodenum and proximal small bowel, which influence the rate of gastric emptying. This paper reports the effect of vagal denervation on gastric emptying and also examines the site and mode of action of receptors in the proximal small bowel. It has been demonstrated in the dog that most, if not all, the receptors controlling gastric emptying lie in the proximal 50 cm of the small bowel. Following truncal vagotomy the emptying time of each instillation increased significantly and the differential rate of emptying of different instillations remained unchanged. The proximal 50 cm of small bowel was capable to differentiating between different instillates even after selective extragastric vagotomy, in which the duodenum was vagally denervated and, therefore, duodenal braking receptors function independently of vagal innervation.
... The results of the few studies which have been undertaken have been conflicting. Buckler (1967) observed that the total emptying time of the stomach was prolonged after operation. Madsen and Pederson (1968), George et al. (1968), andMcKelvey (1970) noted that after operation the stomach emptied more rapidly, particularly in patients with postoperative diarrhoea. ...
The pattern and rate of gastric emptying have been studied in 16 patients before and after vagotomy and pyloroplasty. The rate of emptying, expressed as half life in minutes, was not greatly changed by operation. After operation, however, there was a rapid initial phase of emptying, particularly marked in patients who had post-vagotomy diarrhoea.
... After vagotomy and Heineke-Mikulicz pyloroplasty, gastric emptying was slower. This finding was consistent with the observations of Buckler (1967), using a radio-opaque meal to study gastric emptying after vagotomy and pyloroplasty. Such delay is fairly easy to comprehend when the mechanism of the 'antroduodenal pump' is considered ( Johnson, 1961). ...
The rate of gastric emptying was estimated in 29 patients with duodenal ulcers, before and after vagotomy and drainage operations, by measuring the disappearance from the stomach of a standard meal containing radioactive chromium. When Heineke-Mikulicz pyloroplasty accompanied vagotomy gastric emptying was observed to be slowed, whereas after vagotomy and Fitmey pyloroplasty the rate of gastric emptying was more rapid when compared with the preoperative rate. Gastric emptying after vagotomy and gastrojejunostomy showed no consistent alteration in rate. Temporary gastric stasis occurred in the early postoperative period after vagotomy and drainage procedures.
Gastric emptying and secretion were studied by means of test meal method on healthy controls and patients with petic ulcer. The following studies were made by giving water-, caffeine-, or peptontest meal containing phenol red to the subjects, and withdrawing gastric contents after 20 minutes period. Volume of secretion and acid output were calculeted following to Hunt's formula (1951).
The results were briefly summerized as follows:
1) Good correlation was found between the maximal acid response by gastric tube method and the acid output obtained by test meal method, when 6ug/kg of penta gastrin was used as stimulant.
2) The rate of the emptying and the secretion was proved to be paralled with the volume of test meal, so far as 50ml, 200ml and 500ml of water-test meal were used.
3) Both gastric emptying and secretion were stimulated significantly by addition of caffeine to water test meal. Moreover, the similar accelerating effect of caffeine upon the gastric function was observed both in previous oral and parenteral administration. Caffeine was proved to affect upon gastric function not only by its local stimulation but also though systemic effect after absorption.
4) Pepton-test meal (2.6%) promoted acid secretion more remarkably than caffeine test meal, but no influence was observed on emptying. Acid outupt obtained by 200ml of pepton test meal in 20minutes period corresponded to 80% of that by maximal histalog stimulation.
5) Function of the stomach of patients with peptic ulcer was examined using 200ml of pepton test meal in 20minutes period.
High acid output and rapid emptying were detected in duodenal ulcer patients, and low acid output but normal emptying were observed in gastric ulcer patients.
The ratio of the acid output obtained by test meal method to maximal histalog response was about 90% in patients with duodenal ulcer, and about 80% in patients with gastric ulcer and normal controls. It was suggested that antral release of gastrin might be more active in cases with duodenal ulcer than in cases with gastric ulcer and in healthy controls.
6) Effect of some anticholinergic drugs were examined by test meal method. Propantheline bromide and total alkaloid of the scopolia root were proved to depress both gastric emptying and secretion. However, oral administration of hyoscine butylbromide affected little upon them.
Unter einem pylorischen Ulcus verstehen wir ein Ulcus, das maximal 2cm proximal des Pylorus gelegen ist und/oder bis in den Pylorus hineinreicht [1, 7, 12]. Eine Trennung von intra- und präpylorischen Ulcera scheint uns überflüssig [2]. Synonyme für das pylorische Ulcus sind prä-pylorisches Ulcus [10], Ulcus ventriculi vom Typ 3 nach Johnson [8,9] und juxtapylorisches Ulcus [17].
Der Magen läßt sich hinsichtlich seiner Motilität in 2 Abschnitte unterteilen (Übersichten bei [54] und [65]): einen proximalen Abschnitt, bestehend aus Fundus und oralem Drittel des Korpus und einen distalen Abschnitt, bestehend aus den aboralen beiden Dritteln des Corpus, dem Antrum und dem Pylorus. Der proximale Abschnitt dient als Reservoir. Eine vorwiegend vagal vermittelte Druckregulation (rezeptive Relaxation und Akkomodation) reguliert die Flüssigkeitsentleerung. Nach Fundusresektion oder Vagotomie sinkt die Akkomodationsfähigkeit. Dadurch kommt es bei Füllung zum Druckanstieg und einer rascheren Entleerung von Flüssigkeiten. Der distale Magenabschnitt dient vorwiegend der Zerkleinerung fester Nahrungsbestandteile [38, 68]. Pathologische Veränderungen in diesem Magenteil schlagen sich deshalb in der Entleerung fester Mahlzeiten nieder. So führt eine Resektion von Antrum und Pylorus zu einer mangelhaften Zerkleinerung und überstürzten Entleerung fester Partikel [38]. Denervierung führt zu einer Stase fester Nahrungsbestandteile. Das Antrum hat wahrscheinlich keine Funktion in der Flüssigkeitsentleerung. Chirurgische Zerstörung des Pylorus hingegen läßt die Menge von Mageninhalt, die den Pylorus passiert, ansteigen. Da gleichzeitig jedoch der Reflux aus dem Duodenum erhöht wird, bleibt die Nettoentleerung der Flüssigkeiten aus dem Magen konstant [83, 84]. Eine dritte Form der Entleerung aus dem nicht operierten Magen stellt die Pyloruspassage nicht zerkleinerbarer Nahrungsbestandteile dar. Sie verbleiben im Magen, bis das digestive dem interdigestiven Motilitätsmuster Platz macht, und werden durch die Aktivitätsfront des ersten interdigestiven myoelektrischen Komplexes aus dem Magen entfernt [27, 80].
It is generally assumed that many of the postprandial symptoms occurring in patients after partial gastrectomy are caused by a disordered pattern of gastric emptying. Several studies reporting enhanced rates of emptying of liquids and solids after partial gastrectomy have been published (1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12), but it should be noted, that differences in both measurement technique and patient selection render comparison of these studies impossible. In some studies patients with different types of resections were examined, in many studies the type of resection was insufficiently described, and in other studies vagotomizad patients were included. Since the rate of emptying might be influenced by the size of the anastomosis (13) and will definitely be affected by vagotomy (highly selective or truncal) (9,10) the relevance of those studies is limited.
Die gastromtestinale Motilität dient der Regulation und Integration aller gastromtestinalen Funktionen. Grundsȧtzlich lassen sich verschiedene Bewegungen im Magen-Darm-Trakt unterscheiden Propulsion und (selten) Retropulsion, die der Fortbewegung dienen, sowie die Segmentation, die fur die Durchmischung und Resorption des Darmmhalts notwendig ist. Bedeutsam für Bewegung des Darminhalts sind ebenfalls die stationaren Hochdruckzonen (Sphmcteren), die Ruckfluß verhindern und eine kontrollierte Entleerung ermȯglichen. Die Abb. 8.1 veranschaulicht diese unterschiedlichen Funktionen.
The effects of various surgical procedures on gastric emptying have been studied by several groups of workers in recent years1–9. Some measure of agreement is now emerging, following recognition that apparently conflicting results may be explained by the fact that emptying patterns of liquids and solids may differ, and that emptying rates during the first few minutes after a meal may bear no relationship to the rates occurring thereafter. There have been few studies in which emptying of the liquid and solid components of a mixed meal have been measured simultaneously, and in this paper we report our use of a scintigraphic technique to study this in patients who have undergone truncal vagotomy and pyloroplasty or highly selective vagotomy on account of chronic duodenal ulceration.
Although the majority of patients do relatively well following gastric surgery, some develop severe malabsorption and present difficult problems of nutritional management. Partial gastric resection was the procedure most frequently performed for peptic ulcer disease up to a decade ago and is still performed today. These patients, particularly those with Billroth II gastric resection, present potentially serious malabsorption problems. Weight loss commonly occurs after gastrectomy, the incidence being variously reported between 30% and 84% (1–13). The most common cause of postgastrectomy weight loss, although it may be multifactorial, is not malabsorption but inadequate food intake, due to poor appetite early sensations or fear of postcibal symptoms [7, 12]. Weight changes are found mostly in the first year after operation, but thereafter small changes are observed. Johnston et al. [12] observed that those patients who had lost weight prior to subtotal gastrectomy tended to gain afterwards, but those who had maintained a steady weight or had had an increase in weight before the operation tended to lose afterwards (Fig. 57). After truncal vagotomy, Wastell [13] found that the method of drainage (pyloroplasty or gastro-enterostomy) did not influence the loss of weight, and about half or more of the patients lost weight after vagotomy and drainage. Wheldon et al. [5] found a weight more than 4 kg below standard in 47% of men and in 64% of women after truncal vagotomy with gastro-enterostomy.
The stomach stores food through the operation of a process usually called receptive relaxation. It mixes and delivers food to the bowel by the process of antral peristalsis.
Johnson (1957, 1965) and Johnson et al. (1964) held that gastric ulcers should not only be classified anatomically according to their distance from the pylorus, but also in accordance with their associated acid-secretory or pathophysiological characteristics. While most gastric ulcer patients were acid hypo-secretors, some were moderate and others hypersecretors of acid. On this basis the following three types of gastric ulcers were recognized: type I consisted of those patients in whom the ulcer was situated to the left of and above the gastric angulus (the angulus being defined as the lowest point of the lesser curvature), without macroscopic abnormalities of the prepyloric region, the pylorus or duodenum; these cases were associated with a low level of acid secretion and possibly hyposecretion of mucus. Type II consisted of those cases in which a gastric ulcer to the left of the angulus was associated with, and probably secondary to, an ulcer or its scar in the pylorus or duodenum; these patients were moderate and sometimes hypersecretors of acid. Type III included all gastric ulcers on or near the pylorus, and might be combined with a duodenal ulcer or a type II gastric ulcer proximally; these patients usually had hypersecretion of acid. Type III was subdivided as follows: (1) ulcers within one inch (2.54 cm) of the pylorus, called true prepyloric ulcers; (2) ulcers to the right of the angulus but further than 2.54 cm from the pylorus, called “other antral” ulcers.
The hypothesis that bile reflux causes a gastritis and so predisposes to ulceration, is supported by many clinical studies. However, all patients with gastric ulcer do not have abnormal amounts of bile in the stomach. In a recent study results within the normal range were obtained in one third of the patients. Moreover, the degree of reflux alters little in individual patients irrespective of whether or not the ulcer heals. Even if the sequence of events postulated in this hypothesis were fully established in the majority of patients, bile reflux may well not be the main etiological factor. Theoretical possibilities are that bile reflux may predispose to ulceration, cause the associated gastritis, delay healing of the ulcer or play no significant role in the pathogenesis. Support for the significance of bile reflux would be strengthened if one could break the chain of events which is postulated, and accelerate healing of the ulcer. The demonstration that carbenoxolone protects gastric mucosa against bile damage is of interest in this respect. The authors suggest that bile reflux produces a gastritis, which may predispose to ulcer in some patients. The mucosal damage which follows bile reflux appears to be closely related to the back diffusion of hydrogen ion from gastric contents into the mucosa. This concept is of importance in view of the development of compounds which 'strengthen' the mucosa against bile damage and reduce the back diffusion of hydrogen ion. There is a striking difference between the immediate effect of bile reflux on gastric secretion and the long term consequences. Whereas hypersecretion may play a part in the short term, one of the long term effects is the development of atrophic gastritis with loss of parietal cell mucosa. It is clear that neither of the two main hypotheses for the etiology of gastric ulcer provide an entirely adequate explanation of the cause in all patients. Both hypotheses, however, appear to describe quite adequately the sequence of events in some patients and it is perhaps unwise to search for one unified hypothesis which will account for all patients. There are several types of gastric ulcer and the cause need not necessarily be the same in all of them.
各種の迷切, 幽成術ならびに迷切兼幽成術後の胃内容排出態度について実験的に観察し検討した.その結果, 迷切では選近迷切が最も胃内容排出障害が少なく, 幽成ではFinney法が最も良くドレナージ効果を示した.またFinney法を除く幽成は正常胃の内容排出に対しては促進効果を示さず, 迷切胃の内容排出に対しては促進効果を示した.さらに迷切兼幽成術後の胃内容排出態度は摂食後早期に急速な排出を示し, 時期の経過とともにかえって排出が遅延する傾向がみられ, その排出機転には胃の内圧が大きく関与していると考えられた.このような排出態度が本術式後のダンピング症候群, あるいはGastric Stasisを来して潰瘍の再発にも関連すると推定された.
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The hydrogen clearance method for measuring blood flow in unanesthetized unrestrained animals has been adapted to the alimentary tract of dogs and the method briefly described. Basal perfusion rates in both the jejunum (0.91 ml./gm./min.) and the ileum (0.89 ml./gm./min.) were measured but there was no statistical difference between mean values. At a subsequent operation bilateral truncal vagotomy together with a pyloroplasty were performed on all the dogs and paired observations in the early (under 3 weeks) and late (over 3 weeks) postvagotomy periods undertaken. In the early postoperative period significant reductions in blood flow occurred in both the jejunum and ileum amounting to 49.5 and 48%, respectively. The late effects of vagotomy were observed in only five dogs. Four of these dogs escaped from the induced ischemia although the onset of the release phenomenon is variable. The significance of these findings is discussed.
A two-marker technique avoiding transpyloric intubation was used to measure the volume of gastric secretion, the rate of gastric emptying and the degree of postprandial duodenogastric reflux in 8 dogs, 5 without and 3 with Heineke–Mikulicz pyloroplasties. The stomach emptied after a liquid fatty meal at an overall rate of 4·9 ml/min ± 0·2 s.e.m. in animals with a normal pylorus and 5·7 ± 0·2 ml/min in those with pyloroplasties (P < 0·05). Though mean fractional emptying rates were similar, the fractional emptying rate was greater in animals with pyloroplasties than in those without in the first 10 and in the last 20 minutes. The rate of duodenogastric reflux was likewise greater in animals with pyloroplasties than in those without (1·8 ± 0·2 ml/min and 0·7 ± 0·2 ml/min respectively, P < 0·05). The rates of gastric secretion did not differ materially (2·2 ± 0·3 ml/min and 2·1 ± 0·2 ml/min), but a greater proportion of the gastric contents was emptied more than once in animals with pyloroplasties than in those without (7·7 ± 1·5 per cent and 2·3 ± 1·0 per cent, P < 0·05).
1An oral alcohol-tolerance test using a bodyweight-related dose of alcohol was performed on two groups of patients undergoing truncal vagotomy and a drainage procedure for uncomplicated chronic duodenal ulcer. Eight patients received 0.65g. of absolute alcohol per kg. body-weight and 12 received 0.35 g. per kg. body-weight. The test was performed before operation and 4 months after operation on each patient.2After operation the peak blood-alcohol concentration was significantly higher than before operation, and occurred significantly sooner after the ingestion of alcohol.3The cause of these changes is discussed, and it is concluded that they are probably due to an increased rate of gastric emptying.4The relevance of these results to the Road Safety Act, 1967, is discussed.
A consecutive series of 25 patients with chronic duodenal ulcer has been treated by highly selective vagotomy without a drainage procedure. The vagal fibres passing to the distal 5–7 cm. of the stomach—the nerves of Latarjet—were left intact, as were the hepatic and coeliac branches of the vagus. The object was to denervate only the parietal cell mass, while preserving normal gastric emptying and normal inhibition of gastric secretion from the antrum and duodenum. This operation should cure the ulcer as effectively as vagotomy with drainage does, and at lower cost in terms of side-effects such as dumping and diarrhoea.
The insulin test was negative in each case, suggesting that vagal denervation of the parietal cell mass was complete. Evidence provided by mucosal biopsies taken at operation does not fully support this view, however. Pentagastrin-stimulated acid output was reduced by 70 per cent, and pepsin output by 51 per cent, 3 months after operation. The volume of resting juice was halved and spontaneous acid output was reduced by 97 per cent at this time. Thus, highly selective vagotomy is as effective as truncal or bilateral selective vagotomy with drainage in reducing gastric acid output in the early months after operation.
There have been no deaths. With 2 exceptions, the patients appear to be doing well clinically and few complain of side-effects, but the period of follow-up is only from 3 to 11 months.
These results are encouraging. They suggest that a highly selective vagotomy, denervating the parietal cell mass but leaving the antrum innervated, may be all that is required to cure most patients who have a chronic duodenal ulcer.
Isosmotic liquid peptone meals adjusted to pH 7, 3, and 1.5 were instilled on separate days into the stomachs of 8 duodenal ulcer patients and 7 healthy controls. Using a marker-dilution method, duodenal acid load (DAL) was measured as the amount of unbuffered hydrogen ions delivered to the duodenum per unit time. Gastric emptying was measured as the total volume of gastric contents, including meal plus gastric secretion, passing through the pylorus per unit time (VPP). Mean pentagastrin-stimulated acid output was not significantly different between the two groups. However, after all three test meals, mean DAL was significantly greater in duodenal ulcer than in normal subjects in both hours of the test, and VPP was significantly greater in ulcer than in normal subjects in the first 40 min. In both groups, following peptone meals of pH 7 and 3, the volume of gastric contents delivered through the pylorus decreased as the amount of free hydrogen ions entering the duodenum increased, but a given load of acid was less effective in slowing emptying in duodenal ulcer patients than in controls. These studies indicate that duodenal ulcer patients empty liquid meals more rapidly than do normal subjects, independent of the initial pH of the meals, and that, in addition, acid inhibition of gastric emptying is defective in duodenal ulcer.
Antrectomy reduced the levels of circulating gastrin but did not change jejunal morphology. In vitro and in vivo absorption as well as the activity of some brush border enzymes were increased. The observed alterations are discussed on the basis of antrectomy-induced alterations in the release of gastrointestinal hormones, gastric and pancreatic secretion and gastric emptying.
The effect of hydrochloric acid at pH 1.2-3.2 ON ERYTHROMYCIN STEARATE AND COMMERCIAL DOSAGE FORMS OF ERYTHROMYCIN STEARATE WAS STUDIED. Under all conditions examined, erythromycin was readily dissolved from the stearate as hydrochloride, and rapidly lost its biological activity in solution. The inclusion of pepsin in the test systems did not affect the results. Although formulation differences somewhat affected the rate of destruction, acid lability was exhibited by all products examined, except enteric-coated tablets. Amounts of acid considered to be normal in the fasting stomach contents of adults during the time likely for a dose to remain in the stomach caused 70-90% destruction within 15 min after the shells started to rupture. Amounts of hydrochloric acid appreciably less than 1 mEq, representing abnormally small quantities even in the fasting state, caused destruction ranging from 30 to 70% of the doses in 15 min. These results are not reconcilable with published statements that the sensitivity of erythromycin to gastric acid is overcome by providing the antibiotic in the form of stearate salt.
Stadaas, J. O. Intragastric pressure/volume relationship before and after proximal gastric vagotomy. Scand. J. Gaslroenl. 1975, 10, 129-134.
The examinations were performed before and after proximal gastric vagotomy (PGV) in 10 patients with duodenal ulcer. A flaccid plastic balloon located in the corpus-fundus region was stepwise filled with known volumes of water. Post-operative insulin tests were negative in 8 patients and late positive in two. Basal and pentagastrin-stimulated acid output were reduced by a mean of 88 and 62 per cent, respectively. Intragastric pressure was significantly increased after PGV, whereas rhythmic contractions were reduced in all cases. It is concluded that PGV interferes with gastric motility and adaptation to volume variations.
Venho, V. M. K., Aukee, S., Jussila, J. & Mattila, M. J. Effect of gastric surgery on the gastrointestinal drug absorption in man. Scand. J. Gastroenl. 1975, 10, 43-47.
The effect of gastric surgery on the absorption of quinidine, ethambutol, and sulphafurazole was studied in 14 male patients, all serving as their own controls. Antrectomy with gastroduodenostomy (ABI) and selective vagotomy lowered the serum levels of all drugs significantly during the 6-hour test period. Excretion of drugs in 6-hour urine also decreased. Three patients showed practically no absorption up to 2 hours, and even thereafter the absorption was lowered. Over one year after operation the urinary excretion of ethambutol, but not of the other drugs, was improved. ABI alone did not modify absorption. Preoperative gastric retention seemed to delay absorption.
A new technique is described whereby gastric emptying of a 51Cr-labelled solid meal (hamburger, vegetables, potatoes) was measured by way of a movable NaJ(T1) detector. The technique allowed separate measurements over the proximal and the distal part of the stomach. Seven volunteers took part in a study which revealed good correlation between two individual consecutive tests. Eight patients who took part in a controlled randomized series of parietal cell vagotomy (PCV) versus total gastric selective vagotomy and pyloroplasty (SV+P) underwent the test preoperatively and 6 to 8 months postoperatively. Following both operations gastric emptying was retarded. The time taken for the amount of meal remaining in the stomach to be reduced to 75,50 and 25% respectively was significantly longer postoperatively than before surgery, but there were no differences in this respect between PCV and SV+P. The retardation of gastric emptying of solids was in contrast to the emptying of 10% glucose solution, which in the same series of patients was found to be accelerated. Following PCV there was a change in the distribution of the meal within the stomach immediately after the intake of the meal: a larger part of the meal was found in the proximal stomach post-operatively than before operation. There was no significant change in this intragastric distribution of the meal after SV+P.
Gastric emptying has been studied in patients operated upon for duodenal ulcer by either 1) parietal cell vagotomy without or 2) with pyloroplasty, 3) truncal vagotomy combined with pyloroplasty or 4) antral resection, 5) gastric resection a.m. Billroth I or 6) Billroth II. Isotonic saline and 10% glucose solution have been used as test meals. Volumes of meal remaining 10 and 30 minutes after the instillations of the saline and the glucose meal respectively have been estimated. After parietal cell vagotomy without pylorplasty (PCV) the gastric emptying rate of 10% glucose solution was significantly faster than in unoperated duodenal ulcer patients. After all the other surgical procedures the gastric emptying rate of saline as well as of glucose solution was in turns significantly faster than after PCV. These results indicate the importance of the antrum-pyloric region for the control of gastric emptying rate of isotonic saline and hyperosmolar glucose solution.
Serum immunoreactive gastric inhibitory polypeptide (IR-GIP), gastrin (IRG), and insulin (IRI) were estimated in 41 normal weight patients with duodenal ulcer (DU) and 25 age-matched controls in response to a high calorie liquid test meal. 28 out of 41 DU patients had a hyperglycaemic glucose response during the test meal, and 15 had a pathological oral glucose tolerance test. Fasting and food-stimulated IR-GIP and IRG levels were significantly elevated in the DU patients. Serum IRI also increased to significantly higher levels in DU patients after the test meal. The degree of the greater hormone response was dependent on the glucose increase after the test meal in the case of insulin and GIP, but not in the case of gastrin. It is concluded: firstly, that a faster glucose absorption (possibly due to rapid initial gastric emptying or increased intestinal motility) is responsible for the high and short-lasting glucose peak and the increased GIP and insulin secretion; secondly, that the GIP response could well be causally related to the insulin response; thirdly, that hyposcretion of GIP is ruled out as a possible factor in the pathogenesis of gastric acid hypersecretion of duodenal ulcer patients.
The relationship of body size to rates of gastric emptying of solid food was investigated in order to obtain data that may allow this variable to be considered when populations of varying size are studied. Rates of gastric emptying were measured using a beef stew meal to which were added pieces of chicken liver tagged with [99mTc]sulfur colloid, and following the passage of the isotope through the gastrointestinal tract with intermittent gamma-imaging. Results showed an inverse linear relationship between gastric emptying rates and body surface area, and between gastric emptying rates and body weight. The variable of body size must be taken into account when measurements of gastric emptying of solid food are measured.
The gastric emptying of 10, 20, or 40 ml/kg body mass milk meals was measured before and after Heineke-Mikulicz pyloroplasty of 3, 5, or 7 cm (6 dogs) or truncal vagotomy (3 dogs). The pyloroplasty group then underwent vagotomy, following which the tests were repeated. Initial gastric emptying (in the first 10 min) was increased after 5-and 7-cm pyloroplasties (P<0.01) and particularly after vagotomy with all sizes of pyloroplasty (P=0.001). Regardless of the volume of meal used, after vagotomy and pyloroplasty there was a 51-63% decrease in intragastric volume within the first 10 min. Increased duodenogastric reflux occurred in those dogs who showed rapid initial gastric emptying. After the first 10 min all groups were shown to have virtually normal gastric emptying, except the truncal vagotomy group in which gastric emptying was delayed (P<0.05). It is the combination of pyloroplasty with vagotomy which is required to produce the very rapid initial gastric emptying of a liquid meal following vagotomy with pyloroplasty. It is concluded that two mechanisms control the gastric emptying of a milk meal. The first acts quickly, is dependent on an intact pylorus, and is influenced by the intragastric volume; the second is a more slowly acting mechanism, requiring up to 10 min to have its effect, and is not dependent on an intact pylorus or the intragastric volume. After vagotomy and pyloroplasty, the speed of gastric emptying in the first 10 min is proportional to the original meal volume, and therefore the therapy of postvagotomy diarrhea and dumping with small frequent meals seems rational.
A test meal consisting of food (Galactomin 18), and a barium preparation (Raybar) was given to 47 patients who had undergone truncal vagotomy combined with either antrectomy or gastric drainage, and to five normal subjects. The radiological findings were correlated with the symptomatology. Total gastric emptying was not significantly different between normal controls, post-operative but asymptomatic cases, or those in whom dumping of diarrhoea was provoked. Small intestinal transit was significantly faster in cases of post-cibal diarrhoea than in other groups, and was also more rapid than normal when dumping was provoked. Colonic entry time was also faster than normal in these two groups. Marked dilution of the meal in the small bowel only occurred in the presence of the dumping syndrome. Jejunal interposition prevented the occurrence of dumping and restored the radiological appearances in the intestine to normal. The test meal gave excellent correlation with the patients' symptomatology. The relationship of the findings to the mechanisms of post-cibal diarrhoea and the dumping syndrome is discussed.
The emptying of a solid meal labelled with Indium 113mDTPA from the stomach was studied with a gamma camera in 26 normal subjects, 27 patients with duodenal ulcer, on 41 occasions after truncal vagotomy and pyloroplasty and 38 times after highly selective vagotomy. Applying the method of principal component analysis to the results, differences were detected between control and duodenal ulcer subjects and two probable subgroups of duodenal ulcer were observed. Half emptying times did not reveal these patterns. After vagotomy, delayed emptying was general at one week. At one month, patients after highly selective vagotomy had a more normal result than those with truncal vagotomy and pyloroplasty (TV), but by six months no significant difference in overall emptying rate was found, although changes in the pattern of gastric emptying persisted in some patients after TV.
After parietal cell vagotomy in dogs antral motility and gastric emptying time is unaffected. Addition of a drainage procedure changed the motility considerably by decreasing the force of contractions and diminishing the number of peridtaltic waves. After cutting the antral nerves complete atony occurred, but emptying rate was unaltered as the contrast meal passed passively through the anastomosis. Selective gastric vagotomy without drainage caused atony and significantly prolonged emptying time.
The present understanding of the normal control and regulation of gastric emptying has been established by investigations spanning more than 100 yr. Alterations in the normal physiology have been implicated in the aetiology of gastroduodenal disease, while a number of studies attribute some of the unpleasant sequelae following gastric surgery to changes in emptying. Over this time a variety of methods have been developed to measure the rate of gastric emptying. These tests are reviewed, with particular emphasis on their clinical application and on the possible explanations for the conflicting results obtained before and after surgery for peptic ulceration. The mechanisms and regulation of gastric emptying have been the subject of previous extensive reviews, and a brief outline is given below to provide a background to the subsequent discussion on gastric emptying tests.
Drug absorption from the gastrointestinal (GI) tract and the impact of GI surgery and disease on drug absorption are discussed. Recommendations are made to manage problems of drug malabsorption. Absorption from the GI tract is a first-order process described by its rate and extent.
GI surgery changes the anatomy of the GI tract and alters important variables in the absorption process. In the wake of procedures which diminish small bowel surface area, the extent of absorption of phenytoin, digoxin, cyclosporin, aciclovir, hydrochlorothiazide and certain oral contraceptives is reported to be reduced. The underlying cause of the reduction is unknown. When gastric emptying time or pH are altered by surgery, the rate of drug absorption appears to be reduced. However, it is not clear which variable is more important in determining therapeutic effects.
The effects of coeliac and inflammatory bowel diseases on the distribution and clearance of drugs must be considered before attributing abnormal serum concentrations of drugs to malabsorption. GI disease may slow gastric emptying and delay the complete absorption of drugs when their rate of absorption depends on gastric emptying time. Other inflammatory GI diseases such as graft-versus-host disease (GVHD) of the gut, Behçet’s syndrome and scleroderma involving the GI tract may directly reduce absorption of drugs such as cyclosporin, amitriptyline, benzodiazepines, anticonvulsants, paracetamol (acetaminophen) and penicillamine. GI diseases which alter gut pH affect the absorption only of drugs with limited water solubility and pH-dependent dissolution such as ketoconazole.
Clinicians should be aware of the variable absorption seen after GI disease and surgery and monitor their patients accordingly.
This study was undertaken to compare the effects of subtotal Billroth II gastrectomy on gastric emptying and gastrointestinal motility with previously published results in intact dogs and in dogs with subtotal Roux-Y gastrectomy. Extraluminal strain gauge transducers were used to study gastrointestinal motility after Billroth II gastrectomy in four conscious dogs. Gastric emptying was measured radiographically. In Billroth II dogs gastric emptying of low-viscosity meals was biphasic with an initial rapid emptying. The addition of nutrients to low-viscosity meals delayed gastric emptying accompanied with reduction in gastric and jejunal motility. Similar to that in Roux-Y dogs, gastric emptying of noncaloric medium-viscosity meals was delayed because of segmenting motor patterns of the jejunal loops, in contrast to the propulsive jejunal motor pattern in intact dogs. Nutrients added to medium-viscosity meals did not change the jejunal motor pattern; gastric emptying was delayed compared with intact dogs. Results show that meal viscosity and jejunal motor pattern influence gastric emptying after Billroth II gastrectomy.
It would appear that there are no clear data to suggest that elective operations for GU be abandoned. Perhaps at least one half of patients with GU are candidates for surgical intervention. Current data support the continued use of distal gastric resection for GU with or without vagotomy depending on ulcer type. Truncal or selective gastric vagotomy with drainage and ulcer excision generally yield results inferior to resection. Vagotomy and drainage, with resection of the ulcer, have a definite role when faced with the poor risk patient, and in selected circumstances when the ulcer process does not lend itself safely to resection. PGV plus ulcer excision appears at present to be an acceptable operation for a type I ulcer. Sufficient data, however, are not available to show that PGV is superior to distal resection with a Billroth I anastomosis. Currently, data are not available to evaluate the role of PGV in the treatment of the type II ulcer and it appears safe to state that the procedure in these circumstances is still experimental. For a type III ulcer PGV is definitely contraindicated and for the present, both type II and III ulcers are best treated by gastric resection plus vagotomy.
We wanted to clarify the way in which nutrients influence gastrointestinal motility and gastric emptying following distal gastrectomy with Billroth-I gastroduodenostomy. Four gastrectomized dogs were equipped with extraluminal strain gauge transducers. Gastric emptying was measured radiographically. Four intact dogs were used as controls for emptying studies. Following gastrectomy, gastric emptying of both acaloric and nutrient meals was rapid in the initial period of the experiments. Gastric outflow was supported by propagating duodenal contractions. Compared with control dogs, the early emptying of nutrient meals was accelerated. In the following period, nutrients markedly slowed gastric emptying compared with acaloric meals due to a segmenting contractile pattern of the duodenum and a significant diminution of gastrointestinal motility. Results suggest that after Billroth-I gastrectomy (1) the control of gastric emptying by nutrients acts too late to slow the initial enhanced gastric outflow, and (2) the duodenal contractile patterns influence gastric emptying.
The aim of the present study was to elucidate factors influencing gastric emptying in dogs after a two-thirds distal gastrectomy with either Roux-Y or Billroth I reconstruction. The effects of a medium-viscosity nutrient meal on gastrointestinal motility and gastric emptying were investigated. Motility was recorded with long-term implanted extraluminal strain gauge force transducers; gastric emptying was measured radiographically. Gastric emptying after Roux-Y gastrectomy was almost linear and not different from that in intact control dogs. In contrast to Roux-Y gastrectomy, emptying after Billroth I gastrectomy was initially accelerated and followed by a slow emptying phase. During the initial period, the segmenting activity of the Roux-Y limb significantly differed from the propulsive contractile pattern of the duodenum after Billroth I reconstruction. Force and frequency of gastrointestinal contractions were equivalent after both reconstruction procedures. Results indicate that after subtotal gastrectomy, the intestinal contractile patterns are important determinants of gastric emptying. They are the main causes for the different emptying patterns of viscous nutrient meals.
The aim of the study was to examine gastrointestinal motility after distal gastrectomy and the influence of meal viscosity on gastric emptying. Gastrointestinal motility and gastric emptying of acaloric meals with different viscosities were measured in normal dogs and after a two-thirds gastrectomy with Billroth-I or Roux-Y gastroenterostomy. After distal gastrectomy, gastric emptying depended on the viscosity of the meal, as in normal dogs. Acaloric viscous meals emptied significantly faster in the Billroth-I than in the Roux-Y group due to different contractile patterns of the duodenum and jejunum. In comparison to normal dogs, gastric emptying of viscous meals was accelerated in the Billroth-I and delayed in the Roux-Y group. Several motility parameters of the stomach and intestine differed between the normal and gastrectomized dogs. Thus, after distal gastrectomy, the viscosity of the meal and the contractile patterns of the small intestine are important determinants of gastric emptying.
In a prospective multicenter trial, 560 patients with peptic ulcer were treated with proximal gastric vagotomy (PGV) without drainage. Four hundred ninety-three patients had duodenal ulcer (DU), 35 pyloric (PU), and 32 prepyloric ulceration (PPU). Actuarial 5-year recurrence rates were 14%, 35%, and 33%, respectively, and were significantly higher in PU and PPU than in DU. In a separate study, thickness of the pyloric and antral wall was assessed in the resection specimens of patients with similarly defined ulcer types and in controls. There was significant thickening of the muscular layer of the pylorus and antrum in patients with PU and PPU compared to those with DU and controls. It appears that this muscular hypertrophy and fibrosis could be one factor responsible for the failure of PGV without drainage in PU and PPU. Preliminary results indicate a possible beneficial effect of adding a drainage procedure to PGV when treating pyloric channel ulcers. Our results emphasize that pyloric channel ulcers must be considered as a particular entity of peptic ulcer disease and should no longer be assigned to the duodenal ulcer group.
An introduction on the history of vagotomy and the anatomy of the vagus nerve is followed by a discussion on its function. A survey is given of the actions of the vagus on the stomach, liver and biliary tract, pancreas and small intestine. The clinical consequences of vagotomy are then summarized.
The study was performed to demonstrate possible relations between gastric emptying rate for fluid meals and the completeness of vagotomy after truncal vagotomy and pyloroplasty for duodenal ulcer. Seventy-three patients with postcibal symptoms or recurrence after this operation were examined by a fluid nutritional contrast medium several months later, and insulin tests were performed on the 10th day and 2 to 4 years after the operation. A retrospective analysis revealed no relation between the completeness of the vagotomy and the gastric emptying rate, but an increase in spontaneous acid secretion with decreasing emptying rate. Also, patients with recurrence had a lower emptying rate than those with non-recurrence.
Gastric emptying of a food barium meal was measured radiographically in patients with duodenal ulcer without pyloric stenosis before operation, and in well matched groups of patients who were in good health more than 1 yr after highly selective vagotomy, truncal vagotomy and pyloroplasty and selective vagotomy and pyloroplasty. In each patient, the vagotomy was complete on insulin testing in the early postoperative period. The meal was palatable, and semi solid in consistency. The patients were allowed to sit in a chair or to walk about in the intervals between X rays. The meal began to leave the stomach slightly earlier, but not significantly, in patients after truncal and selective vagotomy with pyloroplasty than in preoperative patients or patients after highly selective vagotomy. The stomach was completely empty significantly sooner in patients who had undergone truncal and selective vagotomy with pyloroplasty than in duodenal ulcer patients or in patients after highly selective vagotomy. The head of the meal reached the colon significantly sooner in patients after truncal and selective vagotomy with pyloroplasty than in preoperative duodenal ulcer patients. Thus, gastrointestinal transit was significantly faster in patients who had undergone truncal or selective vagotomy with pyloroplasty than in patients with duodenal ulcer before operation. In patients after HSV, small bowel transit was slightly faster than in duodenal ulcer patients, but was much less rapid than in patients after truncal or selective vagotomy with pyloroplasty. These findings indicate that gastric emptying and small bowel transit times are closer to normal in patients who have undergone HSV than in patients who have undergone truncal or selective vagotomy with pyloroplasty. On the other hand, there was no evidence of delayed gastric emptying after highly selective vagotomy.
Gastric emptying of solids and liquids was measured in 12 dogs with and without corporal or antral gastrojejunostomy. Both types of stoma hastened the onset but did not alter the time from onset to complete emptying of 40 small plastic spheres. Corporal gastrojejunostomy slowed the emptying of 400 ml. of 154 mM NaCl but not of 500 mM glucose, whereas antral gastrojejunostomy slowed the emptying of both.
The rate of gastric emptying was measured by means of a new method, in which the stomach was scanned at intervals after a standard breakfast containing Cr-51 had been given. Most of the meal left the stomach in an exponential manner. The rate of gastric emptying can be expressed as the half-life of the meal in the stomach.
Introduction
Vagotomy and gastric drainage is an increasingly popular procedure in the care of patients with complicated duodenal ulcer disease. The infrequency of major morbidity is in part responsible for the enthusiasm with which this operation has been received. This study is concerned, however, with one significant complication which is peculiarly related to this operation—postvagotomy gastric atony.Definitions
Gastric atony is a motor dysfunction of the stomach resulting in profound gastric retention in the absence of organic obstruction. This failure of the stomach to empty must by definition not be secondary to any of the other well-recognized complications such as intraperitoneal abscess, wound infection, pancreatitis, hypokalemia, hyponatremia, hypoproteinemia, thrombo-embolism, pneumonitis, and cardiovascular alterations. The dysfunction must, in addition, be responsible for a prolonged postoperative course, with more than 14 days elapsing between primary surgical intervention and discharge of the patient from the hospital. A protracted postoperative course due to
A review has been made of our experience in 1,127 patients who have undergone vagotomy and antrectomy for the complications of duodenal ulcer. The follow-up study has extended from less than one to more than fifteen years. The over-all results have been quite satisfactory with 93 per cent of the patients having had an excellent or good result following operation. The incidence of recurrent ulcer remains very low, only 0.6 per cent. The operative mortality of 2.7 per cent in the series is in keeping with that of other resports. Nutritional difficulties, weight loss, diarrhea and anemia have not been major problems. The operation of complete abdominal vagotomy and excision of the gastric antrum successfully controls the ulcer diathesis; and in our opinion, is the most satisfactory surgical procedure for the treatment of duodenal ulcer.
• 1.1. Pyloroplasty and vagotomy, as an operation for duodenal ulcer, displays a rationale dependent upon at least four factors.
• 2.2. First, is the maintenance intact of the entire stomach.
• 3.3. Second, is the inhibition of acid secretion in the cephalic phase by vagotomy.
• 4.4. Third, is the maintenance in continuity of the antrum so that a persistent alkaline secretion never remains in the antrum to stimulate its endocrine activation of the parietal cell.
• 5.5. Fourth, is the avoidance of a circumferential dissection of the duodenum.
• 6.6. The maintenance in situ of an intact stomach without abnormal anastomotic communications, is an advantage which will gain in appreciation as time passes and weightfailure and “dumping” become less prominent on the surgical scene.
• 7.7. Present-day procedures for diagnosis and treatment of duodenal ulcer thus, display a gratifying rationale previously lacking. Recent history leading to this development is reviewed.
The function of the pylorus and the pyloric antrum in the control of gastric emptying has been studied in an isolated rat stomach-duodenum preparation. Pressures in the body and pyloric antrum and flow through the duodenum were recorded using electronic transducers. Vigorous peristalsis and episodic flow were induced by electrical stimulation. The pylorus is normally open until it is transiently closed by an advancing peristaltic wave. High pressures could develop in the antrum when it was separated from the body by another peristaltic wave. Exclusion of the pylorus had very little effect on the pressures developed in body and antrum. The clinical implications of these findings are discussed.
Patients with coexistent duodenal and gastric ulcers were found to display the hypersecretion of gastric juice in the fasting empty stomach characteristic of the duodenal ulcer patient. This finding supports the view that the duodenal ulcer occurs first and produces pyloric stenosis with stasis of food in the stomach and a secondary gastric ulcer. The gastric ulcer is probably caused by hypersecretion due in part to prolonged contact of food with the antral mucosa and resultant release of gastrin. Gastric vagotomy combined with pyloroplasty or gastroenterostomy produced healing of both lesions.
The effects of a placebo, 50 mg. dose, and the “O.E.D.” of Tricyclamol on gastric emptying and intestinal transit of a standard barium mixture and Ewald meal were compared in nine patients with duodenal ulcer. Each patient served as his own control. The medicament was given half an hour prior to the ingestion of the barium mixture and Ewald meal. Serial x-rays of the abdomen were then taken.
No significant differences were found in the rate of gastric emptying following the placebo or a 50 mg. dose of Tricyclamol. However, the “O.E.D.” of Tricyclamol produced a delay in gastric emptying of the barium and Ewald mixture at 1- and 2-hour intervals, but none at the 4-hour period. Thus, the “O.E.D.” of Tricyclamol, though a multiple of the 50 mg. dose, did not produce excessive delay in gastric emptying of the barium mixture and Ewald meal. However, some but no important delay in the progress of the barium along the intestine was noted after Tricyclamol as compared to that produced by the placebo.
Closure of the pylorus is not an essential factor in the delayed emptying from the stomach of oil, acid solutions and certain
other liquids. One function of the pylorus is to control duodenal regurgitation.
DURING the past four years, section of the vagus nerves to the stomach as a method of treatment has been carried out at the University of Chicago in 250 patients with various types of peptic ulcer. The technics employed have been described elsewhere.¹ The clinical results following this method of treatment have been so satisfactory that it has replaced all other types of surgical treatment for this disease on our service. One patient in this series died of pneumonia, making a mortality of 0.4 per cent. Physiologic tests on 170 patients on whom the operation was performed by us have revealed that the section of the vagus nerves was probably incomplete in 18 cases. In this group, 6 patients have complained of recurrent or persistent symptoms of ulcer, and in 2 of these an undamaged vagus fiber was found at a second operation. Division of this nerve was followed
The function of the pylorus and the pyloric antrum in the control of gastric emptying has been studied in an isolated rat stomach-duodenum preparation. Pressures in the body and pyloric antrum and flow through the duodenum were recorded using electronic transducers. Vigorous peristalsis and episodic flow were induced by electrical stimulation. The pylorus is normally open until it is transiently closed by an advancing peristaltic wave. High pressures could develop in the antrum when it was separated from the body by another peristaltic wave. Exclusion of the pylorus had very little effect on the pressures developed in body and antrum. The clinical implications of these findings are discussed.
Two varieties of surgical operation are applied to high-lying gastric ulcers. One consists in resecting the ulcer (if it is on the lesser curvature) with all or part of the lesser curvature and a sufficient part of the greater curvature to give a two-thirds resection; this is followed by repair according to either the type 1 or type 2 Billroth operation. The other consists in leaving the ulcer undisturbed, resecting the distal one-half or two-thirds of the stomach, and concluding according to either the Hofmeister or the type 1 Billroth operation; the ulcer heals without trouble in most instances. Both varieties of operation have given excellent long-term results. In either case, specimens of tissue must be obtained and examined for malignancy, which is the greatest problem in the treatment of high-lying gastric ulcers. The unexpected finding of malignancy by microscopic examination is most common in small ulcers. Concomitant gastric and duodenal ulcers are frequent, and among 98 cases of this kind there was marked retention. When obstruction occurs it must be relieved. The temporary insertion of a gastrotomy tube for feeding is to be considered if obstruction is severe, and a posterior gastroenterostomy may be advisable in poor-risk patients.
The hypersecretion of acid gastric juice, characteristic of the patient with duodenal ulcer, is abolished by complete division of the vagus nerves to the stomach. The interruption of the nervous phase of gastric secretion is generally considered to be the basic principle accounting for the favorable therapeutic results obtained by this method. Unfortunately, vagotomy also exerts a potent influence on gastric motor activity, and the need for an ancillary drainage procedure is apparent. Gastroenterostomy has been widely used for this purpose and has been successful in promoting adequate emptying of the vagotomized stomach. Prominent among disadvantages of this procedure is the interference with normal, acid-base control of the antral "gastrin" mechanism. Reflux of alkaline Duodenal fluids promotes the excessive release of the gastric hormone; this is influenced to a large extent by the location and size of the gastrojejunal stoma.1-4 A high-lying gastrojejunostomy promotes retention in the dilated vagotomized
1. One-hundred and four cases of duodenal ulcer, treated by vagotomy and Finney pyloroplasty are presented. 2. Fourteen cases of chronic lesser curve ulcer, treated by the same method, are discussed. 3. The advantages of the operation, the operative technique and post-operative management are indicated.
The problem of delayed gastric emptying in patients operated upon for obstructing duodenal ulcers has been studied. In eight of thirtytwo patients with obstruction treated by vagotomy and complementary drainage procedures, gastric retention developed which persisted longer than ten days. One patient died as a result of this complication. Delayed gastric emptying did not occur in any of the forty-two patients with pyloric obstruction treated by subtotal gastric resection. There were no deaths in this group. In a series of forty-four patients treated by vagotomy and ancillary drainage procedures for reasons other than pyloric obstruction, there was no instance of delayed gastric emptying and there was no mortality. In our opinion subtotal gastric resection is the treatment of choice for patients with obstructing duodenal ulcer. The results of this study suggest that vagotomy and a complementary drainage procedure is not a conservative operation in patients with pyloric obstruction.