Postvagotomy diarrhoea put into perspective

Long-term results of duodenectomy with highly selective vagotomy in the treatment of complicated duodenal ulcers

BACKGROUND

Highly selective vagotomy and complete circular or partial duodenectomy have been applied to complicated duodenal ulcer for many years. These procedures seem to provide better clinical results than truncal vagotomy and antrectomy.

METHODS

A retrospective analysis was conducted of 120 patients with complicated duodenal ulcer who underwent surgical treatment between 1986 and 1999. Patients with obstruction were treated with either circular complete (17) or partial duodenectomy (3) combined with highly selective vagotomy or truncal vagotomy and antrectomy (37). Those with perforation were treated primarily with highly selective vagotomy and partial duodenectomy, highly selective vagotomy alone, or truncal vagotomy and pyloroplasty. Every patient was followed up either by a clinic visit (75%) or questionnaire to determine the presence of ulcer pain, dumping, diarrhea, vomiting, weight loss, and Visick grade.

RESULTS

Long-term follow-up of patients treated with duodenectomy and highly selective vagotomy for obstruction showed that 94% had sustained weight gain whereas more than half of those treated with truncal vagotomy and antrectomy had weight loss. In patients with perforation, duodenectomy and highly selective vagotomy offered no advantage over highly selective vagotomy alone.

CONCLUSIONS

Highly selective vagotomy and complete circular or partial duodenectomy provide fewer sequelae and better weight gain long term than truncal vagotomy and antrectomy for patients with obstructing duodenal ulcers.

Severe hypothyroidism in patients dependent on prolonged thyroxine infusion through a jejunostomy

BACKGROUND AND AIMS

Enteral absorption of thyroxine (T4) is variable; the duodenum and jejunum appear to be the most important sites of absorption. Our objective is to demonstrate that T4 infused via a standard jejunostomy may occasionally be poorly absorbed.

METHODS

Two patients underwent esophagolaryngeal resection for carcinoma of the cervical esophagus. The procedure was accompanied by complete removal of the thyroid and parathyroid glands. A neck fistula at the gastropharyngeal anastomosis led to a restriction of oral intake; daily requirements of T4 and nutrients were given via the jejunostomy. T4 plasma levels deteriorated and thyroid-stimulating hormone (TSH) levels increased and in the third postoperative week, T4 (300 microg) was administered via a nasogastric tube.

RESULTS

Although given a high dose (300 microg) of T4, both patients developed severe hypothyroidism. Infusion of T4 through the nasogastric tube precipitated the normalization of T4 and TSH plasma levels. Both patients (cases 1 and 2) resumed oral intake during the fifth and sixth postoperative weeks respectively.

CONCLUSION

T4 malabsorption may occur in patients dependent on prolonged T4 infusion via a standard jejunostomy.

Gastric adaptive relaxation and symptoms after vagotomy

Gastric adaptive relaxation is reported to be impaired after vagotomy. This abnormality has been implicated in the pathogenesis of postvagotomy symptoms, but no association has previously been demonstrated between the two. Gastric adaptive relaxation was measured in 15 healthy volunteers and 33 patients more than 1 year after highly selective vagotomy or truncal vagotomy and drainage. Seventeen patients were asymptomatic. The remainder were symptomatic including seven patients with persistent diarrhoea. Fasted subjects were intubated with a Ryle's tube containing a pressure microtransducer within a flaccid (800 ml) plastic bag. Gastric corpus-fundus pressure was recorded during distension of the bag with air (15 ml/s) over 30 s. Pressure indices were derived from the areas under the pressure curves. Median (range) pressure indices were: healthy volunteers 12.7 (7.5-17.1) cmH2O, highly selective vagotomy 14.0 (9.8-15.9) cmH2O (n.s.), truncal vagotomy and drainage 14.5 (8.6-26.8) cmH2O (P = 0.04). All patients with diarrhoea had abnormally high pressure indices (P less than 0.001). Pressure indices in all other patient groups were within the normal range. We conclude that gastric adaptive relaxation remains abnormal in patients with postvagotomy diarrhoea but not in those who are asymptomatic or who have other symptoms.

Anterior lesser curve seromyotomy and posterior truncal vagotomy versus truncal vagotomy and pyloroplasty in the treatment of chronic duodenal ulcer

In a prospective randomized controlled clinical trial, anterior lesser curve seromyotomy with posterior truncal vagotomy (AMPT, n = 77) has been compared with truncal vagotomy and pyloroplasty (TVP, n = 69) in 146 patients with chronic duodenal ulcer with a mean duration of symptoms of 7 years. The mean follow-up time was 4.5 years with a range of 2-7 years. One elderly patient died from a myocardial infarction in the TVP group. Acid secretory inhibition in response to insulin and pentagastrin stimuli was equal in both groups, indicating a similar degree of vagal denervation. Recurrent ulcers were more common after AMPT (five) than TVP (two) (P = 0.29, n.s.). Dumping and diarrhoea were significantly commoner (P less than 0.001) after TVP, with 31 instances as opposed to eight with AMPT. The mean operating time was increased by 6 min when AMPT was performed rather than TVP. The results of this study have shown that AMPT is associated with a lower incidence of dumping and diarrhoea and achieves better overall Visick grading. However, continued monitoring is required to assess the long-term incidence of recurrent ulceration after this procedure.

Relationship between gastric emptying of liquid and postvagotomy diarrhoea

Gastric emptying of liquid was studied in 10 normal volunteers and in 27 patients previously treated with truncal vagotomy and drainage. Thirteen of the twenty-seven patients complained of persistent postvagotomy diarrhoea. For each study 300 ml 15 per cent dextrose, labelled with 99mTc-diethylene triamine penta-acetic acid (DTPA), was ingested at a standard rate by subjects who sat facing a gamma camera. Imaging proceeded for 30 min. Gastric area activity curves were corrected for emptying of the test meal during ingestion, and for movement using a new image alignment technique. Gastric emptying at 15 min was 10 +/- 2.6 per cent (mean +/- s.e.m.) in healthy volunteers, 48 +/- 7.3 per cent in patients without diarrhoea, and 84 +/- 2.3 per cent in those with diarrhoea (P less than 0.001, ANOVA). Gastric emptying from 15 min onwards was slower than normal in both patient groups (P less than 0.001). These results show that initial gastric emptying is rapid following truncal vagotomy and drainage, and this change is greater in patients with postvagotomy diarrhoea. No patient with diarrhoea had normal initial gastric emptying.

Anterior lesser curve seromyotomy with posterior truncal vagotomy versus proximal gastric vagotomy

In a prospective randomized trial anterior lesser curve seromyotomy with posterior truncal vagotomy (ASPTV, n = 48) has been compared with proximal gastric vagotomy (PGV, n = 43). Eighty-eight and eighty-three patients were available for follow-up studies at 1 year and 2 years, respectively. Six months postoperatively the mean reduction in pentagastrin-stimulated peak acid output (PAO) was 48.5 per cent (s.d. 26.3) after PGV and 50.5 per cent (s.d. 23.3) after ASPTV. Two years after the operation satisfactory clinical results (Visick I + II) were found in 84.2 per cent of the patients after PGV and in 88.9 per cent after ASPTV. There was a significant difference in the duration of surgery. No serious postoperative gastric sequelae were encountered after either operation. Up till January 1987, eight endoscopically proven, symptomatic recurrent ulcers have been diagnosed: four in the PGV group (9.3 per cent) and four in the ASPTV group (8.7 per cent). The results of this randomized study suggest that ASPTV is as good as PGV in the surgical treatment of chronic duodenal ulcers.