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There are relations between function of the pylorus and the appearance of duodeno-gastric reflux. However, much speaks for the fact that the pylorus alone is not able to prevent duodeno-gastric reflux. In the problem of the causes of reflux also the motoric behaviour of the upper duodenum must be taken into consideration.
30 cases of pancreaticoduodenectomy with pylorus preservation are reported. The operative mortality has been 6,6%. Technical details of the operation are discussed and the importance of maintaining an optimal vascularization of the duodenal wall is stressed. Long term results (maximum follow-up 2 years) seem to be excellent with a clear improvement of the digestive function as compared to the traditional pancreatectomy with gastric resection. Jejunal ulcerative complications have not been observed. It is believed that pylorus preservation should become the operation of choice in pancreatectomy performed for benign diseases.
Electrodes were chronically implanted in some of 14 cats and acutely inserted in others in the muscle of the high pressure zone of the lower esophagus (LEHPZ), in the duodenum, pylorus and antrum at identical location to register the myogenic electrical activity of the LEHPZ. Simultaneously the intraluminal pressure of the LEHPZ and swallowing contractions were recorded on a 6 channel Beckman R 611 ink-pen polygraph using stationary perfusion manometry. A clear basic electrical rhythm with slow wave activity was regularly found in the LEHPZ. Strong electrical changes (action potentials) were superimposed on the slow waves which were associated with relaxation in the LEHPZ and muscle contraction in the esophagus. Electric stimulation of the duodenum and pylorus with rectangular impulses produced retrograde peristalsis in the antrum but no response in the LEHPZ. Direct stimulation of the LEHPZ and gastric fundus, however, caused a strong transient contraction of the LEHPZ.
The atropine- and guanethidine-resistant contraction of the cat pyloric sphincter induced by efferent stimulation of the cervical vagi, was studied with a new method for measuring transpyloric flow. The pyloric contraction was blocked in a dose-dependent manner by the opiate antagonist naloxone infused intraarterially to the pyloric region. Local intraarterial injection of morphine or enkephalinamide elicited a pyloric and gastric contraction. Leu- and met-enkephalin intraarterially elicited a pyloric contraction and a gastric relaxation. These effects could be prevented or reversed by naloxone. Immunohistochemical studies revealed a particularly rich enkephalinergic innervation of the pylorus with dense networks of varicose nerve fibers with enkephalin-like immunoreactivity both in the circular smooth muscle layer and in the myenteric plexus. Furthermore, many cell bodies of the myenteric plexus with enkephalin-like material were demonstrated. The corpus-antrum was sparsely innervated by enkephalin-like nerves to the circular muscle layer and only few immunoreactive cell bodies were observed in the myenteric plexus. These results together suggest a vagal control of the feline pylorus and stomach mediated via enkephalinergic neurons.
The effect of glucagon on the stomach, pylorus and duodenum was evaluated within the first 30 minutes p.i. Glucagon was administered intravenously in a dose of 0.1, 0.2, 0.4, 0.6 and 1 mg. The hypotonic effect was greater on the duodenum than on the stomach. The dose response of the pylorus was not uniform. It was possible to point out a direct relationship between the intensity and duration of the hypotonic effect and the administered dosage.
It is reported on the endoscopic proof of a double pylorus in a 57-year-old patient. The anamnesis of ulcer of many years and a florid prepyloric gastric ulcer refer to the ulcerous origin of this anomaly. It is referred to the diagnostic importance of the gastroscopy of the acquired or congenital duplication of the pylorus channel which is difficult to be represented radiologically with regard to the avoidance of possible diagnostic errors (e.g. carcinoma of the antrum).
Adenomyoma of the stomach is an exceedingly rare and benign tumour. We report here what we believe to be the first documented case in Singapore. Our patient is unique in three respects; an eight-week old infant presented with signs and symptoms of intestinal obstruction. Operative findings showed a small tumour in the pylorus of the stomach. The abdominal contents were covered with a colourless mucous slime, giving an appearance of pseudomyxoma peritonei. This is a feature which has not been hitherto reported. Microscopically, the lesion was consistent with adenomyoma of the pylorus. The interesting feature is an abundant production of mucin, with rupture and spillage of mucin in some of the glandular structures. We believe that this may account for the appearance of a pseudomyxoma peritonei seen in our patient.
From 1984 to the end of 1993, we performed 51 duodenopancreatectomies with pylorus preservation (27 for chronic pancreatitis and 24 for tumours). We have a complete follow up for 96% of our patients with a mean range of 76 months in the first group and 33 months in the second. There was no per- or postoperative mortality and 15% immediate postoperative morbidity. We observed 5 cases (10%) of anastomotic ulceration. New surgical technics enabled us to avoid this major complication for our last 31 patients. The short and long term benefits of pylorus-preserving duodenopancreatectomy on patients' wellbeing, nutritional status and weight gain were confirmed in 22 patients (82%) with pancreatitis. The mean survival time in patients with tumors (periampullary and head of pancreas adenocarcinoma) is similar to that with the classical Whipple procedure.
BACKGROUND: A late complication of pancreaticoduodenectomy is anastomotic ulcer, and the complication is lessened when pancreaticoduodenectomy is accompanied by preservation of the pylorus. However, the results of some reports suggest that acid levels are not significantly different between patients who undergo pylorus preserving pancreaticoduodenectomy (PPPD) and those having standard pancreaticoduodenectomy. In this study, we measured gastric acidity in the same patients both before and after PPPD. STUDY DESIGN: Twelve patients participated in the study. Acid was measured by monitoring pH levels for 24 hours. Average pH values were calculated for two time periods: during the day (6 AM to 6 PM) and night (6 PM to 6 AM). In addition, the percentages of time during day and night hours that gastric acid was above pH 3 and above pH 4 were calculated and designated as pH holding times. RESULTS: Average pH values and pH holding times during the day revealed no significant differences between patients preoperatively and postoperatively. At night, however, pH holding times significantly decreased in patients postoperatively when compared with patients preoperatively. Of 29 patients who underwent PPPD in our clinic, only one had an ulcer. The gastric acidity of this patient was similar to the others. CONCLUSIONS: These results indicate that gastric acidity, as it relates to pH 3 and pH 4 holding times, increases after PPPD and that gastric acidity, per se, may not be involved in ulcer formation in these PPPD patients. Furthermore, the results of the study indicate that measuring gastric acidity for longer periods of time during the day and during the night might be important in studies on acid secretion.
The most common complication of the pylorus-preserving pancreatoduodenectomy is delay in gastric emptying. Authors present on 18 pylorus-preserving resection performed in the County Hospital of Gyór and Nyíregyháza between 90-92. Delayed gastric emptying (DGE) developed altogether in 7 patients, median length of prolongation of gastric suction was 13.6 days. None of patients had reoperation. Comparing the two groups according to the type of duodeno-jejunostomy, the complication was higher after end to side anastomosis. Authors review the literature and comparing to their own results they study the mechanism, the possible causes and the therapy of DGE. They emphasize that in can be managed conservatively with patience.
Physical results after pylorus-preserving gastrectomy (PPG) with preservation of the vagus nerve were evaluated. The status of 15 patients with early gastric cancer after PPG was compared with that of 14 patients after distal gastrectomy (DG). The postoperative/preoperative body-weight ratio of the PPG group (0.99) was significantly greater than that of the DG group (0.92). Patients who had PPG had fewer postoperative abdominal symptoms than those who underwent DG. The gastric emptying pattern of patients who had a pylorus-preserving procedure was slower than that of those who had conventional gastrectomy, and more similar to the preoperative pattern. Contraction of the gallbladder after PPG was better than after DG. Gastroscopy revealed that the mucosa of the stomach remnant after PPG was less abnormal than after DG. In conclusion, PPG is a more physiological operation than conventional DG and should be applied in carefully selected cases of early gastric cancer.
The authors present an overview of the technique of pancreatoduodenectomy with pylorus preservation. The main technical variants since the original description by Traverso and Longmire in 1978 are described. Advantages and drawbacks of the technique from a carcinologic and functional point of view are presented and discussed. Pancreatoduodenectomy with pylorus preservation appears to be the procedure of choice in most cases. However, it should be avoided in a few patients with invasion of the proximal duodenum by a periampullary carcinoma for whom a curative resection requires the addition of a gastrectomy.
Male Wistar rats were subjected to one of three types of operative reflux procedure that allowed part or all of the duodenal contents to flow back into the stomach through the pylorus, thus producing models of bile reflux alone, pancreaticoduodenal reflux alone, and combined reflux. All surviving animals were killed 50 weeks after surgery and the development of gastric cancer was assessed. No cancer was seen in 16 animals with pancreaticoduodenal reflux or in 32 control animals with gastrotomy, whereas 2/8 animals with bile reflux and 11/29 animals with combined reflux had gastric carcinoma. Compared with the control group, the incidence of carcinoma in animals with bile or combined reflux was significantly higher (P less than 0.05 and P less than 0.01 respectively). All carcinomas developed in the antral area near the pylorus. Adenomas were observed only in the groups of animals developing carcinoma and occurred in the same region of the stomach. These results suggest that bile, and not pancreaticoduodenal secretions, is the component of the duodenal contents responsible for the development of gastric carcinoma.
Digestive and nutritional alterations are a common occurrence after pancreatic resections. The authors report the results of a multiparametric evaluation performed in a group of 26 patients submitted to total or cephalic pancreatectomy. Patients were divided into two groups according to the surgical procedure; group A (n = 13) included gastroresected patients and group B (n = 13) included those submitted to pylorus-sparing pancreatic resection. Subclinical digestive and absorptive impairment has been found in 61.5% of group A patients; the nutritional status was clinically poor in four cases from the same group. Digestive alterations have also been found in 69.2% of group B cases, but nutritional status was always satisfactory in the whole group. The more positive results obtained with the pylorus-sparing technique encourage wider adoption of this procedure.
We would like to place on record a case of an isolated complete duodenal avulsion distal to the pylorus after blunt abdominal trauma, in a 78-year-old patient. From all relevant literature, this is the first case known to us of duodenal rupture, around its complete circumference, in close proximity to the pylorus, which did not result in the injury of any further organs, in the absence of chronically infectious alterations. A duodenal injury in the case of blunt abdominal trauma is rare and amongst injuries to hollow organs is of no great importance. In isolated cases of duodenal injuries, it is normally the second or third section that is affected, both of which are fairly rigidly anchored to the retroperitoneum. If the first section is injured this is normally accompanied by considerable injury to the liver or head of the pancreas.
Gastroparesis after a pylorus-preserving pancreatoduodenectomy has two main aspects, namely early gastric stasis and subsequent postprandial delayed gastric emptying. Early gastric stasis producing an excessive amount of gastric juice during the immediate postoperative period might be caused by the absence of phase III activity of the gastric migrating motor complex (MMC), and such symptoms usually subside within a month or two. Subsequent postprandial delayed gastric emptying leading to belching, fullness of the stomach, nausea, and vomiting after the resumption of oral intake normally continues for up to 6 months before complete recovery. There are many possible mechanisms to explain these phenomena. The early recovery of phase III of the MMC does not necessarily predict an early relief of postprandial delayed gastric emptying, thus suggesting that these two phenomena are caused by various mechanisms. The phenomena, mechanisms, and treatment strategies for gastroparesis after pylorus-preserving pancreatoduodenectomy are described in this review.
A retrospective study was conducted to establish the criteria for performing a pylorus-preserving gastrectomy. This study was performed on 491 patients who had cancer of the middle-third stomach and had been curatively treated with a distal gastrectomy. The incidence of node metastasis for each lymph node station (the group of regional lymph nodes which have been anatomically defined and classified by the Japanese Classification of Gastric Carcinoma) was evaluated with reference to the depth of invasion, tumor size, and circumferential location, to show any significant correlations with an increase in tumor diameter or in the depth of tumor invasion. The benefits of resecting each station was then evaluated based on the incidence of metastasis to each station and the rate of long-term survivors among those with metastasis to each station. The benefit was substantial for the lymph nodes along the lesser curvature, along the right gastroepiploic artery, and at the base of the left gastric artery, while the advantages were almost negligible for the suprapyloric nodes and right paracardial nodes. In conclusion, carcinoma that fulfills either of the following conditions may thus be indicated to undergo a pylorus-preserving gastrectomy: (i) restricted to a depth of m or sml, (ii) a depth of sm2 or mp with a diameter of less than 2cm, (ii) a depth of sm2 or mp and located in the greater curvature.
BACKGROUND/AIMS: Fat feeding increases not only serum but also cerebrospinal fluid concentration of apolipoprotein (apo) A-IV, a protein produced mainly by the small intestine in the rat. We hypothesized that apo A-IV may have a central effect on gastric secretion. METHODS: Gastric juice was collected by the pylorus ligation method. Rats underwent pylorus ligation and received intracisternal injection of apo A-IV under brief isoflurane anesthesia. Two hours after the injection, gastric juice was collected and gastric acid output determined. RESULTS: Intracisternal injection of 0.5 microgram apo A-IV had no effect on gastric secretion. However, gastric acid secretion was significantly inhibited by intracisternal injection of 1 microgram apo A-IV. Furthermore, intracisternal administration of higher doses of apo A-IV (2.0 and 4.0 microgram) resulted in greater inhibition of gastric acid secretion in a dose-dependent manner. On the contrary, 4 micrograms of apo A-I intracisternally injected failed to inhibit gastric acid secretion. Intraperitoneal administration of 15 micrograms of apo A-IV did not alter gastric secretion. CONCLUSIONS: These results suggest that apo A-IV may act in the brain to inhibit gastric acid secretion. Apo A-IV might be a central enterogastrone, which is a gastric inhibitor produced by the small intestine in response to fat feeding.