THE PATTERN OF GASTRIC SECRETION FOLLOWING POLYA SUBTOTAL GASTRECTOMY F. G. SMIDDY, F.R.C.S. From the Department of Surgery, Leeds General Infirmary, Leeds, England It is generally conceded that one of the main effects of partial or subtotal gastrectomy performed for peptic ulceration of the duodenum should be the control of gastric hyperacidity which is believed to be one of the primary fac- tors in the development of duodenal ulceration. By subtotal gastrectomy reduction in the volume of acid secreted is produced by excision of approxi- mately three-quarters of the gastric mucosa, the gastric phase of secretion is abolished by excision of the antrum, and free reflux of intestinal juices into the gastric remnant is obtained through the gastrojejunal stoma. Watson! reviewed the results of 132 Polya-type resections performed for duodenal ulcer and found that, in 49 patients investigated by the gruel meal technique, 7 patients secreted free acid. Shay2 investigated the secretory activity of the gastric remnant in 6 patients and found free acid in the gastric remnant within the first few weeks after operation in all cases and considered that anacidity did not develop until some months after resection. This time lag in the development of anacidity had been previously noted by Wangen- steen et at.,3 who reported 10 cases of subtotal resection of Polya type in which achlorhydria, although not a constant finding, was more common after many months than in the immediate postoperative period. In Shay's opinion, the degree of gastric acidity after operation is suffcient to justify medical treatment with antacids for several months. The method of investigation used by both Watson! and Shay2 was the gruel meal technique with aspirations performed at half-hour intervals. Watson! determined the acidity of the gastric aspirate by titration with Topfer's rea- gent, while Shay2 in a more detailed analysis determined the degree of acidity by electrometric methods. The value of this method of determining acidity has been stressed by Hollander 4 and by Watkinson and James." These writers are agreed that electrometric methods are superior to titration with indicators, since the effective acidity which is the important factor in the activation of pepsin is measured, as compared to the concentration of acid which gives no indication of the degree of ionization. The workers referred to above have investigated the activity of the gastric remnant in a fragmentary fashion only, a partial picture of the daily pattern of acid secretion being obtained. It occurred to the writer that it would be of Submitted for pablication September 28, 1956. Accepted for publication November 18, 1956. 1066
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The Pattern of Gastric Secretion Following Polya Subtotal GastrectomyF. G. SMIDDY, F.R.C.S.
From the Department of Surgery, Leeds General Infirmary, Leeds, England
It is generally conceded that one of the main effects of partial or subtotal gastrectomy performed for peptic ulceration of the duodenum should be the control of gastric hyperacidity which is believed to be one of the primary fac tors in the development of duodenal ulceration. By subtotal gastrectomy reduction in the volume of acid secreted is produced by excision of approxi mately three-quarters of the gastric mucosa, the gastric phase of secretion is abolished by excision of the antrum, and free reflux of intestinal juices into the gastric remnant is obtained through the gastrojejunal stoma.
Watson! reviewed the results of 132 Polya-type resections performed for duodenal ulcer and found that, in 49 patients investigated by the gruel meal technique, 7 patients secreted free acid. Shay2 investigated the secretory activity of the gastric remnant in 6 patients and found free acid in the gastric remnant within the first few weeks after operation in all cases and considered that anacidity did not develop until some months after resection. This time lag in the development of anacidity had been previously noted by Wangen steen et at.,3 who reported 10 cases of subtotal resection of Polya type in which achlorhydria, although not a constant finding, was more common after many months than in the immediate postoperative period. In Shay's opinion, the degree of gastric acidity after operation is suffcient to justify medical treatment with antacids for several months.
The method of investigation used by both Watson! and Shay2 was the gruel meal technique with aspirations performed at half-hour intervals. Watson! determined the acidity of the gastric aspirate by titration with Topfer's rea gent, while Shay2 in a more detailed analysis determined the degree of acidity by electrometric methods. The value of this method of determining acidity has been stressed by Hollander4 and by Watkinson and James." These writers are agreed that electrometric methods are superior to titration with indicators, since the effective acidity which is the important factor in the activation of pepsin is measured, as compared to the concentration of acid which gives no indication of the degree of ionization.
The workers referred to above have investigated the activity of the gastric remnant in a fragmentary fashion only, a partial picture of the daily pattern of acid secretion being obtained. It occurred to the writer that it would be of
Submitted for pablication September 28, 1956. Accepted for publication November 18, 1956.
1066
June 1957 GASTRIC SECRETION AFTER POLY A SUBTOTAL GASTRECTOMY 1067
interest to apply the 24-hr. gastric analysis technique described by James and Pickering6 to the investigation of gastric secretory response immediately after a Polya type of gastric resection, and also to investigate patients on whom this type of gastrectomy had been performed several months previously.
METHODS
The technique used was that described by James and Pickering. 6 A Ryle's tube was passed via the nose and sited radiologically in the fundus of the stomach in preoperative patients or in the gastric remnant after operation. The patients took a liberal diet; milk did not comprise one of the major articles of diet since these patients were awaiting operation. As a general rule, the first drink was taken at 6 a.m.; three main meals per day were eaten with supplementary drinks of the patients' own choice at 10.15 a.m., 3 p.m., and 9 p.m. On such a dietary regime the pattern of the 24-hr. secretory response in the intact stomach is governed by the site from which the gastric contents are aspirated. If the tube lies within the fundus, a typical "flat" curve is obtained, whereas if the tube lies within the antral portion of the stomach postprandial neutralization may be found, as was described by James and Pickering.6 In the gastric remnant the position of the tube is of even greater importance, since small deviations in the position of the tube produce a juice wholly alkaline in character from aspiration of bile and pancreatic juice at the line of the anasto mosis. Since rapid emptying of the gastric remnant occurs, only small volumes of fluid averaging 3 to 5 ml. can be obtained at any given time.
Clinical Material
Thirty-two patients were investigated immediately prior to operation and again on the twelfth postoperative day (group 1). In all these patients a duodenal ulcer had been demonstrated radiologically and its presence con firmed at operation. The patients in this group may be subdivided according to the operative technique employed. In group 1A (16 patients) the lesser curve of the stomach was completely denuded of all extrinsic tissue from the cardio-esophageal junction downwards to the point selected for resection. This was performed by division of the left gastric artery at its origin followed by division of the lesser omentum to the cardio-esophageal junction, the extrinsic tissues were then stripped distally. In group 1B (16 patients) the left gastric artery was divided on the lesser curve of the stomach at the point selected for resection. In group 1A and group 1B the greater curve was mobil ized by division of its vessels in routine fashion, two or three short gastric arteries were usually left supplying the gastric remnant on the greater curve and resection was performed a short distance below their point of entry into the stomach wall.
1068 F. G.SMIDDY Vol. 32, No.6
TABLE 1
Patient Reason for Admission Findings Interval after Gastrectomy
1 Routine investigation Nil 8 mo. 2 Perforated anastomotic ulcer Perforation 2 yr., 3 mo. 3 Routine reinvestigation Nil 3 yr. 4 Dumping Nil 1 yr. 5 Dyspepsia Nil 9 mo. 6 Stomal ulceration Stomal ulcer 11 mo. 7 Dyspepsia Nil 5 yr. 8 Dyspepsia Nil 6 yr. 9 Dyspepsia Nil 12 yr.
10 Routine investigation Nil 1 yr.
A further group of 10 patients (group 2) was also studied in whom a Polya type of gastrectomy had been performed at some time prior to investigation. Table 1 shows the reason of each patient for admission to the hospital, the positive findings if any, and the interval of time between gastric resection and investigation. Of these 10 patients, 2 were subjected to the type of procedure described for group lA and the remaining 8 patients were subjected to the group IB procedure. The mean interval between partial gastrectomy and investigation in group 2 was 36.9 months.
RESULTS
The results obtained have been analyzed in respect to two features which appear to have some bearing on the problem of peptic ulceration.
The duration of anacidity. The activity of pepsin in vitro is markedly in fluenced by the pH of the substrate, at pH 3.5 its activity is reduced to 40 per cent. At this pH also titration against Topfer's reagent fails to demonstrate the presence of free acid; in clinical terms achlorhydria is present. For these reasons the duration of anacidity has been defined as the number of hours during which a gastric juice of pH greater than pH 3.5 was withdrawn.
Maximal acidity. The most acid specimen withdrawn from the gastric remnant has been considered to represent the maximal acidity. Since a high nocturnal acidity is characteristic of duodenal ulcer patients the 24-hr. period has been divided into nocturnal and diurnal phases. The nocturnal phase was between 11 p.m. and 6 a.m. inclusive; during this period no food enters the gastric pouch. The diurnal phase is the remainder of the 24-hr. period and represents a time interval of 16 hr.
Duration of Anacidity
Patients with duodenal ulceration and an intact stomach rarely show an achlorhydric phase. In the 32 patients investigated preoperatively the mean duration of this phase was 1.2 hr. In group 1A the mean duration was 16 hr., in
June1957 GASTRIC SECRETION AFTER POLYA SUBTOTAL GASTRECTOMY 1069
MAXIMAL AC IOITY
pHS ,,\T SfOfMEAN02S
pH 4
pH S MEAN. S.EOFMEAN 025 MEAN. S.E.OFMEAN O'OS MEAN S.EOF MEANOIS
3-2 Col ~
t-:---GI\OUP IA-----..... ' o---GI'OUPI B -----~, o---GROU~
FIG. 1. Maximal acidity during nocturnal and diurnal phases of secretion in 40 patients. Each result is the maximal acidity recorded in each phase for each patient studied.
group lB, 10 hr., and in group 2,11.5 hr. In calculating the period of anacidity in group 2 patients only those patients operated upon by group IB techniques were considered, since it was already known that of the remaining 2 patients both would have complete achlorhydria throughout the entire 24 hr., they having been previously investigated in group lA. Statistical analysis of the dura,tion of anacidity shows significance as between the intact stomach and group IA and lB. There is no statistical difference, however, between group lB and group 2.
Maximal Acidity
The maximal acidity found in the diurnal and nocturnal phases is shown in figure 1. For purposes of comparison the mean value of the total results ob tained has been calculated.
Group lA: Mean nocturnal acidity ..................... pH 3.2 (S.E. of mean = 0.28) Mean diurnal acidity ....................... pH 3.1 (S.E. of mean = 0.25)
In this group of 16 patients, 2 were found completely achlorhydric through out the entire 24-hr. period. In 5 patients nocturnal anacidity only was present. In addition, in 2 patients diurnal anacidity was present, free acid being demon strated during the nocturnal phase.
Group IB: Mean nocturnal acidity. Mean diurnal acidity ....
pH 2.4 (S.E. of mean = 0.087) pH 2.4 (S.E. of mean = 0.24)
1070 F. G. SMIDDY Vol. 32, No. (j
In only 1 patient in this group was anacidity found throughout an entire period and in this patient complete diurnal anacidity was present. In the remaining 15 patients free acid was demonstrable at some period throughout the 24 hours.
Group 2: Mean nocturnal acidity. . . . . . . . . . . . . . . . . . . . . .. pH 2.5 (S.E. of mean = 0.32) Mean diurnal acidity ......................... pH 2.4 (S.E. of mean = 0.15)
In this group 2 patients previously found to have a complete achlorhydria in the early postoperative phase have been excluded from further consideration. Only the remaining 8 patients operated upon by the technique used for group 1E have been considered. Nocturnal anacidity has not been found in any of the remaining patients but in one patient diurnal anacidity was present.
Comparison between Group lA, Group IB, and Group 2
No significant statistical difference was found between the diurnal level of maximal acidity of groups 1A and lB. During the nocturnal phase of secretion a highly significant difference was found, a difference which is also shown in figure 2. This figure shows the more highly acid nocturnal secretion of group 1E patients as compared with the achlorhydria present during this phase in group 1A.
Comparison between group 1E and group 2 shows no significant difference between the maximal acidity in the early postoperative and the late results.
Secretory Pattern throughout the 24-Hr. Period
Figure 2 shows the 24-hr. secretory pattern for patients with intact stomachs, duodenal ulcers present, group 1A and 1E.
pHI 24HR.SECRElQfIY PATTE8N
pH2
pHJ
GRP.18 -"
FIG. 2. The 24-hr. secretory pattern. Upper line, duodenal ulcer patients; middle line, group IB; lower line, group lA. This figure demonstrates the significant deviation in the acid secretory patterns between group lA and group lB.
June1957 GASTRIC SECRETION AFTER POLYA SUBTOTAL GASTRECTOMY 1071
The most significant finding present is the divergence of the secretory pat terns found in group lA and lB during the nocturnal phase of secretion. Group 2 has not been shown in the figure as no significant difference was found by Student's t test during the nocturnal phase between this group and group lB.
In many patients when the 24-hr. secretory patterns are individually analyzed postprandial neutralization is found in the gastric remnant; this resembles, therefore, the pattern found when antral aspirations are analyzed from the intact stomach.
The pattern of secretion found in the intact stomach is remarkably constant from day to day. 6 This constancy of secretory pattern is not so clearly defined in the gastric remnant. Marked variation in pattern with variation in the precise duration of anacidity has been found in 2 patients investigated at intervals, constancy of nocturnal pattern appearing more pronounced than in the diurnal phrase.
DISCUSSION
Opinion as to the extent of gastric resection necessary to protect against recurrent ulceration at or about the line of anastomosis has altered considerably during the last two decades. Hemigastrectomy advocated by HunF has given way to a three-quarter resection of the stomach and this radical approach to the surgery of peptic ulceration is advocated by the majority of authors on this subject, reviewed by Snel1.8
The proportion of patients who will develop gastric anacidity following this degree of resection has been variously estimated by different workers. Watson! considered that 85 per cent were completely achlorhydric, Gaviser9 is in agree ment with this figure, while Walters!3 estimated that probably 60 to 75 per cent of patients would be achlorhydric after operation. There appears to be little doubt that if complete achlorhydria is achieved anastomotic ulceration will not occur, and that in patients who develop recurrent ulcer free acid is found on investigation providing that the aspirating tube is correctly positioned.
Investigations performed by previous authors such as Wangensteen et al.,3 Watson,! and Shay2 on the secretory activity of the gastric remnant have utilized the glUel meal technique, withdrawing the meal at half-hour intervals, or have employed intermittent injections of histamine with subsequent with drawal of the recoverable gastric juice. Such methods lead to fragmentary knowledge of the behavior of the gastric acidity pattern following resection. To obtain a more complete picture the 24-hr. meal technique has been employed.
In considering the effects of the Polya type of resection reference must be made to the surgical technique employed. In group lA the lesser curve was stripped of all extrinsic tissue from the cardio-esophageal junction to the point of resection, while in group lB stripping was not performed. The effect of stripping the lesser curve is to produce, in combination with extensive mobiliza-
1072 F. G. SMIDDY Vol. 32, No.6
tion of the greater curve, a more mobile gastric segment. This may allow a more radical excision to be performed than can be achieved in group 1B. Wangensteen 11
recommended this procedure as part of the routine to be followed in the opera tive technique of resection.
A further effect of stripping the lesser curve from the cardio-esophageal junction must be considered. McCraelO in the classical paper on the abdominal distribution of the vagus nerves found that the main gastric branches of the vagus lie in the neighborhood of the lesser curvature at the cardio-esophageal junction. The possibility arises, therefore, that if complete stripping of the lesser curve is employed as a routine procedure in partial gastrectomy in some cases a complete vagotomy will also be achieved.
Examination of the effects of resection in both group 1A and group 1B sug gests that the resections performed were approximately of equal extent, since in the diurnal phase of secretion no significant difference occurs in the pattern of H-ion concentration. Examination of the nocturnal phase, however, shows significant differences. In group 1A in 7 patients complete nocturnal anacidity occurred and the over-all picture in this group is one of nocturnal neutraliza tion in the gastric remnant. In group 1B such neutralization does not occur. With vagal denervation alone nocturnal acid secretion is profoundly lowered, although some stimulation of gastric secretion results from the presence of food both in the stomach and upper intestine.
These results suggest that following the Polya type of gastrectomy, using well-recognized methods of performing a radical excision of gastric tissue, the effect of such a method is produced by complete vagal denervation of the stomach remnant consequent upon the dissection required in the region of the cardia. The inconsistency of complete nocturnal anacidity in this group of 16 patients is probably due to anatomic variations in the position of the vagus about the lesser curve since, as Woodward et al. 13 showed, division of the vagus fibers to be effective must be complete. In group 1B patients in whom resection was considered anatomically adequate a nocturnal acidity below pH 3.5 was present at some time in all patients, suggesting the presence of active vagal stimulation of the gastric remnant. To ascertain precisely the presence or absence of vagal stimulation of the gastric remnant would require the applica tion of the insulin test meal technique. This test is being applied to a further similar series of patients, the possible significance of the results described in this paper having not been appreciated until the groups were reviewed as a whole.
In two of the achlorhydric gastric remnants, histamine provoked a secretory response which resulted in a rise of intragastric acidity from pH 6.5 to pH 1.4 and pH 1.6 respectively, demonstrating the presence of parietal cells capable of response to an adequate stimulus.
htne 1957 GASTRIC SECRETION AFTER POLY A SUBTOTAL GASTRECTOMY 1073
Shay2 considered that the time factor following gastrectomy was important in relation to the development of anacidity. The results in this paper do not completely substantiate this hypothesis. A gastroenterostomy stoma allowing reflux between the small bowel and stomach is known to produce changes in the immediate vicinity of the anastomosis.14
The 10 patiwts in group 2, however, had possessed such a free anastomosis for an average period of 3.9 yr. In these patients, proof of the continuing ability of the gastric remnant to secrete acid was obtained in 8 of the patients at intervals of between 9 mo. and 12 yr. after operation. This would suggest that the area of "gastritis" seen in relation to the anastomosis following gastrojejunal anastomosis is clearly not "atrophic" in the functional sense or, if "atrophic," is confined to the gastric ponch in area of the anastomosis and does not affect the whole.
Reproducibility of the secretory pattern is not possible in the gastric rem nant. A gastric remnant which is achlorhydric over a certain period on one occasion may well show the presence of free acid if the test is repeated at intervals. There would appear to be, however, greater consistency in the nocturnal secretory pattern-which suggests that , if anastomotic ulceration is suspected, free acid will be more easily demonstrated in the nocturnal phase of secretion. The inconstancy of response and the long period of anacidity which occur after every gastric resection may well explain the inability of other work ers to demonstrate free acid within the gastric remnant after the gastrectomy has been established for some time. Alternatively, faulty positioning of the tube may have led to the belief that achlorhydria is present, since even slight descent of the tube towards the line of anastomosis leads to the withdrawal of an achlorhydric juice.
SUMMARY
1. The 24-hr. secretory pattern of free acidity in 32 patients with duodenal ulceration is described.
2. The patients were then subjected to a Polya type of gastric resection. In 16 patients (group 1A) extensive mobilization of the lesser curve was per formed as a routine, while in group lB (16 patients) the left gastric artery was divided just proximal to the area selected for the anastomosis.
3. In 7 patients in whom radical mobilization of the lesser curve was per formed by dissection to the cardia (group 1A) free acid was not found during the nocturnal phase ; in group lB, in which less radical mobilization was routinely used, free acid was present in all patients. It is postulated that the anacidity found during the nocturnal phase in patients operated upon by the…
From the Department of Surgery, Leeds General Infirmary, Leeds, England
It is generally conceded that one of the main effects of partial or subtotal gastrectomy performed for peptic ulceration of the duodenum should be the control of gastric hyperacidity which is believed to be one of the primary fac tors in the development of duodenal ulceration. By subtotal gastrectomy reduction in the volume of acid secreted is produced by excision of approxi mately three-quarters of the gastric mucosa, the gastric phase of secretion is abolished by excision of the antrum, and free reflux of intestinal juices into the gastric remnant is obtained through the gastrojejunal stoma.
Watson! reviewed the results of 132 Polya-type resections performed for duodenal ulcer and found that, in 49 patients investigated by the gruel meal technique, 7 patients secreted free acid. Shay2 investigated the secretory activity of the gastric remnant in 6 patients and found free acid in the gastric remnant within the first few weeks after operation in all cases and considered that anacidity did not develop until some months after resection. This time lag in the development of anacidity had been previously noted by Wangen steen et at.,3 who reported 10 cases of subtotal resection of Polya type in which achlorhydria, although not a constant finding, was more common after many months than in the immediate postoperative period. In Shay's opinion, the degree of gastric acidity after operation is suffcient to justify medical treatment with antacids for several months.
The method of investigation used by both Watson! and Shay2 was the gruel meal technique with aspirations performed at half-hour intervals. Watson! determined the acidity of the gastric aspirate by titration with Topfer's rea gent, while Shay2 in a more detailed analysis determined the degree of acidity by electrometric methods. The value of this method of determining acidity has been stressed by Hollander4 and by Watkinson and James." These writers are agreed that electrometric methods are superior to titration with indicators, since the effective acidity which is the important factor in the activation of pepsin is measured, as compared to the concentration of acid which gives no indication of the degree of ionization.
The workers referred to above have investigated the activity of the gastric remnant in a fragmentary fashion only, a partial picture of the daily pattern of acid secretion being obtained. It occurred to the writer that it would be of
Submitted for pablication September 28, 1956. Accepted for publication November 18, 1956.
1066
June 1957 GASTRIC SECRETION AFTER POLY A SUBTOTAL GASTRECTOMY 1067
interest to apply the 24-hr. gastric analysis technique described by James and Pickering6 to the investigation of gastric secretory response immediately after a Polya type of gastric resection, and also to investigate patients on whom this type of gastrectomy had been performed several months previously.
METHODS
The technique used was that described by James and Pickering. 6 A Ryle's tube was passed via the nose and sited radiologically in the fundus of the stomach in preoperative patients or in the gastric remnant after operation. The patients took a liberal diet; milk did not comprise one of the major articles of diet since these patients were awaiting operation. As a general rule, the first drink was taken at 6 a.m.; three main meals per day were eaten with supplementary drinks of the patients' own choice at 10.15 a.m., 3 p.m., and 9 p.m. On such a dietary regime the pattern of the 24-hr. secretory response in the intact stomach is governed by the site from which the gastric contents are aspirated. If the tube lies within the fundus, a typical "flat" curve is obtained, whereas if the tube lies within the antral portion of the stomach postprandial neutralization may be found, as was described by James and Pickering.6 In the gastric remnant the position of the tube is of even greater importance, since small deviations in the position of the tube produce a juice wholly alkaline in character from aspiration of bile and pancreatic juice at the line of the anasto mosis. Since rapid emptying of the gastric remnant occurs, only small volumes of fluid averaging 3 to 5 ml. can be obtained at any given time.
Clinical Material
Thirty-two patients were investigated immediately prior to operation and again on the twelfth postoperative day (group 1). In all these patients a duodenal ulcer had been demonstrated radiologically and its presence con firmed at operation. The patients in this group may be subdivided according to the operative technique employed. In group 1A (16 patients) the lesser curve of the stomach was completely denuded of all extrinsic tissue from the cardio-esophageal junction downwards to the point selected for resection. This was performed by division of the left gastric artery at its origin followed by division of the lesser omentum to the cardio-esophageal junction, the extrinsic tissues were then stripped distally. In group 1B (16 patients) the left gastric artery was divided on the lesser curve of the stomach at the point selected for resection. In group 1A and group 1B the greater curve was mobil ized by division of its vessels in routine fashion, two or three short gastric arteries were usually left supplying the gastric remnant on the greater curve and resection was performed a short distance below their point of entry into the stomach wall.
1068 F. G.SMIDDY Vol. 32, No.6
TABLE 1
Patient Reason for Admission Findings Interval after Gastrectomy
1 Routine investigation Nil 8 mo. 2 Perforated anastomotic ulcer Perforation 2 yr., 3 mo. 3 Routine reinvestigation Nil 3 yr. 4 Dumping Nil 1 yr. 5 Dyspepsia Nil 9 mo. 6 Stomal ulceration Stomal ulcer 11 mo. 7 Dyspepsia Nil 5 yr. 8 Dyspepsia Nil 6 yr. 9 Dyspepsia Nil 12 yr.
10 Routine investigation Nil 1 yr.
A further group of 10 patients (group 2) was also studied in whom a Polya type of gastrectomy had been performed at some time prior to investigation. Table 1 shows the reason of each patient for admission to the hospital, the positive findings if any, and the interval of time between gastric resection and investigation. Of these 10 patients, 2 were subjected to the type of procedure described for group lA and the remaining 8 patients were subjected to the group IB procedure. The mean interval between partial gastrectomy and investigation in group 2 was 36.9 months.
RESULTS
The results obtained have been analyzed in respect to two features which appear to have some bearing on the problem of peptic ulceration.
The duration of anacidity. The activity of pepsin in vitro is markedly in fluenced by the pH of the substrate, at pH 3.5 its activity is reduced to 40 per cent. At this pH also titration against Topfer's reagent fails to demonstrate the presence of free acid; in clinical terms achlorhydria is present. For these reasons the duration of anacidity has been defined as the number of hours during which a gastric juice of pH greater than pH 3.5 was withdrawn.
Maximal acidity. The most acid specimen withdrawn from the gastric remnant has been considered to represent the maximal acidity. Since a high nocturnal acidity is characteristic of duodenal ulcer patients the 24-hr. period has been divided into nocturnal and diurnal phases. The nocturnal phase was between 11 p.m. and 6 a.m. inclusive; during this period no food enters the gastric pouch. The diurnal phase is the remainder of the 24-hr. period and represents a time interval of 16 hr.
Duration of Anacidity
Patients with duodenal ulceration and an intact stomach rarely show an achlorhydric phase. In the 32 patients investigated preoperatively the mean duration of this phase was 1.2 hr. In group 1A the mean duration was 16 hr., in
June1957 GASTRIC SECRETION AFTER POLYA SUBTOTAL GASTRECTOMY 1069
MAXIMAL AC IOITY
pHS ,,\T SfOfMEAN02S
pH 4
pH S MEAN. S.EOFMEAN 025 MEAN. S.E.OFMEAN O'OS MEAN S.EOF MEANOIS
3-2 Col ~
t-:---GI\OUP IA-----..... ' o---GI'OUPI B -----~, o---GROU~
FIG. 1. Maximal acidity during nocturnal and diurnal phases of secretion in 40 patients. Each result is the maximal acidity recorded in each phase for each patient studied.
group lB, 10 hr., and in group 2,11.5 hr. In calculating the period of anacidity in group 2 patients only those patients operated upon by group IB techniques were considered, since it was already known that of the remaining 2 patients both would have complete achlorhydria throughout the entire 24 hr., they having been previously investigated in group lA. Statistical analysis of the dura,tion of anacidity shows significance as between the intact stomach and group IA and lB. There is no statistical difference, however, between group lB and group 2.
Maximal Acidity
The maximal acidity found in the diurnal and nocturnal phases is shown in figure 1. For purposes of comparison the mean value of the total results ob tained has been calculated.
Group lA: Mean nocturnal acidity ..................... pH 3.2 (S.E. of mean = 0.28) Mean diurnal acidity ....................... pH 3.1 (S.E. of mean = 0.25)
In this group of 16 patients, 2 were found completely achlorhydric through out the entire 24-hr. period. In 5 patients nocturnal anacidity only was present. In addition, in 2 patients diurnal anacidity was present, free acid being demon strated during the nocturnal phase.
Group IB: Mean nocturnal acidity. Mean diurnal acidity ....
pH 2.4 (S.E. of mean = 0.087) pH 2.4 (S.E. of mean = 0.24)
1070 F. G. SMIDDY Vol. 32, No. (j
In only 1 patient in this group was anacidity found throughout an entire period and in this patient complete diurnal anacidity was present. In the remaining 15 patients free acid was demonstrable at some period throughout the 24 hours.
Group 2: Mean nocturnal acidity. . . . . . . . . . . . . . . . . . . . . .. pH 2.5 (S.E. of mean = 0.32) Mean diurnal acidity ......................... pH 2.4 (S.E. of mean = 0.15)
In this group 2 patients previously found to have a complete achlorhydria in the early postoperative phase have been excluded from further consideration. Only the remaining 8 patients operated upon by the technique used for group 1E have been considered. Nocturnal anacidity has not been found in any of the remaining patients but in one patient diurnal anacidity was present.
Comparison between Group lA, Group IB, and Group 2
No significant statistical difference was found between the diurnal level of maximal acidity of groups 1A and lB. During the nocturnal phase of secretion a highly significant difference was found, a difference which is also shown in figure 2. This figure shows the more highly acid nocturnal secretion of group 1E patients as compared with the achlorhydria present during this phase in group 1A.
Comparison between group 1E and group 2 shows no significant difference between the maximal acidity in the early postoperative and the late results.
Secretory Pattern throughout the 24-Hr. Period
Figure 2 shows the 24-hr. secretory pattern for patients with intact stomachs, duodenal ulcers present, group 1A and 1E.
pHI 24HR.SECRElQfIY PATTE8N
pH2
pHJ
GRP.18 -"
FIG. 2. The 24-hr. secretory pattern. Upper line, duodenal ulcer patients; middle line, group IB; lower line, group lA. This figure demonstrates the significant deviation in the acid secretory patterns between group lA and group lB.
June1957 GASTRIC SECRETION AFTER POLYA SUBTOTAL GASTRECTOMY 1071
The most significant finding present is the divergence of the secretory pat terns found in group lA and lB during the nocturnal phase of secretion. Group 2 has not been shown in the figure as no significant difference was found by Student's t test during the nocturnal phase between this group and group lB.
In many patients when the 24-hr. secretory patterns are individually analyzed postprandial neutralization is found in the gastric remnant; this resembles, therefore, the pattern found when antral aspirations are analyzed from the intact stomach.
The pattern of secretion found in the intact stomach is remarkably constant from day to day. 6 This constancy of secretory pattern is not so clearly defined in the gastric remnant. Marked variation in pattern with variation in the precise duration of anacidity has been found in 2 patients investigated at intervals, constancy of nocturnal pattern appearing more pronounced than in the diurnal phrase.
DISCUSSION
Opinion as to the extent of gastric resection necessary to protect against recurrent ulceration at or about the line of anastomosis has altered considerably during the last two decades. Hemigastrectomy advocated by HunF has given way to a three-quarter resection of the stomach and this radical approach to the surgery of peptic ulceration is advocated by the majority of authors on this subject, reviewed by Snel1.8
The proportion of patients who will develop gastric anacidity following this degree of resection has been variously estimated by different workers. Watson! considered that 85 per cent were completely achlorhydric, Gaviser9 is in agree ment with this figure, while Walters!3 estimated that probably 60 to 75 per cent of patients would be achlorhydric after operation. There appears to be little doubt that if complete achlorhydria is achieved anastomotic ulceration will not occur, and that in patients who develop recurrent ulcer free acid is found on investigation providing that the aspirating tube is correctly positioned.
Investigations performed by previous authors such as Wangensteen et al.,3 Watson,! and Shay2 on the secretory activity of the gastric remnant have utilized the glUel meal technique, withdrawing the meal at half-hour intervals, or have employed intermittent injections of histamine with subsequent with drawal of the recoverable gastric juice. Such methods lead to fragmentary knowledge of the behavior of the gastric acidity pattern following resection. To obtain a more complete picture the 24-hr. meal technique has been employed.
In considering the effects of the Polya type of resection reference must be made to the surgical technique employed. In group lA the lesser curve was stripped of all extrinsic tissue from the cardio-esophageal junction to the point of resection, while in group lB stripping was not performed. The effect of stripping the lesser curve is to produce, in combination with extensive mobiliza-
1072 F. G. SMIDDY Vol. 32, No.6
tion of the greater curve, a more mobile gastric segment. This may allow a more radical excision to be performed than can be achieved in group 1B. Wangensteen 11
recommended this procedure as part of the routine to be followed in the opera tive technique of resection.
A further effect of stripping the lesser curve from the cardio-esophageal junction must be considered. McCraelO in the classical paper on the abdominal distribution of the vagus nerves found that the main gastric branches of the vagus lie in the neighborhood of the lesser curvature at the cardio-esophageal junction. The possibility arises, therefore, that if complete stripping of the lesser curve is employed as a routine procedure in partial gastrectomy in some cases a complete vagotomy will also be achieved.
Examination of the effects of resection in both group 1A and group 1B sug gests that the resections performed were approximately of equal extent, since in the diurnal phase of secretion no significant difference occurs in the pattern of H-ion concentration. Examination of the nocturnal phase, however, shows significant differences. In group 1A in 7 patients complete nocturnal anacidity occurred and the over-all picture in this group is one of nocturnal neutraliza tion in the gastric remnant. In group 1B such neutralization does not occur. With vagal denervation alone nocturnal acid secretion is profoundly lowered, although some stimulation of gastric secretion results from the presence of food both in the stomach and upper intestine.
These results suggest that following the Polya type of gastrectomy, using well-recognized methods of performing a radical excision of gastric tissue, the effect of such a method is produced by complete vagal denervation of the stomach remnant consequent upon the dissection required in the region of the cardia. The inconsistency of complete nocturnal anacidity in this group of 16 patients is probably due to anatomic variations in the position of the vagus about the lesser curve since, as Woodward et al. 13 showed, division of the vagus fibers to be effective must be complete. In group 1B patients in whom resection was considered anatomically adequate a nocturnal acidity below pH 3.5 was present at some time in all patients, suggesting the presence of active vagal stimulation of the gastric remnant. To ascertain precisely the presence or absence of vagal stimulation of the gastric remnant would require the applica tion of the insulin test meal technique. This test is being applied to a further similar series of patients, the possible significance of the results described in this paper having not been appreciated until the groups were reviewed as a whole.
In two of the achlorhydric gastric remnants, histamine provoked a secretory response which resulted in a rise of intragastric acidity from pH 6.5 to pH 1.4 and pH 1.6 respectively, demonstrating the presence of parietal cells capable of response to an adequate stimulus.
htne 1957 GASTRIC SECRETION AFTER POLY A SUBTOTAL GASTRECTOMY 1073
Shay2 considered that the time factor following gastrectomy was important in relation to the development of anacidity. The results in this paper do not completely substantiate this hypothesis. A gastroenterostomy stoma allowing reflux between the small bowel and stomach is known to produce changes in the immediate vicinity of the anastomosis.14
The 10 patiwts in group 2, however, had possessed such a free anastomosis for an average period of 3.9 yr. In these patients, proof of the continuing ability of the gastric remnant to secrete acid was obtained in 8 of the patients at intervals of between 9 mo. and 12 yr. after operation. This would suggest that the area of "gastritis" seen in relation to the anastomosis following gastrojejunal anastomosis is clearly not "atrophic" in the functional sense or, if "atrophic," is confined to the gastric ponch in area of the anastomosis and does not affect the whole.
Reproducibility of the secretory pattern is not possible in the gastric rem nant. A gastric remnant which is achlorhydric over a certain period on one occasion may well show the presence of free acid if the test is repeated at intervals. There would appear to be, however, greater consistency in the nocturnal secretory pattern-which suggests that , if anastomotic ulceration is suspected, free acid will be more easily demonstrated in the nocturnal phase of secretion. The inconstancy of response and the long period of anacidity which occur after every gastric resection may well explain the inability of other work ers to demonstrate free acid within the gastric remnant after the gastrectomy has been established for some time. Alternatively, faulty positioning of the tube may have led to the belief that achlorhydria is present, since even slight descent of the tube towards the line of anastomosis leads to the withdrawal of an achlorhydric juice.
SUMMARY
1. The 24-hr. secretory pattern of free acidity in 32 patients with duodenal ulceration is described.
2. The patients were then subjected to a Polya type of gastric resection. In 16 patients (group 1A) extensive mobilization of the lesser curve was per formed as a routine, while in group lB (16 patients) the left gastric artery was divided just proximal to the area selected for the anastomosis.
3. In 7 patients in whom radical mobilization of the lesser curve was per formed by dissection to the cardia (group 1A) free acid was not found during the nocturnal phase ; in group lB, in which less radical mobilization was routinely used, free acid was present in all patients. It is postulated that the anacidity found during the nocturnal phase in patients operated upon by the…
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