Pancreatic function and the absorption of fat, iron,

Transcription

1 Gut, 196,, 26 Pnreti funtion nd the bsorption of ft, iron, vitmin B12, nd lium fter totl gstretomy for gstri ner K. FISCHRMANN, S. HARLY, H. WORNING, AND A. ZACHO From the Finsen Institute, Deprtment of Surgery, the Finsen Lbortory nd the Centrl Lbortory, Blegdmshospitlet, Copenhgen DITORIAL COMMNT Twelve ptients who hd hd totl gstretomy hve been refully studied. No differene ws found in those ptients who hd hd either Roux or n interposition type of opertion. In the surgil tretment of gstri ner totl gstretomy my be required. Suh n extensive surgil proedure is only justified if the opertive mortlity is suffiiently low nd the ptient's generl ondition fter the opertion tolerble. The first ptient who survived totl gstretomy ws operted upon by Shltter in 19. A few months lter Hofmnn (19) demonstrted tht the ptient ould be kept in positive nitrogen blne; he ould even obtin retention of nitrogen by dministering high-protein diet. In reent dedes totl gstretomy hs been used to n inresing extent in the tretment of gstri ner. The primry mortlity hs fllen to eptble levels: Nkym (19).2 %; ReMine, Priestley, nd Berkson (196) 16%; fskind, Bugge-Asperheim, nd Helsingen (196) 9 %. The five-yer survivl rte hs remined onstnt, between nd 12%, but in few series (Allison, 196) it is %. Severl Sndinvin uthors hve published studies on totl gstretomy in the tretment of gstri ner (Holst, 19; Mikkelsen nd Wndll, 199; Fretheim, 19; Zho nd Fishermnn, 199, 1961, nd 1966; Lewin, 196; nd fskind et l., 196). Holst, in prtiulr, must be emphsized s the Sndinvin pioneer of totl gstretomy in gstri rinom. In the Surgil Deprtment of the Finsen Institute 61 ptients with ner of the stomh were treted during the period 19 to 196 (Zho nd Fishermnn, 1966). In 2 of these ses the tumour ws removed, in 2 by totl gstretomy. Totl gstretomy ws rried out in ses where the oesophgus s well s duodenum hd to be reseted 26 to obtin minimum distne of m. from the tumour. Thus, totl gstretomy ws only performed on ptients hving lrge, widespred tumours in the stomh. The primry mortlity of the rdil totl gstretomies ws % in the lst five-yer period from 199 to 196 inlusive nd the five-yer survivl rte is shown in Figure 1. The primry mortlity is so low nd the five-yer survivl rte so high tht totl gstretomy must be onsidered fully justified in treting ner of the + e Rdil proedures. *--- Pttitive proedures. ". 1 K- -_* _-- %o 1 2 Yers. FIG. 1. Five-yer survivl mong 2 ptients who hd survived totl gstretomy (Zho nd Fishermnn, 1966). Gut: first published s.116/gut...26 on 1 June 196. Downloded from on 1 April 19 by guest. Proteted by opyright.

2 Pnreti funtion nd the bsorption offt, iron, vitmin B12, nd lium fter totl gstretomy 261 stomh. The generl ondition nd the results of B12, ft, iron, nd lium. Moreover, externl pnreti number of funtion tests on ptients who hve hd funtion ws investigted. totl gstretomy form the substne of our report. Vitmin B12 bsorption ws studied by the Shilling test shortly fter the opertion in ll subjets. As might MATRIALS AND MTHODS be expeted, it ws very low (-1 %). Absorption of ft ws investigted by determining the Twelve ptients who hd undergone totl gstretomy verge fel exretion of ft on diet hving dily for ner of the stomh were seleted t rndom ft ontent of g. (Tble I). None of these ptients hd signs of reurrene Iron bsorption ws studied in whole-body ounter, t the time of the follow-up exmintion; the follow-up the ounts being mde before nd fter orl dminiperiod rnged from six months to 1 yers. strtion of ferrosulphte ontining -6,uC 9Fe s desribed by Fber nd Leroy (196). Clium bsorption ws studied by dily ounting in TABL I whole-body ounter following orl dministrtion of SURVIVAL TIM AND TYP OF OPRATION IN gc C in the form of hloride dissolved in wter 12 PATINTS WITH TOTAL GASTRCTOMY or milk. The seven-dy retention ws used s mesure No. Sex Age t Type of Follow-up of the lium retention. Opertion (yr.) Opertion Time (yr.) Pnreti funtion ws investigted by the method of Thysen, Mullertz, Worning, nd Bng (196). A thin tube of polyvinyl ws pssed down to the ligment of 2 1 Treitz, in ses with nstomoses to site 6 12 just distl to the entero-nstomosis. The sitution of V the tube ws heked rdiologilly. After the fsting 6 d 9 6 intestinl ontents hd been olleted, the ptients were s 6 given stndrdized liquid mel by mouth, nd during the 9 9 subsequent minutes, frtionted into four -minute 6 1 portions, the intestinl ontents were olleted. The ph 1 d 6 1 s well s the onentrtion of the enzymes -mylse, 12 ~ 6 1 lipse, trypsin, nd hymotrypsin in the spirtes were determined (Worning nd Mullertz, 196). In ddition to removl of the entire stomh, ll hd hd high vgotomy, nd hlf of them, in ddition, prtil resetion of the pnres. In four gstrointestinl ontinuity ws re-estblished by nstomosis. In the remining eight n intestinl segment hd been interposed isoperistltilly between the oesophgus nd duodenum. This segment ws tken either from the jejunum s dvoted by Longmire nd Bel (192) nd Henley (192) or from the trnsverse olon s suggested by Stte, Brly, nd Kelly (191). From the time of the opertion the ptients hd been on high-protein, low-ft diet, whih ws otherwise omposed ording to eh individul ptient's hbits nd tste. During the sme period ll the ptients hd reeived permnent supplement of vitmins A, B, nd C by mouth nd vitmin B12 in the form of Cyobemin intrmusulrly 6 gg. every third week, nd iron in the form of ferromine eti id (Glyifer). All the ptients were dmitted to hospitl for the followup exmintion whih inluded thorough questioning regrding symptoms nd signs s well s physil exmintion. BLOOD STUDIS Hemoglobin, serum iron, trnsferrin, lium, phosphorus, nd protein were estimted, nd pper eletrophoreti seprtion of the plsm proteins ws done. RADIOGRAPHS The skeletl bones were exmined to detet osteoporosis. ABSORPTION TSTS These were performed for vitmin RSULTS The ptients weie subjetively feeling well. They hd no postprndil omplints suh s nuse, vomiting, or regurgittion. None hd dumping. All were ble to et norml portions. The stools were of norml pperne with no mrosopilly visible ft. We do not im t the pre-morbid weight, s most of the ptients hd been overweight before developing gstri ner (Zho, Lrsen, nd Christinsen, 196), but we im t n idel weight. Tble II lists the hemoglobin onentrtion s well s the serum levels of iron, trnsferrin, nd protein. Two ptients hd moderte nemi nd redued serum level of iron. The serum protein ws norml in ll ses, nd pper eletrophoresis showed norml distribution of protein in ll ses. The bsorption of ft ws investigted in three of the ptients with nstomoses. The verge dily fel exretion rnged from 1 to g. (Tble III). Iron bsorption ws studied in six ptients. All six hd norml hemoglobin onentrtion t the time of the investigtion. In the three ptients with short follow-up period (less thn one yer) there ws n iron bsorption of.2,., nd. % whih must be onsidered redued. In the other three, Gut: first published s.116/gut...26 on 1 June 196. Downloded from on 1 April 19 by guest. Proteted by opyright.

3 K. Fishermnn, S. Hrly, H. Worning, nd A. Zho TABL II SRUM CONCNTRATIONS OF HAMOGLOBIN, IRON, TRANSFRRIN, AND PROTIN No. Sex Age t Type of Follow-up Hemoglobin Serum Iron Trnsferrin Serum Protein Opertion Opertion Time (yr.) (g./ ml.) (mg./ ml.) (mg./ ml.) (g.1 ml.) (yr.) TABL III FAT ABSORPTION IN THR PATINT ROUX-Y ANASTOMOSS Ptient Anstomosis Follow-up No. Time (yr.) l with follow-up periods of from one nd hlf to x-ry exmintion of the bones. 12 yers, the bsorption ws norml ( 1- %). One ptient hd redued serum lium level, Clium bsorption ws studied in ptients. low serum phosphorus level, redued Nordin's The results re given in Figs. 2,,; nd nd in produt (196), nd rdiologilly onfirmed osteo- to some porosis, but norml bsorption of lium. Of Tble IV. The retention of lium deipends extent upon the form in whih the. lium slt is the two ptients with low lium bsorption, one dministered. Retention ppers to be t mximum hd questionble osteoporosis, but both hd norml when it is dministered in queous solution; the serum levels. ddition of rrier, or solution in milik redues the Pnreti funtion ws studied in nine ptients,. 6. : FIG. 2. & & (& C& retention. Figure illustrtes the retention in five rs WITH norml subjets; the seven-dy retention is between 12 nd 2 %. The retention in ptients with Ft xretion in nstomoses nd with interposition (vergesgdy) opertions is shown in Figures 2,, nd. It is _, *, _ = 1 -.._1 1 2 G Dys fter dministrtion of Co pprent tht only two hd seven-dy retention 1. below 12%. In both the follow-up period ws less -2 thn one yer. In Tble IV these vlues re om- 2- pred with serum lium, serum phosphorus, 1- Nordin's produt (196), nd the result of the GP C-) t s FIG Dys fter dmnidstrtion of C FIG. 2. Clium retention in four ptients who reeived C in wter. The dotted lines represent ptients with Roux- Y nstomoses nd the solid line the retention in one ptient who hd hd n interposition opertion. FIG.. Clium retention in three ptients with Roux- Y nstomoses. In these ses C ws dministered in wter to whih hd been dded lium hloride. Gut: first published s.116/gut...26 on 1 June 196. Downloded from on 1 April 19 by guest. Proteted by opyright.

4 C- Pnreti funtion nd the bsorption offt, iron, vitmin B12, nd lium fter totl gstretomy U 'X Dys fter dmfrnistrtron of C Dys fter dministrtion of C FIG.. FIG.. FIG.. Clium retention in eight ptients in whom totl gstretomy hd been followed by interposition of segment of the smll bowel between the oesophgus nd duodenum. In these ses C ws dministered in milk. FIG.. Clium retention in five normls. C ws dministered in milk. nd the results re given in Tble V nd Figure 6. The ph in the smll intestine, exept for the first portion, is signifintly higher thn in helthy persons with hlorhydri. The onentrtions of enzymes re lso illustrted in Figure 6. As the enzyme onentrtions in norml popultion show positive skew distribution, normlized by logrithmetiztion (Thysen et l., 196), the negtive stndrd devitions in liner system (Fig. 6) re onsequently smller thn the positive ones. This explins the skew position of the men vlues in the figure. TABL V ph IN TH INTSTINAL LUMN DURING DIGSTION OF A FLUID MAL IN NORMALS WITH ACHLORHYDRIA AND IN PATINTS W1TH TOTAL GASTRCTOMY Portion of Lumen N Men S.D. p II I IV TABL IV Normls Totl gstretomy Normls Totl gstretomy Normls Totl gstretomy Normls Totl gstretomy SRUM LVLS OF CALCIUM AND PIIOSPHORUS, NORDIN S PRODUCT, AND RSULTS OF X-RAY XAMINATION OF SKLTAL BONS Serum C Serum P Nordin's Produt Absorbed 'C Osteoporosis Anstomosis (mg./ ml.) (mg./ ml.) [C] [ XP]" (-dy ',) (,6-,) !j A_ ,1 1,19 6,96,9,11 1,66,29,29 1,1,, 1,99 9, N.S. <- <- < Gut: first published s.116/gut...26 on 1 June 196. Downloded from on 1 April 19 by guest. Proteted by opyright.

5 N to C N WU CL K. Fishermnn, S. Hrly, H. Worning, nd A. Zho + N W v I l 1 -- C + OW I II m I o~ ~ 6,, FIG. 6, b,, nd d. The onentrtion of () mylse, (b) trypsin, () hymotrypsin, nd (d) lipse in the four intestinl spirtes in ptients with totl gstretomy. The olumns indite the norml onentrtion (men ± 2 stndrd devitions). + nstomosis. Intestinl interposition. In the norml orgnism the onentrtion of enzymes is highest in the portion first olleted, while in the subsequent three portions it is sttionry. In the ptients the onentrtion of enzymes ws lowest in the first portion, inresing in i i V) J o O CP the subsequent portions. This ws lest mrked with lipse, whih ws, on n verge, signifintly redued in ll portions, while the onentrtions of mylse, trypsin, nd hymotrypsin were redued only in the first portion nd norml in the others. b O I fi m 1 r---, lo d I m io Gut: first published s.116/gut...26 on 1 June 196. Downloded from on 1 April 19 by guest. Proteted by opyright.

6 Pnreti funtion nd the bsorption offt, iron, vitmin B12, nd lium fter totl gstretomy 26 DISCUSSION The ptients' ondition following totl gstretomy depends upon the method of re-estblishing the ontinuity, the omposition of the diet, nd the prophylti dministrtion of vitmins, iron, et. The previously employed end-to-side nstomoses between the oesophgus nd the jejunum, in some ses ombined with Brun nstomosis, use severe trouble in the form of regurgittion, postgstretomy omplints, nd weight loss (Bugge- Asperheim nd Helsingen, Jr., 196). This method should therefore not be used. Inidentlly, Hedenstedt nd Heijkenskjold (196) hve demonstrted tht these omplints my be relieved by interposing jejunl segment between the oesophgus nd the duodenum. In the present study no differene ws found between the results in ptients with nstomoses nd those who hd hd interposition opertions. However, the ltter should probbly be preferred, s they re-rete norml ontinuity in the gstrointestinl trt, nd it is our impression tht these ptients mke more rpid reovery. It is well known tht totl gstretomy invribly entils stetorrhoe, whih my be due to one or more of the following ftors: redued pnreti funtion, n unfortunte mixture of food nd digestive juies, rpid pssge through the intestine, nd n ltered bteril flor in the smll intestine. The enzyme onentrtion in the intestine is low during the erly stge of digestion, just s following subtotl gstretomy by the Billroth II method (Lundh, 19). This is presumbly due to the rpid emptying of the stomh nd the onsequently greter dilution of the pnreti juie, not to redued seretion of enzymes, s the onentrtion of enzymes in the subsequent portions olleted ws norml. An exeption is the lipse onentrtion whih ws redued in ll portions in number of the ptients. It is impossible to tell whether this phenomenon represents dpttion to the low-ft diet tht the ptients hve tken sine the opertion. There is no experimentl proof tht lipse seretion should dpt itself to the diet (Grossmn, Greengrd, nd Ivy, 19; Abdeljlil nd Desnuelle, 196), but it is possible tht the experimentl period hs been too short in these studies. The bteril flor in the smll bowel ws not investigted in the present mteril, but the ltered environment during digestion (Tble V) must entil ltered onditions for growth. The iron bsorption findings re rther diffiult to ssess, s ll the subjets hd norml hemoglobin levels t the time of the tests. However, the vlues for bsorption were strikingly low in the three ptients whose follow-up periods were less thn one yer. Whether the iron bsorption improves in time nnot be nswered on the bsis of the present findings, but it is worth noting tht only few of the ptients showed signs of slight iron defiieny, even fter long follow-up period (Tble II). In 1 totlly gstretomized ptients Niolysen nd Rigird (19) found loss of lium, but kbom nd Hed (196) explined this s redued lium intke, rther thn redued bsorption. This ssumption is supported by the present results whih showed redution of lium bsorption in only very few ptients. The osteoporosis found in the ptient with norml lium bsorption is presumbly due to redued intke of lium. SUMMARY In the Surgil Deprtment of the Finsen Institute in Copenhgen we hve treted 61 ptients with ner of the stomh from 19 to 196 inlusive. In 2 of these ses the tumour ws removed, in 2 by totl gstretomy. The primry mortlity for rdil totl gstretomy ws % during the lst five-yer period from 199 to 196, nd the five-yer survivl rte (19-199) 26% for ptients hving rdil surgery nd % for those hving pllitive opertions. The generl ondition nd the results of number of funtion tests in 12 ptients subjeted to totl gstretomy re desribed. The investigtions reveled tht the ptients were in good generl ondition. It is onluded tht totl gstretomy for ner of the stomh, when the nstomosis is estblished by stisftory tehnique, is not disbling proedure. RFRNCS Abdeljlil, A. B., nd Desnuelle, P. (196). Sur I'dpttion des enzymes exorines du pnres l omposition du regime. Biohim. biophys. At (Amst.), 1, Allison, P. R. (196). Rdil totl gstretomy for rinom of the stomh. Lnet, 1, Bugge-Asperheim, B., nd Helsingen, N., Jr. (196). The stte of nutrition of ptients who hve undergone totl gstretomy. At hir. snd., suppl. 2, 6-. fskind, L., Bugge-Asperheim, B., nd Helsingen, N., Jr. (196). Lte results in the tretment of high gstri rinom requiring totl gstretomy. Ibid., suppl. 2, -. kbom, K., nd Hed, R. (196). Clium studies in prtilly gstretomized ptients with speil referene to the orl intke of lium. At med. snd., 1, Fretheim, B. (19). Crinom ventriuli behndlet med bdominothorl totl gstrektomi. Akdemisk Trykningsentrl, Oslo. Fber, M., nd Leroy, S. (196). Iron bsorption fter totl gstretomy. At hir. snd., suppl., Grossmn, M. I., Greengrd, H., nd Ivy, A. C. (19). ffet of dietry omposition on pnreti enzymes. Amer. J. Physiol., 1, Gut: first published s.116/gut...26 on 1 June 196. Downloded from on 1 April 19 by guest. Proteted by opyright.

7 266 K. Fishermnn, S. Hrly, H. Worning, nd A. Zho Hedenstedt, S., nd Heijkenskjold, F. (196). Jejunl trnsposition in ptient with totl gstretomy. At hir. snd., suppl. 2, -9. Henley, F. A. (192). Gstretomy with replement. Brit. J. Surg.,, Hofmnn, A. (19). Stoffwehselunlersuhungen nh totler Mgenresetion. Munh. med. Wshr.,, 6-6. Holst, J. (19). Syv tilfelle v totl gstrektomi med oesophgojejunostomi. [With nglish summry.] Norsk Mg. Legevidensk., 9, Lewin,. (196). Gstri ner. At hir. snd., suppl., 262. Longmire, W. P., Jr., nd Bel, J. M. (192). Constrution of substitute gstri reservoir following totl gstretomy. Ann. Surg., 1, 6-6. Lundh, G. (19). Intestinl digestion nd bsorption fter gstretomy. At hir. snd., suppl., 21. Mikkelsen,., nd Wndll, H. H. (199). Totl gstretomy in the tretment of gstri rinom. At med. snd., 16, suppl. 2, Nkym, K. (19). Die rgebnisse der totlen Mgenresektion beim Mgenkrebs. Chirurg, 29, 1-. Niolysen, R., nd RAgird, R. (19). The lium nd phosphorus metbolism in gstretomized ptients. Snd. J. lin. Lb. Invest.,, Nordin, B.. C. (196). Hyperprthyroidism, osteomli nd osteoporosis. Clin. ndor., 1, 2-2. ReMine, W. H., Priestley, J. T., nd Berkson, J. (196). Cner of the Stomh. Sunders, Phildelphi nd London. Shltter, C. (19). Ueber rnihrung und Verduung nh vollstndiger ntfernung des Mgens-Oesophgoenterostomiebeim Menshen. Bruns' Reit. klin. Chir., 19, -6. Stte, D., Brly, T., nd Kelly, W. D. (191). Totl gstretomy with utiliztion of segment of trnsverse olon to reple the exized stomh. Ann. Surg., 1, -1. Thysen,. H., Mullertz, S., Worning, H., nd Bng, H.. (196). Amylse onentrtion of duodenl spirtes fter stimultion of the pnres by stndrd mel. Gstroenterology, 6, 2-1. Worning, H., nd Mullertz, S. (1966). ph. nd pnreti enzymes in the humn duodenum during digestion of stndrd mel. Snd. J. Gstroent., 1, Zho, A., nd Fishermnn, K. (199). Totl gstretomy in rinom of the stomh. At hir. snd., 11, (1961). Stomh ner. The results of surgil tretment. [In Dnish.] Nord. Med., 6, , - (1966). The results of surgil tretment of ner of the stomh. Surg. Gyne. Obstet., 12, -9., Lrsen, V., nd Christinsen, J. (196). Body weight nd ner of the stomh. At hir. snd., 1, Gut: first published s.116/gut...26 on 1 June 196. Downloded from on 1 April 19 by guest. Proteted by opyright.