22 Februry 1964 Vgotomy-Cox nd Bond MMDICLJ OURNAL 465 REFERENCES * Austen, W. G., nd Edwrds, H. C. (1961). Gut, 2, 158. Bel, J. M., nd Dineen, P. (195). Arch. Surg., 6, 23. * Bettie, A. D. (195). Lncet, 1, 525. Burge, H. W. (196). Postgrd. med. 7., 36, 2. nd Clrk, P. A. (1959). Brit. med. 7., 1, 1142. (196). Gstroenterology, 39, 572. Rizk, A. R., Tompkin, A. M. B., Brth, C. E., Hutchison, J. S. F., Longlnd, C. J., McLennn, I., nd Miln, D. C. (1961). Lmiwt, 2, 897. * Clrk, C. G. (1961). Brit. med. 7., 1, 125. * Crile, G., Jones, T. E., nd Dvis, J. B. (1949). Ann. Surg., 13, 31. * Dvies, J. A. L. (1956). Brit. med. 7., 2, 186. Drgstedt, L. R., nd Woodwrd, E. R. (1951). 7. Amer. med. Ass., 145, 795. * Edwrds, L. W., nd Herrington, J. L. (1953). Ann. Surg., 137, 873. Elliot-Smith, A., Pinter, N. S., nd Porter, R. (1961). Lncet, 2, 136. Fik, S., Grindly, J. H., nd Mnn, F. C. (195). Surgery, 28, 546. * Feggetter, G. Y., nd Pringle, R. (1963). Surg. Gynec. Obstet., 116, 175. Frnksson, C. (1948). Act chir. scnd., 96, 49. Frzer, A. C. (1955). Brit. med. 7., 2, 85. Griffith, C. A. (1962). West. 7. Surg., 7, 175. * Grimson, K. S., Rowe, C. R., nd Tylor, H. M. (1952). Ann. Surg,, 135, 621. * Hmilton, J. E., Hrbrecht, P. J., Robbins, R. E., nd Kinnird, D. W. (1961). Ibid., 153, 934. Hrper, A. A. (1959). Gstroenterology, 36, 386. * Hendry, W. G. (1961). Postgrd med. Y., 37, 137. Henson, G. F., nd Rob, C. G. (1955). Brit. med. 7., 2, 588. Hindmrsh, F. D. (1957). Lncet, 1, 1113. Hoerr, S.. (1955). Surgery, 38, 149. Holt, R. L., nd Lythgoe, J. P. (1961-2). Brit. 7. Surg., 49, 255. * Klug, T. J., Zollinger, R. M., nd Ellensohn, J. (1963). Amer. 7. Surg., 15, 37. * Krft, R. O., Fry, W. J., nd Rnsom, H. K. (1962). Arch. Surg., 8S, 687. Mchell, T. B., nd Lorber, S. H. (1948). Gstrocnterolog%, 11, 426. * McKelvie, A. A. (1957). Brit. med. 7., 1, 321. * Orr, 1. M., nd Johnson, H. D. (1949). Ibid., 2, 1316. * Pollock, A. V. (1952). Lncet, 2, 795. Ross, B., nd Ky, A. W. (1964). Gstroenterology. In press. * Ross, C. C., Geddes, J. H Huch, P. P., nd Scrtch, N. W. (195). Cnd. med. Ass. 7., i3, 347. * Roth, H. P., nd Bems, A. J. (1959). Gstroenterology, 36, 452. * Smith, R. C., Ruffin, J. M., nd Bylin, G. J. (1947). Sth. med.. (Bghm, Al.), 4, 1. Wddell, W. R., nd Wng, C. C. (1952-3). 7. ppl. Physiol., 5, 75. Wlters, W., nd Mobley, J. E. (1957). Ann. Surg., 145, 753. * Weinstein, V. A., Hollnder, F., Luber, F. U., nd Colp, R. (195). Gstroenterology, 14, 214. * These ppers provided dt for Tble I. Aspects of Nutrition fter Vgotomy nd Gstrojejunostomy ALAN G. COX,* M.D.; MICHAEL R. BONDt M.B., CH.B. ;DENNIS A. PODMORE4t A.R.I.C. DAVID P. ROSE, M.B., CH.B. Brit. med. i., 1964, 1, 465-469 The choice of opertion in the surgicl tretment of chronic duodenl ulcer remins controversil subject. Prtil gstrectomy is now performed less frequently, s surgeons re incresingly ttrcted to the dvntges of vgotomy, which effects substntil reduction of gstric-cid secretion in most cses. Recurrent ulcertion ppers to be more common fter vgotomy thn fter prtil gstrectomy, but this disdvntge of vgotomy is blnced nd possibly outweighed by the higher post-opertive mortlity rte fter prtil gstrectomy. The mjor criticism of prtil gstrectomy is tht it leds to n uncceptbly high incidence of lte complictions, which include limentry symptoms such s postprndil bdominl discomfort, dumping, nd vomiting, nd lso impired nutrition mnifested by loss of weight, nemi, nd more rrely osteomlci. Although greement is not complete, mny publictions support the contention tht untowrd limentry symptoms re comprtively infrequent fter vgotomy. However, there is remrkbly little informtion in the literture to substntite the view tht impired nutrition is rre fter vgotomy. In order to provide dt relevnt to this ltter problem, this pper reports the results of study of ptients fter vgotomy nd gstrojejunostomy for chronic duodenl ulcer. Vgotomy hs been extensively used in Sheffield since 1958, nd the intervl between opertion nd the present review vried between 37 nd 57 months in the ptients studied; we hve therefore considered the results s representing post-opertive * Reserch Assistnt in Surgery, University Deprtment of Surgery, Royl Infirmry, Sheffield. Present ddress: Deprtment of Surgery, Western Infirmry, Glsgow. t Assistnt Lecturer in Surgery, University Deprtment of Surgery, Royl Infirmry, Sheffield. 4tPrincipl Biochemist, Deprtment of Chemicl Pthology, United Sheffield Hospitls. S Registrr in Clinicl Pthology, Deprtment of Chemicl Pthology, United Sheffield Hospitls. investigtion t pproximtely four yers. A gstric dringe procedure must be performed simultneously with vgotomy, which by itself cuses high proportion of symptoms due to delyed gstric emptying. Gstrojejunostomy ws combined with vgotomy in the present series, nd the ptients hving pyloroplsty in the period under considertion hve not been included s they were too few to merit detiled investigtion. The study ws designed to give s much informtion s possible without requiring more co-opertion thn could resonbly be expected from our ptients. The tests were therefore restricted to peripherl blood exmintion, estimtion of serum-iron nd serum-vitmin-b12 levels, nd mesurement of vitmin-b1, bsorption nd fecl ft excretion. In ddition, the ptients were sked bout limentry symptoms nd weight chnges before nd fter opertion. Insulin tests to confirm completeness of vgotomy were not performed in ll ptients, but recent study from this deprtment suggests tht vgl-nerve section ws chieved in pproximtely 9% of ptients (Ross nd Ky, 1964). Clinicl Mteril From consecutive series of 12 ptients with chronic duodenl ulcer treted by vgotomy nd posterior gstrojejunostomy pproximtely four yers previously, 25 were excluded becuse of deth (5), reopertion (7), filure to ttend (7), nd distnce from Sheffield (6). The 95 ptients remining for detiled investigtion were 75 mles nd 2 femles. Some were unble to undergo ll the tests plnned. All results described s " fter opertion" refer to the study of these ptients pproximtely four yers fter vgotomy nd gstrojejunostomy. In order to hve dt with which to compre the results, informtion ws tken from vrious sources, which re described in the next section. This informtion is clled "control" dt.
466 22 Februry 1964 Methods Hemoglobin concentrtion ws determined s oxyhemoglobin in grey-wedge photometer (King et l., 1948). The red-cell count ws mde in n EEL electronic counter. The immedite pre-opertive hemoglobin level ws known in 71 of the ptients, but red-cell counts hd not been performed routinely t the time of opertion. Control dt were tken from the records of 185 helthy dults undergoing routine hemtologicl check during the period of our study ; ll hd hemoglobin estimtion nd 13 red-cell count. These tests were mde becuse the subjects, minly nurses, rdiogrphers, nd industril workers, were exposed to rdition risk, but in none ws there ny evidence of hemtologicl bnormlity. Serum-iron concentrtion ws estimted by Rmsy's (1953) method, using blood tken between 9 nd 11.m. wherever possible. Control dt were tken from previous study by one of us (Bird et l., 1957) in which serum-iron levels hd been estimted by the sme method nd in the sme lbortory in series of non-nemic ptients witing opertion. Serum-vitmin-B12 levels were ssyed by Dr. S. Vrdi nd Mr. A. Elwis in the Sheffield City Generl Hospitl using the Euglen grcilis method (Ross, 1952). Vitmin-B,2 bsorption ws estimted with rdioctive 58Colbelled vitmin B,2 by urinry excretion method (Schilling, 1953). A 1 -flg. dose of 58Co-lbelled vitmin B12 (specific ctivity 1 tac/ttg.), contined in single-dose mpoule obtined Vgotomy-Cox et l. from the Rdiochemicl Centre, Amershm, ws mde up to pproximtely 23 ml. with distilled wter. Exctly 2 ml. ws immeditely dministered by mouth to the fsting ptient nd n intrmusculr injection of 1 mg. of crrier vitmin BL2 ws given simultneously. The 58Co content of ll urine pssed in the next 24 hours ws mesured in ring counter mde up of six 26-cm. Geiger-Muller tubes, using for the stndrd mesured liquot from the originl dose solution. The result ws expressed s percentge of the dose excreted in 24 hours. Control dt were obtined during the period of study from 27 volunteer ptients with no significnt limentry or hemtologicl bnormlity. Fecl ft excretion ws mesured by the method of vn de Kmer et l. (1949). Feces were collected by the ptient over period of either four or five dys by previously described method (Cox, 1961). No specil dietry restrictions were mde except to be sure tht the subject hd n dequte dietry ft intke of more thn 75 g./dy. The result ws expressed s grmmes of ft (s ftty cid) per dy. Fecl ft estimtions hd been mde by one of us (Cox, 1963) in identicl mnner in 52 ptients with peptic ulcer before opertion, nd these dt were vilble for comprison. Body Weight.-The ptient's weight t the time of opertion nd four yers fter vgotomy nd gstrojejunostomy ws recorded. In ddition, the ptients were sked to estimte their heviest weight before opertion, nd this is referred to s " estimted best weight." The idel weight ccording to BRITISH MEDICAL JOURNAL sex, height, nd ge ws tken from the Document Geigy Scientific Tbles (1956). Peripherl Blood Studies.-The results for mles nd femles re presented seprtely in this section nd re summrized in Tble I. The men red-blood-cell counts in the ptients fter TABLE I.-Hemoglobin nd Red-cell Count in Controls nd Ptients Before nd Four Yers After Vgotomy nd Gstrojejunostomy Control subjects Before vgotomy After vgotomy Hemoglobin (g./1 ml.) No. Rnge Red-cell Count Men No. Rnge S.D. S.D. Mles 111 13 3-18- 15-4±1-88 4-6-4 5-1: 5 56 8-8-17-5 15-3±1-7 71 8-1-18-1 15-2±1-5 68 3-5-5-8 4 9±: 7 Control subjects. 74 11-8-16 14-±-9 15 4-1-5-3 4 6± 3 Before vgotomy.. 15 9-2-16-6 13-5 1-8 - After vgotomy.. 19 5-7-16 8 12 8±2-7 19 2-4-5-1 4-4±-6 vgotomy re not significntly different from those in the control subjects nd will not be considered further. In both sexes the men hemoglobin concentrtions of the control subjecits nd of the ptients before opertion show no significnt difference. In the mles the men of the ptients fter opertion is not significntly different from the men of the control subjects or ptients before opertion. In the femles the men of the ptients fter opertion does not differ from tht of the ptients before opertion but is significntly lower thn the men of the control subjects (P<.1). However, fter opertion five of the femle ptients reported such fctors s menorrhgi nd recent orl iron therpy, which tend to confuse the pttern; when the results of these ptients re excluded from considertion the men hemoglobin concentrtion in the remining 14 is 13.6 g./1 ml. (S.D.= 1.9), which is not significntly different from the men of the control femle subjedts or of the femles before opertion. The distribution of hemoglobin levels (Tble II) is pproximtely the sme before nd fter opertion. These results indicte tht the hemoglobin TABLE II.-Distribution of Hernoglobin Levels Before nd Four Yers After Vgotomy nd Gstrojejunostomy No. of Mles No. of Hemoglobin (g.f1 ml.) Before After Before After Vgotomy Vgotomy Vgotomy Vgotomy (56) (71) (15) (19) 13-6 nd over.49 64 9 9 116-13-5 5 5 3 6 9-6-11-5 1 1 2 2 9-5 nd less 1 1 1 2 TABLE III.-Detils of Ptients With Hemoglobin Levels Below 11.8 g./1 ml. Four Yers After Vgotomny nd Gstrojejunostonty Hemoglobin (g./1 ml.) Other fter Igotomy Ptient Age Before After After Red-cell Serum Iron Serum Vitmin Other Clinicl Fetures Vgotomy Vgotomy Orl Iron Count (pg./1 ml.) B,2 (P41g./mi.) G.C... G.R... [.J... F.B... K.F... 57 44 36 47 41 9-2 11-4 1 8 14-5 9.9 11-6 8-3 9.9 5-7 12-4 13-3 13-1 14-1 12 3 Mles F.G..... 52 1-6 11-1 S.L. -.., 57 17 5 8-1 13-5 3 8 4-1 4-1 3-3 2-4 5-3.9 13 92 34 3 374 262 22 218 222 25 137 Piles 1 254 Nil Chronic nephritis Menorrhgi Anemi in pregnncy Nil Menorrhgi
22 Februry 1964 concentrtion is little ltered four yers fter vgotomy nd gstrojejunostomy. Anemi occurred in some ptients before nd fter opertion but not in the control subjects. Using s the criterion of nemi hemoglobin levels below 13.3 g./1 ml. (9% on Hldne scle) for men nd 11.8 g. (8%) for women, the incidence of nemi fter opertion in women (26 %) is significntly (P<.5) higher thn in men (8%). However, nemi is not necessrily consequence of vgotomy nd gstrojejunostomy, since ptients with low hemoglobin levels fter opertion often hd correspondingly low levels before opertion (Tble III), nd fctors unconnected with the opertion were clerly importnt in severl; these include bleeding piles, menorrhgi, nd nemi of pregnncy. No such fctor could be detected in two ptients (F. B. nd S. L. in Tble III). The nemi of the post-opertive ptients ws typicl of iron deficiency. A course of orl iron therpy lsting for one to three months ws sufficient to restore norml hemoglobin levels. Serum-iron levels re presented seprtely for mles nd femles (Tble IV). The control dt cn be compred with TABLE IV.-Serum-iron Levels in Control Subjects nd Ptients Pour Yers After Vgotomy nd Gstrojejunostomy No. of Vgotomy-Cox et l. Serum-iron Levels (ug./1 ml.) Rnge Men : S.D. Min Control subjects.48 51-261 143 ± 39 Whole group.64 1-197 99 38 Hb > 13-3.. 55 33-197 13 29 Control subjects.13 15-139 97 ± 34 Ptients Whole group.18 13-121 62 +'32 Hb > 11-8 g..12 3-121 72 +±3 the results in the ptients fter opertion. The ltter re divided into two groups: the first group includes ll ptients irrespective of their hemoglobin level; the second group differs from the first in tht nemic ptients re excluded, since nemic subjects were lso excluded from the control series (Bird et l., 1957). In mle ptients the men serum-iron level fter opertion, even when the nemic ptients re excluded, is significntly lower thn the control men (P<.1). In femle ptients the men serum-iron level fter opertion is lso lower thn the control men (P<.1); however, when the results in the femle ptients with nemi re excluded there is no significnt difference between the controls. nd ptients. When the results in femles with dditionl complicting fctors such s menorrhgi nd recent iron therpy re lso excluded the men serum iron in the remining 1 ptients (77,tg./1 ml.) is not significntly lower thn the control men, which my be due to the smll number of femle ptients fter exclusion. Tking vlues below 6,tg./1 ml. s bnorml, the incidence of hypoferremi is 5% in women nd 12.5% in men; this difference is significnt (P<.1). Becuse of the low serumiron levels the dt were studied to see if there ws fll in the serum-iron vlues with incresing time fter opertion. The men vlues in ptients grouped t monthly intervls showed tendency to fll, but this could not be confirmed by sttisticl nlysis, possibly becuse the time spn of 37 to- 57 months occupied by the ptients in this study is too short to revel definite trend. Serum-vitmin-B12 levels in 83 ptients fter vgotomy nd gstrojejunostomy were: 66 mles, men 35 + S.D. 12 Fug./ ml. (rnge 137 to 529 /utg), nd 17 femles, men 314 + S.D. 132 Fufg. (rnge 198 to 74 Fuqeg.). The mle nd femle mens re not significntly different nd correspond to the men vlues in the lbortory where the ssys were performed. Only one result ws below the norml rnge of 15 to 85,u.tg./ml. BRTrrISH MEDICAL JOURNAL 467 The men vlues in ptients grouped t monthly intervls do not show tendency to fll with time fter opertion. The tests of vitmin-b12 bsorption by the Schilling test indicte significntly reduced bsorption in the ptients when compred with the control subjects (Tble V). The men vlue in the TABLE V.-24-Hour Urinry Excretion of "Co Vitmin B12 in Control Subjects nd Ptients Four Yers After Vgotomy nd Gstrojejunostomy 24-hour Urinry Excretion No. of of "Co Vitmin B12 (% of Dose) Rnge Men i S.D. Controls.27 4-1- 39-1 15-6 6-7 Mles.42 2-3-34-4 119 +6-. 15 2-7-16-6 11-6 4-4 Whole group.57 2-3 - 34-4 11-8 5-6 mle ptients does not differ significntly from the men in the femles. Tking 7% of the dose s the lower limit of norml 24-hour excretion of rdioctive 5"Co, there were 19% bnorml results in the mle ptients nd 13 % in the femle ptients ; this difference is not significnt. Fecl Ft Excretion.-Tking dily fecl ft excretion of 7 g. or more s bnorml, the incidence of stetorrhoe in the men (43%) is not significntly different from tht in the women (33%). The distribution of results (Fig. 1) shows tht stetorrhoe ws only mild in the mjority. The men fecl ft excretion of 84 ptients fter vgotomy nd gstrojejunostomy (Tble VI) is significntly higher thn tht of 52 ptients with ' ob IL 22-2 I 14. 16-12- 1 8 6-4. A I I I I B --- 79. FIG. 1.-A comprison of fecl ft excretion in 52 ptients with peptic ulcer before opertion (A), with 84 ptients four yers fter vgotomy nd gstrojejunostomy for chronic duodenl ulcer (B). The interrupted line t 7 g. ft pec dy represents the upper level of norml fecl ft excretion. Men dily ft excretion: A, 3.9 g.; B, 7.5 g. P<.1. TABLE VI.-Fecl Pt Excretion in Control Subjects nd Ptients Pour Yers After Vgotomy nd Gstrojejunostomy No. of Fecl Ft Excretion (g./dy) Rnge Men + S.D. Controls.52 1-11-6 39+2-1 Mles.65 1-19-8 7-3 41. 19 1-5 - 2-2 8-2 4 9 Whole group.84 1-2-2 7-5 + 4-3 peptic ulcer before opertion (P<.1). The men vlue in the mles does not differ significntly from the men in the femles. Weight Chnge.-The mjority of ptients reported gin in weight between the time of opertion nd follow-up (Tble VII). In the whole group there ws men weight gin of 2.8 kg; the men gin in femles (5.5 kg.) does not differ significntly from the men gin in mles (2.1 kg.). More -.1 - -.,.j:,.
468 22 Februry 1964 Vgotomy-Cox et l. BMA RNA detiled nlysis indictes tht weight chnge in the four yers fter opertion depends in prt upon the reltion between the ptient's estimted best weight before opertion nd his weight t the time of opertion (Fig. 2). Ptients whose weight t the TABLE VII.-Distribution of Weight Gins nd Losses Four Yers After Vgotomy nd Gstrojejunostomy Weight Chnge in kg. No. of Ptients Mles Totl r > 15.8 2 1) Gins 1-14 9 1 2 3 5-99 15 5 2~ 1.6 <5.19 8 27J No chnge 5 5 r<5.15 1 16 Losses 1-149 995 6 >1 19.. 28 2 1 3 cr.x 'Im c.c ' "I. >>15.3 3 3 25 2 + l o 1-5 - - 5-1 - i - 2-25 - x X men weight chnge in ech group Nil -- 5-5 toto 1-totS ->15 Difference between opertion weight nd previous estimted bestweight Ckg.) FIG. 2.-Reltion between chnge in weight before nd four yers fter vgotomy nd gstrojejunostomy. On the horizontl xis, the ptients re divided into groups ccording to difference between the ptient's weight t the time of opertion nd his estimted previous best weight (those who gined weight up to the time oi opertion re grouped with those showing no chnge). Anlysis of vrince shows significnt (P<.1) difference between the men chnges in the five groups, nd inspection of these mens shows trend indicting tht weight chnge fter opertion is inversely relted to weight chnge before opertion. The regression line fitted to the ungrouped dts hs coefficient of -.58 (S.E.=.84), which is highly significnt (P'O.1). time of opertion ws most below their previous estimted best weight gined most weight fter opertion, nd, conversely, ptients t their estimted best weight t the time of opertion lost most weight subsequently. The weight of the mjority of ptients four yers fter vgotomy nd gstrojejunostomy remined below their estimted best weight before the opertion. In four of the five groups shown in Fig. 2 the men weight deficit rnges from 3.8 to 5.5 kg. However, the group of ptients who were more thn 15 kg. below their previous estimted best weight t the time of opertion remined on verge 12.5 kg. below their previous best weight. The number of ptients seriously below their idel weight is much smller four yers fter opertion thn before (Tble VIII). TABLE VIII.-Reltion of Actul Weight to Idel Weight Before nd Four Yers After Vgotomy nd Gstrojejunostomy Actul Weight s % of Idel Weight <8% 8-9% 9-11% >11% No. of ptients Before vgotomy 19 26 53 2 After vgotomy.. 7 19 67 5 I/ /S\.I: T -:1 *; The min purpose of this study Discussion ws to provide informtion relting to nutrition fter vgotomy nd gstrojejunostomy. The intervl between opertion nd study ws pproximtely four yers, nd longer intervl might modify the pttern of results. However, since informtion is lmost entirely lcking on the effects of vgotomy on nutrition, this is field which requires Post-opertive insulin tests to confirm completeness of vgotomy were not performed routinely in this study, nd the number of fully vgotomized ptients is therefore uncertin. However, the results of ugmented histmine nd insulin tests in recent study of ptients treted by vgotomy in this deprtment suggest tht n dequte vgotomy 9%o ws chieved in extensive investigtion. of 1 consecutive ptients (Ross nd Ky, 1964). The sme opertive technique ws used in our ptients in whom n pproximtely similr finding might be expected. The likelihood tht n indequte vgotomy occurred in 1% of the ptients in the present study detrcts from the purely physiologicl interest of the results but does not nnul their vlue in reflecting the overll pttern of chnge fter the opertion. Furthermore, it cn resonbly be rgued tht the end-result of the opertion is compounded of mny vribles which no mount of testing could evlute fully-these include pre-opertive gstrointestinl function, completeness or otherwise of vgotomy to stomch, nd extrgstric structures such s the pncres, biliry tree, nd smll intestine, nd size, position, nd function of the gstro-enterostomy. An nlogy cn be drwn with comprble studies fter prtil gstrectomy in which the extent of gstric resection remins n unknown but importnt fctor. Hemtologicl sttus hs not previously been studied in detil fter vgotomy, but bnormlities re generlly believed to be uncommon. Hemoglobin levels below 9% hve been reported in 14% of 4 ptients eight yers fter vgotomy nd gstrojejunostomy (Burge nd Pick, 1958), nd in pproximtely 1% of 29 ptients studied 1 to 14 yers fter opertion by Feggetter nd Pringle (1963). In neither study ws considertion given to possible sex differences or to hemoglobin vlues before opertion. The present study suggests tht low hemoglobin vlues develop only rrely within four yers of vgotomy nd gstrojejunostomy, since men hemoglobin levels nd the number of ncmic ptients were the sme s before opertion. For the most prt, nemi occurred in the sme individuls before nd fter opertion, nd only two ptients known to hve norml hemoglobin vlues t the time of opertion were found to be nemic t the time of our investigtion. Although the cuse of nemi ws not lwys obvious, it occurred more often in women, in whom fctors such s menorrhgi nd pregnncy seemed to be importnt. The good response to orl iton therpy implicted iron deficiency s the cuse of the nemi. Although the hemoglobin levels were stisfctory, the possibility tht iron deficiency is compliction of vgotomy nd gstrojejunostomy, nd my cuse symptoms in lter yers, is suggested by the significntly reduced serum-iron concentrtions. There my be grdul depletion of iron stores fter opertion, but our results did not spn sufficient period of time to llow sttisticl confirmtion of this. Longer-term studies might revel definite pttern nd show whether nemi cn be expected to occur more frequently with the pssge of time. However, Deller nd Witts (1962) were unble to find significnt correltion between serum iron nd time fter prtil gstrectomy, lthough progressive fll in hemoglobin levels fter this opertion ws demonstrted by these uthors nd by Bird et l. (1959). Since hemoglobin nd serum-iron levels do not necessrily run prllel, both require further investigtion fter vgotomy nd gstrojejunostomy. Studies concerning vitmin showed serum concentrtions B,2 lmost entirely within the norml rnge but significntly reduced men level of bsorption in ptients fter vgotomy nd
22 Februry 1964 Vgotomy-Cox et l. MEDICAL 469 gstrojejunostomy. These two findings re not incomptible, since the body's norml stores of vitmin B12 re sufficient to cope with considerble period of totl deprivtion (Schloesser et l., 1958). The degree of reduced bsorption in the vgotomized ptients ws reltively smll nd most would be expected to replenish their stores t rte sufficient to meet norml requirements. However, the detiled observtions hve to be viewed in the light of recent doubts concerning the relibility of the Schilling test used in the present study. Adms nd Crtwright (1963) filed to obtin reproducible results in individul post-gstrectomy ptients. If the sme occurs fter vgotomy nd gstrojejunostomy, too much importnce cnnot be ttched to the result in n individul ptient, lthough the combined results of individul tests in group of ptients my still be mesure of bsorptive cpcity in the group s whole. Eqully importnt questions rise from the observtion of Deller et l. (1961) tht the bsorption of dose of rdioctive vitmin B12 in post-gstrectomy ptients vries with the method of dministrtion of the dose. Similr observtions hve been mde with the bsorption of rdioctive iron (Bird nd Wilson, 1959) nd rdioctive ft (Cox, 1963). The sme problems my exist in ptients fter vgotomy nd gstrojejunostomy, in whom it would be of interest to study the influence on vitmin-b,2 bsorption of such fctors s food, intrinsic fctor, nd crbchol or histmine stimultion. Menwhile the finding of reduced bsorption in the present studies suggests tht megloblstic type of nemi might develop in few ptients some yers fter vgotomy nd gstrojejunostomy. The incresed fecl ft excretion in the post-opertive ptients provides further evidence of some impirment of bsorption fter vgotomy nd gstrojejunostomy. Men fecl ft excretion ws only slightly bove the norml level, nd the smll ssocited clorie loss would be unlikely to hve recognizble effect on nutrition. The physiologicl explntion of the rised fecl ft is subject of interest which merits further study. Butler (1961) hs shown similr incidence of incresed fecl ft excretion fter Poly prtil gstrectomy (gstrojejunl nstomosis) but much lower incidence fter the Billroth I gstrectomy (gstroduodenl nstomosis) ; he lso found tht fecl ft excretion incresed in the presence of long fferent loop fter the Poly gstrectomy. These observtions could be ccounted for by reduced pncretic secretions nd poor mixing of ingested food with the pncretic enzymes in ccordnce with the work of Lundh (1958). The sme considertions my pply fter vgotomy nd gstrojejunostomy, giving support to the current preference for pyloroplsty insted of gstrojejunostomy s the gstric dringe procedure. Some would fvour the suggestion tht the rise in fecl ft excretion is due to section of the vgus-nerve supply to the gll-bldder, pncres, nd smll intestine. Although severl investigtors hve studied the effects of vgl denervtion on the function of these orgns, correltion between the effects observed nd fecl ft excretion does not seem to hve been demonstrted. In these circumstnces, the subject remins confused nd needs more complete study of ll the fctors involved thn hs yet been ttempted. A study of the weight chnges fter opertion showed tht in the mjority there ws either no ltertion or gin nd tht the overll chnge ws men gin of just under 3 kg. Although these findings re fvourble, weight chnges fter gstric surgery should lso tke ccount of weight chnges before opertion. The importnce of this fctor ws clerly illustrted in the present study, which showed tht ptients who lost weight before opertion tended to gin fterwrds nd tht ptients who did not lose weight before opertion tended to lose weight fterwrds. Although the mjority of ptients fter opertion were below wht they considered to hve been their best weight before opertion, reltively few were substntilly below their theoreticl idel weight ccording to height nd ge. Johnston et l. (1958) hve reported pproximtely similr findings fter prtil gstrectomy, but the nlysis of weight chnges is not strictly comprble. This study provides evidence of stisfctory stte of nutrition in most ptients four yers fter vgotomy nd gstrojejunostomy. Although certin bnormlities were discovered, most were only mild nd some were not necessrily direct result of opertion. The dt were exmined to see if bnorml results were more frequent in certin ptients, but no definite reltionships could be estblished except for the concurrence of nemi, hypoferremi, nd low red-cell counts. Abnorml results were not more common in ptients with limentry symptoms such s bile-vomiting nd dumping, nd no correltion could be found between fecl ft excretion nd weight chnge or bowel hbit. Perhps the most importnt prcticl finding ws the generl tendency to low serum-iron concentrtions. Ptients my need regulr hemoglobin estimtions fter vgotomy nd gstrojejunostomy in order to detect the development of nemi. Our findings indicte tht this is reltively minor problem requiring only orl iron therpy to obtin rpid improvement in the hemoglobin level. Further studies re required to investigte the longer-term effects of vgotomy nd gstrojejunostomy on nutrition. It would lso be of interest to hve comprble dt in series of ptients fter vgotomy combined with pyloroplsty in order to ssess the reltive merits of the dringe procedure employed. Summry Hemtologicl sttus, intestinl bsorption, nd weight chnge were studied in 95 ptients pproximtely four yers fter vgotomy nd gstrojejunostomy. Hemoglobin nd serum-vitmin-b12 levels showed little ltertion from norml, but serum-iron concentrtion ws reduced. Absorption of vitmin B12 ws reduced nd fecl ft excretion ws slightly rised. Most ptients gined weight fter the opertion ; there ws n inverse reltionship between chnge in weight before nd fter opertion. The significnce of these findings is discussed. We wish to thnk the following: Professor A. W. Ky nd Mr. W. J. Lytle for encourging us to study their ptients nd for dvice in the preprtion of this pper; Dr. E. K. Blckburn for providing control hemoglobin nd red-cell-count dt; Dr. H. P. Brody for llowing study of his ptients to obtin control vitmin-b 2- bsorption dt; Dr. S. Vrdi for serum-vitmin-b12 estimtions; Miss H. M. Dvis for sttisticl dvice; Miss C. Cresey for much secretril help ; Misses Z. Hinchliffe nd H. Peck nd Messrs. D. Bowen nd D. Robertshw for technicl ssistnce; nd the Tuberculosis Reserch Fund of the University of Sheffield for generous support. REFERENCES Adms, J. F., nd Crtwright, E. J. (1963). Gut, 4, 32. Bird,. I. M., Blckburn, E. K., nd Wilson, G. M. (1959). Qurt. 7. Med., 28, 21. - Podmore, D. A., nd Wilson, G. M. (1957). Clin. Scd., 16, 463. nd Wilson, G. M. (1959). Qurt. 7. Med., 28, 35. Burge, H., nd Pick, E. J. (1958). Brit. med. 7., 1, 613. Butler, T. J. (1961). Ann. roy. Coll. Surg. Engl., 29, 3. Cox, A. G. (1961). Brit. med. 7., 2, 933. (1963). Gstroenterology, 44, 275. Deller, D. J., Germr, H., nd Witts, L. J. (1961). Lncet, 1, 574. nd Witts, L. J. (1962). Qurt. 7. Med., 31, 71. Document Geigy Scientific Tbles, 1956, 5th ed., p. 255. Feggetter, G. Y., nd Pringle, R. (1963). Surg. Gynec. Obstet., 116, 175. Johnston, I. D. A., Welbourn, R., nd Acheson, K. (1958). Lncet, 1, 1242. Kmer, J. H. vn de, Huinink, H. Ten B., nd Weyers, H. A. (1949). 7. biol. Chem., 177, 347- King, E. J., Wootton, I. D. P., Donldson, R., Sisson, R. B., nd Mcfrlne, R. G. (1948). Lncet, 2, 971. Lundh, G. (1958). Act chir. scnd., Suppl. No. 231. Rmsy, W. N. M. (1953). Biochem. 7., 53, 227. Ross, B., nd Ky, A. W. (1964). Gstroenterology. In press. Ross, G. I. M. (1952). 7. clin. Pth., 5, 25. Schilling, R. F. (1953). 7. Lb. clin. Med., 42, 86. Schloesser, L. L., Deshpnde, P., nd Schilling, R. F. (1958). Arch. intern. Med., 11, 36.