25

Section ofSurgery

and available from J G Franklin Ltd at the above address (British Patent No. 1268034).

reversal. Our anmesthetic colleagues have overcome these problems and I am grateful to Dr E K Brownrigg for details of the following regime:

REFERENCES Dunn D C (1971) British Medical Journal i, 283 (1973) British Journal of Surgery 8, 594 (1976) Journal of Cardiovascular Surgery (in press)

Mr Frank Tovey (Basingstoke District Hospital, Park Prewett, Basingstoke, Hampshire, RG24 9NA) The Use of the Burge Vagotomy Stimulator in Proximal Gastric Vagotomy and Revision Vagotomy In some reports comparing vagotomy and drainage procedures with gastrectomy there has been disappointingly little difference in the, Visick gradings. The reason for this has been the incidence of either dumping or of recurrent ulcer after vagotomy and drainage. Proximal gastric vagotomy without a drainage procedure has been a great step forward because it has almost completely eliminated dumping. The problem of recurrent ulceration due to incomplete vagotomy remains and the solution depends on being able to be sure at operation that denervation of the acid-producing portion of the stomach is complete. The Maurice Lee leukomethylene blue test is valuable (Lee 1969), but it stains other strands such as small blood vessels as well as nerve fibres. The original Grassi test with a pH probe involves a gastrotomy and irrigation of the stomach with the risks of soiling. The modified test with an intragastric probe has the difficulty of manceuvring the electrode to explore the whole mucosal surface. In addition, in 30% of cases in a recent European multicentre trial it was not possible to define the acid zone. Harold Burge described how the use of his vagotomy stimulator in proximal gastric vagotomy had the advantage that one is able not only to test for completeness of the vagotomy but also, at the same time, to check that the innervation of the antrum is intact and sufficient to obviate the necessity for a drainage procedure.

Anticholinergic drugs must be avoided, likewise halothane, pethidine and phenothiazines. Diazepam can be given preoperatively but its effect is variable and morphine is probably preferable. For anesthesia the following drugs are used: thiopentone; gallamine; phenoperidine 2 mg with droperidol 10 mg (diluted to 10 ml; 3-5 ml initially); suxamethonium; d-tubocurarine. Induction is with thiopentone. Gallamine 20-4 mg is then given to protect the heart against vagal stimulation and reduce muscle pains due to suxamethonium. This is followed by the combination of the neuroleptics phenoperidine and droperidol and by suxamethonium. The cords are sprayed with 4% lignocaine and before intubation the Burge tube is passed into the the stomach. To reduce the total dose of d-tubocurarine required the first dose is delayed until the operation is about to start. During the operation incremental doses of d-tubocurarine or of the phenoperidine-droperidol mixture are given. If there is any bradychardia more gallamine can be given. The towelling is arranged so that the anmsthetist has free access to the head of the patient.

Checking the Antral Ihiniervation The lesser omentum is dissected free upwards from the crow's foot where the lesser curve is crossed by the terminal fibres of the anterior nerve of Latarjet, and the lower end of the cesophagus is freed. The flat electrode (Fig 1) is then placed, with the negative contact lying distally, on the separated lesser omentum (Fig 2). The stimulator is switched on and this results in strong contractions of the antrum. This confirms that cholinergic fibres have not been blocked by the anesthetic and also shows the extent of the antrum that remains innervated. It indicates that the antral emptying

......

The Ancesthetic One reason why the use of the stiniulator was disliked in the past was the problem of operating on patients without atropine with the resulting sweating and tachycardia. Large doses of gallamine (Flaxedil) were often Lised with problems of

855

Fig 1 Flat elect -ode

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856 Proc. roy. Soc. Med. Volume 69 November 1976

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Fig 2 Flat electrode applied to lessel onmentitun

Fig 3 Ring electrode and occlhsion clamnp in position

mechanismn is intact and that no drainage pro-

atropine, it will no longer be possible to use the stimulator to check the result. Another valuable application of the instrument is during revision surgery for an incomplete vagotomy. It is more common to find persistent posterior fibres than anterior, the most frequent site being towards the left of the cesophagogastric junction. The latest model of the stimulator has a pen recorder which gives a permanent record that can be filed in the patient's notes. The result can then be verified by others at a later date if any question arises.

cedure will be necessary.

Checking the Completeniess of the Vagotomy The position of the intragastric tube is then checked and the ring electrode is applied to the lower cesophagus. An intestinal occlusion clamp is placed across the stomach just proximal to the innervated portion (Fig 3). The cuff is inflated and sufficient air is introduced into the stomach to produce a satisfactory swing on the pressure gauge or recorder. The stimulator is switched on for one minute. If the vagotomy is incomplete there is a rise in pressure of more than 2 mni of water. The rise takes place after 10 or 20 seconds Acknowledgment: Figs 2 and 3 are reproduced by of stimulation and slowly falls when stimulation kind permission of Messrs Romer Pharmais finished. It needs to be distinguished from an ceuticals (Instruments) Ltd, 20/24 Church Street, immediate rise which may occur as a result of Hampton, Middlesex, who are the suppliers of skeletal muscle contraction from spread of the the stimulator and its accessories. electrical impulse in a patient who has not had sufficient d-tubocurarine. If a genuine positive REFERENCE response occurs one must go back again and Lee M (1969) British Journal of Surgery 56, 10-13 again and look for more nerve fibres until the response becomes negative. Very occasionally there is doubt as to whether a persistent response is genuine or due to skeletal muscle contraction, in which case atropine 1.25 mg The following paper was also read: can be given intravenously. This will effectively Modifications of Intubation Techniques in abolish the response if it is due to incomplete CEsophageal Malignant Strictures vagotomy, in which case one should look again Mr T W Balfour for more fibres. Unfortunately, having given the (General Hospital, Nottingham, NG] 6HA)

The use of the burge Vagotomy stimulator in proximal gastric vagotomy and revision vagotomy.

25 Section ofSurgery and available from J G Franklin Ltd at the above address (British Patent No. 1268034). reversal. Our anmesthetic colleagues ha...
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