Vagotomy for Relief of Pain in Some Upper Gastrointestinal Neoplasms Oluwole G. Ajao, MB, BS (Lond), FRCS (C), FMCS (Nig) Ibadan, Nigeria
At the University College Hospital, Ibadan, Nigeria, upper gastrointestinal neoplasms are usually seen very late when they have become unresectable. The resectable upper gastrointestinal neoplasms seen in this institution are less than ten percent of all the cases seen. The reasons for such delay before presentation are ignorance and fear of hospitals. Following an editorial by Merendino,1 a study was conducted on ten patients who had inoperable upper gastrointestinal neoplasms. Even though the assessment of pain sensation has many variables, and there is a significant suggestive effect in any pain-relieving procedure, it is felt that vagotomy combined with any indicated diversion procedures definitely reduces the pain associated with terminal upper gastrointestinal neoplasms, while not affecting patient mortality. Merendino first suggested the possibility of the use of vagotomy for the relief of pain in pancreatic carcinoma.1 He reported a case of unresectable pancreatic carcinoma that was free of pain following vagotomy and a drainage. At the University College Hospital, Ibadan, Nigeria, upper gastrointestinal tract neoplasms are not uncommon, In a 12-month period extending from January to December 1975, 23 cases of unresectable gastric cancer had exploratory laparotomy. Resectable gastrointestinal neoplasms seen in this institution are rarely more than ten percent of all cases seen. The reasons are ignorance and fear of hospitals. In
tropical Africa, some people regard going to a hospital as going to a mausoleum. Therefore, cases are seen at late and terminal stages with ascites, peritoneal seedings, and gastric outlet o b s t ruction. The associated pain makes these patients miserable. This study was carried out to see whether their pain could be relieved, thus making what is left of their lives less unbearable without continuously loading them with narcotics. This paper reports the findings from ten cases of unresectable upper gastrointestinal neoplasm treated by vagotomy, gastrojejunostomy and, when indicated, cholecystojejunostomy
From the Department of Surgery, University of Ibadan and University College Hospital, Ibadan, Nigeria. Requests for reprints should be addressed to Dr. Oluwole G. Ajao, Department of Surgery, University of Ibadan and University College Hospital, Ibadan, Nigeria.
Patients and Methods Three groups of upper gastrointestinal neoplasms were used for this
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 9, 1977
study: (1) unresectable carcinoma of the stomach; (2) unresectable carcinoma of the pancreas; and (3) unresectable carcinoma of the gallbladder. Before surgery, the patients were asked to describe the intensity of the pain experienced as: Nil (0), Slight (1+), Moderate (2±), Severe (3+), and Agonizing (4+). There was always a bit of overlapping and confusion about the expression of "severe'" and "agonizing". "Agonizing" pain was described to patients as "next-todeath" type of pain. All the patients had upper midline incisions and the extent of the spread of neoplasm was assessed. The cases of gastric carcinoma in this series originated in the antrum of the stomach. One case, not included in this series, had a huge tumor arising from the fundus of the stomach and invading the diaphragmatic surface. The biopsy showed leiomyosarcoma. Vagotomy was not done because of technical difficulty due to the extent of the tumor growth. Another patient, not included in this series, had a tumor presumably arising from the pancreas, spreading along the lesser curvature of the stomach to the esophageal hiatus and spreading retroperitoneally downwards to the level of the bifurcation of the aorta. Vagotomy was not performed on this patient because of the technical difficulty associated with the extent of the tumor. This tumor was an adenocarcinoma. The ten other patients in this series had bilateral truncal vagotomy, antecolic gastrojejunostomy and, when biliary drainage was interfered with, cholecystoje655
junostomy. They were given pain medication post-operatively for about three to five days. By the tenth postoperative day, after the sutures had been removed, and before discharge, they were again asked to describe whether the pain was: Nil, Slight, Moderate, Severe, or Agonizing. After discharge from the hospital, they were seen in the clinic within two to four weeks and during this time they were asked about their degree of performance of day-to-day activities. A performance chart was filled as follows: bedridden (0), slight activity (1+). moderate activity (2+), and normal activity (3+).
Results In this series of ten patients, four had unresectable carcinoma of the pancreas, five had unresectable carcinoma of the stomach, and one had unresectable carcinoma of the gallbladder. There were five males and five females. Their ages ranged from 40 to 73 years. As shown in Table 1, five of the patients presented with degree of pain classified as severe (3+); two presented with agonizing pain (4+); two presented with moderate pain (2+); and the single case of carcinoma of the gallbladder presented with slight pain ( 1+). Assessment of pain after surgery showed that out of the five people that had severe pain (3+) pre-operatively, three had slight pain (1+) and two had no pain at all (0). Out of the two patients that had agonizing pain (4+) pre-operatively, one had moderate pain (2+) and the other slight pain (1+) post-operatively. Out of the two patients with moderate pain (2+) pre-operatively, one died during the post-operative period before any assessment could be meaningful and the other had slight pain (1+) postoperatively. The case of gallbladder carcinoma with slight pain ( 1+) preoperatively showed no change postoperatively (Table 1 ). 656
At the follow-up clinic, about two to four weeks post-operatively, the patients were questioned about their everyday activities so as to compare their degree of performance before and after surgery. Seven patients had slight degree of performance (1+) before surgery; one had moderate degree of performance (2+); and two were bedridden (0). Post-operatively, six had moderate degree of performance (2+), one who before surgery was bedridden (0) had slight degree of performance (1+), and three others were lost to follow-up (Table 2). It was noticed at the follow-up clinic that even though patient performances improved, there was evidence of pitting edema, ascites, weight loss, and, ultimately, demise.
Discussion The vagus nerve is composed of motor and sensory fibers. It has eight to ten rootlets originating from the medulla oblongata. The motor fibers are distributed in the abdomen to the stomach, small intestine, and large intestine to the middle of the transverse colon. There is doubt about the particular sensory fibers terminating in the nucleus, but there is considerable evidence to suggest that afferent fibers from the esophagus and abdominal part of the alimentary canal terminate in the dorsal vagal nucleus.2 Functionally, the abdominal vagus can be divided into gastric, hepatic, and celiac divisions.3 The anterior and posterior gastric vagi innervate the anterior and posterior walls of the stomach, respectively.4 The hepatic vagi innervate the biliary tract and proximal duodenum. The celiac vagi innervate the entire mid-gut from the pylorus to the splenic flexure of the colon.3 Hepatic vagi probably innervate the ventral pancreas and the celiac vagi, and the dorsal pancreas.5 In man, truncal vagotomy causes
progressive
dilatation
of the gall-
bladder6 and ileus of the entire midgut as a result of loss of hepatic and celiac vagi.5 Vagotomy inhibits gastric secretion and motility and this is the basis for vagotomy and a drainage procedure in the surgical management of duodenal ulcer. It is, therefore, understandable how the pain of gastric hyperperistalsis that may be associated with gastricoutlet obstruction from any obstructive cause can be reduced by vagotomy. It has been suggested that pain resulting from pancreatic carcinoma may be related to perineural invasion or pressure on the nerves by tumor growth.1 Splanchnic nerves and the celiac plexus are regarded as producing the sensory pathway for pain in some patients. This would suggest that the sensory pathways, at least, must partly be through the vagus nerves.1 Obstruction and distention of biliary and pancreatic ducts also cause pain. Before claiming success for any pain-relieving procedure, the suggestive effects of the treatment must be considered. Keele7 claimed that about 50 percent of cases may respond to any procedure with a highly suggestive content, whether or not there is any specific interference with the physiology of pain. Pain is a word used to describe various types of unpleasant experiences and should not be regarded as a term that carries several connotations.8 The assessment of pain depends on the reliability of the patient's statement and the observer's judgement. The patient's statement also depends on his or her threshold of pain and this varies widely from individual to individual. Other factors affecting the degree of pain experienced by an individual depend on social influence, subjective beliefs, motivational changes, and emotional
states.9,1 °
Total relief of pain is not possible in many conditions, but by changing certain properties either through surgical procedures or through administration of medications, pain may become much more bearable. In frontal lobe lesions, the aversive quality of pain and the urge to seek relief are reduced. Lobotomy does not disrupt sensory pathways; its effect seems to depend on the motivational effective dimension of pain experienced.8 The experience of pain may be either purely organic or psychogenic or a
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 9, 1977
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At the University College Hospital, Ibadan, Nigeria, upper gastrointestinal neoplasms are usually seen very late when they have become unresectable. The resectable upper gastrointestinal neoplasms seen in this institution are less than ten percent of all the cases seen. The reasons for such delay before presentation are ignorance and fear of hospitals. Following an editorial by Merendino,1 a study was conducted on ten patients who had inoperable upper gastrointestinal neoplasms. Even though the assessment of pain sensation has many variables, and there is a significant suggestive effect in any pain-relieving procedure, it is felt that vagotomy combined with any indicated diversion procedures definitely reduces the pain associated with terminal upper gastrointestinal neoplasms, while not affecting patient mortality. Merendino first suggested the possibility of the use of vagotomy for the relief of pain in pancreatic carcinoma.1 He reported a case of unresectable pancreatic carcinoma that was free of pain following vagotomy and a drainage. At the University College Hospital, Ibadan, Nigeria, upper gastrointestinal tract neoplasms are not uncommon, In a 12-month period extending from January to December 1975, 23 cases of unresectable gastric cancer had exploratory laparotomy. Resectable gastrointestinal neoplasms seen in this institution are rarely more than ten percent of all cases seen. The reasons are ignorance and fear of hospitals. In
tropical Africa, some people regard going to a hospital as going to a mausoleum. Therefore, cases are seen at late and terminal stages with ascites, peritoneal seedings, and gastric outlet o b s t ruction. The associated pain makes these patients miserable. This study was carried out to see whether their pain could be relieved, thus making what is left of their lives less unbearable without continuously loading them with narcotics. This paper reports the findings from ten cases of unresectable upper gastrointestinal neoplasm treated by vagotomy, gastrojejunostomy and, when indicated, cholecystojejunostomy
From the Department of Surgery, University of Ibadan and University College Hospital, Ibadan, Nigeria. Requests for reprints should be addressed to Dr. Oluwole G. Ajao, Department of Surgery, University of Ibadan and University College Hospital, Ibadan, Nigeria.
Patients and Methods Three groups of upper gastrointestinal neoplasms were used for this
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 9, 1977
study: (1) unresectable carcinoma of the stomach; (2) unresectable carcinoma of the pancreas; and (3) unresectable carcinoma of the gallbladder. Before surgery, the patients were asked to describe the intensity of the pain experienced as: Nil (0), Slight (1+), Moderate (2±), Severe (3+), and Agonizing (4+). There was always a bit of overlapping and confusion about the expression of "severe'" and "agonizing". "Agonizing" pain was described to patients as "next-todeath" type of pain. All the patients had upper midline incisions and the extent of the spread of neoplasm was assessed. The cases of gastric carcinoma in this series originated in the antrum of the stomach. One case, not included in this series, had a huge tumor arising from the fundus of the stomach and invading the diaphragmatic surface. The biopsy showed leiomyosarcoma. Vagotomy was not done because of technical difficulty due to the extent of the tumor growth. Another patient, not included in this series, had a tumor presumably arising from the pancreas, spreading along the lesser curvature of the stomach to the esophageal hiatus and spreading retroperitoneally downwards to the level of the bifurcation of the aorta. Vagotomy was not performed on this patient because of the technical difficulty associated with the extent of the tumor. This tumor was an adenocarcinoma. The ten other patients in this series had bilateral truncal vagotomy, antecolic gastrojejunostomy and, when biliary drainage was interfered with, cholecystoje655
junostomy. They were given pain medication post-operatively for about three to five days. By the tenth postoperative day, after the sutures had been removed, and before discharge, they were again asked to describe whether the pain was: Nil, Slight, Moderate, Severe, or Agonizing. After discharge from the hospital, they were seen in the clinic within two to four weeks and during this time they were asked about their degree of performance of day-to-day activities. A performance chart was filled as follows: bedridden (0), slight activity (1+). moderate activity (2+), and normal activity (3+).
Results In this series of ten patients, four had unresectable carcinoma of the pancreas, five had unresectable carcinoma of the stomach, and one had unresectable carcinoma of the gallbladder. There were five males and five females. Their ages ranged from 40 to 73 years. As shown in Table 1, five of the patients presented with degree of pain classified as severe (3+); two presented with agonizing pain (4+); two presented with moderate pain (2+); and the single case of carcinoma of the gallbladder presented with slight pain ( 1+). Assessment of pain after surgery showed that out of the five people that had severe pain (3+) pre-operatively, three had slight pain (1+) and two had no pain at all (0). Out of the two patients that had agonizing pain (4+) pre-operatively, one had moderate pain (2+) and the other slight pain (1+) post-operatively. Out of the two patients with moderate pain (2+) pre-operatively, one died during the post-operative period before any assessment could be meaningful and the other had slight pain (1+) postoperatively. The case of gallbladder carcinoma with slight pain ( 1+) preoperatively showed no change postoperatively (Table 1 ). 656
At the follow-up clinic, about two to four weeks post-operatively, the patients were questioned about their everyday activities so as to compare their degree of performance before and after surgery. Seven patients had slight degree of performance (1+) before surgery; one had moderate degree of performance (2+); and two were bedridden (0). Post-operatively, six had moderate degree of performance (2+), one who before surgery was bedridden (0) had slight degree of performance (1+), and three others were lost to follow-up (Table 2). It was noticed at the follow-up clinic that even though patient performances improved, there was evidence of pitting edema, ascites, weight loss, and, ultimately, demise.
Discussion The vagus nerve is composed of motor and sensory fibers. It has eight to ten rootlets originating from the medulla oblongata. The motor fibers are distributed in the abdomen to the stomach, small intestine, and large intestine to the middle of the transverse colon. There is doubt about the particular sensory fibers terminating in the nucleus, but there is considerable evidence to suggest that afferent fibers from the esophagus and abdominal part of the alimentary canal terminate in the dorsal vagal nucleus.2 Functionally, the abdominal vagus can be divided into gastric, hepatic, and celiac divisions.3 The anterior and posterior gastric vagi innervate the anterior and posterior walls of the stomach, respectively.4 The hepatic vagi innervate the biliary tract and proximal duodenum. The celiac vagi innervate the entire mid-gut from the pylorus to the splenic flexure of the colon.3 Hepatic vagi probably innervate the ventral pancreas and the celiac vagi, and the dorsal pancreas.5 In man, truncal vagotomy causes
progressive
dilatation
of the gall-
bladder6 and ileus of the entire midgut as a result of loss of hepatic and celiac vagi.5 Vagotomy inhibits gastric secretion and motility and this is the basis for vagotomy and a drainage procedure in the surgical management of duodenal ulcer. It is, therefore, understandable how the pain of gastric hyperperistalsis that may be associated with gastricoutlet obstruction from any obstructive cause can be reduced by vagotomy. It has been suggested that pain resulting from pancreatic carcinoma may be related to perineural invasion or pressure on the nerves by tumor growth.1 Splanchnic nerves and the celiac plexus are regarded as producing the sensory pathway for pain in some patients. This would suggest that the sensory pathways, at least, must partly be through the vagus nerves.1 Obstruction and distention of biliary and pancreatic ducts also cause pain. Before claiming success for any pain-relieving procedure, the suggestive effects of the treatment must be considered. Keele7 claimed that about 50 percent of cases may respond to any procedure with a highly suggestive content, whether or not there is any specific interference with the physiology of pain. Pain is a word used to describe various types of unpleasant experiences and should not be regarded as a term that carries several connotations.8 The assessment of pain depends on the reliability of the patient's statement and the observer's judgement. The patient's statement also depends on his or her threshold of pain and this varies widely from individual to individual. Other factors affecting the degree of pain experienced by an individual depend on social influence, subjective beliefs, motivational changes, and emotional
states.9,1 °
Total relief of pain is not possible in many conditions, but by changing certain properties either through surgical procedures or through administration of medications, pain may become much more bearable. In frontal lobe lesions, the aversive quality of pain and the urge to seek relief are reduced. Lobotomy does not disrupt sensory pathways; its effect seems to depend on the motivational effective dimension of pain experienced.8 The experience of pain may be either purely organic or psychogenic or a
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