PARTIAL GASTRECTOMY UNDER ACUPUNCTURE ANESTHESIA

Yu Zhiqin1, Wu Gaosheng1, Zhao Ruitang1 Sun Tao1, Yu Renjie1, Wang Youliang'2, Zou Wanzhong

529 cases (132 cases with acupuncture anesthesia) of partial gastrectomy with whole stratum everting chain suture plus seromuscular layer interrupted embedding had been performed in July 1976-Dec. 1982 and achieved good results. No patient died of surgical operation, neither early nor late complications directly associated with operations were observed. Among them, 230 cases were followed up for 1-5 years after the operation.

Results: Excellent, 183 cases (79.6%); 44 cases (19.1%). Rate of excellent and good cases, 98.7%. From patients with good results, 5 cases were sampled randomly and gastro-fiberscopy were undertaken. In 4 cases (B II type), superficial gastritis appeared in the lesser curvature of the rudimentary stomach (ends of silk threads could be seen in 2 cases). In 1 cases (B I type), there was regurgitating gastritis. A random sampling analysis of the gastric juice in 20 cases showed that all these free hydrochloric acid curves were obviously lower than those of normal men. Stomachs were fluosroscopied after barium meal. There were no abnormal findings except their evacuation time was more shorter.

Characteristics of surgical operation: 1) Operative procedures were simplified, tissue damage and irritation slight, process of ligation and hemostasis omitted, anastomotic openings smooth. No hemorrhage at anastomotic openings appeared and no fistula developed at the rudimentary part. 2) So long as the lesser gastric curvature was sufficiently excised, recurrence of ulceration was not easy. When the greater gastric curvature was adequately excised, a definite amount of gastric capacity was retained, symptoms of microgastria refrained, recovering of physical strength facilitated. 3) Modified gastric forceps (JW-1 type and )W-2 type) were used. They were easy to manipulate and their local tissue injuries were slight. Moreover, the anastomosis was changed from the open type to the closed type. Therefore, the chance of contamination of the abdominal cavity was decreased. 4) Whole stratum everting chain suture (2-0 or 3-0 chromic catgut) plus seromuscular layer interrupted embedding suture (1-0 silk thread) was used instead of the whole stratum silk suture. Symptoms caused by ends of threads exposed within the anastomotic openings were avoided.

In order to ascertain the healing states of anastomotic openings operated on by different methods, two groups of animal experiments were carried out.

Group I: 25 healthy rabbits, divided into 7 groups (control, killed immediately after operation, 24 hrs. after operation, 48 hrs., 72 hrs., 2 weeks, 1 month, Anterior wall of rabbit's stomach was incarcerated with modified gastric forceps (JW-1 type) and incised. Thereafter whole stratum everting chain suture was performed using silk threads or catgut, and seromuscular layer was sutured interruptedly and embedded. Rabbits were killed according to the schedule given above and the resisting pressures of their gastric anastumotic openings were measured. Healing states of anastomosis were examined. Tissues incarcerated by modified gastric forceps (JW-1 and JW-2 type) were inspected histopathologically.

Group II: 32 healthy rabbits were randomly divided into 4 groups (8 per group) and 4 different kinds of anastomotic techniques were employed. They were whole stratum everting interrupted suture (seromuscular layer not embedded), "U" form lockstitch everting suture (seromuscular layer not embedded), simple seromuscular layer interrupted suture (not embedded), and whole stratum inverting interrupted suture (seromuscular layer embedded).

Results: Although healing occurred in all these conditions (Group II), whole stratum everthing chain suture plus seromuscular layer interrupted embedding suture (Group I) proved to be the best according to the numerical values of measurements and the reports of histological examination. From animal experiment Group I, it could be confirmed that:

1) Pressure resisting state of anastomotic openings: Among 25 rabbits, leakage of air from anastomosis occurred only in 1 rabbit (48 Mrs. after operation). This was due to technical errors. Pressure resistance in all the rest 24 rabbits surpassed those of the normal gastric wall, indicating that whole stratum everting chain suture plus seromuscular layer embedding could tolerate a definite mechanical tension and there was no significant relationship between pressure resistance and the duration after operation.

2) Macroscopic examination of anastomotic openings: 24 hrs. after operation, the greater omentum had already covered the surface of membrane serosa. With the lapse of time after the operation, the adhesion separated gradually or disappeared. Pathological changes had not been found in tissues where modified gastric forceps incarcerated, except a moderate congestion of mucous membrane seen in 72 hrs. group. The opposite sides of mucous membranes matched soundly and smoothly at the anastomotic opening, without hemorrhage. After 72 hrs., edema subsided.

5) Microscopic examination of the pathological changes at the anastomotic opening;

In animal group killed immediately after the operation, blood clot was formed at the anastomotic opening. In animal group killed after 24 hrs., diapedesis of white blood cells appeared with inflammatory reactions of various degrees. In animal group killed after 72 hrs., degeneration and necrosis occurred in different degrees, hyperplasia of fibroblasts and infiltration of monocytes could be seen. In animal group killed after 2 weeks, fibroblasts proliferated actively, with irregular hyperplasia of mucous epithelium, blood clots and necrotic tissues were substituted gradually. In animal group killed after 1 month, there were complete mucous regeneration and reconstruction, cicatrization occurred at submucosa, muscular layer, and subserosa. No significant changes were seen at areas where modified gastric forceps incarcerated.

Observation of the above animal experiments demonstrated that using this surgical operative technique, the healing and repairing process of gastric anastomosis in rabbits were in accordance with the general healing process of stomach wall.

1. Rongcheng County People's Hospital, Shandong

2. The Third Hospital of Beijing Medical College, Beijing

3. Department of Patho-Anatomy of Beijing Medical College, Beijing