intractable gastric ulcer diseasedisease - department of ... · pdf fileintractable gastric...

Intractable Gastric Ulcer Intractable Gastric Ulcer DiseaseDisease

Aaron M. Winnick, M.D.Aaron M. Winnick, M.D.SUNY Downstate Medical CenterSUNY Downstate Medical Center

February 13, 2009February 13, 2009

3 ½ months…3 ½ months…107 days…107 days…

2 568 hours2 568 hours2,568 hours…2,568 hours…154,080 minutes…until graduation154,080 minutes…until graduation

www.downstatesurgery.org

Case PresentationCase PresentationGastric Ulcer

Case PresentationCase Presentation44 yo Female44 yo Femaleyy

Intractable peptic ulcer disease x 2yrsIntractable peptic ulcer disease x 2yrsTreated for H. pylori in the pastTreated for H. pylori in the pastG stri tl t bstr ti nG stri tl t bstr ti nGastric outlet obstructionGastric outlet obstructionIVDAIVDAreported 100 lb weight loss over 9 monthsreported 100 lb weight loss over 9 months

PSH: DeniedPSH: DeniedMeds: Methadone, prevacidMeds: Methadone, prevacidAll i C d i ASAAll i C d i ASAAllergies: Codeine, ASAAllergies: Codeine, ASASocial: previous cocaine and heroine abuseSocial: previous cocaine and heroine abuseEndoscopiesEndoscopies stenosis at pyloris withstenosis at pyloris withEndoscopies Endoscopies –– stenosis at pyloris with stenosis at pyloris with

scarringscarring



Case PresentationCase Presentation

T 98 BP 110/65 P 95 T 98 BP 110/65 P 95 Gen: AAOx3, thin, malnourishedGen: AAOx3, thin, malnourishedGen: AAOx3, thin, malnourishedGen: AAOx3, thin, malnourishedHEENT: no JVDHEENT: no JVDCV: s1,s2, no murmursCV: s1,s2, no murmursLungs: CTA b/lLungs: CTA b/lAbd: Soft, thin, nontender. No scars Abd: Soft, thin, nontender. No scars Ext: equal palpable pulses b/l, no edemaExt: equal palpable pulses b/l, no edema




10/06/08 10/06/08 --> OR> ORFindingsFindings-- large, thick stomach; scarring around large, thick stomach; scarring around gg g , ; gg , ; g

pylorus/duodenum pylorus/duodenum Truncal vagotomyTruncal vagotomyAntrectomyAntrectomyRetrocolic loop gastrojejunostomyRetrocolic loop gastrojejunostomy




POD #1 POD #1 –– severe painsevere painMethadone SQ, FentanylMethadone SQ, FentanylQ, yQ, y

POD #3 POD #3 –– flatusflatusPOD #4POD #4 –– NGT removed started on postNGT removed started on post--POD #4 POD #4 NGT removed, started on postNGT removed, started on post

gastrectomy dietgastrectomy dietPOD #6POD #6-- abdominal distention postabdominal distention post--op ileusop ileusPOD #6POD #6 abdominal distention, postabdominal distention, post op ileusop ileus

Pain intermittent Pain intermittent Started on TPNStarted on TPNStarted on TPNStarted on TPNRefused Nasogastric tubeRefused Nasogastric tube


POD #6 www.downstatesurgery.org

POD #7www.downstatesurgery.org

POD #9www.downstatesurgery.org



POD #11 POD #11 –– NGT inserted, yielding 600cc feculent NGT inserted, yielding 600cc feculent materialmaterialmaterial material

POD #12 POD #12 –– ReRe--ExplorationExplorationRetrocolic loop gastrojejunostomy intactRetrocolic loop gastrojejunostomy intactRetrocolic loop gastrojejunostomy intactRetrocolic loop gastrojejunostomy intactEntire small bowel herniated through transverse Entire small bowel herniated through transverse

mesocolon posteriorlymesocolon posteriorlymesocolon posteriorlymesocolon posteriorlyMesentery, including root, herniated through Mesentery, including root, herniated through

defectdefectdefectdefect




OR…(cont)OR…(cont)Small bowel edematous venous congestionSmall bowel edematous venous congestionSmall bowel edematous, venous congestionSmall bowel edematous, venous congestionperforation of distal ileum perforation of distal ileum --> SBR with anastomosis> SBR with anastomosisGastrojejunostomy revised to antecolic RouxGastrojejunostomy revised to antecolic Roux--enen--YYGastrojejunostomy revised to antecolic RouxGastrojejunostomy revised to antecolic Roux enen Y Y

GastrojejunostomyGastrojejunostomyMesenteric defect closedMesenteric defect closed

Pt transferred to PACU on pressors, intubatedPt transferred to PACU on pressors, intubated


Hospital CourseHospital CourseGastric Ulcer

Hospital CourseHospital Course

POD #1POD #1Levophed and vasopressin. Acidosis correctedLevophed and vasopressin. Acidosis correctedTransfused 4 units pRBC, started on broadTransfused 4 units pRBC, started on broad--spectrum Antibiotics, TPNspectrum Antibiotics, TPN

POD#2 POD#2 –– WBC 26,000 (from 11,000)WBC 26,000 (from 11,000)Adequate urine outputAdequate urine outputAdequate urine output Adequate urine output

POD#3POD#3-- weaned off pressorsweaned off pressorsPOD#4POD#4-- WBC decreased to 11,000WBC decreased to 11,000POD#5POD#5-- Febrile to 102FFebrile to 102FPOD# 7POD# 7-- foul smelling drainage from abdominal wound foul smelling drainage from abdominal wound --> Succus> SuccusPOD# 7POD# 7 T k b k ORT k b k ORPOD# 7POD# 7-- Taken back to OR…Taken back to OR…




OR...(take 3)OR...(take 3)Necrotic distal/terminal ileum at prior anastomosis siteNecrotic distal/terminal ileum at prior anastomosis siteppAbdominal washoutAbdominal washoutDrainage with Malecot tubes x2 and HemovacDrainage with Malecot tubes x2 and HemovacGastrojejunostomy anastomosis intact Gastrojejunostomy anastomosis intact




POD # 1POD # 1-- 2020Weaned from pressorsWeaned from pressorsppExtubatedExtubatedDiet advancedDiet advancedDrainage catheters removedDrainage catheters removedPhysical therapyPhysical therapy/ i bd i l d b k i/ i bd i l d b k ic/o persistent abdominal and back painc/o persistent abdominal and back pain




POD # 21POD # 21-- 5050Pain managementPain managementgg

Weaned from methadoneWeaned from methadone

Wound care for stage II sacral decubitus ulcerWound care for stage II sacral decubitus ulcerPhysical therapyPhysical therapyRejected from outside facilities due to past drug historyRejected from outside facilities due to past drug history

POD # 69POD # 69POD # 69POD # 69DVT left lower extremity DVT left lower extremity –– femoral femoral --> popliteal veins> popliteal veinsStarted on anticoagulationStarted on anticoagulationStarted on anticoagulationStarted on anticoagulation




PODPOD ## 119119……

A i i di h h h blA i i di h h h blAwaiting discharge home when able to Awaiting discharge home when able to ambulate independently…ambulate independently…


History of Gastric UlcerHistory of Gastric Ulcer

Gastric Ulcer


350 B.C. 350 B.C. –– Diocles of Carystos described existenceDiocles of Carystos described existence131131 201 A D201 A D C l d G lC l d G l131131--201 A.D. 201 A.D. –– Celsus and GalenCelsus and Galen1586 1586 –– Marcellus Donatus of Mantua Marcellus Donatus of Mantua –– described at described at ttautopsyautopsy1880 1880 –– Theodor Billroth Theodor Billroth –– First distal gastrectomy First distal gastrectomy d t d d td t d d tand gastroduodenostomyand gastroduodenostomy1885 1885 –– Billroth Billroth –– First distal gastrectomy and First distal gastrectomy and t j j tt j j tgastrojejunostomygastrojejunostomy



Gastric Ulcer

History of Gastric UlcerHistory of Gastric UlcerPyloroplastyPyloroplastyPyloroplastyPyloroplasty

Heineke (1886) and Mikulicz (1888)Heineke (1886) and Mikulicz (1888)Jaboulay (1892) gastroduodenostomyJaboulay (1892) gastroduodenostomyFinney (1902)Finney (1902)Finney (1902)Finney (1902)

Subtotal GastrectomySubtotal GastrectomyHaberer and Finsterer (early 1900’s)Haberer and Finsterer (early 1900’s)

hhTruncal vagotomy (Transthoracic)Truncal vagotomy (Transthoracic)Lester Dragsteadt and Owen (1953)Lester Dragsteadt and Owen (1953)

Truncal vagotomy and hemigastrectomyTruncal vagotomy and hemigastrectomyg y g yg y g yFarmer and Smithwick (1952)Farmer and Smithwick (1952)

Truncal vagotomy and antrectomyTruncal vagotomy and antrectomyEdwards and Herrington (1953)Edwards and Herrington (1953)Edwards and Herrington (1953)Edwards and Herrington (1953)

Parietal cell vagotomyParietal cell vagotomyGriffith and Harkins (1957)Griffith and Harkins (1957)



Gastric Ulcer


Medical ManagementMedical ManagementPrior to 1980’s Prior to 1980’s –– antacidsantacids1980’s 1980’s –– HH2 2 receptor antagonistsreceptor antagonists1990’s 1990’s –– Proton pump inhibitorsProton pump inhibitorsp pp pPresent Present ––

H. pyloriH. pylori infection and peptic ulcer infection and peptic ulcer –– PPI and eradicationPPI and eradicationNSAIDNSAID--induced ulcer induced ulcer –– stopping medicationstopping medication



Gastric Ulcer


Surgical ManagementSurgical ManagementPrior to 1940’s Prior to 1940’s –– Subtotal gastrectomySubtotal gastrectomyg yg y19401940--1950’s 1950’s –– Vagotomy, antrectomy, pyloroplastyVagotomy, antrectomy, pyloroplasty1960’s 1960’s –– Proximal gastric vagotomyProximal gastric vagotomyg g yg g y1990’s 1990’s –– Laparoscopic vagotomyLaparoscopic vagotomyPresent Present –– LifeLife--threatening complications of PUDthreatening complications of PUD

BleedingBleedingPerforationPerforationObstructionObstruction


Anatomy of StomachAnatomy of StomachAnatomy of StomachAnatomy of Stomachwww.downstatesurgery.org

Arterial and Venous Supplyte al and Venous Supplywww.downstatesurgery.org

Lymphatic DrainageLy phat c a nagewww.downstatesurgery.org

InnervationInnervationGastric Ulcer

InnervationInnervationGastric secretory and motor Gastric secretory and motor

functionfunctionIntrinsiIntrinsiIntrinsicIntrinsic

Submucosal plexus (Meissner)Submucosal plexus (Meissner)Myenteric plexus (Auerbach)Myenteric plexus (Auerbach)

Extrinsic parasympathetic Extrinsic parasympathetic innervationinnervation

Vagus nerve (Acetylcholine)Vagus nerve (Acetylcholine)Vagus nerve (Acetylcholine)Vagus nerve (Acetylcholine)75% of axons in vagal trunks are 75% of axons in vagal trunks are afferent afferent

Nerves of LatarjetNerves of Latarjetjj“crow’s foot”“crow’s foot”Criminal nerves of GrassiCriminal nerves of Grassi


Physiology of acid secretionPhysiology of acid secretion

Gastric Ulcer

Physiology of acid secretionPhysiology of acid secretion

1 billion parietal cells1 billion parietal cellsStimulation by gastrinStimulation by gastrinStimulation by gastrin, Stimulation by gastrin,

acetylcholine, and histamineacetylcholine, and histamineBasal acid secretionBasal acid secretionBasal acid secretion Basal acid secretion

22--5 mEq/hr5 mEq/hrS i l d id iS i l d id iStimulated acid secretion Stimulated acid secretion

1515--25 mEq/hr25 mEq/hr


Evaluation of PUDEvaluation of PUDGastric Ulcer

Evaluation of PUDEvaluation of PUD

EndoscopyEndoscopyRadiologic testsRadiologic testsgg

Plain CXRPlain CXRDouble contrast upper GI seriesDouble contrast upper GI seriesppppCT scanCT scanMRIMRIMRIMRI

EUSEUSTests for H pyloriTests for H pyloriTests for H. pyloriTests for H. pyloriScintigraphyScintigraphy


Helicobacter pyloriHelicobacter pyloriGastric Ulcer

Helicobacter pyloriHelicobacter pyloriSerologicSerologic

NoninvasiveNoninvasiveSensiticity >80%, Specificity 90%Sensiticity >80%, Specificity 90%y , p yy , p y

Urea breath testUrea breath testConfirmatory test after 4 weeks of therapyConfirmatory test after 4 weeks of therapySensitivity and specificity 90Sensitivity and specificity 90--99%99%Sensitivity and specificity 90Sensitivity and specificity 90 99%99%ExpensiveExpensive

Histologic testHistologic testSensitivity 80Sensitivity 80 100% specificity >95%100% specificity >95%Sensitivity 80Sensitivity 80--100%, specificity >95%100%, specificity >95%

Rapid urease testRapid urease testSimple, invasiveSimple, invasiveS i i i 80S i i i 80 95% ifi i 9595% ifi i 95 100%100%Sensitivity 80Sensitivity 80--95%, specificity 9595%, specificity 95--100%100%False negativesFalse negatives


Medical ManagementMedical ManagementGastric Ulcer

Medical ManagementMedical ManagementStop smokingStop smokingAvoid alcoholAvoid alcoholA id NSAIDS A i iA id NSAIDS A i iAvoid NSAIDS, AspirinAvoid NSAIDS, AspirinH. pyloriH. pylori (+) needs eradication(+) needs eradication

First line triple therapyFirst line triple therapy --> PPI + clarithromycin +amoxicillin> PPI + clarithromycin +amoxicillinFirst line triple therapy First line triple therapy > PPI + clarithromycin +amoxicillin> PPI + clarithromycin +amoxicillinSecond line treatmentSecond line treatment--> PPI + bismuth salts + > PPI + bismuth salts + Metronidazole + tetracyclineMetronidazole + tetracycline

H l iH l i (( ))H. pyloriH. pylori ((--) ) HH22 receptor blockerreceptor blockerPPIPPIPPIPPISulcralfateSulcralfateAntacidsAntacids


Indications for SurgeryIndications for SurgeryGastric Ulcer

Indications for SurgeryIndications for Surgery

BleedingBleedingPerforationPerforationPerforationPerforationObstructionObstructionIntractabilityIntractability

Definition uncertainDefinition uncertainSuspicion of malignancySuspicion of malignancy

Fail re of an lcer to heal after 12 eeks of medicalFail re of an lcer to heal after 12 eeks of medicalFailure of an ulcer to heal after 12 weeks of medical Failure of an ulcer to heal after 12 weeks of medical therapytherapy


Goals of SurgeryGoals of SurgeryGastric Ulcer

Goals of SurgeryGoals of Surgery

Permit ulcer healingPermit ulcer healingPrevent or treat ulcer complicationsPrevent or treat ulcer complicationsPrevent or treat ulcer complicationsPrevent or treat ulcer complicationsAddress the underlying ulcer diathesisAddress the underlying ulcer diathesisMi i i i di i lMi i i i di i lMinimize postoperative digestive sequelaMinimize postoperative digestive sequela


Principles of SurgeryPrinciples of SurgeryGastric Ulcer

Principles of SurgeryPrinciples of Surgery

Acid reductionAcid reductionDrainageDrainageDrainageDrainageResection and reconstructionResection and reconstructionO l hO l hOmental patchOmental patchOversewingOversewing


Goals of SurgeryGoals of SurgeryGastric Ulcer

Goals of SurgeryGoals of Surgery

Operation for duodenal ulcerOperation for duodenal ulcerSectioning the vagus (Vagotomy)Sectioning the vagus (Vagotomy)Sectioning the vagus (Vagotomy)Sectioning the vagus (Vagotomy)Eliminating hormonal stimulation from antrum Eliminating hormonal stimulation from antrum (Antrectomy)(Antrectomy)(Antrectomy)(Antrectomy)Decreasing the number of parietal cells (Gastric Decreasing the number of parietal cells (Gastric resection)resection)resection)resection)


VagotomyVagotomyGastric Ulcer

VagotomyVagotomy

Eliminates direct cholinergic stimulation to acid Eliminates direct cholinergic stimulation to acid secretionsecretion

Makes parietal cells less responsive to histamine and Makes parietal cells less responsive to histamine and gastringastringastringastrin

Abolishes vagal stimulus for release of antral gastrinAbolishes vagal stimulus for release of antral gastrinT lT lTruncalTruncalSelectiveSelectiveHighly selective (Parietal Cell)Highly selective (Parietal Cell)


Acid reductionAcid reduction VagotomyVagotomy

Gastric Ulcer

Acid reductionAcid reduction--VagotomyVagotomyTruncal Truncal

Reduces basal acid output 80%Reduces basal acid output 80%Reduces stimulated acid 50%Reduces stimulated acid 50%Abolishes receptive relaxationAbolishes receptive relaxationAbolishes receptive relaxation, Abolishes receptive relaxation, Impairs triturationImpairs triturationNeed drainage proceduresNeed drainage proceduresPostPost--vagotomy syndromevagotomy syndromePostPost vagotomy syndromevagotomy syndrome

SelectiveSelectivePreserves celiac and hepatic Preserves celiac and hepatic b hb hbranchesbranchesStill requires drainageStill requires drainage

Parietal cell (Highly selective)Parietal cell (Highly selective)( g y )( g y )Denervates parietal cell massDenervates parietal cell massNo need for drainage procedureNo need for drainage procedure


ResectionResectionGastric Ulcer

ResectionResectionSubtotal Subtotal –– Reduces basal acid secretion 75%, stimulated 50%Reduces basal acid secretion 75%, stimulated 50%

Emptying of solid and liquids more rapidEmptying of solid and liquids more rapidAntrectomy + vagotomyAntrectomy + vagotomy-- remove cholinergic and gastrin stimulusremove cholinergic and gastrin stimulus

Basal acid secretion abolished; stimulated acid decreased 80%Basal acid secretion abolished; stimulated acid decreased 80%Basal acid secretion abolished; stimulated acid decreased 80% Basal acid secretion abolished; stimulated acid decreased 80% Billroth I shows no functional difference compared to Billroth IIBillroth I shows no functional difference compared to Billroth II


Highly Selective Vagotomy vsHighly Selective Vagotomy vs

Gastric Ulcer

Highly Selective Vagotomy vs Highly Selective Vagotomy vs Antrectomy vs. DrainageAntrectomy vs. Drainagey gy g

Mortality and early morbidity highest for V+D, lowest for Mortality and early morbidity highest for V+D, lowest for HSVHSVHSVHSV

Avoids opening GI tractAvoids opening GI tractIncidence of side effects similar for TV+A or TV+D, but Incidence of side effects similar for TV+A or TV+D, but

i ifi l l f HSVi ifi l l f HSVsignificantly lower for HSVsignificantly lower for HSVRecurrence rates significantly lower for TV+ARecurrence rates significantly lower for TV+ATV +D had higher recurrence rate and more unfavorableTV +D had higher recurrence rate and more unfavorableTV +D had higher recurrence rate and more unfavorable TV +D had higher recurrence rate and more unfavorable

side effectsside effects


Gastric ulcerGastric ulcerGastric ulcerGastric ulcerwww.downstatesurgery.org

PostPost--Gastrectomy Gastrectomy yySyndromesSyndromes


Antecolic versus retrocolic alimentary Antecolic versus retrocolic alimentary Gastric Ulcer

limb in laparoscopic Rouxlimb in laparoscopic Roux--enen--Y gastric Y gastric bypass: a comparative studybypass: a comparative studybypass: a comparative study.bypass: a comparative study.

Escalona A, Devaud N, et.al. Surg Obes Relat Dis 2007 Jul-Aug;3(4):423-7.

754 patients undergoing LRYGB754 patients undergoing LRYGB300 patients retrocolic technique300 patients retrocolic technique454 patients antecolic technique454 patients antecolic techniquep qp q

36 patients (4.7%) required exploration for obstruction36 patients (4.7%) required exploration for obstruction28 (9.3%) retrocolic vs 8 (1.8%) antecolic28 (9.3%) retrocolic vs 8 (1.8%) antecolicInternal hernia in 24 vs 3 patientsInternal hernia in 24 vs 3 patientsInternal hernia in 24 vs 3 patientsInternal hernia in 24 vs 3 patients

Greater incidence of intestinal obstruction and internal hernia Greater incidence of intestinal obstruction and internal hernia in retrocolic group in retrocolic group


QuestionsQuestionsGastric Ulcer

QuestionsQuestions1)1) A 45 yearA 45 year old man requires surgery for intractableold man requires surgery for intractable1)1) A 45 yearA 45 year--old man requires surgery for intractable old man requires surgery for intractable

duodenal ulcer. Which operation best prevents duodenal ulcer. Which operation best prevents ulcer recurrence?ulcer recurrence?A) Subtotal gastrectomyA) Subtotal gastrectomyB) Truncal vagotomy and pyloroplastyB) Truncal vagotomy and pyloroplastyB) Truncal vagotomy and pyloroplastyB) Truncal vagotomy and pyloroplastyC) Truncal vagotomy and antrectomyC) Truncal vagotomy and antrectomyD) S l ti tD) S l ti tD) Selective vagotomyD) Selective vagotomyE) Highly selective (Parietal cell) vagotomy E) Highly selective (Parietal cell) vagotomy



QuestionsQuestions2)2) Advanced gastric outlet obstruction isAdvanced gastric outlet obstruction is2)2) Advanced gastric outlet obstruction is Advanced gastric outlet obstruction is

characterized by which one or more of the characterized by which one or more of the following metabolic abnormalities?following metabolic abnormalities?w g b bw g b b

A) Hypochloremia and increased urinary chlorideA) Hypochloremia and increased urinary chlorideB) Hypokalemia secondary to urinary potassium lossB) Hypokalemia secondary to urinary potassium loss) yp y y p) yp y y pC) Metabolic alkalosis with alkaline urineC) Metabolic alkalosis with alkaline urineD) Metabolic alkalosis with acid urineD) Metabolic alkalosis with acid urine))E) Increased serum ionized calciumE) Increased serum ionized calcium



QuestionsQuestions3)3) Which of the following statements is true regarding theWhich of the following statements is true regarding the3)3) Which of the following statements is true regarding the Which of the following statements is true regarding the

surgical therapy of gastric ulcer?surgical therapy of gastric ulcer?A) A type I ulcer at the incisura is effectively treated by A) A type I ulcer at the incisura is effectively treated by ) yp y y) yp y y

distal gastrectomy without vagotomydistal gastrectomy without vagotomyB) A type I ulcer at the incisura is preferably treated by B) A type I ulcer at the incisura is preferably treated by

d l ld l lvagotomy and pyloroplastyvagotomy and pyloroplastyC) A type III preC) A type III pre--pyloric ulcer without obstruction is pyloric ulcer without obstruction is

best treated by parietal cell vagotomybest treated by parietal cell vagotomybest treated by parietal cell vagotomybest treated by parietal cell vagotomyD) Type II ulcers are best treated by subtotal D) Type II ulcers are best treated by subtotal

gastrectomy without vagotomygastrectomy without vagotomyg y g yg y g yE) A type I ulcer on the lesser curve near the GE E) A type I ulcer on the lesser curve near the GE

junction is best treated by total gastrectomyjunction is best treated by total gastrectomy



QuestionsQuestions4)4) Which of the following is true about theWhich of the following is true about the4)4) Which of the following is true about the Which of the following is true about the

postoperative effects on gastric emptying?postoperative effects on gastric emptying?A) T l d l i f li idA) T l d l i f li idA) Truncal vagotomy delays emptying of liquidsA) Truncal vagotomy delays emptying of liquidsB) Truncal vagotomy accelerates emptying of solidsB) Truncal vagotomy accelerates emptying of solidsC) P i l ll d ff iC) P i l ll d ff iC) Parietal cell vagotomy does not affect gastric C) Parietal cell vagotomy does not affect gastric emptyingemptyingD) P l l l i f lidD) P l l l i f lidD) Pyloroplasty accelerates emptying of solidsD) Pyloroplasty accelerates emptying of solidsE) RouxE) Roux--enen--Y gastrojejunostomy delays gastric Y gastrojejunostomy delays gastric emptyingemptyingemptyingemptying



QuestionsQuestions4)4) Which of the following is true about theWhich of the following is true about the4)4) Which of the following is true about the Which of the following is true about the

postoperative effects on gastric emptying?postoperative effects on gastric emptying?A) T l d l i f li idA) T l d l i f li idA) Truncal vagotomy delays emptying of liquidsA) Truncal vagotomy delays emptying of liquidsB) Truncal vagotomy accelerates emptying of solidsB) Truncal vagotomy accelerates emptying of solidsC) P i l ll d ff iC) P i l ll d ff iC) Parietal cell vagotomy does not affect gastric C) Parietal cell vagotomy does not affect gastric emptyingemptyingD) P l l d ff i f lidD) P l l d ff i f lidD) Pyloroplasty does not affect emptying of solidsD) Pyloroplasty does not affect emptying of solidsE) RouxE) Roux--enen--Y gastrojejunostomy delays gastric Y gastrojejunostomy delays gastric emptyingemptyingemptyingemptying


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