Changes in gastric mucosa after vagotomy and gastrojejunostomy for duodenal ulcer.

Gastric mucosa was studied histologically in 141 patients. Eighty two had undergone vagotomy and gastrojejunostomy between 15 and 25 years previously for duodenal ulcer, and 59 control patients had a long history (minimum 15 years) of duodenal ulcer treated medically. No carcinoma was found in either group. Two patients with severe dysplasia and 13 patients with moderate dysplasia were found in the study group, compared with none in the control group (p less than 0.01). Intestinal metaplasia was seen in 44 (53%) of the study group and 16 (27%) of the control group (p less than 0.01). Atrophy and gastritis were more severe (p less than 0.01 for atrophy; p = 0.05 for gastritis) in the study group. Gastric mucosal changes were more severe after surgical treatment for duodenal ulcer than after medical treatment, and possibly a high incidence of gastric carcinoma may occur 25 years after vagotomy and gastrojejunostomy.     

Five- to Eight-year Results of Truncal Vagotomy and Pyloroplasty for Duodenal Ulcer

From January 1963 to December 1965 inclusive 192 men with duodenal ulcer were treated by elective truncal vagotomy and pyloroplasty with one death. Ten subsequent deaths were due to causes unrelated to the ulcer or operation, and 17 patients became untraceable. The remaining 164 patients have been followed up for five to eight years. The late results have been compared with those obtained in a previous study of patients five to eight years after truncal vagotomy and gastroenterostomy, truncal vagotomy and antrectomy, and subtotal gastrectomy respectively for duodenal ulcer.Of the various postgastric operation syndromes early dumping, late dumping, bilious vomiting, and diarrhoea were all less frequent, but not significantly so, after vagotomy and pyloroplasty than after vagotomy and gastroenterostomy.Recurrent ulceration was commoner after vagotomy and pyloroplasty than after all the other operations, the incidence of proved and suspected recurrent ulcers being respectively 6·7 and 7·3% after vagotomy and pyloroplasty, but only 2·5 and 5·9% after vagotomy and gastroenterostomy, 0 and 5·2% after vagotomy and antrectomy, and 0·9 and 3·7% after subtotal gastrectomy. The differences between vagotomy and pyloroplasty and vagotomy and antrectomy or subtotal gastrectomy are statistically significant, but those between vagotomy and pyloroplasty and vagotomy and gastroenterostomy are not.Overall assessment (Visick grading) of the outcome gave poorer results after vagotomy and pyloroplasty than after any other operation, with 14% of category IV cases after vagotomy and pyloroplasty, 11% after vagotomy and gastroenterostomy, 8% after vagotomy and antrectomy, and 6% after subtotal gastrectomy—differences that are significant between vagotomy and pyloroplasty and vagotomy and antrectomy or subtotal gastrectomy but not between vagotomy and pyloroplasty and vagotomy and gastroenterostomy.In the light of these findings it is suggested that truncal vagotomy and pyloroplasty has not lived up to expectations and its place as the currently most popular procedure in the elective surgical treatment of duodenal ulcer should be reconsidered.     

What is the Best Elective Operation for Duodenal Ulcer?

During the past 40 years, after gastroenterostomy and pyloroplasty for duodenal ulcer had been replaced by partial gastrectomy in many centres, partial gastrectomy itself gave way to combinations of vagotomy with gastroenterostomy, pyloroplasty or antrectomy. Opinions differ concerning the procedure of choice and in this paper the author examines the causes of this diversity of opinion and assesses the reliability of conclusions that can be drawn about the elective treatment of duodenal ulcer today. Most reports of results from various operations have come from retrospective studies, and the causes of variability among such reports are analyzed to point out the great difficulty in making a valid judgment about the relative worth of the various operations used to treat duodenal ulcer. Results of some of the few prospective studies with randomized operations assessed blindly are then presented and note is taken of the surprising observation that greatly different operations appear to give remarkably similar results. From the data available the author develops a logical way of approaching the choice of operation for the various problems related to duodenal ulcer that require elective surgical treatment.     

DUODENAL ULCER—Gastrectomy Versus Vagotomy with Accessory Procedures

Vagotomy should be added to whatever other surgical procedure is used in the treatment of duodenal ulcer. Vagotomy with pyloroplasty is the procedure of choice in most patients with duodenal ulcer. Gastroenterostomy and gastrectomy with vagotomy are procedures of necessity in certain clinical situations.     

Duodenal ulcer; gastrectomy versus vagotomy with accessory procedures

Vagotomy should be added to whatever other surgical procedure is used in the treatment of duodenal ulcer. Vagotomy with pyloroplasty is the procedure of choice in most patients with duodenal ulcer. Gastroenterostomy and gastrectomy with vagotomy are procedures of necessity in certain clinical situations.     

Changes in the mucosa of the duodenum and stomach as a result of experimental duodenal ulcers and vagotomy

By means of the transmissive and scanning electron microscopy methods and radioautography, structure of mucous membrane of the stomach and duodenum has been studied under experimentally induced duodenal ulcers before and after vagotomy during various time. The vagotomy results in accelerated healing of the ulcer defect. This is connected with an increased proliferative activity in the crypta cells, however, this is accompanied with deceleration of their differentiation. Under the duodenal ulcers the amount of chief and parietal cells increases in the gastric mucous membrane, this depends on gastrostasis produced by stenosis of the pylorus. At vagotomy the amount of the chief and parietal cells in the fundal glands of the mucous membrane decreases; this is accompanied with a lowered secretory activity.     

DUODENAL ULCER—Rationale and Results of Antrectomy and Subtotal Vagotomy

Results in a series of 107 cases indicated that antrectomy (hemigastrectomy) combined with subtotal vagotomy of both vagus nerves for duodenal ulcer is followed by better overall results than the more radical subtotal gastrectomy or vagotomy plus drainage procedures.Antrectomy combined with total vagotomy is followed by a slightly smaller incidence of marginal ulcer but is accompanied by more motility disturbances.     

Results of the Surgical Treatment of Duodenal Ulcer Between 1946 and 1966

The experience with various surgical procedures performed for duodenal ulcer at the Winnipeg Clinic between 1946 and 1966 has been analyzed. Operative mortality has been low and ulcer control has been provided in a large proportion of patients treated. Of 864 cases, 719 (83%) have been available for follow-up study.All procedures employed provided satisfactory ulcer control. The vagotomy-with-gastric-resection group, although small, showed no ulcer recurrence and good general results. This outcome justifies the consideration of antrectomy and vagotomy as the operation of choice, with other procedures as alternatives. The combined procedure represents a more technically involved operation and possibly is indicated only in cases where the symptoms, complications and very marked acid secretion suggest a strong possibility of ulcer recurrence. Concern that a patient''s ulcer diathesis may return as time elapses after vagotomy has not been borne out by our experience.     

Comparison of different strategies for treatment of duodenal ulcer.

A simple model of a Markov chain was used to study the long term outcome of different strategies for the treatment of duodenal ulcer. Maintenance treatment with H2 receptor antagonists surpassed intermittent drug treatment and proximal gastric vagotomy with respect to the relapse free interval and severe postoperative morbidity. With maintenance treatment the rate of complications and the number of deaths related to ulcer were slightly higher than after proximal gastric vagotomy. Nevertheless, because the few deaths from proximal gastric vagotomy occur at the initiation of treatment the loss of life years during maintenance treatment exceeded that of proximal gastric vagotomy only after 20 years. Despite its rarity, severe postoperative morbidity after proximal gastric vagotomy far exceeded that after the few emergency operations which would become necessary in the course of maintenance treatment. The superiority of maintenance treatment over proximal gastric vagotomy remained insensitive to changes in the assumptions underlying the recurrence rate with both treatments and the postoperative morbidity of proximal gastric vagotomy.     

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Results in a series of 107 cases indicated that antrectomy (hemigastrectomy) combined with subtotal vagotomy of both vagus nerves for duodenal ulcer is followed by better overall results than the more radical subtotal gastrectomy or vagotomy plus drainage procedures.Antrectomy combined with total vagotomy is followed by a slightly smaller incidence of marginal ulcer but is accompanied by more motility disturbances.     

Somatostatin release induced by gastrin-releasing peptide in man. Effect of proximal gastric vagotomy and cholinergic blockade

The influence of intragastric pH on the basal release of somatostatin has been studied in healthy controls and in duodenal ulcer patients. In addition the somatostatin response to gastrin-releasing peptide infusion has been evaluated both regarding the effect of intragastric pH and the influence of vagal innervation and muscarinic blockade. No difference was found in basal blood levels, when changing the intraluminal pH, although a slightly higher basal somatostatin concentration was noticed in patients with duodenal ulcer disease. Neither proximal gastric vagotomy nor cholinergic blockade had any effect on basal somatostatin concentrations. GRP infused in stepwise increasing doses from 20 pmol/kg/h to 400 pmol/kg/h induced a small but significant response. This effect of GRP was most evident, when the stomach was perfused with 0.1 M HCl. The small, somatostatin response to GRP infusion was not influenced by vagal denervation of the parietal cell area, neither by cholinergic blockade. Despite the previously observed effects of vagotomy and cholinergic blockade on gastrin release induced by GRP, a corresponding inverse effect on somatostatin is not apparent.     

Highly selective vagotomy for duodenal ulcer: do hypersecretors need antrectomy?

Two to five years after highly selective vagotomy (H.S.V.) for duodenal ulcer the results were similar in patients with high preoperative maximal acid outputs and those with lower acid outputs. Pain of ulcer type was experienced at some time by 6% of patients from each group, but it was mild and transient in some. No patients had recurrent ulceration at endoscopy or laparotomy, while incidence of individual symptoms was about equal in the two groups. Hence H.S.V. is adequate surgical treatment for patients with both duodenal ulceration and high levels of acid secretion. Antrectomy in such patients is not necessary provided that the incidence of incomplete vagotomy can be kept low.     

Vagotomy and pyloric dilatation in chronic duodenal ulceration.

A total of 101 patients suffering from duodenal ulcer underwent truncal vagotomy (TV) combined with pyloric dilatation (PD). They were followed up over six years, and the results were found to compare favourably with those in patients who underwent alternative surgical measures. Before any revisionary surgery 79 patients were classified as Visick grades I plus II. The incidence of recurrent ulceration was 4%. Side effects were noticeably less common than in patients in whom a drainage procedure had been performed, and overall results were compared with those reported for groups of patients treated by proximal gastric vagotomy. The combination of TV and PD is commended on account of its simplicity, safety, and effectiveness at a time when medical treatment for duodenal ulcer is becoming more specific and increasingly effective.     

Selective Vagotomy without Drainage. An Interim Report

The results of surgical treatment for duodenal ulcer were compared in two groups of patients—51 who had undergone selective vagotomy without drainage and 17 who had had selective vagotomy and pyloroplasty. It is suggested that in the absence of organic pyloric or duodenal stenosis the former method seems both preferable and desirable, since postoperativley dumping does not occur and there is a steady improvement in gastric emptying.     

Gastric Stasis and Gastric Ulcer after Selective Vagotomy Without a Drainage Procedure

Two independent trials of selective vagotomy without the addition of a drainage procedure in the treatment of uncomplicated duodenal ulcer have shown that gastric stasis may occur after the operation and that in some cases this may be complicated by gastric ulcer. These findings do not support the contention that selective vagotomy alone allows normal gastric emptying.     

Emergency Vagotomy and Pyloroplasty for Perforated Duodenal Ulcer: Study of 73 Cases

Seventy-three unselected patients with perforated duodenal ulcer were treated by vagotomy and pyloroplasty in a six-year period. Postoperative complications were commoner when the operation was carried out after more than six hours after perforation. The follow-up results were similar to those for elective vagotomy and pyloroplasty carried out in the hospital during the past nine years.     

Comparative concurrent results of vagotomy procedures,conventional gastric resection and hemigastrectomy with subtotal vagotomy

The question of the best surgical treatment of duodenal ulcer remains unanswered. In a series of 132 patients, results following gastric resection and hemigastrectomy with subtotal vagotomy were better than those following vagotomy procedures alone.     

COMPARATIVE CONCURRENT RESULTS OF VAGOTOMY PROCEDURES,CONVENTIONAL GASTRIC RESECTION AND HEMIGASTRECTOMY WITH SUBTOTAL VAGOTOMY

The question of the best surgical treatment of duodenal ulcer remains unanswered.In a series of 132 patients, results following gastric resection and hemigastrectomy with subtotal vagotomy were better than those following vagotomy procedures alone.     

Somatostatin release from perifused rat and human gastric mucosa

In the present study the release of somatostatin-like immunoreactivity (SLI) was evaluated in vitro from isolated rat antral and fundic mucosa and from biopsy specimens of human antral mucosa. Perifusion of antral mucosa with Earle's balanced salt solution showed a pH-dependent release of SLI. SLI release did not change in response to a reduction from pH 7 during the baseline period to pH 3, whereas a significant increase occurred when the pH was changed to 2.5 or 2, respectively. Fundic SLI release remained at baseline levels during the decrease of the pH value of the buffer solutions. Atropine at doses of 10(-6) to 10(-4) M did not alter acid-induced SLI release from the isolated antral mucosa, suggesting different mechanisms in vitro compared to the acid-induced SLI release in vivo. SLI release from human mucosa was 450 +/- 217 pg/min X mg wet weight in response to perifusion with the buffer pH 2 in 7 control subjects. No significant difference was observed in patients with duodenal ulcer or acute gastritis, whereas gastric ulcer patients had significantly lower values (66 +/- 44) compared to controls and duodenal ulcer patients. These data do not support the hypothesis that impaired somatostatin production and release might be a pathogenetic factor for gastric acid hypersecretion and development of duodenal ulcer.     

Occurrence of Campylobacter pylori in gastric mucosa and selected parameters of cell-mediated immunity in patients with duodenal ulcer and individuals with non-ulcerative dyspepsia]

The study was aimed at investigating a relationship between Campylobacter pylori infection in the gastric mucosa and selected parameters of cell-mediated immunity in patients with duodenal ulcer and the individuals with non-ulcerative dyspepsia. A relationship between Campylobacter pylori and gastritis has also been studied. Endoscopic and immunological tests were carried out in the group of 45 patients, including 14 patients with duodenal ulcer and 29 with non-ulcerative dyspepsia. Specimens of gastric mucosa were collected endoscopically for histological and bacteriological examinations. Immunological tests included an assessment of the number of lymphocytes T (and their subpopulations) forming active rosettes (ARFC); total - (TRFC) and theophylline-resistant in active rosettes fraction (ARFC-TR); total (TRFC-TR) and theophylline-sensitive lymphocytes in both fractions (ARFC-TS and TRFC-TS) in 1 mm3 of the peripheral blood. Results suggest, that there is correlation between an infection of the gastric mucosa by Campylobacter pylori and duodenal ulcer and gastritis. No correlation between the infection by Campylobacter pylori and examined parameters of immunity in both patients with duodenal ulcer and non-ulcerative dyspepsia was found.