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.     

VAGOTOMY—Clinical Results,with a Note on Temporary Gastrostomy

Sixty replies to questionnaires sent to more than 100 patients who had had vagotomy for peptic ulcer showed that 93 per cent had satisfactory results. There were no deaths in this series. Three times as many unsatisfactory results occurred in a group of patients who had had gastrectomy. There were no proved recurrent or marginal ulcers in either group.Vagotomy plus a complementary procedure has proved, in the author''s experience, to be the operation of choice in chronic duodenal ulcer. At present gastrectomy plus vagotomy appears to be less desirable than vagotomy plus pyloroplasty or gastroenterostomy.     

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.     

ACUTE GASTRODUODENAL PERFORATION—An Analysis of 496 Patients Treated Surgically

Of 496 patients treated surgically for acute gastroduodenal perforation, 144 were treated by simple closure, 317 by immediate subtotal gastrectomy, 22 by immediate hemigastrectomy and vagotomy and 13 by delayed subtotal gastrectomy. In our most recent experience with 225 consecutive resections, the postoperative mortality rate was no greater than that observed following elective subtotal gastrectomy for other complications of ulcer disease. A review of the late results indicated that the response of patients with this complication is similar to that of patients with other complications of ulcer disease treated in the same manner. It was concluded that a definitive surgical procedure should be employed as the operation of choice in properly selected patients.     

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.     

Vagotomy or Gastrectomy for Gastric Ulcer

Patients treated in a randomized controlled comparison of management of benign gastric ulcer of the body of the stomach, comprising 50 patients treated by Billroth I partial gastrectomy and 50 patients treated by vagotomy and pyloroplasty and biopsy of the ulcer, were followed up for about five years (range one and a half to eight and a half years). No statistically significant difference has been found between the functional results (Visick grading) of the two groups. There was no operative mortality. Postoperative morbidity (17 against 5) and length of stay in hospital (14 against 10 days) were significantly greater after gastrectomy. Seven patients after vagotomy have been submitted to gastrectomy (three for recurrent gastric ulceration, three for gastric cancer, and one for bleeding), which is a statistically significant excess compared with no reoperation after gastrectomy. While vagotomy and pyloroplasty can be useful to avoid a technically difficult gastrectomy, it cannot be said to replace partial gastrectomy in the treatment of gastric ulcer.     

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.     

More Medicare

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.     

Vagotomy and Pyloroplasty for Gastric Ulcer

In a series of 68 patients with gastric ulcer who were treated by vagotomy and pyloroplasty there were no operative deaths, though one patient who received massive transfusions died 14 weeks later from hepatic necrosis probably associated with serum hepatitis. Four patients developed recurrent peptic ulceration requiring further surgical treatment. The clinical condition of all but three of the remainder was satisfactory after an average follow-up period of three years and two months. Of the 14 patients who presented with an acutely bleeding gastric ulcer, one subsequently required gastrectomy for continued bleeding; in all the others the immediate and long-term results were satisfactory. Of 21 patients with a “high” ulcer and 29 with combined gastric and duodenal ulceration one (4·8%) and three (10%) respectively suffered recurrences. We conclude that vagotomy and pyloroplasty is a satisfactory form of treatment for a high or bleeding gastric ulcer, but that for all other gastric ulcers some form of gastric resection is preferable.     

Endometriosis; a review

The Billroth I gastric resection, with and without vagotomy, was used in 20 selected cases of peptic ulcer. Vagotomy and pyloroplasty is considered the operation of first choice for duodenal ulcer. The cases for Billroth I resections were selected from cases not suitable for pyloroplasty. Operations for peptic ulcer which preserve the gastrointestinal continuity are considered to be physiologically superior. Vagotomy and pyloroplasty, and Billroth I gastric resection both qualify in this regard. The postoperative digestive symptoms after Billroth I gastric resection in the present series were minimal, which tends to confirm this theoretical superiority.     

SUBTOTAL GASTRIC RESECTION—An Appraisal of a Means of Treatment of Benign Peptic Ulceration of the Stomach and Duodenum

In a series of 400 cases of subtotal gastric resection for the treatment of benign ulceration of the stomach and duodenum, the mortality, morbidity and recurrence rate was acceptably low. Fifty-six per cent of the patients had a perfect result, 38 per cent satisfactory, and 6 per cent unsatisfactory. However, the postoperative nutritional status was sufficiently interfered with in a number of patients whose preoperative weight was subnormal that the routine adoption of 75 per cent gastric resection must be questioned. Vagotomy with either pyloroplasty or partial resection may prove to be the most valuable procedure for patients of this type. In properly selected patients, however, gastric resection is a rewarding procedure for both patient and surgeon.     

Subtotal gastric resection; an appraisal of a means of treatment of benign peptic ulceration of the stomach and duodenum

In a series of 400 cases of subtotal gastric resection for the treatment of benign ulceration of the stomach and duodenum, the mortality, morbidity and recurrence rate was acceptably low. Fifty-six per cent of the patients had a perfect result, 38 per cent satisfactory, and 6 per cent unsatisfactory. However, the postoperative nutritional status was sufficiently interfered with in a number of patients whose preoperative weight was subnormal that the routine adoption of 75 per cent gastric resection must be questioned. Vagotomy with either pyloroplasty or partial resection may prove to be the most valuable procedure for patients of this type. In properly selected patients, however, gastric resection is a rewarding procedure for both patient and surgeon.     

Late mortality after vagotomy and drainage for duodenal ulcer.

Seven hundred and thirty five patients who underwent elective vagotomy and drainage procedures in one hospital during 1957-67 were followed up until 1 September 1982. At this time 281 were dead compared with an expected 184. This gives a ratio of observed to expected deaths of 1.53 (p less than 0.0001). The most important cause of increased mortality was lung cancer, which accounted for 33 of the excess deaths (observed to expected ratio 3.53). Gastric cancer yielded an observed to expected ratio of 3.3. Other causes of death that were significantly more common than expected were cerebrovascular accident, bronchopneumonia, and colorectal cancer. It is concluded that although gastric cancer occurs more commonly after vagotomy and drainage than in the general population, it is not as important a cause of death as diseases related to smoking.     

Vagotomy without Diarrhoea

The incidence of diarrhoea after three types of vagotomy was assessed “blind” at a gastric follow-up clinic one year after operation. Diarrhoea was recorded in 24% of patients after truncal vagotomy and pyloroplasty, in 18% after selective vagotomy and pyloroplasty, but in only 2% of patients after highly selective vagotomy without a drainage procedure. The incidence of diarrhoea was significantly less (P < 0·01) after highly selective vagotomy than after either of the other procedures.Hypertonic glucose solution given by mouth to 15 representative patients from each group and to 15 patients before operation provoked the onset of diarrhoea in 67% of the patients who had undergone truncal vagotomy and pyloroplasty, in 60% of those who had undergone selective vagotomy and pyloroplasty, in 13% of those who had undergone highly selective vagotomy without a drainage procedure, and in none of the preoperative patients. Again the difference between the “highly selective” group and the other two groups of vagotomized patients was statistically significant.It is suggested that postvagotomy diarrhoea is attributable both to unregulated gastric emptying after truncal or selective vagotomy with a drainage procedure and to the extragastric denervation produced by truncal vagotomy. “Postvagotomy” diarrhoea can be virtually eliminated by using highly selective vagotomy without a drainage procedure.     

Mortality after Vagotomy and Pyloroplasty for Duodenal Ulcer

A retrospective survey of 4,026 patients having truncal vagotomy and pyloroplasty for duodenal ulceration showed a mortality rate of 1·4% (55 patients). On analysis the commonest causes of death were found to be bronchopneumonia 37% (18 patients) and sepsis 20% (10 patients). More than half of the deaths occurred in patients aged over 50.     

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.     

COMPLICATIONS FOLLOWING SUBTOTAL GASTRECTOMY

Four hundred consecutive cases in which subtotal gastrectomy was done for duodenal and gastric ulcer were reviewed. The mortality rate was 3.5 per cent. There were 57 complications, an incidence of 14 per cent. Of the fatal complications, duodenal stump disruption was the most common and serious—11 cases and 7 deaths. The other fatal complications included various types of obstruction, pulmonary embolus, hemorrhagic pancreatitis and separation of the abdominal incision. Of the nonfatal complications, obstruction of the stoma, anastomotic bleeding, pneumonia, venous thrombosis and wound infection were the most common.Catheter duodenostomy is helpful in the closure of a difficult duodenal stump. Where this was done in the present series there were no fatalities.Electrolyte balance, correction of protein deficiencies, blood replacement and the judicious use of antibiotics are important prophylactic factors against postoperative complications.     

The effect of subtotal vagotomy of the plexus myentericus (Auerbach) on the function of the intramural nervous system. A quantitative histochemical examination in white laboratory mice]

The effect of a subtotal vagotomy on the function of the intramural nervous system of different parts of the intestinal tract is studied by means of quantitative measurements of the acetylcholinesterase (AChE) activity. By sham vagotomy it was possible to explore the effect of narcosis and laparotomy on the intramural nervous system of the intestine. Vagotomy is followed by a decrease in AChE activity of the ganglionic cells in all parts of the intestinal tract. A minimum of activity, about 50% of the normal concentration, is attained at the 16th postoperative day. After this time, a continual increase in AChE activity, along with a reactivation of the function of the ganglionic cells, can be observed. 90 days after vagotomy the ganglionic cells of the intramural nervous plexus show a normal enzyme activity. These results support the hypothesis that most of the cells of the myenteric plexus build up an autonomic nervous plexus, which is stimulated in an excitatory way by the vagus nerve and which will be inhibited by sympathetic stimulation.     

Prospectively randomised trial of proximal gastric vagotomy either with or without pyloroplasty in treatment of uncomplicated duodenal ulcer.

A consecutive series of 100 men with uncomplicated duodenal ulcer was randomly divided into two groups: one group of 52 underwent proximal gastric vagotomy (PGV), the other group (48) underwent PGV with pyloroplasty (PGVP). Preoperative peak acid output (PAOP) was measured in all patients. Those with a higher preoperative PAOP were significantly more likely to develop recurrent ulceration. Three patients developed recurrent ulceration after PGV and seven after PGVP. Dumping was both more common and more severe after PGVP than PGV. An overall satisfactory result was achieved in 92% after PGV and 81% after PGVP. We conclude that combining pyloroplasty with PGV has no appreciable advantages.