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.     

PYLOROPLASTY FOR GASTRIC DRAINAGE WITH VAGOTOMY

Heineke-Mikulicz pyloroplasty for gastric drainage in connection with vagotomy was carried out in 50 cases.Postoperatively a nasogastric tube with suction was used for 72 hours. The diet then was increased very slowly from liquid to bland, over a period of several weeks. If symptoms suggestive of retention developed, the oral intake was sharply decreased and if no relief was noted the tube was reinserted for 24 to 48 hours.Of the 50 patients, 46 had no retention symptoms after operation. Of the four who had, one required gastroenterostomy but was later found to have carcinoma of the pancreas with ulceration into the duodenum. The remaining three responded to conservative measures.     

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.     

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.     

PUBLIC HEALTH REPORT: Increase in Arthropod-Borne Encephalitis a Possibility

Marginal peptic ulceration occurs with sufficient frequency in elderly patients to constitute a real problem. A study was made of 22 patients more than 65 years of age in whom such ulcers developed. Marginal ulcers in elderly patients are frequently associated with dangerous complications such as massive hemorrhage or perforation. Advancing age does not necessarily reduce the tendency to marginal ulcer formation. Such operative procedures as gastroenterostomy without vagotomy, and minimal gastric resection, do not afford adequate protection from marginal ulceration in elderly patients. When marginal ulcers occur in elderly patients, adequate gastric resection (70 to 75 per cent) or vagotomy in combination with resection is usually necessary.     

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.     

Proximal gastric vagotomy versus long-term maintenance treatment with cimetidine for chronic duodenal ulcer: a prospective randomised trial.

Forty-four patients with chronic duodenal ulceration were allocated randomly to either long-term maintenance treatment with cimetidine or proximal gastric vagotomy. All were followed up both clinically and endoscopically for periods of one to four years. The rate of recurrence of ulcer during and after medical treatment was 54% while after surgery it was 10%. One patient developed severe allergic hepatitis while receiving maintenance treatment with cimetidine, and two others had to stop treatment because of possible drug reactions. Patients whose ulceration recurs while they are receiving treatment with cimetidine should be offered the possibility of operation.     

Proximal gastric vagotomy: interim results of a randomized controlled trial.

In a randomized controlled trial 50 patients with duodenal ulcer treated by proximal gastric vagotomy (P.G.V.) without drainage were compared with 50 who underwent selective vagotomy and gastrojejunostomy. The clinical results were assessed in 99 patients one to four years after operation. Patients who had undergone P.G.V. had significantly less dumping, nausea, and bile vomiting and fared better in their overall clinical grading. The postoperative Visick grading of the 50 patients with P.G.V. was similar to that of 56 controls with no known gastrointestinal disease who had not undergone operation. The results obtained in the patients who had had P.G.V. without drainage were compared with those of a further group of 24 patients subjected of P.G.V. with gastrojejunostomy, and the better results obtained in the former group were thought to be due to elimination of the drainage procedure. The average follow-up period of the trial was just over two years, but there were no indications that the recurrent ulceration rate after P.G.V. would be any higher than after other types of vagotomy and drainage.     

Highly selective vagotomy and duodenal ulcers that fail to respond to H2 receptor antagonists

A study was conducted to see whether patients with duodenal ulcers that failed to heal in response to H₂ receptor antagonists had a higher incidence of recurrent ulceration after highly selective vagotomy than patients whose ulcers healed with these drugs. Between 1977 and 1983, 157 patients had a highly selective vagotomy for uncomplicated duodenal ulcer; in 57 patients the ulcer had failed to heal despite treatment with H₂ receptor antagonists (refractory group), 19 patients had developed recurrent ulceration while receiving maintenance treatment, 67 patients had remained healed while taking H₂ receptor antagonists but suffered frequent relapses when treatment was stopped, and 14 patients had not been given these drugs before operation. The overall incidence of recurrent ulceration was 6% after two years and 11% after five years of follow up. In the refractory group, however, the incidence of recurrent ulceration was 18% at two years and 34% after five years, whereas the incidence of recurrence was only 1.5% at two years and 3% after five years in patients whose ulcers had healed with H₂ receptor antagonists. Resistance to H₂ receptor antagonists was not related to preoperative basal or peak acid output but was related to cigarette smoking. Factors associated with recurrent ulceration after highly selective vagotomy were basal acid outputs before and after operation, cigarette smoking, and the surgeon who performed the operation.Duodenal ulcers that fail to respond to H₂ receptor antagonists represent a more severe ulcer diathesis, for which highly selective vagotomy is less effective.     

Effects of truncal,selective, and highly selective vagotomy on glucose tolerance and insulin secretion in patients with duodenal ulcer. Part I-Effect of vagotomy on response to oral glucose.

An oral glucose tolerance test was performed in patients who had undergone truncal vagotomy and pyloroplasty, bilateral selective vagotomy and pyloroplasty, or highly selective vagotomy without a drainage procedure at least six months earlier. The results were compared with those from patients with chronic duodenal ulcer before operation. In all three groups of patients after vagotomy more rapid rates of rise of blood glucose and higher peak concentrations were observed than in patients who were tested before operation. These differences were statistically significant only in patients who had undergone truncal or selective vagotomy with pyloroplasty and were probably due to more rapid rates of gastric emptying after these operations. Plasma insulin concentrations were lower after truncal vagotomy than after selective or highly selective vagotomy, the difference between truncal vagotomy and highly selective vagotomy being statistically significant. Truncal vagotomy resulted in a diminished insulin response to oral glucose, which could have been due to vagal denervation of the pancreas or, more probably, impaired release of small-bowel hormones which normally augment the pancreatic insulin response.     

Operative mortality and postoperative morbidity of highly selective vagotomy.

In a world-wide survey of the results of 5539 highly selective vagotomies (HSVs) performed electively for duodenal ulcer the operative mortality was found to be 0-3%. This was lower than that found in collected series after either vagotomy with drainage (0-8%) or gastric resection with or without vagotomy (over 1%). Necrosis of the lesser curvature occurred in 10 patients (0-2%) after HSV and caused death in 5(0-1%). Such necrosis is probably ischaemic in origin. Hence reperitonealisation of the raw area on the lesser curvature and prompt laparotomy if the patient develops signs of peritonitis might lower the mortality still further. Three deaths were due to pulmonary embolism, one to mesenteric vascular occlusion, and four to myocardial infarction; such deaths might be reduced by the prophylactic use of low-dose heparin. Persisting gastric stasis requiring drainage occurred in only 0-1% of the patients in the early postoperative period and in 0-6% of the patients later. Hence drainage procedures, which produce side effects such as early dumping, bilious vomiting, and diiarrhoea, could be abandoned if the mean incidence of recurrent ulceration after HSV remains close to its present level. HSV is probably the safest operation for duodenal ulcer because the alimentary tract is not opened and there is no anastomosis, suture line, or stoma.     

FISTULAS FOLLOWING GASTRECTOMY

Postoperative fistula occurred in 16 of 761 cases in which subtotal gastrectomy was done. Twelve of the 16 patients died.In the majority of cases complications arose because of the anatomical location of the ulcer with surrounding inflammation.Abrupt and dramatic onset of symptoms following leakage occurred in only a few cases. Perforation occurred in a few cases after the patient had been discharged home well and asymptomatic.Obstruction of the proximal limb was not present in any of the cases in which postmortem examination was carried out.The exclusion operation with resection of antral mucosa may not be a safe procedure. For treatment of ulcer which cannot be removed, gastroenterostomy with vagotomy is advised.     

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.     

Effects of serotonin and stress on the state of the gastric mucosa in rats with the intact and transsected vagus nerve

In experiments on vagotomized and intact rats with the use of two models of experimental gastric ulceration (injection of serotonin and stress) it was demonstrated that the inhibitory action of vagotomy on haemorrhagic gastric effectiveness was more pronounced in stress than after serotonin application. Vagotomy decreased stress-induced erosive lesions but increased serotonin-induced erosions that may be a result of the increase of gastric tissue sensitivity to this amine which developed simultaneously with significant decrease of its level in gastric wall after vagotomy. Serotonin-antagonist peritol decreased stress-induced gastric disturbances in vagotomized rats more significantly than in intact rats; this suggested the great role of serotonin in anti-ulcerogenic effect of vagotomy.     

Incidence of Dumping after Truncal and Selective Vagotomy with Pyloroplasty and Highly Selective Vagotomy without Drainage Procedure

The incidence of dumping after truncal or selective vagotomy with pyloroplasty and highly selective vagotomy without a drainage procedure was assessed both clinically and experimentally. At a gastric follow-up clinic dumping was found to be significantly less frequent in patients who had undergone highly selective vagotomy without a drainage procedure than in patients who had undergone truncal or selective vagotomy with pyloroplasty (P < 0·05 or < 0·001, respectively). Hypertonic glucose given by mouth provoked the onset of dumping in 20% of patients with duodenal ulcer before operation, in 73% after truncal vagotomy and pyloroplasty, in 80% after selective vagotomy and pyloroplasty, and in 47% after highly selective vagotomy. The test meal also produced significantly greater decreases in blood pressure and increases in pulse rate in patients who had undergone vagotomy with pyloroplasty than in patients who had undergone highly selective vagotomy.     

Endocrine cells of the gastric mucosa in patients with duodenal ulcer after vagotomy]

Bioptates of the stomach mucous membrane (SMM) have been investigated in 169 patients suffering from duodenal ulcer (DU). According to the nocturnal gastric secretion test among them there are "hypersecretors" and persons with moderate elevation of acid formation. In conformity with the efficiency of the operative treatment among the patients examined, groups are defined: those with recurrent disease and those recovered after vagotomy. The DU endocrine apparatus undergoes both qualitative and quantitative alterations after vagotomy. When recovery after vagotomy takes place, the number of endocrine cells only slightly exceeds these parameters in the patients with a moderately manifested acid production. These alterations are adaptive. The recurrence of DU in patients with moderately manifested acid production before the operation can be explained by hyperplasia of G-cells. A high degree of hyperplasia of all elements of the endocrine apparatus in the "hypersecretors" can be one of the causes of the DU recurrence. The data about the state of G-, Ec- and EcL-cells before and after vagotomy can be used at prognostication the results of surgical treatment of patients with DU.     

Proximal gastric vagotomy,fundoplication, and lesser-curve necrosis.

Out of 400 patients who underwent proximal gastric vagotomy (PGV), three developed lesser-curve necrosis (LCN) leading to perforation within the first seven days. In each case diagnosis was delayed but the patient survived after a second operation. In each an associated Nissen fundoplication had been carried out; we used the combined operation in only 33 patients. Delayed LCN occurred in a patient who had undergone splenectomy at the time of the PGV and in a fifth patient treated elsewhere who had also undergone fundoplication. These findings indicate that early postoperative gastric distension with gas, not readily voided after fundoplication, may aggravate local vascular factors and predispose to LCN. We suggest that PGV combined with fundoplication may be dangerous.     

Selective Proximal Vagotomy with and without Pyloroplasty

The early results of a prospective randomized clinical trial of selective proximal vagotomy with and without gastric drainage in a total of 36 patients are reported. In spite of adequate average acid reduction and little evidence of gastric retention two definite recurrent ulcers have occurred in the 16 patients who did not have a pyloroplasty. Further trials of the effect of selective proximal vagotomy without gastric drainage are necessary before the procedure is widely adopted.     

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.     

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.