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.     

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.     

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.     

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.     

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.     

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.     

Vagotomy for Gastric Ulcer

Out of a series of 75 patients who were treated by vagotomy and drainage for gastric ulcer 66 have been followed up for one to seven years (average three-and-a-half years). Four recurrent gastric ulcers occurred among the 33 cases of ulcer of the lesser curve or body with no antral or duodenal lesion (type I). Among the 42 patients with an antral ulcer or an associated active or healed pyloric or duodenal lesion (type II or III) there was only one recurrence. The recurrence rate for men was 5% and for women 12%. One patient died two years after operation from cancer which may have originated in the stomach. The clinical results in patients without recurrences were generally satisfactory.Vagotomy, preferably selective, with drainage is a satisfactory operation in gastric ulcers of types II and III. For ulcers of type I, gastrectomy is to be preferred except in selected cases.     

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.     

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.     

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.     

Treatment of severe side effects after vagotomy and gastroenterostomy by closure of gastroenterostomy without pyloroplasty.

We describe nine patients who had severe, persistent abdominal pain, vomiting, dumping, or diarrhoea several years after truncal vagotomy and gastroenterostomy had been performed for duodenal ulceration. Each patient was judged to have a bad clinical result (Visick grade 4). There was no evidence of recurrent ulceration in any of the patients, and in each the patency of the pyloric canal was confirmed radiologically or endoscopically. Each patient was treated by simply dismantling the gastroenterostomy without addition for a pyloroplasty. In one patient the surgeon suspected that a vagal trunk might have been left intact, and a revagotomy was performed by the "highly selective" technique. Postoperatively, none of the patients developed gastric retention. Symptomatic improvement occurred in eight patients, and four of them achieved perfect results (Visick grade 1). Side effects are common after vagotomy and gastroenterostomy, and are largely attributable to the presence of the gastroenterostomy stoma. Our results show that the symptoms may be alleviated by closing the gastroenterostomy, without precipitating gastric retention.     

Evidence for intrinsic regulation of met-enkephalin-immunoreactivity in gastroenteropancreatic tissues of the rat

In a study whether gastrointestinal endogenous opioids can be modified by vagal denervation or by pharmacological application of an opiate, we examined met-enkephalin-immunoreactivity in gastrointestinal tissue in rats with and without truncal vagotomy and with and without subcutaneously implanted morphine pellets. The immunoreactivity of the tissue extracts gave dose-response lines in the radioimmunoassay for met-enkephalin which were near parallel to that for the standard. On Sephadex chromatography the met-enkephalin immunoreactivity eluted at a position similar to synthetic met-enkephalin. Tissue concentration of met-enkephalin immunoreactivity was not significantly different from the respective control after vagotomy and after morphine treatment. Total gastric met-enkephalin immunoreactive content increased significantly after vagotomy in line with gastric hypertrophy occurring after vagotomy without a drainage procedure. From these results it is concluded that met-enkephalin immunoreactivity in the rat gastrointestinal tract is regulated intrinsically, it is neither altered by vagal denervation nor by exogenous opiate administration.     

Effect of proximal selective vagotomy on gastric prostaglandin content in the Shay-rat ulcer model

During Shay-ulcer formation damages to the barrier of the gastric mucosa develop even before the appearance of macroscopic ulceration. Proximal selective vagotomy prevents these damages. Following pyloric ligation the prostaglandin content of the mucosa changes in parallel with the injuries of the mucosal barrier: TXB2 content of the forestomach increases, while PGF2 alpha content of both the forestomach and the antrum decreases. Following PSV operation the 6-keto-PGF1 alpha content of the mucosa decreases, whereas PGF2 alpha and TXB2 contents exhibit no alteration. As a combined effect of proximal selective vagotomy pretreatment and pyloric ligation the 6-keto-PGF1 alpha and PGF2 alpha contents of the mucosa remain low and the TXB2 increase, otherwise detectable after pyloric ligation, does not take place.     

Characterization of 5-HT7-receptor-mediated gastric relaxation in conscious dogs

We aimed to evaluate the gastric relaxant capacity of the 5-HT(1/7)-receptor agonist 5-carboxamidotryptamine (5-CT) in conscious dogs and to clarify the mechanism of action by use of selective antagonists, vagotomy, and in vitro experiments. A barostat enabled us to monitor the intragastric volume in response to different treatments (intravenously administered) before and after supradiaphragmatic vagotomy [results presented as the maximum volume change after treatment (mean; n = 5-11)]. In vitro experiments were performed with isolated muscle strips cut from four different stomach regions of the vagotomized dogs [results were fitted to the operational model of agonism to determine the efficacy parameter tau (n = 5)]. 5-CT (0.5-10 microg/kg) caused a dose-dependent gastric relaxation (29-267 ml) that was completely blocked by the selective 5-HT(7)-receptor antagonist SB-269970 (50 microg/kg). After vagotomy, the relaxation to 10 microg/kg 5-CT was significantly less pronounced (73 vs. 267 ml; P < 0.05) but still blocked by SB-269970, whereas the response to the nitric oxide donor nitroprusside was similar to that before vagotomy (178 vs. 218 ml). In vitro, 5-CT concentration dependently inhibited the PGF(2alpha)-contracted muscle strips before and after vagotomy. Although before and after vagotomy the response in every region was mediated by 5-HT(7) receptors (apparent affinity dissociation constant: SB-269970, 8.2-8.6 vs. 8.3-8.6, respectively), the response after vagotomy was less efficacious (log tau: 1.9 to 0.5 vs. 1.4 to -0.1). The results indicate that the 5-CT-induced proximal stomach relaxation in conscious dogs before and after vagotomy is mediated via 5-HT(7) receptors. The decreased efficacy of 5-CT in vitro after vagotomy is probably related to vagotomy-induced changes in receptor density or coupling efficiency and provides a possible explanation for the decreased in vivo response to 5-CT after vagotomy.     

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.     

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.     

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

Paired oral and intravenous glucose tolerance tests were carried out in patients who had undergone truncal vagotomy and pyloroplasty, selective vagotomy and pyloroplasty, or highly selective vagotomy at least six months earlier. Intravenous glucose tolerance was similar in all three groups. Oral glucose elicited significantly higher concentrations of plasma insulin in patients who had undergone selective and highly selective vagotomy than in those treated by truncal vagotomy. When the same amount of glucose was given intravenously, however, plasma insulin concentrations were similar in all three groups of patients. The insulin secreted in response to intravenous glucose expressed as a percentage of that secreted in response to oral glucose was 112% for truncal vagotomy, 51% for selective vagotomy, and 52% for highly selective vagotomy. Truncal vagotomy thus led to a diminished insulin response to oral glucose, which was probably due to impaired release of small-bowel hormones.     

Differential effects of selective vagotomy and tropisetron in aminoprivic feeding

Both total subdiaphragmatic vagotomy (TVAGX) and serotonin(3) receptor blockade with tropisetron or ondansetron attenuate amino acid-imbalanced diet (Imb) anorexia. Total vagotomy is less effective than tropisetron in reducing Imb-induced anorexia and also blunts the tropisetron effect. With the use of electrocautery at the subdiaphragmatic level of the vagus, we severed the ventral and dorsal trunks as well as the hepatic, ventral gastric, dorsal gastric, celiac, and accessory celiac branches separately or in combination to determine which vagal branches or associated structures may be involved in these responses. Rats were prefed a low-protein diet. On the first experimental day, tropisetron or saline was given intraperitoneally 1 h before presentation of Imb. Cuts including the ventral branch, i.e., TVAGX, ventral vagotomy (above the hepatic branch), and hepatic + gastric vagotomies (but not hepatic branch cuts alone) caused the highest (P < 0.05) Imb intake on day 1 with or without tropisetron. The responses to tropisetron were not affected significantly. On days 2-8, groups having vagotomies that included the hepatic branch recovered faster than sham-treated animals. Because the hepatic and gastric branches together account for most of the vagal innervation to the proximal duodenum, this area may be important in the initial responses, whereas structures served by the hepatic branch alone apparently act in the later adaptation to Imb.     

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.     

The Immediate Results of Operations for Duodenal Ulcer: A Comparative Study of the Morbidity and Mortality of Vagotomy and Pyloroplasty versus Subtotal Gastrectomy

Immediate postoperative results of vagotomy and pyloroplasty were compared with those of subtotal gastrectomy. Ulcer recurrence rate and the long-term complications of the two procedures were not studied. Age and sex distribution, and preoperative indications in the two groups of patients were almost identical. Vagotomy and pyloroplasty has gradually superseded subtotal gastrectomy at St. Michael''s Hospital, Toronto. One hundred and seventy vagotomy and drainage procedures were compared with 173 subtotal gastric resections performed over a five-year period. There were 39 postoperative complications and five deaths in the subtotal gastrectomy group, an overall mortality of 2.8% and an elective mortality of 2.4%. In the vagotomy and pyloroplasty group there were 31 postoperative complications and two deaths, an overall mortality of 1.2% and an elective mortality of zero. Vagotomy and pyloroplasty is a relatively safe procedure, associated with fewer complications, shorter hospital stay and a lower mortality than subtotal gastrectomy.