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.     

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.     

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.     

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.     

Factors effecting recurrence of duodenal ulcers after highly selective vagotomy]

Recurrence of duodenal ulcer was diagnosed in 15 patients who underwent highly selective vagotomy before 6-13 years, i.e. in 12.2%. Factors possibly contributing to such a recurrence were analysed. Patients with ulcer recurrence were: 1) non-qualified workers, 2) tobacco smokers, 3) heavy drinkers, 4) users of ulcerogenic medicines, and 5) were involved into conflict situations.     

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.     

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.     

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.     

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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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Effect of vagotomy, alpha-tocopherol and arachidene on lipid peroxidation in various areas of the gastroduodenal zone in rats with experimental peptic ulcer

Lipid peroxidation (LPO) was investigated in the mucosa of different gastroduodenal areas in rats with ulcer. The animals were subject to various types of vagotomy and given various drugs. The ulcerogenic agent--cystamine--was shown to have a different degree effect on the activation of free radical reactions, most pronounced in duodenal mucosa. Selective proximal vagotomy was most effective in decreasing LPO activity, as compared to total and partial vagotomy. The use of an antioxidant--alpha-tocopherol, particularly its combination with arachidene, a preparation of polyunsaturated fatty acids, prevented the development of duodenal ulcer in 75% of cases and markedly decreased both ascorbate- and NADP X H-dependent LPO. It is suggested that LPO is directly involved in the pathogenesis of ulcer and that factors attenuating the process of LPO may prevent ulcerogenesis.     

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.