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.

The influence of the individual surgeon and of the type of vagotomy upon the insulin test after vagotomy

Six hundred and seventy-six insulin tests performed in the early postoperative period after vagotomy and drainage for duodenal ulcer were analysed by the criteria of Hollander. Consultants had done 364 vagotomies, of which 17.6% were shown to be incomplete. Registrars and senior registrars had done 312, of which 12.2% were incomplete. Thus, consultants may not be significantly better, on average, than their juniors at achieving complete gastric vagotomy, even when allowance is made for the fact that they tend to take on the more difficult cases. The ability to achieve a complete vagotomy varied widely from surgeon to surgeon, regardless of his status. Of 515 truncal vagotomies, 15.7% were incomplete compared with 14.3% of 161 bilateral selective vagotomies. An ;early-positive' secretory response within one hour of the insulin injection, which is commonly regarded as indicating inadequate vagotomy, was found in 5.6% of patients after truncal vagotomy and 3.1% of patients after selective vagotomy.

Effect of antroneurolysis on gastric secretion in dogs with total gastric fistula

The operation of antroneurolysis is performed by circumferential sharp dissection in the submucosal plane of the entire gastric antrum, which severs the vagal nerve-supply to the antral mucosa. It might thus be regarded as a conservative variant of antrectomy, the purpose of which is to diminish gastrin release without disturbing antral peristalsis or the mechanism of the pylorus. Its possible value as an adjunct to highly selective vagotomy in man is evaluated in this study in the dog.

The antroneurolysed antrum was left in continuity with the remainder of the stomach whose vagal nerve-supply remained intact. Gastric secretion was collected via a cannula or fistula draining the whole stomach. Outputs of acid and pepsin in response to insulin, pentagastrin, meat extract, and acetylcholine were found to be undiminished after antroneurolysis. It is concluded that antroneurolysis has no place at present in clinical gastric surgery.

A controlled trial of inverting versus everting intestinal suture in clinical large-bowel surgery

A controlled evaluation of a single-layer everting technique of suture versus a conventional two-layer inverting technique has been attempted in clinical large-bowel surgery. Thirty-five patients suffering from carcinoma or other diseases of the large intestine were allocated randomly to each technique in the conduct of various forms of colonic resection with anastomosis or closure of a transverse colostomy. There were 3 operative deaths after everting suture and 1 after inverting suture, all attributable mainly to anastomotic failure. A higher proportion of patients developed wound infection or peritonitis after everting than inverting suture—51 as against 35 per cent. Overt faecal fistulation was observed in no less than 43 per cent of the patients having everting suture, but in only 8·6 per cent of those treated by inverting suture. Late stricture formation was noted in 2 cases after everting suture, but in none after inverting suture.

These experiences are considered to provide a clear condemnation of the use of an everting technique of suture in the large intestine in clinical practice.