Highly selective vagotomy without a drainage procedure in the treatment of duodenal ulcer

A seven-year follow-up of proximal gastric vagotomy. Clinical results

During a 7-year period proximal gastric vagotomy (PGV) was performed in 565 patients. Of these, 210 patients with duodenal ulcer and 14 with dyspepsia without demonstrable ulcer at the time of operation were followed for 5--7 years. Sixty-six percent are symptom-free (Visick I), 23% have no complaints when they take certain dietary measures (Visick II), 3% are improved but still have periods of dyspepsia (Visick III), and 8% are failures because of recurrent ulcer (Visick IV). There were 4 duodenal, 3 pyloric, 5 prepyloric, and 7 lesser-curve gastric recurrences. There were one operative death (0.2%) and one major complication (0.2%). The side effects after PGV are mild, infrequent, and seldom of any significance to the patients. Diarrhoea and dumping are virtually eliminated. Body weight was stable during the whole period of study, and blood chemistry did not disclose any deficiency in haemoglobin, serum iron, or vitamin B12 which might be attributed to PGV. It is concluded that 5--7 years after proximal gastric vagotomy for duodenal ulcer there is a 10% recurrence rate, but the low risk of death and of severe complications and the lack of significant side effects more than outweight the high recurrence rate.

The value of corpus-antrum border determinations in highly selective vagotomy

In order to know whether the exact determination of the corpus–antrum border is of importance in highly selective vagotomy (HSV) the operation was performed on two matched groups of patients with duodenal ulcers. In group 1 (35 patients) HSV was performed using anatomical landmarks to define the distal extent of dissection. In group 2 (35 patients) HSV was performed using the same technique and then a gastrotomy was made and any remaining acid-secreting mucosa was identified using pH-metry under pentagastrin stimulation. In 22 cases secretion of acid was observed distal to the anatomically defined corpus-antrum border. In these patients afurther distal division of vagal branches was done until no acid secretion was observed. Two months and 1 year after the operation, basal acid output (BAO), pentagastrin-stimulated acid output (PAOpg), insulin-stimulated acid output (PAO1) and basal serum gastrin determinations were done and compared with the corresponding preoperative data. Our results show that despite the more extensive division of the antral vagal branches in group 2, BAO and PAOpg were similar in both groups postoperatively. Postoperative PAOI was also similar. Differences were observed, however, in postoperative serum gastrin levels–group 1 42.5 ± 6.0 pmol/l and group 281.7 ± 7.4 pmol/l 1 year after the operation. In no cases did the more extensive dissection of antral vagal branches lead to clinical or radiological gastric stasis. Thus, if the branches of the nerves of Latarjet are used as landmarks in performing HSV, in many cases vagally innervated, acid-secreting mucosa will be left in the stomach, but apparently this is quantitatively of minor importance. On the other hand, a more extensive distal vagal dissection leads to disturbingly high postoperative serum gastrin values.

Fasting and postprandial serum gastrin levels before and after highly selective gastric vagotomy, truncal vagotomy with pyloroplasty and truncal vagotomy with antrectomy: is there a cholinergic antral gastrin inhibitory and releasing mechanism?

Fasting serum gastrin levels and postprandial gastrin response were measured before and 1 month after highly selective vagotomy, truncal vagotomy with pyloroplasty and truncal vagotomy with antrectomy. The three groups of patients, 12 in each group, were closely matched for age, sex, maximum acid output and completeness of vagotomy. After highly selective and truncal vagotomy an identical and significant increase in fasting gastrin was observed, whereas after truncal vagotomy with antrectomy the pre- and postoperative fasting gastrin levels were not different. The net postprandial gastrin output over basal value was significantly increased after highly selective vagotomy, unchanged after truncal vagotomy and significantly lowered after truncal vagotomy with antrectomy. These results suggest the presence in the intact subject of a cholinergic inhibitory mechanism in the gastric body and fundus for the release of antral gastrin in the fasting and postprandial states and a possible cholinergic facilitatory mechanism for the release of antral gastrin after meals.

Highly selective vagotomy or truncal vagotomy and pyloroplasty for chronic duodenal ulceration: a randomized, prospective clinical study

The results of a randomized, prospective clinical trial of highly selective vagotomy (HSV) versus truncal vagotomy and pyloroplasty (TVP) in 126 male patients undergoing elective surgery for chronic duodenal ulceration are presented. The operations were performed by surgeons of all grades of experience. At a mean follow-up time of just over 3 years a satisfactory result was obtained in 93 per cent of patients following HSV and 78 per cent of patients following TVP, the difference being probably statistically significant (P less than 0.05). The incidence of early and late dumping, bile vomiting, flatulence, post-prandial epigastric discomfort and wound infection was statistically significantly less after HSV than after TVP. Three patients have developed a recurrent duodenal ulcer after each type of operation (5.4 per cent). At this early stage HSV has advantages over TVP; it will be interesting to see if these are maintained with the passage of time.

Effect of selective proximal vagotomy and truncal vagotomy on gastric acid and serum gastrin responses to a meal in duodenal ulcer patients

To assess the effectiveness of selective proximal vagotomy (SPV) in reducing the acid response to food, we have compared pre- and postoperative gastric acid and serum gastrin responses to a meal in 11 duodenal ulcer patients with intractable pain treated by SPV, with those of seven ulcer patients with gastric outlet obstruction treated by truncal vagotomy and drainage (TV + D). Acid secretion was measured by an intragastric titration method which measures acid response to food within the stomach (5% amino acid meal) adjusted to various pH levels (5.5, 2.5, and 1.5). Studies were performed before and two to six weeks after operation. The preoperative intragastric acid output (IGAO) was about 50% of maximal acid response to Histalog. The mean preoperative IGAO at pH 5.5 For 11 SPV patients was 17.4 +/- 3.1 mEq/hour; this was decreased by 72% to 4.3 +/- 1.1 mEq/hour after operation. The mean IGAO at pH 5.5 in nine patients treated by TV + D was 21.6 +/- 3.4 mEq/hour; this was decreased by 67% to 7.3 +/- 2.1 mEq/hour. Gastrin levels were significantly higher in postop than in preop SPV PATIENTS EVEN THOUGH PH values were constant. Gastrin levels were higher in postop TV + D patients than in postop SPV patients. This study demonstrates that acid reduction achieved by SPV is reliable and at least comparable with that achieved by turncal vagotomy. Postoperative elevation of gastrin in the SPV patients suggests that the vagus may release a humoral inhibitor of gastrin release from the gastric fundus; there may also be a further direct vagal inhibitor of antral gastrin release.

Gastric motility after selective proximal vagotomy

Effects of vagotomy on gastric motor activity were studied on 39 patients after vagotomy for gastric or duodenal ulcer by fluoroscopic examination and by monitoring of intragastric pressure using a balloon introduced into the stomach. These patients were divided into three groups according to types of vagotomy; selective proximal vagotomy (SPV), selective vagotomy (SV) and atypical selective proximal vagotomy. In atypical SPV, dorsal antral branches of vagal gastric nerves were sacrificed in addition to conventional SPV because of local conditions around the ulcer. In patients after SPV or atypical SPV, no gastric stasis was observed on fluoroscopic examination. However, marked gastric stasis with delayed emptying was a constant finding in patients after SV, especially at the early postoperative period. In recording of intragastric pressure, basic peristaltic waves of a 20-second rhythm were observed following inflation of the balloon in all patients after any type of vagotomy. In addition, an alternation of active and resting periods of motor activity and confluence of large waves at the end of active period were observed as characteristoc findings in patients after both SPV and atypical SPV. The large waves were considered to coincide with active propulsive movements seen on fluoroscopy in these patients. The results in this study confirmed that good gastric motility could be preserved in patients after SPV and even after atypical SPV.

Gastric emptying after treatment of stenosis secondary to duodenal ulceration by proximal gastric vagotomy and duodenoplasty or pyloric dilatation

A consecutive series of 12 patients with stenosis secondary to duodenal ulceration were treated by proximal gastric vagotomy (PGV) and duodenoplasty or PGV and dilatation of the stenosis. Three months after operation the rate and pattern of gastric emptying of a solid meal was measured in each patient and compared with 18 patients with uncomplicated duodenal ulcer treated by PGV alone. Two patients developed gastric stasis in the early postoperative period which resolved with medical treatment. All patients were asymptomatic and were eating normally three months after operation. There was no significant difference in the rate of gastric emptying postoperatively between the patients who had stenosis and those who had uncomplicated duodenal ulcers. These results indicate that despite early postoperative difficulties in some patients pyloric dilatation or duodenoplasty with PGV are both effective treatments for stenosis due to duodenal ulceration.

The present status of proximal gastric vagotomy

It is now clearly established that proximal gastric vagotomy, which has been in clinical use for over seven years, had lower mortality and morbidity rates than all other forms of operation currently used in the treatment of chronic duodenal ulcer. Although no long-term figures are yet available, the ulcer recurrence rates is not likely to be greater than that for truncal vagotomy. The technique is not without problems, however, and has yet to gain wide acceptance in this country.

five years' experience with proximal gastric (highly selective) vagotomy

In the five-year period 1972 to 1976 the author's preferred treatment for patients with chronic duodenal or prepyloric peptic ulcer requiring surgery was proximal gastric vagotomy. In spite of this preference, only two-thirds of such patients were so treated. Most patients with bleeding and stenosis were treated by bilateral truncal vagotomy and drainage, and a few by Pólya gastrectomy. Proximal gastric vagotomy proved to be a safe elective operation without mortality and with a proven ulcer recurrence rate so far of 6%. Compared with those who had bilateral truncal vagotomy and drainage, the proximal gastric vagotomy patients complained less often of diarrhoea but more often of weight loss and reflux. Two patients have had persistent postprandial non-peptic pain, thought possibly due to upper gastric ischaemia.

Proximal gastric vagotomy without drainage

Proximal gastric vagotomy without drainage is widely accepted in Great Britain and Europe but in the United States has been done mainly in university centers. The operation denervates the acid-secreting parietal cell mass of the stomach, preserving vagal innervation to the gastric antrum and extragastric abdominal viscera. The procedure is safe and is associated with few underisrable side effects. Long-term studies are needed to determine the rate of recurrence of duodenal ulcer in patients treated surgically in this way.

Gastric response to meat extract stimulation in patients with gastroduodenal ulcer and patients after vagotomy or antrectomy

Gastric acid secretion basally and in response to intragastric meat extract instillation or to tetragastrin, and circulating gastrin concentration basally and after meat extract stimulation were studied in 67 patients with gastroduodenal ulcer, 30 patients after highly selective vagotomy or selective vagotomy for duodenal ulcer, 12 patients after antrectomy for or gastric ulcer and 10 control subjects. Circulating gastrin concentration increased significantly after meat extract stimulation in control subjects, patients with ulceration and patients after highly selective vagotomy, and acid secretion in each group was increased significantly above basal level. In patients after selective vagotomy, significant increase of circulating gastrin concentration was observed, but it was not associated with significant increase of acid secretion. After antrectomy, neither gastrin nor acid secretion increased significantly after meat extract stimulation. In conclusion, present study suggested that (1) gastric acid secretion in response to intragastric meat extract is chiefly affected by the responsiveness of oxyntic cells and release of antral gastrin and that (2) the presence of the antrum is almost essential for acid secretion after a test meal, and release of duodenal gastrin after antrectomy would not be so potent biologically as to result in an acid secretion.

Closure of gastrojejunostomy for the relief of post-vagotomy symptoms

When dumping, diarrhoea or bile vomiting follows vagotomy and gastrojejunostomy, simple closure of the stoma, without alternative drainage, has been performed in 19 patients. Thirteen patients, 5 with truncal, 7 with selective and 1 with proximal gastric vagotomy, have been followed up for 1-6 years. Five were completely relieved of symptoms, 7 improved and there was only 1 complete failure. Bile vomiting was more often relieved than dumping or diarrhoea. The procedure is safe and significant gastric retention does not occur provided that at least one year is allowed to elaspse after the primary operation.

Highly selective vagotomy using tantalum clips

A technique is described for performing highly selective vagotomy in cases of duodenal ulcer. Tantalum clips are used instead of conventional ligatures for securing the nerves and blood vessels that pass to the lesser curve of the stomach. With this technique the author has found the operation of highly selective vagotomy quicker and easier to perform.

Proximal gastric vagotomy without drainage for duodenal ulcer: results after 5-8 years

Experience with proximal gastric vagotomy without drainage in the treatment of 316 men with duodenal ulcer is surveyed, with particular reference to the 117 who have been followed up for 5–8 years and whose results are compared with those obtained after other standard elective operations.

There were no operative deaths. Symptoms suggestive of recurrent ulceration developed in 12·0 per cent of the entire series of 316 cases, but in only 3·8 per cent was the presence of a recurrent ulcer definitely established. In the 117 cases followed up for 5–8 years similar symptoms were noted in 15·4 per cent, but the presence of a recurrent ulcer was proved in only 4·3 per cent.

At 5–8 year follow-up dumping was virtually completely absent and diarrhoea was significantly less than after truncal vagotomy with drainage or antrectomy, whilst there were insignificant reductions in the incidence of post-prandial epigastric fullness and bile vomiting.

Visick grading at 5–8 years rated the result as excellent or very good in 75 per cent of the cases, as fair in 13 per cent and as a failure in another 12 per cent.

The advantages and disadvantages of proximal gastric vagotomy without drainage relative to those of truncal vagotomy with drainage or antrectomy are discussed.

The relative effects of lesser curvature vagotomy and esophageal vagotomy on the acid secretory effect of proximal gastric vagotomy

Proximal gastric vagotomy is an operation consisting of division of all vagal fibers to the acid-secreting portion of the stomach. These fibers are usually divided along the lesser curvature of the stomach; however, because of a high rate of duodenal ulcer recurrence in some series, it has become apparent that it is important to divide the vagal fibers to the stomach leaving the main vagal trunks along the distal 5 cm of esophagus in order to achieve both adequate control of acid secretion and also a lower duodenal ulcer recurrence rate. The data presented in this study of ten mongrel dogs suggest that, in the dog, division of the vagal fibers along the lesser curvature is more important in reducing acid secretion than is esophageal vagotomy; but the data also emphasize the contribution of the vagal fibers along the distal esophagus since a marked reduction in 2 DG-stimulated acid secretion can only be achieved by dividing the vagal fibers around the distal esophagus as well as those along the lesser curvature.

[The technique of proximal selective vagotomy (author's transl)]

A standard technique of proximal selective vagotomy is described (PSV) that has proved reliable and safe in a broad multicenter clinical trial. We proceed in six steps: (1) determination of the antral-fundic boundary by anatomic criteria; (2) preliminary vagomotor electrotest; (3) identification of the nerve trunks and branches to be preserved; (4) dissection of the lesser curvature; (5) dissection of the cardia and of the intraabdominal esophagus up to 6 cm above the cardia; and (6) intraoperative assessment of completeness by the vagomotor electrotest. PSV is usually carried out without a drainage procedure.

Proximal gastric vagotomy compared with vagotomy and antrectomy and selective gastric vagotomy and pyloroplasty

A prospective, randomized study of proximal gastric vagotomy without drainage (PGV) was done in 174 adult men with chronic duodenal ulcer intractable to medical therapy. PGV was randomized against truncal vagotomy with antrectomy (TV + A) and against selective gastric vagotomy with Finney pyloroplasty (SGV + P). Postgastrectomy sequelae (dumping, diarrhea and reflux gastritis) were less after PGV. One patient after PGV developed a recurrent ulcer as did one patient after SGV + P. Two patients developed gastric ulcers after PGV. Good to excellent results (Visick I and II) were obtained in 96% of patients with PGV, 94% with TV + A and 86% with SGV + P. Follow-up studies were from six months to four years.

Electrical, contractile, and radiographic studies of the stomach after proximal gastric vagotomy

The effects of proximal gastric vagotomy on the gastric electrical and contractile activities and on gastric emptying of solid food were studied in dogs. Proximal gastric vagotomy produced only minimal alteration of the electrical activity and did not significantly alter the response of the electrical and contractile activities to vagal stimulation (insulin) and local stimulation (food). Barium meal studies showed no delay in gastric emptying time after proximal gastric vagotomy but significant delay after truncal vagotomy. The findings support the clinical impression that gastric motility and empyting (solid) remain relatively normal after proximal gastric vagotomy.

Recurrence after proximal gastric vagotomy without drainage for duodenal ulcer: a 3-6-year follow-up

During the period December 1970 to August 1973, 99 patients with duodenal ulcer underwent proximal gastric vagotomy without drainage, and 93 per cent of the patients were followed up for 3-6 years after the operation. A proved recurrent duodenal ulcer was noted in 4.3 per cent and a strongly suspected recurrent duodenal ulcer in 2 per cent. It is suggested that this rate of recurrence on medium term follow-up is compatible with the continued use of proximal gastric vagotomy in the surgical treatment of duodenal ulcer.

Recurrent ulcer after proximal gastric vagotomy for duodenal and pre-pyloric ulcer

Factors thought to be important in the development of recurrent ulcer after proximal gastric vagotomy were investigated 1-4 years after operation in 211 patients with duodenal ulcer and in 49 with pre-pyloric ulcer. Recurrent ulcer was found in 25 patients with duodenal ulcer (12 per cent) and in 6 with pre-pyloric ulcer (12 per cent). Recurrence was not related to age, sex, duration of dyspepsia, radiological findings or peak acid output before and 10 days after vagotomy. Fifty-six patients were operated upon by the method of Amdrup and Jensen (1970), including skeletonization of about 2 cm of the oesophagus. The remaining 204 patients were operated on by a technique in which the dissection of the lesser curve was begun at the 'crow's foot' and the oesophageal dissection was extended, in most cases, to more than 4 cm above the cardia. Recurrence was more frequent among the 56 patients in the first group than among the remaining patients with duodenal ulcer. Recurrence was positively related to basal acid output after vagotomy. An increase of peak acid output of 50 per cent was seen in a smaller group with recurrence and patients with dyspepsia within 18 months of vagotomy. It was concluded that the risk of recurrence is not related to the number of parietal cells, as expressed by peak acid output to histamine. The risk may probably be reduced by extension of the oesophageal skeletonization. A marked increase in peak acid output may be seen during the first year after proximal gastric vagotomy in patients with recurrence or dyspepsia.

Review of elective surgical treatment of chronic duodenal ulcer

This article is a review of 20 clinical trials of various forms of elective surgical treatment of chronic duodenal ulcer conducted between 1964 and 1975, some of them prospective and others retrospective in nature. Comparisons have been made of the results following truncal vagotomy with drainage, truncal vagotomy with antrectomy, and partial gastrectomy. Additionally, selective vagotomy and truncal vagotomy have been compared in some studies and various forms of drainage, such as pyloroplasty and gastrojejunostomy, have been compared in others. In general, the results of all current forms of elective surgery for chronic duodenal ulcer have been very good, and the differences among the effects of the various procedures have been small. There have been no significant differences in the mortality rates associated with the several operations when they have been performed electively. The rate of ulcer recurrence and incidence of diarrhea have been somewhat higher after truncal vagotomy with drainage, whereas the frequency of dumping and amount of weight loss have been somewhat greater after all forms of gastric resection. Selective vagotomy appears to be associated with less frequent and severe diarrhea than does truncal vagotomy. There have been no apparent differences in the results of the various drainage procedure that have been combined with vagotomy. Highly selective vagotomy without drainage, the most recent operation for duodenal ulcer, has resulted in the lowest incidence of post-operative side effects of any surgical procedure in current use. However, the frequency of ulcer recurrence after this therapeutic measure remains to be determined by long-term studies.

Parietal cell (highly selective or proximal gastric) vagotomy for peptic ulcer disease

Parietal cell vagotomy has been in clinical use for 7 years in elective treatment of nonobstructive duodenal ulcer, and for even a shorter period for complicated cases and for gastric ulcer The evolution of the surgical technique has not yet come to an end and the ability to perform the procedure is still improving. It can therefore be questioned, if this operation is yet ripe for a realistic clinical trial, and the great variation in recurrence rate reported in pilot series as well as in prospective randomized clinical trials points to the possibility that we will have to wait several years before the anticipated mean recurrence rate is known. At present it can be stated that even if gastric emptying is not quite undisturbed, the addition of a drainage procedure in nonobstructive cases is unnecessary. The same may be true in some patients with pyloric obstruction. Furthermore, the mortality rate is very low and the incidence of moderate-to-severe dumping and diarrhea is virtually nil.

The role of gastrin in duodenal ulcer surgery

The role of gastrin and of serum gastrin analysis in duodenal ulcer disease and duodenal ulcer surgery is analysed. As far as etiology and pathogenesis are concerned up to now gastrin has never been shown to play a significant role. Neither does it provide any diagnostic help in the typical duodenal ulcer disease (but it will allow for diagnosis of the retained antrum after Billroth II resection and of the Zollinger Ellison syndrome). Gastrin determination therefore is not helpful in the choice of the correct operative procedure for the ulcer disease. In today's clinical practice its major role consists in the control of surgical results. This is illustrated by a prospective randomized study on proximal selective vagotomy with and without pyloroplasty. In these patients serum gastrin analysis has shown that the omission of pyloroplasty is not followed by antral stasis. It furthermore always exhibits the typicel vagotomy profile, although vagotomy is incomplete in the 2-DODG-test.

Changing trends in the surgical treatment of duodenal ulcer

On the basis of fully or partly controlled clinical trials the long term results of several standard operations for duodenal ulcer have been compared--subtotal gastrectomy, truncal vagotomy and antrectomy, truncal vagotomy and gastro-enterostomy, truncal vagotomy and pyloroplasty, selective vagotomy and pyloroplasty and proximal gastric vagotomy without drainage. Few statistically significant differences emerge but the following observations seems to be justified: (a) Subtotal gastrectomy and vagotomy and antrectomy probably offer better protection against recurrent ulceration than any of the other operations examined, but the greater intrinsic operative risks of these two resection procedures is emphasized. (b) Disturbances of alimentary function occur to a variable extent after all operations but appear to be least troublesome after proximal gastric vagotomy without drainage. In particular this operation is followed by a negligible incidence of diarrhoea compared with truncal vagotomy procedures. (c) On overall (Visick) grading the two resection operations and proximal gastric vagotomy without drainage do better than truncal vagotomy with drainage, proximal gastric vagotomy being specially notable for the relatively small proportion of patients in category 3 after its use. Surgical strategy in the choice of elevtive operation for duodenal ulcer is discussed.

Multiple recurring gastric erosions/aphthous ulcers)

Five patients are described who had repeated endoscopy because of continuing dyspeptic symptoms associated with a negative barium meal. They were found to have multiple recurring gastric erosions (aphthous ulcers). No common aetiological factor could be found, although four of these patients did have a mild or moderatley active superficial chronic gastritis. Conventional peptic ulcer therapy failed to control either symptoms or ulceration. Two patients finally came to gastric surgery (highly selective vagotomy), which resulted in the relief of symptoms and healing of the gastric aphthous ulceration.

Gastric emptying in control subjects and patients with duodenal ulcer before and after vagotomy

The emptying of a solid meal labelled with Indium 113mDTPA from the stomach was studied with a gamma camera in 26 normal subjects, 27 patients with duodenal ulcer, on 41 occasions after truncal vagotomy and pyloroplasty and 38 times after highly selective vagotomy. Applying the method of principal component analysis to the results, differences were detected between control and duodenal ulcer subjects and two probable subgroups of duodenal ulcer were observed. Half emptying times did not reveal these patterns. After vagotomy, delayed emptying was general at one week. At one month, patients after highly selective vagotomy had a more normal result than those with truncal vagotomy and pyloroplasty (TV), but by six months no significant difference in overall emptying rate was found, although changes in the pattern of gastric emptying persisted in some patients after TV.

Highly selective vagotomy plus dilatation of the stenosis compared with truncal vagotomy and drainage in the treatment of pyloric stenosis secondary to duodenal ulceration

Twenty-three consecutive patients with duodenal ulceration complicated by pyloric stenosis who came under the care of one surgeon were treated by highly selective vagotomy (HSV) combined with digital dilatation of the stenosis through a gastrotomy. No form of drainage procedure was used. Thus the antral "mill" and the pyloric sphineter were left intact. Since the stenosis is usually distal to the pylorus rather than truly pyloric such dilatation does not damage the pyloric ring, although it may on occasion lead to perforation of the first part of the duodenum. The subsequent progress of these patients was compared with that of a similar, consecutive series of 23 patients with pyloric stenosis who were treated by truncal vagotomy with a drainage procedure by other surgeons on the same surgical unit. Patients were followed up for between four months and five years. The clinical assessment was carried out in "blind" fashion at a special gastric follow-up clinic. No evidence of recurrent ulceration was found in either group of patients. Two patients from each group subsequently came to reoperation for the relief of gastric stasis. Twenty-two of the 23 patients (96%) who had undergone HSV plus dilatation eventually achieved a good-to-excellent clinical result (Visick grades 1+2), wheras only 17 of the 23 patients (74%) who had undergone truncal vagotomy with drainage achieved such a result. The main clinical difference between the two groups was that side effects such as diarrhoea and abdominal pain or discomfort were more common after vagotomy with drainage than after HSV. These results bear witness to the remarkable propulsive powers of the gastric antrum after HSV, which were evidently sufficient to overcome any tendency to re-stenosis in more than 90% of patients. The 9% incidence of failure due to re-stenosis could perhaps be avoided if a small duodenoplasty were performed instead of simple digital dilatation. The results support the hypothesis that damage to the antral mill and pyloric sphincter can be avoided in the course of operations for "pyloric" stenosis secondary to duodenal ulceration. Avoidance of the drainage procedure is of benefit to the patient, just as it is in patients who have duodenal ulceration without stenosis.

Basal and meat extract plasma gastrin before and after parietal cell vagotomy and selective gastric vagotomy with drainage in patients with duodenal ulcer

Basal and meat extract stimulated plasma gastrin (PG) levels and basal and stimulated gastric acid secretion were evaluated pre and postoperatively in duodenal ulcer patients who underwent parietal cell vagotomy without antral drainage (normal duodena) (PC, n=32) or selective vagotomy with drainage (pyloric stenosis) (SV +P, n=11). Before operation, both groups had comparable basal PG values of 52+/-13 pg/ml (PCVP) AND 51+/-18 PG/ML (SV+P), while the peak gastrin level to meat extract stimulation was 173+/-40 pg/ml for the total group of patients. After both operations basal PG levels increased (107+/-18 pg/ml (PCV) and 152+/-45 pg/ml (SV+P) and the gastrin response to meat extract stimulation was augmented after PCV, while the response after SV+P was the same as before operation. Patients with PCV often demonstrated an acid response following meat extract stimulation (3.6+/-0.9 mEq HC1/hr), and pentapeptide stimulation (18.8+/-2.0 mEq/hr) while patients with SV/P showed a minimal response (1.3+/-1.2 mEq HC1/hr meat extract), and 10.7+/-1.8 mEq/hr pentapeptide stimulation. The comparatively intact acid response in the PCV patients may augur a high ultimate recurrence rate.

Parietal cell vagotomy

In a series of 100 consecutive patients who had parietal cell vagotomy performed, no drainage procedure was performed in 56 while 44 were drained. Dumping was significantly less in those who were not drained. All patients were tested for adequacy of vagotomy and for function of the nerve of Latarget at operation. Four patients have had further operations, two for proven recurrent ulcers. Parietal cell vagotomy has given excellent clinical results in this group of patients.

Gastric emptying following vagotomy and antrectomy and proximal gastric vagotomy

Gastric emptying of solid meals labelled with 129Cs was studied in patients for up to one year after vagotomy and antrectomy or after proximal gastric vagotomy. Significant delay was found one month after vagotomy and antrectomy but this had returned to normal by six months. No delay was found after proximal gastric vagotomy. The effect of posture on gastric emptying was also studied in the same subjects. No significant differences were found between gastric emptying in the supine or sitting positions after solid meals.

Localized avascular necrosis of lesser curve of stomach complicating highly selective vagotomy

The fourth case of localized avascular necrosis of the lesser curve of the stomach after highly selective vagotomy is reported. The pathogeneses was probably related to the relative poverty of the submucosal blood supply along the lesser curve. This complication may be prevented by peritonealizing the lesser curve before closing the abdominal wall.

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 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.

Motility changes in the antrum after proximal gastric vagotomy

The normal pattern of resting and post-prandial motor activity in the gastric antrum has been established by observations in 6 dogs. There was a gradual increase in the amplitude of contraction during the first 2 hours after eating; this was maintained for 3 hours and then declined. For the first 45 minutes terminal antral contraction occurred, partially retaining and triturating the gastric contents. After 45 minutes the waves became sequential, symmetrical, increased in vigour and actively pumped food into the duodenum. Vagotomy modified the mechanism of the antrum in various ways. Truncal and selective vagotomy reduced the work capability to 20 per cent of its normal value when recorded 1 month after operation. In both groups the waves were disorganized. Proximal gastric vagotomy abolished the braking mechanism and removed the initial inhibitory stimuli to antral motility. Within 1 month of operation the antrum had regained 58 per cent of its normal work capability and the contractions were well organized.

Vagotomy and double pyloroplasty for peptic ulcer

Seventy patients with peptic ulcers (55 duodenal and 15 gastric) were treated by truncal vagotomy and doulbe pyloroplasty during the past four years. Clinical and experimental data as presented lead us to believe that transecting the pylorus twice produces an incontinent pyloric sphincter and a larger gastric outlet than is found in other methods of pyloroplasty. This decreases gastric stasis and has led to a lower ulcer recurrence rate (1.5%). In addition the untoward postoperative sequelae are minimal. The 70 patients treated (for the most pare consecutive cases) exhibited the usual complications of peptic ulcer disease. Thirty-three had intractable pain, 23 bleeding (15 massive), 13 obstruction, and one acute perforation. There were no operative or postoperative deaths and the only serious postoperative complication was unrelated to the double pyloroplasty. During the followup period four patients have died of unrelated diseases. Of the remaining 66 patients one developed a probable recurrent peptic ulcer which has responded to medical management. Four patients have intermittent dumping, three have mild diarrhea and one has failed to gain weight, Constipation and weight gain are more common complaints. It would appear that vagotomy with double pyloroplasty is a safe and effective operation for peptic ulcers and that further clinical trials are warranted.