Selective vagotomy and pyloroplasty in the treatment of gastric ulceration: some clinical observations and results

Surgical treatment of high gastric ulcer

The purpose of this study has been to review the late results of surgical treatment of 244 patients with endoscopically proved benign chronic gastric ulcer located 5 cm or less from the cardia. In five patients, a total gastrectomy with esophagojejunostomy was performed. Proximal gastrectomy was used in 3 patients, mesogastrectomy in 5 patients, a partial Schoemaker's procedure in 73 patients, Pauchet's procedure in 70 patients, and Csendes' procedure in 23 patients. Nonresective procedures were employed in 67 patients and included the Kelling-Madlener procedure in 23 patients, pyloroplasty alone in 10 patients, gastrojejunostomy alone in 4 patients, local or wedge excision of the ulcer in 9 patients, and vagotomy and pyloroplasty in 21 patients. The follow-up evaluation was performed in 91 percent of the patients (mean 9 years postoperatively, range 5 to 15 years), with emptying endoscopy in all nonresected patients. A high mortality was observed after total or proximal gastrectomy, as well as after nonresective procedures. After the other resective techniques, low postoperative morbidity and mortality were observed. No recurrent ulcer was seen after the resective procedures. Based on these results, we propose that when the ulcer is located 5 cm below the cardia, Schoemaker's or Pauchet's procedure should be performed; if the ulcer is located 2 cm or less from the cardia, Csendes' procedure or the Kelling-Madlener procedure should be employed.

Pylorectomy and prepyloric antrectomy for gastric ulcer

From July 1970 to May 1977 79 patients with chronic gastric ulcer were submitted to a pylorectomy and prepyloric antrectomy (only 4--5 cm of the distal stomach being removed). In most, the excision extended in the form of a narrow tongue along the lesser curvature to include the ulcer. Vagotomy was added when signs of a healed or active duodenal ulcer were seen (19 cases). Associated lesions in the distal stomach were detected in 38 more patients. Up to the present no recurrence has been observed and functional results have been satisfactory in 90 per cent of patients. Preliminary results show that this operation produces a satisfactory cure for gastric ulcer, thus making more extensive resections unnecessary.

Recurrence of gastric ulcer after selective vagotomy and pyloroplasty for chronic uncomplicated gastric ulcer: a 5-10 year follow-up

Selective vagotomy and pyloroplasty were used in the surgical treatment of 73 patients with benign gastric ulcer between July 1964 and February 1970. Over the long period of observation recurrence of the gastric ulcer was found in 13 patients (19-1 per cent). This complication occurred equally commonly after treatment of primary and secondary gastric ulcers and was twice as frequent in women as in men. Possible reasons for these recurrences are discussed. It is concluded that vagotomy and pyloroplasty cure benign gastric ulcer in about 80 per cent of patients, and this should be taken into account in the choice of surgical treatment, especially in patients in whom a gastrectomy might put the patient's life at risk. However, because of the high recurrence rate, it is doubtful whether this operation should be considered the treatment of choice for all cases of gastric ulcer.

Vagotomy and pyloroplasty in the elective treatment of gastric ulcer

Vagotomy and pyloroplasty have been used in the elective treatment of gastric ulcer in 72 patients. In 33 patients there was associated duodenal ulcer (G.D.U.). In the other 39 patients (G.U.) there was no evidence of duodenal ulcer. Patients with prepyloric gastric ulcer were excluded. The operative mortality was nil.

At an average follow-up of 3 1/2 years the functional results in the G.U. group were good for 89 per cent of the cases, satisfactory for 5-5 per cent, and poor for 5-5 per cent compared with 73, 10, and 17 per cent respectively in the G.D.U. group. Two patients in each group showed recurrent ulcer, an incidence of 5-4 per cent in the G.U. group and 6-7 per cent in the G.D.U. group. There is no statistically significant difference in these results.

Vagotomy and pyloroplasty appear to comprise a satisfactory treatment for gastric ulcer whether or not the ulcer is associated with duodenal ulcer. The present findings do not support the view that the good results previously reported were due to the inclusion of patients with pre-pyloric gastric ulcer or with associated duodenal ulcer.

Three patients showed malignancy in the ulcer and a further case has been recorded in the total of 102 patients undergoing surgery during the period of the review (an incidence of 4 per cent), underlining the need for biopsy of the ulcer in all cases.

Treatment of gastric ulcer by highly selective vagotomy without a drainage procedure: an interim report

Fourteen patients with gastric ulcer alone and 5 patients with combined gastric and duodenal ulceration- have been treated by highly selective (parietal-cell) vagotomy without a drainage procedure (H.S.V.) the past 3 years. Before operation no evidence of gastric stasis was found, clinically, radiologically, or during tests of gastric secretion. Spontaneous acid out was low. Acid output in response to a test meal of meat extract was also found to be low. There no evidence that in the patients with gastric ulcer alone the ulcer was due to pyloric channel disease with excessive release of gastrin by the antrum.

Each gastric ulcer was proved by frozen-section examination to be benign at the time of operation. Problems with gastric stasis were encontered in early postoperative period. The vagotomy was shown to be complete on insulin testing in each of 17 patients tested.

Follow-up ranges from 1 month to 3 years. The clinical progress of the patients has been good, and has symptoms suggestive of recurrent ulceration gastric retention. Barium-meal examination in 11 patients who were follwed up for more than 9 months showed satisfactory gastric emptying, without recurrent ulceration. While the need for much longer follow-up is obvious, these preliminary results are encouraging. Further trial of H.S.V. for gastric ulcer, preferably in the form of a prospective, randomized comparison with Billroth-I gastrectomy, now seems desirable.

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.