Peroperative grading of pyloric stenosis: a long term clinical and radiological follow-up of patients with severe pyloric stenosis treated by highly selective vagotomy and dilatation of the stricture

The outcome of fluoroscopically guided balloon dilation of pyloric stricture in Crohn disease

PURPOSE

To evaluate the clinical efficacy and safety of fluoroscopically guided balloon dilation for pyloric stricture associated with Crohn disease (CD) while monitoring the outcome.

MATERIALS AND METHODS

Five patients (age range 15-34 y) were diagnosed with symptomatic pyloric stricture associated with CD between November 2006 and August 2009. All five patients underwent fluoroscopically guided balloon dilation one or more times.

RESULTS

The initial balloon dilations were technically successful in all patients. Two patients showed improvement of symptoms without further need of dilation, two patients had one more session of dilation, and one patient underwent two more sessions of repeated dilation. There were no procedure-related complications. Overall technical and clinical success rates were 100%. After the last dilation, all patients remained healthy, with no case of relapse of obstructive symptoms during the median follow-up of 16 months (range 6-22 mo).

CONCLUSIONS

Fluoroscopically guided balloon dilation seems to be a useful tool for management of symptomatic pyloric stricture in CD and may be a viable alternative to open surgery.

Benign strictures of the esophagus and gastric outlet: interventional management

Benign strictures of the esophagus and gastric outlet are difficult to manage conservatively and they usually require intervention to relieve dysphagia or to treat the stricture-related complications. In this article, authors review the non-surgical options that are used to treat benign strictures of the esophagus and gastric outlet, including balloon dilation, temporary stent placement, intralesional steroid injection and incisional therapy.

Benign duodenal strictures: treatment by means of fluoroscopically guided balloon dilation

Fluoroscopically guided balloon (15 or 20 mm in diameter) dilation was performed on eight patients with benign duodenal strictures caused by peptic ulcers (n = 6), Crohn's disease (n = 1), and postoperative adhesion (n = 1). The procedure was technically and clinically successful without complications in seven of the eight patients (88%). Duodenal perforation occurred immediately after 20-mm-diameter balloon dilation in one patient who underwent emergency surgery. During the mean follow-up of 30 months (range, 2-103 months), there was recurrence in two of the seven patients (29%) who then underwent surgery. The other five patients (71%) showed good results with no recurrence.

Gastric outlet obstruction

Acquired gastric outlet obstruction is more commonly owing to malignancy than ulcer disease. Endoscopy is the preferred method for diagnosis. Surgical palliation for malignant disease has poor results and high rates of morbidity and mortality. Initial experiences with endoscopic palliation with expandable metallic endoprostheses appear promising. Peptic ulcer-induced gastric outlet obstruction can be treated safely with endoscopic balloon dilation. About 65% of patients have sustained symptom relief, but many require more than one dilation session. Outcomes may be improved with effective ulcer therapy with acid reduction and eradication of H. pylori. Surgery is associated with significant morbidity and mortality and should be reserved for endoscopic treatment failures.

Prospective randomized study comparing three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer

A prospective randomized clinical trial was performed in order to evaluate the results of three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer. Ninety patients with clinical and laboratory evidence of gastric retention were enrolled. After laparotomy, patients underwent either highly selective vagotomy (HSV) + gastrojejunostomy, HSV + Jaboulay gastroduodenostomy, or selective vagotomy (SV) + antrectomy. One patient died after HSV + Jaboulay gastroduodenostomy due to postoperative acute pancreatitis. There were no differences in the postoperative course of the three groups. Patients were followed for a mean of 98 months (range: 30 to 156 months). There was a significantly better result after HSV + gastrojejunostomy than after Jaboulay anastomosis (p < 0.01), but not after SV + antrectomy. Gastric acid reduction was similar in the small group of patients studied. We propose HSV + gastrojejunostomy as the treatment of choice in patients with duodenal ulcer and gastric outlet obstruction.

Change of gastric liquid emptying after highly selective vagotomy and pyloric dilatation for patients with obstructing duodenal ulcer

Gastric liquid emptying was studied in duodenal ulcer patients with and without stenosis before highly selective vagotomy (HSV) and 1 week, 3 months, and 1 year after. The test meal consisted of 1 mCi of 99m Technetium-diethylene penta-acetic acid (DTPA) in 500 ml of isotonic saline. The patients were divided into 2 groups: group 1 (16 cases) without clinical stenosis, who underwent HSV alone, served as control; group 2 (14 cases) with mild to moderate stenosis, who underwent HSV and transgastric dilatation to 20 mm in diameter. Before HSV, the stenotic group showed a significantly slower liquid emptying than the nonstenotic. Most of the stenotic group could resume a normal diet quickly after operation, but they still had prolonged liquid emptying. At 3 months, the emptying curve of the stenotic patients had approached that of the preoperative controls without a significant difference, while the nonstenotic patients showed an accelerated initial emptying. Although there was a significant improvement with the appearance of accelerated initial emptying at 1 year, the stenotic group still demonstrated slightly slower emptying than the nonstenotic group. A temporary state of preexistent gastric atony due to chronic outlet obstruction may explain the delayed emptying in the early postoperative period; however, minor residual resistance in the fibrotic, scarred tissue was postulated to be persistent despite dilatation, and responsible for the slower emptying of the stenotic than the nonstenotic group at 1 year.

Parietal cell vagotomy and dilatation for peptic duodenal stricture

Gastric outlet obstruction due to peptic duodenal stricture (pyloric stenosis) was treated with parietal cell vagotomy and dilatation of the stricture in 32 patients. Follow-up is in the range of 5 years in 37.4% of the patients, while 6 to 10 years follow-up is available in 62.4% of the patients. At their last follow-up, 74.9% of the patients were in either Visick 1 or 2 clinical status. Recurrence rates have been 3.1% at 1 year, 9.3% at 5 years, and 21.8% after 6 to 10 years follow-up. There has been only one instance (3.1%) of restenosis. Two patients required reoperation because of recurrence and one of them died.

Role of highly selective vagotomy and duodenoplasty in the treatment of postbulbar duodenal obstruction

The indications for highly selective vagotomy have expanded in recent years, with the technique being applied to selected cases of perforation and bleeding. Its use in obstruction is controversial, but two options are available for managing the stenotic pylorus or duodenum: dilatation or duodenoplasty. The latter choice requires that the stenosis be located in the postbulbar area. Since 1981, we have managed 15 patients with postbulbar stenosis by means of highly selective vagotomy and duodenoplasty. All patients had a previous history of ulcer disease, and vomiting was a consistent symptom. All patients were referred for surgery, 10 by a gastroenterologist. There was no operative mortality or procedure-related morbidity. Two patients have been lost to follow-up. Both were classified as Visick I and had normal endoscopic results at their last visit. The remaining 13 patients have all been followed very recently. Twelve patients (92%) are currently classified as Visick I or II. One patient (Visick IV), who was essentially asymptomatic, was found to have a recurrent ulcer on endoscopy. Endoscopic (11 patients) or radiographic (1 patient) patency of the duodenoplasty has been demonstrated in 12 patients. Highly selective vagotomy and duodenoplasty should be a surgical consideration when the pathologic anatomy of the duodenum lends itself to that choice.

Indications for parietal cell vagotomy without drainage in gastrointestinal surgery

Parietal cell vagotomy (PCV) was used for a variety of gastrointestinal conditions in 658 patients. Operative and late related deaths after PCV were 1.1% (3/273) in patients with intractable duodenal ulcers, 1.1% (1/91) in perforated ulcers, 0% (0/43) in Type I gastric ulcers, 0% (0/45) in pyloric and prepyloric ulcers, 3.2% (6/188) when combined with fundoplication, 8.7% (2/23) when combined with vascular surgery, and 4.2% (1/24) in ulcer patients with acute bleeding. The recurrent ulcer rate after PCV was 8.4% in patients operated on for duodenal ulcer, 6.4% for perforated ulcer, 5.3% for bleeding ulcers, 10% for Type I gastric ulcers, and 31% for pyloric and prepyloric ulcers. PCV was preferred to total gastrectomy in four patients in whom a gastrinoma could not be located. PCV was used in 188 patients with reflux esophagitis and in 12 patients with achalasia to facilitate fundoplication and placement of the myotomy, respectively. Based on the results of the study, PCV is contraindicated in patients with pyloric and prepyloric ulcers. PCV is not recommended when traumatic dilatation of the pylorus is required to overcome obstruction. PCV may have limited application in patients with bleeding ulcers and Type I gastric ulcers. In our experience PCV is not contraindicated in patients with ulcers resistant to H2 receptor antagonists. PCV may be contraindicated when acid hypersecretion exceeds an as-yet undetermined level. PCV is an ideal procedure for intractable duodenal ulcers and perforated ulcers.

Postoperative gastric atony after vagotomy for obstructing peptic ulcer

From 1979 through 1984, truncal vagotomy and drainage were performed in 71 patients with symptomatic obstructing peptic ulcers, whereas proximal gastric vagotomy with or without drainage was performed in 30 patients. Seven patients (7 percent) developed prolonged early postoperative gastric atony. Six of the 71 patients (8 percent) who had truncal vagotomy had atony, whereas only 1 of the 30 patients (3 percent) with proximal gastric vagotomy had atony (p = 0.08). The atony resolved with medical management in all patients after a median of 23 days. At follow-up (median 3 years), 74 percent of patients with truncal vagotomy had an excellent or good result compared with 86 percent of those with proximal gastric vagotomy (p greater than 0.1). The conclusion was that prolonged early postoperative gastric atony occurs uncommonly after vagotomy for obstructing peptic ulcer. Preservation of antropyloric innervation by using proximal gastric vagotomy instead of truncal vagotomy may be helpful, but does not completely prevent the atony.

[Surgical therapy of stenosing duodenal ulcer--results of an uncontrolled comparative study]

In an uncontrolled trial on 77 patients we investigated the results of different surgical procedures in stenosis secondary to duodenal ulcer. The assignment to a procedure was dependent on the preference of the surgeon. The follow-up investigation after a mean observation time of 40-42 months was performed without knowledge of the surgical procedure. The postoperative mortality was 6.6% after resection, 0% after vagotomy and drainage. Postoperative sequelae were lowest in highly selective vagotomy + gastroduodenostomy (Visick I in 15 out of 17). After resection only 15 out of 33 had Visick I. The worst result was obtained after selective vagotomy and pyloric dilatation (4 out of 9 Visick IV). This procedure has been given up.

Highly selective vagotomy with dilatation or duodenoplasty. A surgical alternative for obstructing duodenal ulcer

Highly selective vagotomy (HSV) is an accepted choice for the treatment of uncomplicated duodenal ulcer. Its use in patients with gastric outlet obstruction, however, remains quite controversial. Since 1980, 69 patients have undergone HSV at the Medical College of Georgia Hospitals. Of these, 20 (29%) underwent either dilatation (14) or duodenoplasty (6) for accompanying outlet obstruction. The obstruction was graded as severe in 17 (85%) and moderate in three (15%). Follow-up evaluation has included Visick grading and endoscopy. There have been two deaths (38 and 54 months following surgery). Both patients were Visick I. Of the 18 patients available for review to date, 12 (67%) are Visick I and four (22%) are Visick II. There have been two failures (11%), discovered only by endoscopic follow-up in asymptomatic patients. No patients have required reoperation. HSV with dilatation or duodenoplasty is a reasonable surgical alternative for the treatment of obstructing duodenal ulcer disease.

Preliminary experience with hydrostatic balloon dilation of gastric outlet obstruction

In treating a group of 15 patients with gastric outlet obstruction, 12 (80%) had good to excellent relief of symptoms. Two patients required surgical intervention. One patient has symptoms that were persistent but mild enough to forego surgery. Balloon dilation offers an alternative to the surgical management of gastric outlet obstruction.

Duodenal ulcer perforation whilst on cimetidine therapy

Nine cases of perforation whilst patients received cimetidine therapy were identified and followed prospectively. There was a high correlation with the other major complications of duodenal ulceration: pyloric stenosis and haemorrhage. Initially, three of the nine patients had simple suture of the perforation, but eventually all required truncal vagotomy and a drainage procedure. The follow-up ranges from 6 months to 2.5 years and the results in the surviving patients are good. The preoperative identification of this group, being established medical failures with the high probability of requiring necessary definitive surgery, will aid the surgical management of this condition.

Highly selective vagotomy in duodenal ulceration and its complications. A 12-year review

Highly selective vagotomy (HSV) was performed in 509 patients over 12 years for the surgical management of duodenal ulceration; 103 HSVs were carried out during the treatment of complications. The overall rate of ulcer recurrence was 7%, ranging from 10% in the first 4 years to 4% in the 6 years between 1975 and 1980. Highly selective vagotomy was performed in addition to closure of a perforated ulcer in 16 patients, with no recurrent ulcers or re-perforations. After the control of their bleeding duodenal ulcers, 25 patients had HSV with no rebleeding, although two patients had recurrent ulceration. Highly selective vagotomy was performed in 62 patients with stenosis in addition to dilatation (44) or duodenoplasty (18). There was a high incidence of recurrent ulceration (7) and stenosis (9) with digital dilatation while duodenoplasty gave better results with one recurrent stenosis and no recurrent ulceration. The authors conclude that HSV is justified by its late results as a definitive operation in chronic duodenal ulceration that allows preservation of the pylorus during surgery for complications.

Parietal cell vagotomy for intractable and obstructing duodenal ulcer

Parietal cell vagotomy can be accomplished with minimal morbidity and mortality. Symptoms and signs of delayed gastric emptying early after operation are common and occur more frequently in patients with preoperative gastric outlet obstruction than in those without, a difference that is statistically significant. These symptoms are generally mild and transient. Dumping and diarrhea were not problems in our series. In patients with preoperative gastric outlet obstruction, parietal cell vagotomy with pyloroduodenal dilatation achieved good or excellent results in 79 percent of patients; however, the possibility of a higher recurrence rate requires further evaluation and suggests caution and selectivity in the use of this procedure. The recurrence rate of 3 percent of these patients without gastric outlet obstruction and a very good or excellent clinical result in 91 percent of these patients appear acceptable and encourage us to continue to use parietal cell vagotomy as the procedure of choice in patients with intractable duodenal ulcer. Most patients with recurrent ulcer have been treated medically with success. Close long-term clinical follow-up studies will be required to assess better the success of this procedure.

Highly selective vagotomy and pyloric dilatation for duodenal ulcer with stenosis

This paper presents the results obtained in 15 patients with duodenal ulcer and stenosis who were treated more than 3 years ago by highly selective vagotomy (HSV) and dilatation of the stenosis without a gastric drainage procedure. Patients were taking solid food 3--6 days postoperatively and were discharged after 7--14 days. There have been no recurrent stenoses. Fourteen of the 15 patients were Visick grade 1 or 2 at their last visit. One patient has a recurrent ulcer, but no restenosis. Barium meals performed on 6 patients with severe stenosis preoperatively showed satisfactory gastric emptying 1--3 years postoperatively. HSV and pyloric dilatation seems to be a safe and effective procedure for the treatment of pyloric stenosis due to chronic duodenal ulceration.

Parietal cell vagotomy

Although long-term follow-up data have not been obtained, it appears that parietal cell vagotomy for the treatment of intractable duodenal ulcer is withstanding the test of time. Operative mortality and morbidity are low, as is the incidence of side effects. The majority of patients who have a recurrent ulcer improve with medical therapy, and only a minority require reoperation.

[Influence of pyloroplasty and pyloric stenosis on motoric and secretory function of the stomach after selective proximal vagotomy--an experimental study (author's transl)]

In conscious fullgrown minipigs simple SPV alone, SPV and pyloric stenosis and SPV and pyloroplasty were performed. After a liquid test meal the motoric and secretory function of the stomach were examined simultaneously by a modified method of intestinal perfusion and aspiration. After simple SPV initially a marked decrease of gastric volume and normal emptying into the duodenum were found. With additional pyloric stenosis no significant change was found. The pyloroplasty lead to an increase of gastric volume and delayed emptying. The acid secretion after feeding reduced by SPV was not changed significantly neither by pyloroplasty nor by pyloric stenosis. The baseline values of serum gastrin were elevated after SPV as well as after SPV in combination with pyloric stenosis or pyloroplasty. After food stimulation there was a delayed increase of gastrin after SPV which differed from that after SPV with pyloric stenosis or pyloroplasty only during the first hour. These results show that after SPV no further improvement of the motoric and secretory function can be achieved by an additional pyloroplasty. Furthermore these findings permit the conclusion that even after SPV with additional artificial pyloric stenosis no delayed gastric emptying occurs and that there is no negative effect postoperatively on the acid secretion and gastrin production.

The combination of proximal gastric vagotomy with a rotational posterior gastropexy for duodenal ulcer

Preoperative oesophageal reflux symptoms have been controlled and the emergence of such symptoms de novo prevented in duodenal ulcer patients by combining proximal gastric vagotomy with a rotational posterior gastropexy. Fifty-two patients having such operations are compared with 46 patients treated by proximal gastric vagotomy (PGV) alone. The two groups match for age, sex and weight but there were more grade 3 refluxers in the group having rotational posterior gastropexy (28) than among those having proximal gastric vagotomy alone (5).

Six out of 28 patients in the PGV group who did not have preoperative regurgitation symptoms developed acid brash postoperatively on a 1–6½-year follow-up as against none of 17 patients in the other group. One year follow-up was complete in 94 cases and 57 had a 3·–6½-year follow-up. The 95 per cent confidence limits for cure of grade 3 reflux symptoms by the combined PGV and gastropexy operation were 44·7–88·7 for heartburn and 57·8–97·5 for regurgitation. Postoperative dysphagia can be minimized by attention to a few details during performance of the simple gastropexy procedure.

A pentagastrin-glucose pH monitoring test has been devised for this study. When the mean duration of reflux episodes during the 1 h after pentagastrin and the 1 h after 200 ml of 20 per cent glucose is plotted against the number of such episodes, the differences indicate that PGV impairs whilst PGV and gastropexy improves function at the gastro-oesophageal junction. Faber's peak acid output (PAO1) discriminant (Faber et al., 1975) was first used to define positive insulin tests in males. Such positive cases have been reported as having a 50 per cent chance of developing recurrent ulceration. We found that 9 out of 31 patients in the PGV group were positive at 1 year as against 2 out of 28 patients having the combined operation (P&lt;0·05). We have now applied Maybury's criterion (Maybury et al., 1977) of PAO1 adjusted for height to our results. Significant differences between the two operations were only evident after a curve derived from Maybury's data was increased by 50 per cent and then applied to our results. Nine out of 36 of the PGV group as against 1 out of 36 of the PGV and gastropexy group were positive by this test (P&lt;0·01). Addition of such a procedure to PGV may reduce the ulcer recurrence rate after PGV alone.