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

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.

In vitro and in vivo technique for assessing vagus nerve regeneration after parietal cell vagotomy in the rat

This study determined if the vagus nerve can regenerate and/or reinnervate the gastric parietal cell mass after parietal cell vagotomy (PCV) and examines tests for assessing vagus nerve regeneration in rats. Microscopic dissection of the neurovascular bundle allowed the vagus nerve to be divided at the gastric body with preservation of the antropyloric nerve and gastric vasculature. Gastric secretory tests were performed under basal and stimulated conditions using secretagogues and insulin hypoglycemia. The candidate hormone, pancreatic polypeptide, was measured in plasma following a mixed meal, insulin hypoglycemia and i.v. secretin. Rats were killed weekly for 9 weeks and the vagal nerve distribution examined by both light and electron microscopy. Stimulated gastric acid output fell from 164 to 26 mumol/h immediately after operation (P less than 0.001). One week following PCV, the nerves were swollen with fibroblast infiltration and collagen around axon groups showed degeneration. By the third week after PCV, the axons were more densely packed with neurofilaments and acid output had increased to 183 mumol/h. In the fourth and fifth weeks, the enlarged Schwann cell processes had more axons and acid output rose to 262 mumol/h. By the seventh week, both large and small axons were identified and the acid output was 93% higher than the preoperative level (P less than 0.001). PCV and antrectomy also was followed by reinnervation of the gastric mucosa. Pancreatic polypeptide concentration in plasma was virtually unchanged following ingestion of food, insulin hypoglycemia or secretin. In rats, following PCV, gastric secretory tests and electron microscopy seem to be the most reliable methods of assessing vagus nerve regeneration.