Antrectomy for recurrent ulcer after parietal cell vagotomy

[Billroth I hemigastrectomy in complicated recurrent ulcer after selective proximal vagotomy]

The outcome of Billroth I hemigastrectomy for complicated recurrent ulcers after proximal selective vagotomy (PSV) for duodenal ulcer was analyzed in a retrospective study of 15 patients followed up for 15-81 months (mean 3.8 years) postoperatively. Bleeding was reported in 4, stenosis in 5, penetration in 3, perforation in 1 and refractory ulcer in 2 cases. None of the patients died during revision surgery, and none developed ulcer recurrence. In 4 patients complications were seen, including bleeding requiring relaparotomy (1) and subhepatic hematoma (3). In 12 patients (80%) a good or excellent result (Visick I/II) was seen at follow-up. Reasons for Visick III or Visick IV classification were reflux esophagitis grades I and II in 2 cases and refractory dyspeptic symptoms in 1 case. Distal gastric resection with a Billroth I anastomosis for complicated recurrent ulcer after PSV proved to involve only low morbidity and to effect reliable prophylaxis of ulcer recurrence in the long term.

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.

Clinical results of reoperation after failed highly selective vagotomy

The results after reoperation after failed highly selective vagotomy during a 10 year period have been reviewed retrospectively. Forty of 306 patients (13 percent) underwent reoperation due to recurrent ulcer (25 patients), severe dyspepsia without proved recurrence (12 patients), and gastric stasis without recurrence (3 patients). In the first two groups, 16 patients had a second vagotomy and 17 underwent partial gastrectomy, 10 with gastroduodenostomy and 7 with gastrojejunostomy. The need for a second reoperation was disquietingly high after both revagotomy (5 of 16 patients) and partial gastrectomy with gastroduodenostomy (4 of 10 patients). These results contrasted with a successful outcome in all seven patients who underwent reoperation with partial gastrectomy and gastrojejunostomy. At the time of follow-up, 85 percent of the reoperated patients (34 of 40 patients) were in Visick grade 1 or 2 as determined by their own judgement.

Prospective controlled vagotomy trial for duodenal ulcer: results after five years

A prospective, randomized, controlled trial was performed to study truncal vagotomy and drainage (TV), selective vagotomy and drainage (SV) and parietal cell vagotomy (PCV) as elective treatment for duodenal ulcer. Five years postoperatively, 233 patients were available for study: 73 TV, 81 SV and 79 PCV. The ulcer recurrence rates were 13.6, 19.8 and 30.4 per cent respectively. The incidence of severe dumping was 4.9, 10.9 and 1.9 per cent; of severe diarrhoea 4.9, 6.3 and 1.9 per cent; of severe pain/dyspepsia 3.3, 6.3 and 3.8 per cent and of severe nausea/vomiting 0, 1.6 and 0 per cent respectively. Women suffered more postvagotomy symptoms than men. After treatment of recurrences and postvagotomy symptoms, more patients after PCV achieved excellent results than after TV and SV, as recurrences were easier to treat than severe postvagotomy symptoms. The only factor found contributing to the high ulcer recurrence following PCV was the large number of surgical trainees operating in the trial.