The Aarhus County vagotomy trial. I. An interim report on primary results and incidence of sequelae following parietal cell vagotomy and selective gastric vagotomy in 748 patients

Function-preserving gastrectomy for gastric cancer in Japan

Surgery used to be the only therapy for gastric cancer, and since its ability to cure gastric cancer was the focus of attention, less attention was paid to function-preserving surgery in gastric cancer, though it was studied for gastroduodenal ulcer. Maki et al developed pylorus-preserving gastrectomy for gastric ulcer in 1967. At the same time, the definition of early gastric cancer (EGC) was being considered, histopathological investigations of EGC were carried out, and the validity of modified surgery was sustained. After the development of H2-blockers, the number of operations for gastroduodenal ulcers decreased, and the number of EGC patients increased simultaneously. As a result, the indications for pylorus-preserving gastrectomy for EGC in the middle third of the stomach extended, and various alterations were added. Since then, many kinds of function-preserving gastrectomies have been performed and studied in other fields of gastric cancer, and proximal gastrectomy, jejunal pouch interposition, segmental gastrectomy, and local resection have been performed. On the other hand, from the overall perspective, it can be said that endoscopic resection, which was launched at almost the same time, is the ultimate function-preserving surgery under the current circumstances. The current function-preserving gastrectomies that are often performed and studied are pylorus-preserving gastrectomy and proximal gastrectomy. The reasons for this are that these procedures that can be performed with systemic lymph node dissection, and they include three important elements: (1) reduction of the extent of gastrectomy; (2) preservation of the pylorus; and (3) preservation of the vagal nerve. In addition, these operations are more likely to be performed with a laparoscopic approach as minimally invasive surgery. Of the above-mentioned three elements, reduction of the extent of gastrectomy is the most important in our view. Therefore, we should try to reduce the extent of gastrectomy if curability of the gastric cancer can still be achieved. However, if we preserve a wider residual stomach in function-preserving gastrectomy, we should pay attention to the development of metachronous gastric cancer.

The gastric mucosa 25 years after proximal gastric vagotomy

OBJECTIVE

Vagotomy causes inhibition of basal and post-prandial acid secretion in humans, but the knowledge about the trophic effect of the vagal nerves is limited. Vagotomy is known to induce hypergastrinemia and we aimed to study the long-term effects of proximal gastric vagotomy (PGV) on the oxyntic mucosa and the enterochromaffin-like (ECL) cell density in particular.

MATERIAL AND METHODS

Eleven patients operated with PGV because of duodenal ulcer and age- and sex-matched controls were examined 26 to 29 years postoperatively by gastroscopy with biopsies from the antrum and oxyntic mucosa. Neuroendocrine cell volume densities were calculated after immunohistochemical labeling of gastrin, the general neuroendocrine cell marker chromogranin A (CgA) and the ECL cell marker vesicular monoamine transporter 2 (VMAT2). Gastritis was graded and Helicobacter pylori (H. pylori) status was determined by polymerase chain reaction of gastric biopsies. Fasting serum gastrin and CgA were measured.

RESULTS

Serum gastrin was higher in the PGV group compared to controls (median 21.0 [interquartile range (IQR) = 22.0] pmol/L vs 13.0 [IQR = 4.0] pmol/L, p = 0.04). However, there was neither a significant difference in serum CgA or in CgA (neuroendocrine) nor VMAT2 (ECL cell) immunoreactive cell volume density in the oxyntic mucosa. There was significantly more inflammation and atrophy in H. pylori-positive patients, but PGV did not influence the grade of gastritis.

CONCLUSION

Despite higher serum gastrin concentrations, patients operated with PGV did not have higher ECL cell mass or serum CgA. Vagotomy may prevent the development of ECL cell hyperplasia caused by a moderate hypergastrinemia.

Jejunal interposition to prevent postgastrectomy syndromes

BACKGROUND

Postgastrectomy syndromes include reflux gastritis and oesophagitis, dumping syndrome, intractable diarrhoea and afferent loop syndrome. To prevent such syndromes, since January 1994 jejunal interposition has been used following distal gastrectomy. The aim of this study was to evaluate the benefit of this procedure.

METHODS

A consecutive series of 42 patients who underwent distal gastrectomy for gastric cancer was studied. Twenty-two patients had a Billroth I procedure before January 1994, and 20 patients had isoperistaltic jejunal interposition using a 10-12-cm segment after January 1994.

RESULTS

The mean operating time was 260 min for Billroth I and 352 min for jejunal interposition. No serious postoperative complications arose. Reflux gastritis occurred in 19 patients after Billroth I but in none after jejunal interposition. Five patients in the Billroth I group had complaints consistent with dumping syndrome, compared with none after jejunal interposition. The barium gastric emptying time was significantly shorter after Billroth I (mean(s.d.) 269(225)s) than after jejunal interposition (736(479) s) (P < 0.01).

CONCLUSION

Jejunal interposition prevented reflux gastritis and inhibited rapid gastric emptying. Postgastrectomy syndromes were effectively prevented by this reconstruction procedure.

Vagotomy

Peptic ulcer disease was for years a common indication for surgery in Danish hospitals and considerable experience in partial gastrectomy was gained. In spite of an unquestionable mortality rate and a number of patients having postgastrectomy complaints, results were generally recognized as acceptable. Danish surgeons were for long reluctant to take up vagotomy and drainage as a primary ulcer operation, but when they did start a large number of procedures were performed. In fact, the use of this treatment culminated during two to three decades. However, on a basis of experiences from these years, Danish research contributed actively to the international evolution of the surgical vagotomy technique, the evaluation of clinical results and the studies of postoperative alterations in gastric physiology. References are selected from an extensive literature and are in no way complete.

The importance of the pylorus as a regulator of solid and liquid emptying from the stomach

The role of the pylorus in the control of gastric emptying of liquids and digestible solids was investigated in the present study by pylorus excision in six pigs. The pylorus was left intact in another six pigs. Antro-pyloro-duodenal motility was recorded by a sleeve sensor and side holes. Liquid emptying was significantly more rapid in pylorus excised than in pylorus intact animals, during intraduodenal infusion of isosmolar dextrose (712 mL vs 107 mL), fatty acid (402 mL vs 46 mL), amino acids (752 mL vs 112 mL), 25% dextrose (392 mL vs 51 mL) and 3 normal saline (705 mL vs 157 mL). In pylorus excised animals, in contrast to pylorus intact animals, the manometric pattern of isolated pyloric pressure waves at the distal stomach was rarely seen (P < 0.05). In a second series of experiments, pylorus excised animals emptied significantly more (P < 0.04) meat over 120 min (181 g) than pylorus intact animals (80 g), but the proportion of particle sizes emptied was unaltered. In the pig, localized pyloric contractions are important for retardation of gastric emptying when nutrient or hyperosmolar solutions enter the duodenum. By contrast, the pylorus is unimportant in determining the size of solid particles emptied from the stomach.

The successful application of jejunal interposition for severe dumping syndrome: report of a case

We report herein the case of a 76-year-old man with intractable dumping syndrome which had manifested itself 3 years after he underwent a gastric resection and Billroth I reconstruction for a gastric ulcer. Despite aggressive medical therapy by the time of admission, he had suffered from disabling dumping symptoms for 9 years. In an attempt to relieve these symptoms, a 15-cm segment of the jejunum was placed isoperistaltically between the lesser curvature of the remnant stomach and the duodenum, and a selective vagotomy was performed. The dumping symptoms that he had experienced preoperatively completely disappeared after the revisory surgery. Postoperatively, an upper gastrointestinal series demonstrated a larger gastric pouch and slower gastric passage into the small intestine than what was seen preoperatively, while gastric emptying studies using the acetaminophen method also showed normal patterns in both the early and late postoperative phases. Thus, we consider that this surgical procedure is a simple and effective way to inhibit rapid gastric emptying and to slow intestinal transit in the treatment of dumping syndrome.

Twenty years after parietal cell vagotomy or selective vagotomy antrectomy for treatment of duodenal ulcer. Final report

OBJECTIVE

This study was a prospective, randomized evaluation of parietal cell vagotomy (PCV) and selective vagotomy-antrectomy (SV-A) in the treatment of duodenal ulcer.

BACKGROUND DATA

Operative treatment of duodenal ulcer is associated with mortality and mechanical and metabolic morbidity. At the time that surgeons appear to have succeeded in developing operations with low morbidity and mortality, the number of patients requiring elective operation has decreased partly because of the simultaneous, dramatic improvement in medical therapy. Nevertheless, surgical therapy still is important, especially in certain socioeconomic environments.

METHODS

After a pilot study of PCV, 200 patients with duodenal ulcers were randomized to PCV or SV-A. One surgeon was responsible for the operations and follow-up studies. An attempt was made to evaluate all patients annually in the hospital. Gastric analyses were performed on each visit, for which the patient gave his/her consent.

RESULTS

There was no operative mortality. The recurrence rate-by-life table analysis was less (p < 0.003) after SV-A than PCV. Dumping was greater (p < 0.001), and there was no difference in the frequency of diarrhea after SV-A compared with PCV. The percentage of patients with grades Visick I or Visick II was not different for the two operations, but more patients were graded Visick I after PCV than after SV-A.

CONCLUSIONS

Selective vagotomy-antrectomy and parietal cell vagotomy are effective and safe operations, when used appropriately. Selective vagotomy-antrectomy is preferable for patients with pyloric and prepyloric ulcers and pyloric obstruction. Parietal cell vagotomy is the authors' choice for duodenal ulcer patients because of the occasional patient who becomes disabled by SV-A.

Bleeding duodenal ulceration: the results of emergency treatment with highly selective vagotomy

We report the results of a prospective study of all patients undergoing highly selective vagotomy (HSV) for bleeding duodenal ulceration (BDU) at Concord Hospital between 1979 and 1989. Highly selective vagotomy was undertaken in 63 patients (58 male, 5 female) with a median age of 69 years (range: 16-89). Fifty-five patients were reviewed, 7 patients having died in the peri-operative period and one being lost to follow-up. The mean period to review was 50 months (range: 1-120). Thirty-six patients have been followed-up for more than 24 months. Thirty-day postoperative mortality was 11% (7 patients). Combined major and minor morbidity was 41%. Postoperative rebleeding occurred in four patients (6.3%), three of whom died. Ulceration had recurred in two of 55 patients (4%). Symptoms have been evaluated in 55 patients since operation and 93% have been graded as Visick I or II. We conclude that HSV is effective in the emergency treatment of BDU and has few long-term sequelae.

Highly selective vagotomy in the treatment of complicated duodenal ulcer

Highly selective vagotomy has been utilized urgently in 33 patients with bleeding duodenal ulcer, 16 patients with pyloric stenosis and six patients presenting with perforated ulcer. Five patients died after surgery for bleeding duodenal ulcer, and two patients rebled after surgery. Forty-eight patients were reviewed at a mean of 28 months with an excellent outcome being obtained in 45 patients. Two of the three patients with poor results had proven ulcer recurrence while the third patient required reoperation for recurrent pyloric stenosis. No patient has suffered diarrhoea after vagotomy. Highly selective vagotomy is an effective treatment for urgent management of complicated duodenal ulceration and is without troublesome post-vagotomy symptoms.

Survival after vagotomy: results of the Aarhus County Vagotomy Trial

In order to investigate whether the previously found excess mortality in surgically-treated patients with peptic ulcer might be due partly to the resections employed, a survival analysis was undertaken in 824 patients 8-13 years after different types of vagotomy. These patients had been submitted to selective gastric vagotomy with drainage, selective gastric vagotomy with antrectomy or parietal cell vagotomy with or without drainage for duodenal ulcer, pyloric ulcer, prepyloric ulcer, or combined ulceration during the period from 1972 to 1977. A statistically significant excessive mortality was found for both sexes in the total material compared to the background population. Analysis of the material, subdivided according to the operative methods employed, revealed a significant excess mortality in men treated with selective gastric vagotomy and antrectomy, whereas the mortality rates were slightly and insignificantly raised in the nonantrectomy groups. No significant difference in the mortality could be demonstrated in relation to the site of the ulcers. Analysis of the cause-specific mortality revealed a significantly raised mortality from gastrointestinal diseases, including a significant excessive mortality in the subgroups of benign peptic ulcer and cirrhosis of the liver. Likewise, the death rate from accidents including the subgroup of suicide was significantly increased. The overall mortality from malignancies was insignificantly raised among patients, whereas cancer in the stomach was significantly increased. An increased mortality from cancer in the lungs and pancreas did not reach statistical significance. These findings are in reasonable accordance with other studies. A significantly increased mortality from gastric cancer has been usual, although not a constant finding after gastric resection.(ABSTRACT TRUNCATED AT 250 WORDS)

Current status of proximal gastric vagotomy

Proximal gastric vagotomy is nearing its twentieth year in clinical use as an operation for peptic ulcer disease. No other acid-reducing operation has undergone as much scrutiny or study. At this time, the evidence of such studies and long-term follow-up strongly supports the use of proximal gastric vagotomy as the treatment of choice for chronic duodenal ulcer in patients who have failed medical therapy. Its application in treating the complications of peptic ulcer disease, which recently have come to represent an increasingly greater percentage of all operations done for peptic ulcer disease, is well-tested. However, initial series suggest that it should probably occupy a prominent role in treating some of these complications, particularly in selected patients, in the future. The operation has the well-documented ability to reduce gastric acid production, not inhibit gastric bicarbonate production, and also minimally inhibit gastric motility. The combination of these physiologic results after proximal gastric vagotomy, along with preservation of the normal antropyloroduodenal mechanism of gastrointestinal control, serve to allow patients with proximal gastric vagotomy the improved benefits of significantly fewer severe gastrointestinal side effects than are seen after other operations for peptic ulcer disease.

Clinical and radionuclide evaluation of Roux-Y diversion for postgastrectomy dumping

From 1973 to 1986, 22 patients underwent Roux-Y gastrojejunostomy for the early postgastrectomy dumping syndrome. In the early years, five patients underwent Roux-Y conversion with the addition of a 10 cm antiperistaltic jejunal segment interposed between the Roux-Y limb and the stomach. Within 4 years, all five patients had the jejunal segment removed due to severe symptoms of gastric retention. These patients underwent reconstruction to create Roux-Y limb only and joined the pool of 17 patients who underwent Roux-Y diversion only for the dumping syndrome. Overall, 19 of 22 patients (86 percent) had almost complete resolution of their dumping symptoms on long-term follow-up. Three patients showed no improvement, two with severe gastric retention and one with recurrent dumping symptoms. Overall, 5 of 22 patients (23 percent) had moderate to severe early and late postoperative gastric retention necessitating medical treatment in three and subsequent near-total gastrectomy in two. Although other procedures such as pyloric reconstruction or the addition of isoperistaltic or antiperistaltic jejunal interpositions have been reported to be equally successful in delaying gastric emptying and resolving dumping symptoms, we have preferred Roux-Y diversion for the treatment of combined alkaline reflux gastritis and dumping or the pure early vasomotor postgastrectomy dumping syndrome. As reported, we have abandoned the use of an antiperistaltic jejunal segment interposed between the stomach and the Roux-Y limb due to the high rate of postoperative gastric retention.

Effect of the pre-operative response to H2 receptor antagonists on the outcome of highly selective vagotomy for duodenal ulcer

From 1979 to 1984, 141 consecutive patients (110 men, 31 women) underwent highly selective vagotomy (HSV) for duodenal ulcer (DU). All patients had received pre-operative treatment with full dose H2 receptor antagonists (H2RA). Indications for surgery were: persistent relapse on withdrawal of H2RA, 107 (75.9 per cent); no response to H2RA, 30 (21.3 per cent); intolerance of H2RA, 1 (0.7 per cent); acute DU bleed, 2 (1.4 per cent); duodenal stenosis, 1 (0.7 per cent). Follow-up with a median of 47 months (24-85 months) revealed six patients (4.4 per cent) with endoscopically proven recurrence, three of whom were on non-steroidal anti-inflammatory drugs (NSAIDs). Only one patient with recurrent DU was a non-responder to H2RA pre-operatively. Twenty-five patients remained symptomatic after HSV without ulcer recurrence, of which a highly significant proportion (41 per cent) were non-responders (P less than 0.001). The pre-operative response to H2RA does not indicate the likelihood of ulcer recurrence after HSV. However, non-responders are more likely to continue with dyspeptic symptoms despite the successful healing of their ulcers. The DU recurrence rate in patients taking long-term NSAIDs is disappointingly high (33 per cent), putting the use of HSV in these patients into question.

Should it be parietal cell vagotomy or selective vagotomy-antrectomy for treatment of duodenal ulcer? A progress report

This is a progress report of a prospective, randomized study involving 200 consecutive patients treated electively with either parietal cell vagotomy (PCV) or selective vagotomy and antrectomy (SV-A). Both groups comprised patients with pyloric, prepyloric, or duodenal ulcers. There was no operative mortality in either group. Patients were examined at 2, 6, 12 months, and every 12 months thereafter for 8-10 years. The two operations produced no statistical difference in the frequency of diarrhea. Dumping (p less than 0.0005) and weight loss (p less than 0.0005-p less than 0.05) were statistically less after PCV than after SV-A. There were two recurrent ulcers (2.2%) after SV-A. One was treated successfully by medical therapy and one patient suspected of having gastrinoma had total vagotomy. Nine patients had recurrent ulcers in the PCV group for an accumulated recurrence rate of 10.1% at 10 years by life-table analysis. There was a significant difference (p less than 0.033) between the curves for recurrent ulcers in the two groups of patients. The recurrent ulcer rate after PCV was 21% for patients with pyloric and prepyloric ulcers and 6% for patients with duodenal ulcer. There was no significant difference between the recurrent ulcer rate for PCV and SV-A if the patients with pyloric and prepyloric ulcers were withdrawn from the study. Of the nine patients with recurrent ulcers in the PCV group, three had an inadequate vagotomy and four had a pyloric or prepyloric ulcer before operation. Three patients were successfully treated with antrectomy. Five patients were treated successfully by medical therapy and remained healed for long periods without recurrence. One patient had five recurrences. He declined operation and remained free of symptoms for 3 years after his last recurrence. Poor gastric emptying necessitated gastroenterostomy in five patients in the SV-A group and in one patient in the PCV group. Patients' clinical results were evaluated according to a simple Visick grading scale. A significantly (p less than 0.0005) greater number of patients were in Visick I category after PCV than after SV-A. The clinical results obtained with PCV make this the operation of choice for the elective surgical treatment of duodenal ulcers even though the results obtained with SV-A were good.

Surgical management of severe intractable postvagotomy diarrhoea

Experience with the surgical management of 23 patients with postvagotomy diarrhoea is outlined. The most common pre-operative abnormalities are rapid gastric emptying (14/23) and fast small bowel transit (23/23). Three patients were found to have steatorrhoea due to organic disease. Peptic ulcer surgery performed at a young age (means = 29 years, range 21-37) appears to be the only identifiable risk factor. The results of medical treatment with bile salt binding agents were disappointing in the long term. In 10 out of 13 patients treated with antiperistaltic segments, the procedure had to be reversed because of episodes of severe postprandial colic, intestinal obstruction and bacterial overgrowth. A good result with relief of the explosive diarrhoea was obtained by the distal onlay reversed ileal graft in six out of seven patients. This procedure creates a passive non-propulsive segment, and has no undesirable sequelae. It should be considered in those patients in whom the diarrhoea is not controlled by conservative measures.

Splenic protection in left upper quadrant operations

Splenectomy produces significant immediate and long-term risks for the patient, and there is general agreement that it should be reserved for clear-cut unavoidable indications. However, accidental injury to the spleen in the course of another operation (incidental splenectomy,) accounts for almost 40% of splenectomies in some series. Incidental splenectomy is most likely to occur in left upper quadrant operations such as proximal gastric vagotomy, or in colonic operations involving mobilization of the splenic flexure. Incidental splenectomy rates of between 2% and 9% have been reported in association with these procedures. The results of an operative strategy of specific protection of the spleen as the first step in a left upper quadrant operation ('defusing' the spleen) are reported. It was not necessary to remove the spleen because of accidental injury in 417 consecutive operations over a 5 year period after implementation of this policy. There were several minor splenic capsular tears which were controlled by intraoperative haemostatic measures. There were no cases of postoperative splenic bleeding. 'Defusing' the spleen is an effective step in preventing splenic injury in left upper quadrant operations.

Duodenal, prepyloric, and combined duodenal/prepyloric ulcer disease: three distinct entities of juxtapyloric ulcer disease?

One hundred and seven patients with long-standing and severe chronic juxtapyloric ulcer disease were classified in accordance with the location of the present ulcer and previous ulcers into 1) pure duodenal (DU), 2) pure prepyloric (PU), and 3) combined duodenal/prepyloric (DU/PU) or prepyloric/duodenal (PU/DU) ulcer disease. In a prospective follow-up study over a 3-year period after parietal cell vagotomy (n = 39) or during continuous treatment with cimetidine (n = 62) patients with DU had recurrent ulcers located exclusively to the duodenal bulb and patients with PU, exclusively to the prepyloric region. In patients with DU/PU and PU/DU recurrent ulcers occurred on either side of the pylorus. Basal acid and basal pepsin outputs were higher and bile acid in gastric juice was lower in patients with DU than in those with PU. There are a considerable number of patients who possess features of both duodenal and prepyloric ulcer disease. The clinical outcome of both continuous cimetidine treatment and vagotomy in these patients (DU/PU and PU/DU) was less satisfactory than in pure DU. All patients presenting with active DU should therefore be investigated for evidence of previous prepyloric ulceration.

Pyloric reconstruction for severe vasomotor dumping after vagotomy and pyloroplasty

The performance of vagotomy and pyloroplasty is followed by the occurrence of dumping symptoms in 10-30% of patients. In a few, these are severe, persistent, and refractory to dietary and medical management. Pyloric reconstruction was performed in nine patients with severe dumping symptoms. All patients were treated conservatively for at least 1 year before reconstruction. Gastric emptying studies, using a 99mTc-sulphur colloid labeled 15% dextrose, were performed before and after reconstruction in each case. All were Visik grade IV before surgery. After pyloric reconstruction, interviews were conducted by a separate clinician not involved in any management of the patients. Overall improvement was obtained in eight of nine patients. Four patients improved to Visik grade II, and four to Visik grade III. With regard to dumping symptoms only, seven of nine were improved to Visik grade II. All patients had double exponential gastric emptying curves before surgery, and six of the nine reverted to single exponential curves similar to those of unoperated controls. The initial 10-minute emptying rate was significantly decreased (p less than 0.05), and the per cent retention at 60 minutes (p less than 0.02) was significantly increased. Improvement in gastric emptying correlated well with relief of symptoms. Pyloric reconstruction is relatively simple and corrects rapid gastric emptying at the gastric outlet. These results indicate that pyloric reconstruction significantly benefits most patients with severe dumping symptoms and should be considered as the initial remedial procedure for dumping after pyloroplasty.

Recurrence after parietal cell vagotomy for peptic ulcer disease

The value of parietal cell vagotomy as a safe surgical procedure in the treatment of chronic peptic ulcer disease has been seemingly limited by the high recurrence rate usually reported. In this 10 year experience of 405 consecutive parietal cell vagotomy operations, 57 patients with recurrent ulceration were evaluated to try to answer the questions of where and why recurrent ulceration appears and how to treat it. Patients with pyloric or prepyloric ulcer disease had recurrence of disease earlier than did patients with chronic duodenal ulcer disease. Consequently, pyloric or prepyloric ulcer patients had a higher recurrence rate in the early postoperative period than chronic duodenal ulcer patients, but this difference disappeared after the seventh postoperative year. Patients with recurrent chronic duodenal ulcer disease have high postoperative acid secretion levels, indicating incomplete vagotomy as a causative factor. Patients with recurrent pyloric or prepyloric ulcer disease have postoperative acid secretion similar to that of patients without recurrence, suggesting another etiologic factor. Thirty of 57 patients with recurrent ulcer had successful medical treatment. A conservative attitude towards recurrences is justified, particularly when symptoms are few and the postoperative acid secretion tests indicate complete or partial vagotomy. Surgical therapy consisting of truncal vagotomy and pyloroplasty in cases of incomplete vagotomy and antrectomy in cases of complete vagotomy should be reserved for patients with symptoms and a disease course that cannot be controlled by conservative treatment.

Prospective, randomized trial of selective vagotomy with pyloroplasty and selective proximal vagotomy with and without pyloroplasty in the treatment of duodenal, pyloric, and prepyloric ulcers

In a prospective, randomized trial, 161 patients with duodenal, pyloric, or prepyloric ulcer underwent selective proximal vagotomy. Randomization was then performed to determine if the operation was finished (52 patients), if a pyloroplasty should be added (56 patients), or in addition, if the nerves of Latarjet should be divided (53 patients). Prepyloric and secondary gastric ulcers were excised for microscopy; all were benign. Sex, age, site of ulcer, and duration and incidence of complications of the ulcer disease were similar for the three groups. There was one operative death. The postoperative complications did not differ for the three groups. Four patients were lost to follow-up. The average follow-up for the 156 patients was 3 years (range 1 to 8 years). Recurrent ulcer was detected up to 5 years after surgery in 4 of 53 patients who had selective vagotomy with pyloroplasty, in 4 of 53 who had selective proximal vagotomy with pyloroplasty, and in 5 of 50 who had selective proximal vagotomy. Diarrhea was rare and mild or absent. Dumping was twice as common after selective vagotomy or selective proximal vagotomy with pyloroplasty than after selective proximal vagotomy only, but dumping resistant to treatment was recorded in only two or three patients in each group. The overall results (modified Visick scale) were unsatisfactory in 7 patients after selective vagotomy with pyloroplasty, in 4 after selective proximal vagotomy with pyloroplasty, and in 10 after selective proximal vagotomy, mainly because of epigastric pain with or without recurrent ulcer. We conclude that pyloroplasty may cause mild dumping without nuisance to the patient. The rates of recurrent ulcer in long-term follow-up trials are essential for final evaluation of the operations.

Sequential ultrastructural study of mucosal innervation following parietal cell vagotomy and antrectomy

Rats having undergone parietal cell vagotomy (PCV) or PCV with antrectomy were sacrificed and gastric mucosal samples studies by electron microscopy. Degeneration of axons was followed by the appearance of small, neurotubule-rich axons which increased in size and number with increasing postoperative interval. The source of these regenerating fibers is unknown but may have come from the fundus.

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.

Pros and cons of parietal cell versus truncal vagotomy

The reliability of parietal cell vagotomy as a primary procedure for duodenal ulcer is still questioned by many, and several surgeons advocate pyloroplasty in certain subgroups. Since the opening of our hospital in 1972, a randomized, prospective study has been under way. Sixty-seven patients were randomized into three groups: truncal vagotomy and Jaboulay pyloroplasty (Group 1), parietal cell vagotomy and Jaboulay pyloroplasty (Group 2), and parietal cell vagotomy without drainage (Group 3). The overall operative mortality was zero, with an 18 percent morbidity. Postoperative Congo red testing revealed truncal vagotomy to be a more reliable vagotomy, with 25 percent of Group 1 patients noted to have some degree of incomplete vagotomy compared with 36 percent of patients in Group 3 (p less than 0.05). The ulcer recurrence in Group 1 was 4 percent, in Group 2 18 percent, and in Group 3 10 percent. No dumping or diarrhea was noted in Group 3 compared with Group 1 in which 4 percent of patients had dumping and 17 percent had diarrhea and Group 2 in which 14 percent of patients had dumping and 23 percent had diarrhea (p less than 0.05). The higher incidences of recurrence and postoperative side effects obviously related to the pyloroplasty made parietal cell vagotomy with pyloroplasty the least desirable operative procedure. Parietal cell vagotomy is technically a more difficult procedure, but if performed satisfactorily, results in greater patient satisfaction, with 81 percent of the patients symptom-free compared with 63 percent of those who had truncal vagotomy and pyloroplasty.

A predictor analysis of patients' assessment of outcome after operation for duodenal ulcer. A one-year prospective study

During a period of one year data were obtained concerning life events, non-specific psychological symptoms, individual social history and ulcer history in consecutive cases of patients about to undergo elective surgical treatment for duodenal ulcer. At a one-year follow-up, a blind clinical evaluation was performed, and information concerning the patients' assessment of outcome was obtained. Those patients who at the one-year follow-up stated no improvement due to the operation could be predicted to some extent from postoperative complications, partly from a long ulcer history. The patients who stated that the result did not come up to their expectations were predicted from older age, and from certain symptoms, especially severe headache. It is suggested that it is relevant to apply the patients' assessment of outcome for the purpose of evaluation, supplementing the clinical assessment of the more biomedical aspects of outcome.

A predictor analysis of clinical assessment of outcome among patients operated on for duodenal ulcer. A 1-year prospective study

During a period of 1 year, data concerning life events, non-specific psychological symptoms, individual social history, and ulcer history were obtained for consecutive cases of patients about to have elective surgical treatment for duodenal ulcer. At the 1-year follow-up examination a blind, clinical evaluation was performed (dumping, dyspepsia, recurrence, and Visick grading), and information concerning the 94 patients' assessment of outcome was obtained. A multivariate predictor analysis was performed. Most patients (85%) benefited from treatment. The excess rate of non-specific psychological symptoms indicating impairment remained unchanged. The patients assessments of outcome were correlated with the clinical assessment. A positive correlation was found for women to have dumping and poor Visick grade and for unmarried persons to have postoperative dyspepsia and a poor Visick grade. A negative correlation between a long ulcer history and postoperative dyspepsia and a positive correlation between pyloroplasty and dumping were found. Non-specific psychological symptoms predicted poor clinical assessments. It is suggested that it is relevant to apply the patients' assessments for the purpose of evaluation, supplementing the clinical assessment of the more biomedical aspects of outcome.

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.

Arhus County Vagotomy Trial: gastric secretory alterations during the first year after selective gastric and parietal cell vagotomy

Changes in gastric acid secretion during the 1st year after selective gastric (SGV) and parietal cell (PCV) vagotomy for duodenal ulcer disease were studied. Pentagastrin tests were performed preoperatively and 3 months and 1 year after surgery in 383 SGV and 302 PCV patients. Resting juice pH showed after both operations a trend towards the preoperative distribution from 3 months to 1 year. Basal acid output showed a similar pattern. The initial reduction in pentagastrin-stimulated peak acid output (PAOpg) was most pronounced after SGV, but an increase occurred for both operations during the 1st postoperative year. An exception from this was the minority of patients who had a less than 20% initial reduction. They had a further decrease in their PAOpg. No sex difference and no influence of the duration of symptoms could be demonstrated. The patients with less than 20% initial reduction were younger than the other groups, and this applied for both SGV and PCV. The patterns of change in gastric acid secretion during the first year after vagotomy suggest that biologic factors are active, in addition to the effect of the surgical technique.

The effect of highly selective vagotomy on sick-listing in peptic ulcer patients

The amount of sick-listing in 75 patients operated on with highly selective vagotomy (HSV) was studied during two periods, the first consisting of 12 months and ending 1 year before operation and the second period, also consisting of 12 months, starting 1 year after operation. Patients with suspected ulcer recurrences were excluded and only patients who, at the 1-year postoperative follow-up study, were without symptoms suggestive of ulcer recurrence are included. The median amount of sick days was 31.3 for the period preceding and 37.2 (NS) after the operation. Before operation 60% of all sick-leave diagnoses were ulcer or gastritis, compared with 20% after operation. A 50% increase in infectious diseases and lumbago occurred. Psychiatric disorders rose from 1 to 16 occasions. We therefore conclude that patients apparently cured of chronic ulcer disease change target and develop symptoms elsewhere. The study shows no potential economic benefits of HSV, at least not with regard to a diminishing amount of sick days after operation.

Proximal gastric vagotomy, truncal vagotomy with drainage, and truncal vagotomy with antrectomy for chronic duodenal ulcer. A prospective, randomized controlled trial

The relative merits of proximal gastric vagotomy (PGV), truncal vagotomy with drainage (TV + D), and truncal vagotomy with antrectomy (TV + A) in the treatment of chronic duodenal ulcer were evaluated and compared in 152 patients in a prospective, randomized and controlled clinical trial. One death occurred after TV + A, resulting in an operative mortality of 2% after gastrectomy and 0.7% for the entire series. After one to six years, stomal and duodenal ulcers proven by endoscopy occurred in eight patients after PGV (16%) and in six patients after TV + D (11.8%); the difference was not statistically significant (p greater than 0.5). One additional patient developed a gastric ulcer nine months after PGV. There was so far no ulcer recurrence after TV + A. Majority (13 patients) of the recurrent ulcers were discovered within three years after surgery. Patients after PGV experienced significantly less unwanted side effects than those after either TV + D or TV + A; particularly, dumping, epigastric fullness, and diarrhea. When the functional status was graded according to a modified Visick system that excluded ulcer recurrence, significantly more PGV patients were placed in the near-perfect grade (82.1%) than TV + A patients (58%). Patients after TV + D fared better than patients after TV + A; but the differences were not significant. However, when ulcer recurrence was included in the functional assessment, the advantage of PGV was lost.

Parietal cell vagotomy in a surgical training program

Parietal cell vagotomy was performed in 48 patients at the Parkland Memorial Hospital and the Dallas Veterans Administration Hospital between April 1977 and January 1981. The maximum follow-up time was 50 months and the average was 28 months. Seventy-five percent of the patients were followed for more than 1 year. There were no operative deaths. Four patients (8.3 percent) had persistent postoperative side effects including two documented ulcer recurrences (4.2 percent). Acid secretion studies were reviewed to characterize the longterm effect of parietal cell vagotomy. These studies demonstrated marked postoperative reductions in gastric acid secretion. The results of this study suggest that with the simplified technique described in this paper, parietal cell vagotomy can be performed with minimal mortality and morbidity by surgical residents under direct staff supervision.

Morphologic and functional evidence of reinnervation of the gastric parietal cell mass after parietal cell vagotomy

The incidence of recurrent ulceration after parietal cell vagotomy varies greatly and the cause is largely unknown. Whether the vagus nerve can regenerate or reinnervate the gastric parietal cell mass after parietal cell vagotomy was investigated. Careful microscopic dissection of the neurovascular bundle in 130 rats allowed the vagus nerve to be divided to the gastric body with preservation of the antropyloric nerve and gastric vasculature. Gastric secretory tests were performed under basal and stimulated conditions after secretagogue and insulin hypoglycemia stimulation. Rats were killed weekly and the vagal nerve distribution examined by electron microscopy. Stimulated gastric acid output decreased from 164 to 26 mumol/hour immediately after operation (p less than 0.001). One week after parietal cell vagotomy the nerves were swollen with fibroblast infiltration and collagen around axon groups showed degeneration. By the third week after parietal cell vagotomy, the axons were more densely packed with neurofilaments and acid output had increased to 183 mumol/hour. In the fourth and fifth weeks, the enlarged Schwann cell processes had more axons and acid output increased to 262 mumol/hour. By the seventh week, both large and small axons were identified and the acid output was 93 percent higher than the preoperative level (p less than 0.001). The sequential neuropathologic changes of vagus nerve degeneration, regeneration and functional reinnervation of the gastric parietal cell mass after parietal cell vagotomy are shown by this study. If this occurs in man, it may be an important cause of recurrent peptic ulceration after parietal cell vagotomy.

Late results of proximal gastric vagotomy without drainage for duodenal ulcer: 5--9-year follow-up

From 1970 to 1974 proximal gastric vagotomy without drainage was performed in 158 patients for duodenal ulcer. One patient died, giving an operative mortality of 0.6 per cent. Nine unrelated deaths occurred during the period of survey and 5 other patients were lost to follow-up. The remaining 143 patients were followed-up for a minimum of 5 years and a maximum of 9 years. The most frequent symptoms were epigastric fullness and intolerance to milk. Early dumping, detected in 6.7 per cent of the patients, was always mild. Diarrhoea, also very slight and often only related to the ingestion of milk, was seen in 9.6 per cent. Recurrent duodenal ulcer was proved in 7.7 per cent and strongly suspected in 0.7 per cent and the presence of a new gastric ulcer was also proved in 1.4 per cent of patients, making a total incidence of recurrence of 9.8 per cent. Approximately 89 per cent of the patients were classed as having a satisfactory result and 11 per cent were classed as unsatisfactory. Proximal gastric vagotomy is clearly effective in reducing the side effects of gastric surgery, while the incidence of recurrent ulceration in the long term is similar to the incidence of recurrence after truncal or selective vagotomy with a drainage procedure. For these reasons, consideration should be given to the wider use of proximal gastric vagotomy in the elective surgical treatment of duodenal ulcer.

A clinical and socio-medical investigation of patients 5 years after surgical treatment for duodenal ulcer. I. Behavioural consequences and psychological symptoms

Within the framework of the Aarhus County Vagotomy Trial a socio-medical interview investigation was performed. Ninety-one patients were asked to participate. Half of the patients had an ulcer history of more than 15 years. One fifth had experienced preoperative complications. Thirty-nine per cent of the patients showed changes in social activity according to Patrick's grading. Within work and leisure time significant improvements had taken place. Most of the patients with paid work were characterized by a high degree of satisfaction, conscientiousness, and stability at work. Symptoms indicating psychological impairment were commoner among the patients than in the background population. No accumulation of tobacco or alcohol abuse was found. The consumption of medicine was rather high. During the period of observation a decrease in the consumption of ulcer drugs, but not in other drugs, was noted. The frequency of sick days was rather high. The rate of consultations at the general practitioner did not differ from what would be expected. It is suggested that surgical cure of an ulcer only has some impact on the total life situation of the patients and that non-specific psychological symptoms in some patients may invalidate the overall result of treatment.

A clinical and socio-medical investigation of patients 5 years after surgical treatment for duodenal ulcer. II. Association of social and psychological factors with surgical outcome

Within the framework of the Aarhus County Vagotomy Trial a socio-medical investigation was performed. Eighty-eight patients were interviewed. Data were collected concerning the patients' own assessments and several psychological symptoms. The interview also comprised questions about education, career, and personal and family problems. The surgeon's assessment, expressed by the Visick classification, was significantly correlated with the patients' assessments. In the analysis of predictors for surgical failure expressed by the Visick classification, age was the only significant predictor. Indicators of social or psychological stress showed a tendency towards association with an unfavourable outcome. No associations were found between the selected predictors and surgical failure expressed as recurrent ulcer. Patients classified as Visick III or IV had an accumulation of non-specific psychological symptoms indicating psychological impairment. It is suggested that evaluations of surgical outcome for duodenal ulcer consider both a specific surgical dimension and a subjective dimension expressed by the patients' judgements and/or expression of their health status.

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.

Impaired pancreatic innervation after selective gastric vagotomy. Reduction of the pancreatic polypeptide response to food and insulin hypoglycemia

The secretion of pancreatic polypeptide (PP) was studied in 38 duodenal ulcer patients before, 4 months after, and, in 25 patients, again 18 months after either selective gastric vagotomy or parietal cell vagotomy. Selective gastric vagotomy on average reduced the PP response to food measured 4 months after operation to 20% of the preoperative value. The prolonged PP response (30-120 min) increased to 50% from the 4th to the 18th postoperative month (p less than 0.005). Parietal cell vagotomy did not significantly change the PP response to food, although in a few patients (3/15) the response was reduced to below one third of the preoperative value. The PP response to insulin hypoglycemia was measured after operation in 16 patients; those who had a reduced PP response to food demonstrated a response to hypoglycemia which was reduced to the same extent. It is concluded that PP secretion is generally unaffected by parietal cell vagotomy but is impaired after selective gastric vagotomy and that the prolonged PP response to food is partially regenerated after vagotomy. It is suggested that selective gastric vagotomy interferes with the vagal innervation of the PP-rich head of the pancreas.

Prospective controlled vagotomy trial for duodenal ulcer: primary results, sequelae, acid secretion, and recurrence rates two to five years after operation

In a prospective, controlled clinical trial, vagotomies for duodenal, pyloric, and prepyloric ulcers were performed on 259 patients. Eighty-three patients were randomly selected for truncal vagotomy and drainage (TV + D), 93 patients were randomly selected for selective gastric vagotomy and drainage (SV + D) and 83 patients were randomly selected for parietal cell vagotomy without drainage (PCV). This interim report deals with the primary results, reduction in acid secretion, sequelae, and recurrence rates two to five years after the operation. One patient died after the operation. Postoperative complications were evenly distributed between the three operations. No differences in spontaneous acid secretion (BAO), peak acid output after pentagastrin stimulation (PAOP), or peak acid output after insulin stimulation (PAOI) were found. Patients with recurrent ulcers ahd smaller reductions in BAO than patients without ulcer recurrences, although not significantly. Patients with ulcer recurrences after TV + D had, in contrast to ulcer recurrences after SV + D and PCV, a significantly smaller reduction in PAOP than patients without recurrences. The overall recurrence rate was 13%: 10% after TV + D, 14% after SV + D and 16% after PCV. The risk of ulcer recurrence within the first three years, calculated by an actuarial method, was found to be significantly higher after PCV (0.52% per month) than after TV + D (0.32% per month), but not different from SV + D (0.42% per month). In contrast to TV + D and SV + D, no recurrences after PCV occurred after three years--25% of the patients were followed for five years. It is concluded that the trial, at present, does not point to any evident superiority of PCV.

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.