Parietal cell (highly selective or proximal gastric) vagotomy for peptic ulcer disease

Postoperative results of distal partial gastrectomy, selective vagotomy plus antrectomy, and selective proximal vagotomy for duodenal ulcers

We investigated the postoperative results of distal partial gastrectomy, selective vagotomy plus antrectomy, and selective proximal vagotomy, to evaluate their effectiveness in the treatment of duodenal ulcers. The operative mortality of selective vagotomy plus antrectomy and selective proximal vagotomy seemed to be lower when compared to distal partial gastrectomy, although each procedure showed a sufficiently low mortality. The acid reduction rate was significantly lower after selective proximal vagotomy than after the other procedures (p less than 0.01). However, the rate of ulcer recurrence following selective proximal vagotomy tended to be higher compared with the other procedures. All three procedures showed good results according to Visick's grading and postoperative symptoms occurred in about 50 per cent of all patients, no matter what the procedure. The regaining of physical ability was significantly greater following selective proximal vagotomy than following distal partial gastrectomy (p less than 0.05) and the capacity to work was also better after vagotomy, particularly selective vagotomy plus antrectomy (p less than 0.05). Thus, although distal partial gastrectomy and selective vagotomy plus antrectomy proved superior regarding the low ulcer recurrence rate and acid reduction, while selective proximal vagotomy proved superior for improving the quality of life, on the whole, the three operations promise almost equivalent results.

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.

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.

Modified sham feeding test after parietal cell vagotomy for juxtapyloric ulcer disease in patients with and without recurrent ulcers

The mean of individual coefficients of variation of acid output after modified sham feeding was 39% in 22 patients operated on with parietal cell vagotomy. The reproducibility of the interpretation of the sham feeding test as 'positive' or 'negative' was good. An intragastric infusion of a marker to correct for pyloric loss did not increase the accuracy of the test. The prognostic value of the qualitative estimation of the sham feeding test 2 months after operation to predict recurrent ulcer after parietal cell vagotomy was poor in 39 patients studied prospectively over 3 years. With the criterion sham feeding minus basal acid output over 1.0 mmol/30 min as a positive test, 63% of patients with a positive and 24% with a negative test later had recurrent ulcers. The consistency of the interpretation as either positive or negative was low in annual tests during the 3 years of follow-up study. After parietal cell vagotomy the sham-feeding-stimulated acid output was higher in patients with duodenal than in those with prepyloric recurrent ulcers and also in those without recurrences. This indicates that the amount of vagal innervation left after parietal cell vagotomy is of special importance in the occurrence of duodenal ulcer relapse.

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.

The four to eight year results of the Sheffield trial of elective duodenal ulcer surgery--highly selective or truncal vagotomy?

In a prospective randomized trial between June 1973 and July 1978 highly selective vagotomy (HSV) was compared with truncal vagotomy and pyloroplasty (TVP) in 137 male patients undergoing elective surgery for chronic duodenal ulceration. Ninety per cent of patients were followed up for between 49 and 102 months (mean 77). A good result was obtained in 49 of 59 patients (83 per cent) after HSV compared with 41 of 64 (64 per cent) after TVP (P less than 0.02). The recurrent ulcer rate was 8.8 per cent after HSV and 9.4 per cent after TVP. Dumping and diarrhoea were significantly commoner after TVP (P less than 0.05). We believe that HSV is a better operation than TVP for the treatment of uncomplicated duodenal ulcer.

A comparison of highly selective vagotomy with truncal vagotomy and pyloroplasty--one surgeon's results after 5 years

In a prospective randomized trial highly selective vagotomy (HSV) was compared with truncal vagotomy and pyloroplasty (TVP). One surgeon performed all the operations. Ninety-eight per cent of patients were reviewed by two physicians after 20-97 mth (mean 61 mth). Fifty-nine of 68 patients (87 per cent) had an excellent or very good result after HSV (Visick grades I and II) compared with 48 of 69 (70 per cent) after TVP (P less than 0.05). There was 1 proven recurrence after HSV and 4 after TVP. Diarrhoea, including mild symptoms, occurred in 5 patients (7 per cent) after HSV and in 27 (39 per cent) after TVP (P less than 0.001). Severe diarrhoea did not occur after HSV but was present in 4 patients (6 per cent) after TVP (P less than 0.001). Flatulence, epigastric fullness and weight loss were also significantly more common after TVP. On average HSV took 72 min to perform compared with 44 min for TVP (P less than 0.001). Transient dysphagia occurred in 19 patients after HSV compared with 8 after TVP (P less than 0.05). HSV gave better results than TVP and was associated with a low recurrence rate (1.5 per cent at a mean of 5 yr). Although technically more demanding, HSV in our hands is a better operation than TVP for uncomplicated duodenal ulcer.

[Results of the surgical treatment of bleeding gastroduodenal ulcers]

Within 11 years 279 operations for acute bleeding from gastroduodenal ulcers were performed at the surgical University Clinic in Würzburg. Of the 279 patients, 140 had to be operated on immediately because of acute severe bleeding. Of the 158 bleeding duodenal ulcers, 104 had a selective proximal vagotomy (SPV), 29 had gastric resection, and in 25 the ulcer was simply closed. The overall mortality after SPV was 8.6%, 62% after gastric resection, and 40% after simple suture ligation. Recurrent bleeding occurred in 8.7% after SPV, 10.3% after gastric resection, and in 24% after suture ligation. Of the 89 bleeding gastric ulcers, 25 had a selective proximal vagotomy, 30 a gastric resection, and 34 excision of the ulcer. The overall mortality after SPV was 16%; after gastric resection it was 23.3% and 41.2% after ulcer excision. Recurrent bleeding was observed in 8% after SPV, in 10% after gastric resection and in 11.7% after ulcer excision.

[The recurrent ulcer patient following selective proximal vagotomy in the treatment of duodenal ulcer (author's transl)]

Selective proximal vagotomy (SPV) in the treatment of duodenal ulcer shows a lethality of 0% in this series. The recurrence rate is 12.4% when 60% of the patients are examined by endoscopy at a mean postoperative interval of 27 months. If only the patients with complaints had been examined by gastroscopy then ulcer recurrence would have been diagnosed in 7.1%. One-third of the recurrences are in the stomach. There is no significant difference in the recurrence rate in male or female patients, whether the ulcer is uncomplicated or complicated or SPV is done with or without pyloroplasty. Ulcers heal under further surveillance in one-third of recurrent ulcer patients; one-half of the rest have to be reoperated upon.

Value of simplified, highly selective transgastric vagotomy in duodenal ulcer surgery

The technique of preservation of the antral vagal nerve supply of the stomach and division of the gastric branches of the nerves of Latarjet remains unchanged. By replacing the transection of th hiatal cardioesophageal vagus nerve branches (including the nerve branches accompanying the arteries entering the fundus of the stomach) with transgastric intramural transection and excision of all nerve fibers entering the fundus, highly superselective vagotomy is achieved. Completeness of this type of vagotomy is controlled intraoperatively by a gastric pH meter and by measuring the oxygen tension of the gastric mucosa. The decrease in oxygen tension of the gastric mucosa below and in the vicinity of the seromuscular incision was similar to that of the rest of the fundus. One year to 18 months after application of highly selective transgastric vagotomy in 74 patients with uncomplicated duocenal ulcers, there was no mortality and insignificant morbidity. The previous ulcer symptoms disappeared. No significant complications such as dumping syndrome or recurrence of ulcer were observed.

Recurrent ulcer 5 1/2--8 years after highly selective vagotomy without drainage and selective vagotomy with pyloroplasty

The recurrent ulcer rates in a prespective randomised trial amounted to 26% and 14%, 5 1/2 t0 8 years after highly selective vagotomy without drainage (HSV) and selective vagotomy with pyloroplasty (SV). Long duration of symptoms before HSV increased the risk of recurrence. High preoperative maximum acid secretion increased the risk of recurrence after SV Furthermore, long duration of symptoms and slow postoperative gastric emptying possibly increased the risk of recurrence after SV. Imcomplete vagotomy as expressed by the quantitative acid response to insulin was also considered to be of significance for the risk of recurrence in the present study.

[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.

Transgastric highly selective vagotomy (HSTRV) without drainage. Preliminary report of a new simplified procedure of treatment of duodenal ulcer

The technique of preserving the antral vagal nerve supply of the stomach and division of the gastric branches of the nerves of Latarjet is common to both operations, but by replacing the transection of the hiatal cardioesophageal vagus nerve branches (including the nerve branches accompanying the arteries entering the fundus of the stomach) with a transgastric intramural transection and excision of all nerve fibers entering the fundus, a highly selective vagotomy is achieved. Completeness of HSTRV is controlled intraoperatively by a gastric pH meter and by measuring the oxygen tension of the gastric mucosa. One year to 18 months after application of HSTRV in 74 patients with uncomplicated duodenal ulcers, mortality was nil, morbidity insignificant, the previous ulcer symptoms no longer present, and dumping syndrome, recurrence and other significant complications were not observed.

Results of proximal gastric vagotomy over 1-5 years in a district general hospital

One hundred and seventy-three underwent proximal gastric vagotomy for duodenal ulceration over a 6-year period. One hundred and fifteen of these have been followed up for 1-5 years. The operative mortality was nil and the result was satisfactory in 91 per cent. The incidence of side effects was small, notably that of dumping being 2.4 per cent and of diarrhoea, 3.6 per cent. Incidence of postoperative heartburn was reduced from 13 per cent to 4 per cent by the introduction of hepatic interposition. The incidence of recurrent ulceration was 5.1 per cent after an average interval of 2 years and that of new gastric ulceration 2.6 per cent after an average of 4 years. There were no recurrent ulcers in those who had peroperative Burge tests, although secretory studies showed no difference between those tested and those not tested. Most recurrences occurred in the earliest cases operated on before Burge testing was introduced and when only 2 cm of the lower oesophagus were exposed.

Gastroesophageal reflux in duodenal ulcer patients before and after vagotomy

Gastroesophageal reflux was investigated in 80 patients with duodenal ulcer by analysis of symptomatology and the acid reflux test. Resting gastroesophageal sphincter pressure (GESP) and postvagotomy reduction in basal and pentagastrin stimulated gastric acid secretion were also studied. Reflux symptoms were present in 40% of the patients, and this incidence was significantly reduced two months after vagotomy. In patients studied late after operation reflux symptoms were still less frequent than before operation, but not significant. After vagotomy, no significant changes in the fasting GESP or in gastroesophageal reflux as determined by the pH glass electrode were demonstrated. Thus, the decrease in reflux symptoms may be explained by the significant reduction in gastric acid secretion. Denervation of the cardia and the lower esophagus does not influence GESP or gastroesophageal reflux.

Effect of selective proximal vagotomy and truncal vagotomy on gastric acid and serum gastrin responses to a meal in duodenal ulcer patients

To assess the effectiveness of selective proximal vagotomy (SPV) in reducing the acid response to food, we have compared pre- and postoperative gastric acid and serum gastrin responses to a meal in 11 duodenal ulcer patients with intractable pain treated by SPV, with those of seven ulcer patients with gastric outlet obstruction treated by truncal vagotomy and drainage (TV + D). Acid secretion was measured by an intragastric titration method which measures acid response to food within the stomach (5% amino acid meal) adjusted to various pH levels (5.5, 2.5, and 1.5). Studies were performed before and two to six weeks after operation. The preoperative intragastric acid output (IGAO) was about 50% of maximal acid response to Histalog. The mean preoperative IGAO at pH 5.5 For 11 SPV patients was 17.4 +/- 3.1 mEq/hour; this was decreased by 72% to 4.3 +/- 1.1 mEq/hour after operation. The mean IGAO at pH 5.5 in nine patients treated by TV + D was 21.6 +/- 3.4 mEq/hour; this was decreased by 67% to 7.3 +/- 2.1 mEq/hour. Gastrin levels were significantly higher in postop than in preop SPV PATIENTS EVEN THOUGH PH values were constant. Gastrin levels were higher in postop TV + D patients than in postop SPV patients. This study demonstrates that acid reduction achieved by SPV is reliable and at least comparable with that achieved by turncal vagotomy. Postoperative elevation of gastrin in the SPV patients suggests that the vagus may release a humoral inhibitor of gastrin release from the gastric fundus; there may also be a further direct vagal inhibitor of antral gastrin release.

Results of elective duodenal ulcer surgery in women: comparison of truncal vagotomy and antrectomy, gastric selective vagotomy and pyloroplasty, proximal gastric vagotomy

This study provides a retrospective comparative analysis of results in 90 women patients who underwent three different elective operations for intractable duodenal ulcer disease. Group I (30 patients) underwent truncal vagotomy/antrectomy (TV + A); group II (30 patients) gastric selective vagotomy/pyloroplasty (GSV + P); and Group III proximal gastric vagotomy (PGV). There were no operative deaths among the 90 patients. No patient after TV + A has developed a recurrent ulcer. Two recurrent ulcers developed after GSV + P, and one gastric ulcer occurred after PGV. Dumping, diarrhea, and reflux gastritis were lower after PGV than with TV + A and GSV + P. Follow-up studies have been from six months to ten years. The clinical results among the three groups of women patients compare favorably with results obtained in a recent prospective randomized study using the identical operative procedures in three groups of men patients operated upon for intractability. There was no statistically significant difference between women and men after similar operative procedures, but the postgastrectomy sequelae were less after PGV in both women and men patients.

The present status of proximal gastric vagotomy

It is now clearly established that proximal gastric vagotomy, which has been in clinical use for over seven years, had lower mortality and morbidity rates than all other forms of operation currently used in the treatment of chronic duodenal ulcer. Although no long-term figures are yet available, the ulcer recurrence rates is not likely to be greater than that for truncal vagotomy. The technique is not without problems, however, and has yet to gain wide acceptance in this country.

Proximal gastric vagotomy without drainage

Proximal gastric vagotomy without drainage is widely accepted in Great Britain and Europe but in the United States has been done mainly in university centers. The operation denervates the acid-secreting parietal cell mass of the stomach, preserving vagal innervation to the gastric antrum and extragastric abdominal viscera. The procedure is safe and is associated with few underisrable side effects. Long-term studies are needed to determine the rate of recurrence of duodenal ulcer in patients treated surgically in this way.

Proximal gastric vagotomy without drainage for duodenal ulcer: results after 5-8 years

Experience with proximal gastric vagotomy without drainage in the treatment of 316 men with duodenal ulcer is surveyed, with particular reference to the 117 who have been followed up for 5–8 years and whose results are compared with those obtained after other standard elective operations.

There were no operative deaths. Symptoms suggestive of recurrent ulceration developed in 12·0 per cent of the entire series of 316 cases, but in only 3·8 per cent was the presence of a recurrent ulcer definitely established. In the 117 cases followed up for 5–8 years similar symptoms were noted in 15·4 per cent, but the presence of a recurrent ulcer was proved in only 4·3 per cent.

At 5–8 year follow-up dumping was virtually completely absent and diarrhoea was significantly less than after truncal vagotomy with drainage or antrectomy, whilst there were insignificant reductions in the incidence of post-prandial epigastric fullness and bile vomiting.

Visick grading at 5–8 years rated the result as excellent or very good in 75 per cent of the cases, as fair in 13 per cent and as a failure in another 12 per cent.

The advantages and disadvantages of proximal gastric vagotomy without drainage relative to those of truncal vagotomy with drainage or antrectomy are discussed.

The effect of parietal cell vagotomy and selective vagotomy with pyloroplasty on gastric acid secretion. A prospective randomized study

The insulin- and pentagastrin-stimulated gastric acid secretion was studied before and 1 week, 1 month, 6 months and 1 year after parietal cell vagotomy (PCV) and selective vagotomy with pyloroplasty (SV + P) in 50 patients who took part in a consecutive randomized trial. The randomization and the operations were performed in such a way that the extent of the denervation of the proximal stomach was identical in the two groups. Basal acid output and the insulin-stimulated acid secretion were significantly increased from 1 month to 1 year after PCV, while there was no such increase after SV + P. There was no change of the pentagastrin-stimulated acid secretion (PAOP) from 6 to 12 months in either groups. One year postoperatively PAOP was significantly greater after PCV than after SV + P. The results are compatible with vagal reinnervation after PCV and support the assumption of a sprouting from the innervated gastric antrum.

Gastroesophageal sphincter pressure and serum gastrin studies following food intake before and after vagotomy for duodenal ulcer

Gastroesophageal sphincter pressure (GESP) and serum gastrin concentration (SGC) were determined in the basal state and after a protein meal in 6 patients with duodenal ulcer (DU) 6 patients after parietal cell vagotomy (PCV) 6 patients after selective gastric vagotomy plus drainage (SGV + D), and 6 patients after selective gastric vagotomy plus precise antrectomy (SGV + A). No correlation in the resting state between GESP and SGC was observed. After food ingestion, DU patients showed a sustained rise in GESP which lasted up to the end of the experiment. The vagotomized patients, however, showed no rise in sphincter pressure after food intake--rather a tendency to decrease in pressure occurred. On the contrary, SGC rose significantly after food ingestion in patients with SGV + D or PCV, while in DU patient this rise was less significant. Patients with vagotomy and antrectomy showed no rise in SGC. These results do not suggest that SGC and extrinsic vagal innervation in the resting state play a significant role in the maintenance of the tone of GES. After food ingestion an interaction may occur between intact vagal innervation and rise in SGC in order to obtain an adequate rise in GESP.

Gastroesophageal sphincter pressure and serum gastrin studies following food intake before and after vagotomy for duodenal ulcer

Gastroesophageal sphincter pressure (GESP) and serum gastrin concentration (SGC) were determined in the basal state and after a protein meal in six patients with duodenal ulcer (DU), six patients after parietal cell vagotomy (PCV), six patients after selective gastric vagotomy plus drainage (SGV + D), and six patients after selective gastric vagotomy plus precise antrectomy (SGV + A). No correlation in the resting state between GESP and SGC was observed. After food ingestion, DU patients showed a sustained rise in GESP which lasted up to the end of the experiment. The vagotomized patients, however, showed no rise in sphincter pressure after food intake--rather a tendency to a decrease in pressure occurred. On the contrary, SGC rose significantly after food ingestion in patients with SGV + D or PCV, while in DU patients this rise was less significant. Patients with vagotomy and antrectomy showed no rise in SGC. These results do not suggest that SGC and extrinsic vagal innervation in the resting state play a significant role in the maintenance of the tone of GES. After food ingestion an interaction may occur between intact vagal innervation and rise in SGC in order to obtain an adequate rise in GESP.

Clinical results of parietal cell vagotomy and selective vagotomy with pyloroplasty in the treatment of duodenal ulcer. Two-year follow-up of a prospective randomized study

Fifty patients were randomized in a consecutive series of parietal cell vagotomy (PCV) and selective vagotomy with pyloroplasty (SV +P) in the treatment of duodenal ulcer. There were no operative deaths, and the length of the hospital stay and time off from work were the same in both groups. The clinical results were evaluated at 1 and 2 years after operation. Within the first 3 years there were two recurrences after PCV and three after SV +P. The overall clinical result 2 years after surgery did not significantly differ between the two groups; 16/24 after PCV and 17/23 after SV +P classified as excellent results (Visick I). Significantly fewer patients had dumping after PCV (3/23) than after SV +P (13/22). No patient had diarrhoea postoperatively. It is concluded that parietal cell vagotomy gives less dumping than selective vagotomy with pyloroplasty. It is, however, too early to say whether the overall clinical result in a long-term follow-up favours PCV rather than SV +P.

[Peptic ulcer: indication for surgical treatment (author's transl)]

Treatment of duodenal ulcer has been improved by proxmial gastric vagotomy and the H2 antagonist cimetidine. These new types of treatment may also be useful in gastric ulcer. Thus, new guidelines for the elective surgery and the treatment of bleeding ulcer are needed. These guidelines are obtained by a compromise between the conflicting viewpoints of a surgeon and an internist.

[The technique of proximal selective vagotomy (author's transl)]

A standard technique of proximal selective vagotomy is described (PSV) that has proved reliable and safe in a broad multicenter clinical trial. We proceed in six steps: (1) determination of the antral-fundic boundary by anatomic criteria; (2) preliminary vagomotor electrotest; (3) identification of the nerve trunks and branches to be preserved; (4) dissection of the lesser curvature; (5) dissection of the cardia and of the intraabdominal esophagus up to 6 cm above the cardia; and (6) intraoperative assessment of completeness by the vagomotor electrotest. PSV is usually carried out without a drainage procedure.

Proximal gastric vagotomy compared with vagotomy and antrectomy and selective gastric vagotomy and pyloroplasty

A prospective, randomized study of proximal gastric vagotomy without drainage (PGV) was done in 174 adult men with chronic duodenal ulcer intractable to medical therapy. PGV was randomized against truncal vagotomy with antrectomy (TV + A) and against selective gastric vagotomy with Finney pyloroplasty (SGV + P). Postgastrectomy sequelae (dumping, diarrhea and reflux gastritis) were less after PGV. One patient after PGV developed a recurrent ulcer as did one patient after SGV + P. Two patients developed gastric ulcers after PGV. Good to excellent results (Visick I and II) were obtained in 96% of patients with PGV, 94% with TV + A and 86% with SGV + P. Follow-up studies were from six months to four years.