Precise antrectomy

Surgery is preferable in patients with severe chronic peptic ulcer disease

Conservative treatment given as interrupted courses is easy and successful for the majority of patients with peptic ulcer disease. For those plagued for years and years by severe chronic complaints the choice will be maintenance treatment or surgery. Maintenance treatment possibly spares the patient for an operation but includes a risk of stenosis claiming the necessity of a drainage operation with risk of sequels. The taking of the pill means a daily remembrance of the disease. Relapse rate is high. The economic problem is not unimportant for the patient. When contra indications are taken seriously into consideration modern ulcer surgery is not dangerous. There are no sequels if the pyloric function can be left intact. The cured patients feel fit and will usually forget the disease. Recurrence rate is lower than that during maintenance therapy but if occurring early they may be difficult to treat. The young patient with severe chronic duodenal ulcer disease should not wait eternally for a parietal cell vagotomy. When the ulcer is located to the pyloric channel prolonged conservative treatment may be advisable. Treatment policy for the gastric ulcer is debatable. No treatment is yet ideal. The advice to the individual patient should be based upon a non-prejudiced evaluation of the advantages and disadvantages of the therapeutic possibilities necessitating that the gastroenterologist and the surgeon have a thorough knowledge of the results of the other speciality.

Vagotomy or gastrectomy for elective treatment of benign gastric ulceration?

The results of elective gastrectomy and vagotomy with drainage for benign gastric ulcer are described in terms of operative mortality, recurrent ulceration, overall clinical results, and risk of malignancy. Although it has a slightly lower operative morbidity and mortality, the results of vagotomy with drainage are not sufficiently superior to abandon gastrectomy. Highly selective vagotomy, without drainage, provides good overall clinical results but has a high associated incidence of recurrent ulceration. Neither gastrectomy nor vagotomy with drainage have a distinct advantage in patients with combined gastroduodenal or prepyloric ulceration.

Antrectomy for recurrent ulcer after parietal cell vagotomy

The results of antrectomy for recurrent ulcer after parietal cell vagotomy are reviewed. Eighteen patients underwent precise antrectomy between 6 months and 7 years after their primary operation. Fourteen patients were reconstructed with a gastroduodenostomy and 4 with a gastrojejunostomy. Eighteen patients were available for follow-up of between 18 months and 10 years. One patient (6.25 per cent) developed a recurrent ulcer 1 year after antrectomy. There was no operative mortality. Six patients (33 per cent) had minor complications in the immediate postoperative period, and one (5.5 per cent) had a major complication. According to Visick grading, 75 per cent had good or excellent results and 25 per cent poor results. Antrectomy following parietal cell vagotomy can be achieved with a low operative mortality, a low ulcer recurrence rate and a satisfactorily low incidence of post-gastrectomy problems.

Selective gastric vagotomy and drainage for duodenal ulcer: a 10-13-year follow-up study

From 1964 to 1968 selective gastric vagotomy (SGV) and drainage was performed in 174 patients. Of these, 105 patients were followed-up 10-13 years after operation; 56 were dead. Ulcers recurred in 18 patients. The cumulated recurrence rate after 13 years (life table method) was 15% (95% confidence limits: 8-23). The method for drainage was usually either a Heineke-Mikulicz or a Finney pyloroplasty. There was a significantly higher risk of ulcer recurrence in the group that underwent Heineke-Mikulicz drainage procedures. The incidence of dumping and diarrhea had not changed during a five-year follow-up period. Two patients were slightly anemic. No patient was iron-deficient. Apart from two recurrent ulcers, gastroscopic examinations in 36 patients revealed no major changes, and biopsy specimens showed slight to moderate chronic atrophic gastritis in most cases. Visick grading showed 77% of the ulcers in Grade I + II, 19% in Grade VI. It is concluded that SGV has no place in the elective treatment of duodenal ulcer. Two alternatives are suggested.

Possible physiological advantages of parietal cell vagotomy

Parietal cell vagotomy (PCV) without drainage is associated with the lowest mortality of any operation currently being widely used for the elective treatment of duodenal ulcer. There are fewer gastrointestinal complaints of the type observed after more orthodox gastric operations. Diarrhea and dumping may occur after PCV in approximately 5 percent of patients, and when these complaints do occur they are milder and more easily controlled than after other types of operation. This improvement is attributed to retention of the peristaltic action of the antrum and an intact pyloric sphincter, which together, permit gastric emptying that is more normal than that which occurs with any other gastric procedure. There is insufficient evidence to indicate that retention of antral innervation exerts an inhibitory or a stimulatory effect on acid secretion which would be either beneficial or detrimental to the duodenal ulcer patients. The acid secretory rates are reduced effectively by PCV and equal the reductions that follow truncal vagotomy and drainage. Acid secretory rates increase during the first postoperative year and then remain rather constant with time. This observation and the reports that the rate of recurrent ulcers after 2 to 4 years follow-up is two to four percent, suggests that PCV is a highly effective procedure.

Effect of antrectomy on the nervous phase of gastric secretion in the dog

A method is described for complete isolation of the stomach in the dog with vagal innervation intact. This involves esophagostomy, double mucosal closure of the pylorus and a Maydl gastric fistula combined with gastrojejunostomy. The latter is occluded during periods of study. In this preparation the responses to sham feeding and to insulin-induced hypoglycemia were reduced approximately 10-fold, reiterating the significant synergistic effect of gastrin on vagal stimulation of the parietal cell mass. However, significant acid secretion could still be induced in this preparation by both sham feeding and insulin-induced hypoglycemia.