Is an antireflux procedure necessary in conjunction with parietal cell vagotomy in the absence of preoperative reflux?

Contemplating the future without Helicobacter pylori and the dire consequences hypothesis

Helicobacter pylori is a serious chronic transmissible pathogen that causes gastric structural and functional damage and is a major cause of morbidity and mortality worldwide. H. pylori is one of the digestive tract pathogens that has traveled with mankind since before humans moved out of Africa. Some have suggested that the long association of H. pylori with humans means there must be a benefit and suggest dire consequences will follow its eradication. Fortunately, there are now sufficient experiences with the outcome of treatment and with populations where the infection disappeared long ago to support the conclusion that H. pylori is a serious chronic transmissible pathogen that no one needs, deserves, or desires. The dire consequence hypotheses have proven to be erroneous attempts to blame some of the problems facing the modern world on a pathogen that was and is responsible for much suffering, morbidity, and mortality. It is time to join together to eradicate it and to let H. pylori join smallpox and polio on the hit list of undesirables.

The changing epidemiology of GERD: geography and Helicobacter pylori

BACKGROUND

Issues have arisen regarding H. pylori infection and GERD that have caused unnecessary confusion among practicing physicians. In the last century GERD became increasingly recognized in the West and it has become evident that the prevalence of GERD is now occurring in many previously underdeveloped countries.

METHODS

This review article fosters understanding of the issues by focusing on the esophageal acid load and the factors that control it. In particular, we discuss the effects of the change in the patterns of gastritis that have occurred naturally as well as after H. pylori eradication and correlate those changes with their effects on the esophageal acid load. We show how it is possible to separate gastroesophageal reflux from gastroesophageal reflux disease based on differences in esophageal acid load. We also describe how the practice of assessing gastroesophageal reflux based on the time the intraesophageal pH is less than 4 resulted in investigators systematically discarding data critical to understanding of the effect of their interventions on esophageal acid load. Testable hypotheses are presented to explain the interactions between H. pylori and GERD and between H. pylori and the changing epidemiology of GERD.

CONCLUSIONS

We propose that the confusion regarding H. pylori and the changing epidemiology of GERD is based on the failure to critically examine the historical evidence in relation to the other H. pylori-related diseases as well as reliance on techniques that are either unable to measure, or systematically discard data critical for understanding effects of various interventions on the esophageal acid load. This has resulted in propagation of erroneous concepts regarding H. pylori and adenocarcinoma of the esophagus and has resulted in some patients being denied appropriate therapy.

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.

Postoperative gastric ischaemia

This review discusses postoperative gastric ischaemia after detailed consideration of the gastric blood supply and the effects of devascularization. Special consideration is given to gastric remnant necrosis, lesser curve ischaemia after highly selective vagotomy, and gastric ischaemia after other operations.