Letter: Complication of proximal gastric vagotomy

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.

Lesser curve necrosis following selective proximal vagotomy--a case report

A case of the lesser curve necrosis following selective proximal vagotomy for a perforated duodenal ulcer is reported. Although little is known of this very rare complication, it is potentially a fatal complication after selective proximal vagotomy. Early recognition and immediate reoperation must be save the life of the patient when this complication is suspected.

Lesser curve superficial seromyotomy--an operation for chronic duodenal ulcer

Lesser curve superficial seromyotomy has been investigated in the dog and in man. The anatomical basis for the operation, which produces an easily performed denervation of the parietal cell mass, is discussed. Acid studies in the dog confirmed that the operation was capable of producing secretory inhibition in keeping with vagotomy of the parietal cell area. A consecutive series of 25 patients with chronic duodenal ulcer has been treated by lesser curve myotomy without a drainage procedure. The operation has the advantages of being easily performed and the risk of damage to the nerve of Latarjet or of ischaemic necrosis of the lesser curvature is obviated. In 20 insulin tests performed within the first month postoperatively all patients have been negative within the first 75 min and there were 4 late positive responses. Early clinical results have been encouraging, there has been no dumping or diarrhoea and all patients are well. It is suggested that further investigation of lesser curve myotomy is warranted.

Proximal gastric vagotomy, fundoplication, and lesser-curve necrosis

Out of 400 patients who underwent proximal gastric vagotomy (PGV), three developed lesser-curve necrosis (LCN) leading to perforation within the first seven days. In each case diagnosis was delayed but the patient survived after a second operation. In each an associated Nissen fundoplication had been carried out; we used the combined operation in only 33 patients. Delayed LCN occurred in a patient who had undergone splenectomy at the time of the PGV and in a fifth patient treated elsewhere who had also undergone fundoplication. These findings indicate that early postoperative gastric distension with gas, not readily voided after fundoplication, may aggravate local vascular factors and predispose to LCN. We suggest that PGV combined with fundoplication may be dangerous.

Changing trends in the surgical treatment of duodenal ulcer

On the basis of fully or partly controlled clinical trials the long term results of several standard operations for duodenal ulcer have been compared--subtotal gastrectomy, truncal vagotomy and antrectomy, truncal vagotomy and gastro-enterostomy, truncal vagotomy and pyloroplasty, selective vagotomy and pyloroplasty and proximal gastric vagotomy without drainage. Few statistically significant differences emerge but the following observations seems to be justified: (a) Subtotal gastrectomy and vagotomy and antrectomy probably offer better protection against recurrent ulceration than any of the other operations examined, but the greater intrinsic operative risks of these two resection procedures is emphasized. (b) Disturbances of alimentary function occur to a variable extent after all operations but appear to be least troublesome after proximal gastric vagotomy without drainage. In particular this operation is followed by a negligible incidence of diarrhoea compared with truncal vagotomy procedures. (c) On overall (Visick) grading the two resection operations and proximal gastric vagotomy without drainage do better than truncal vagotomy with drainage, proximal gastric vagotomy being specially notable for the relatively small proportion of patients in category 3 after its use. Surgical strategy in the choice of elevtive operation for duodenal ulcer is discussed.

Operative mortality and postoperative morbidity of highly selective vagotomy

In a world-wide survey of the results of 5539 highly selective vagotomies (HSVs) performed electively for duodenal ulcer the operative mortality was found to be 0-3%. This was lower than that found in collected series after either vagotomy with drainage (0-8%) or gastric resection with or without vagotomy (over 1%). Necrosis of the lesser curvature occurred in 10 patients (0-2%) after HSV and caused death in 5(0-1%). Such necrosis is probably ischaemic in origin. Hence reperitonealisation of the raw area on the lesser curvature and prompt laparotomy if the patient develops signs of peritonitis might lower the mortality still further. Three deaths were due to pulmonary embolism, one to mesenteric vascular occlusion, and four to myocardial infarction; such deaths might be reduced by the prophylactic use of low-dose heparin. Persisting gastric stasis requiring drainage occurred in only 0-1% of the patients in the early postoperative period and in 0-6% of the patients later. Hence drainage procedures, which produce side effects such as early dumping, bilious vomiting, and diiarrhoea, could be abandoned if the mean incidence of recurrent ulceration after HSV remains close to its present level. HSV is probably the safest operation for duodenal ulcer because the alimentary tract is not opened and there is no anastomosis, suture line, or stoma.

Localized avascular necrosis of lesser curve of stomach complicating highly selective vagotomy

The fourth case of localized avascular necrosis of the lesser curve of the stomach after highly selective vagotomy is reported. The pathogeneses was probably related to the relative poverty of the submucosal blood supply along the lesser curve. This complication may be prevented by peritonealizing the lesser curve before closing the abdominal wall.