Gastroenterostomy and vagotomy for chronic duodenal ulcer

Effects of truncal, selective, and highly selective vagotomy on glucose tolerance and insulin secretion in patients with duodenal ulcer. Part II-Comparison of response to oral and intravenous glucose

Paired oral and intravenous glucose tolerance tests were carried out in patients who had undergone truncal vagotomy and pyloroplasty, selective vagotomy and pyloroplasty, or highly selective vagotomy at least six months earlier. Intravenous glucose tolerance was similar in all three groups. Oral glucose elicited significantly higher concentrations of plasma insulin in patients who had undergone selective and highly selective vagotomy than in those treated by truncal vagotomy. When the same amount of glucose was given intravenously, however, plasma insulin concentrations were similar in all three groups of patients. The insulin secreted in response to intravenous glucose expressed as a percentage of that secreted in response to oral glucose was 112% for truncal vagotomy, 51% for selective vagotomy, and 52% for highly selective vagotomy. Truncal vagotomy thus led to a diminished insulin response to oral glucose, which was probably due to impaired release of small-bowel hormones.

Faecal fat excretion after truncal, selective, and highly selective vagotomy for duodenal ulcer

Faecal fat excretion was measured on a metabolic ward in 16 patients with duodenal ulcer before operation, and in patients who were in good health more than one year after truncal vagotomy and pyloroplasty (n = 11), bilateral selective vagotomy and pyloroplasty (n = 9), or highly selective vagotomy without a drainage procedure (HSV, n = 12). Excretion of faecal fat was significantly greater (p < 0.01) in patients after both truncal and selective vagotomy with drainage than in patients before operation. Fat excretion in HSV patients was little different from that of preoperative patients. If steatorrhoea is defined as a faecal fat output of more than 6 g per day, one of 16 preoperative patients with duodenal ulcer (6%) had steatorrhoea, one of 12 HSV patients (8%) had steatorrhoea, one of nine patients after selective vagotomy and pyloroplasty (11%) had steatorrhoea but five of 11 patients after truncal vagotomy and pyloroplasty (45%) had steatorrhoea.

Incidence of dumping after truncal and selective vagotomy with pyloroplasty and highly selective vagotomy without drainage procedure

The incidence of dumping after truncal or selective vagotomy with pyloroplasty and highly selective vagotomy without a drainage procedure was assessed both clinically and experimentally. At a gastric follow-up clinic dumping was found to be significantly less frequent in patients who had undergone highly selective vagotomy without a drainage procedure than in patients who had undergone truncal or selective vagotomy with pyloroplasty (P < 0.05 or < 0.001, respectively). Hypertonic glucose given by mouth provoked the onset of dumping in 20% of patients with duodenal ulcer before operation, in 73% after truncal vagotomy and pyloroplasty, in 80% after selective vagotomy and pyloroplasty, and in 47% after highly selective vagotomy. The test meal also produced significantly greater decreases in blood pressure and increases in pulse rate in patients who had undergone vagotomy with pyloroplasty than in patients who had undergone highly selective vagotomy.

Highly selective vagotomy without a drainage procedure in the treatment of duodenal ulcer

A consecutive series of 25 patients with chronic duodenal ulcer has been treated by highly selective vagotomy without a drainage procedure. The vagal fibres passing to the distal 5–7 cm. of the stomach—the nerves of Latarjet—were left intact, as were the hepatic and coeliac branches of the vagus. The object was to denervate only the parietal cell mass, while preserving normal gastric emptying and normal inhibition of gastric secretion from the antrum and duodenum. This operation should cure the ulcer as effectively as vagotomy with drainage does, and at lower cost in terms of side-effects such as dumping and diarrhoea.

The insulin test was negative in each case, suggesting that vagal denervation of the parietal cell mass was complete. Evidence provided by mucosal biopsies taken at operation does not fully support this view, however. Pentagastrin-stimulated acid output was reduced by 70 per cent, and pepsin output by 51 per cent, 3 months after operation. The volume of resting juice was halved and spontaneous acid output was reduced by 97 per cent at this time. Thus, highly selective vagotomy is as effective as truncal or bilateral selective vagotomy with drainage in reducing gastric acid output in the early months after operation.

There have been no deaths. With 2 exceptions, the patients appear to be doing well clinically and few complain of side-effects, but the period of follow-up is only from 3 to 11 months.

These results are encouraging. They suggest that a highly selective vagotomy, denervating the parietal cell mass but leaving the antrum innervated, may be all that is required to cure most patients who have a chronic duodenal ulcer.