Highly selective vagotomy plus dilatation of the stenosis compared with truncal vagotomy and drainage in the treatment of pyloric stenosis secondary to duodenal ulceration

Solid Gastric Emptying after Highly Selective Vagotomy and Pyloroplasty in Patients with Obstructing Duodenal Ulcer

Before being superseded by medical management, highly selective vagotomy (HSV) without drainage was the procedure of choice for uncomplicated duodenal ulcer. It is also justified for complications, including perforation and bleeding in selected cases. This prospective study evaluated the effects of HSV plus drainage on solid gastric emptying in 20 patients with chronic duodenal ulcer and pyloric stenosis. Patients were treated with HSV plus pyloroplasty (Heineke-Mikulicz pyloroplasty in five patients, Finney pyloroplasty in six patients and Jaboulay gastroduodenostomy in nine patients) and underwent solid-phase gastric emptying scintigraphic studies pre-operatively and 2 months and 6 months post-operatively. Results were compared with those from 10 controls. No significant differences were observed between the different types of pyloroplasty, although emptying was slightly faster in the gastroduodenostomy group. Gastric emptying returned to normal by 6 months post-operatively. In conclusion, HSV plus pyloroplasty is effective and can be used for the relief of stenosis in selected cases of duodenal ulcer.

The outcome of fluoroscopically guided balloon dilation of pyloric stricture in Crohn disease

PURPOSE

To evaluate the clinical efficacy and safety of fluoroscopically guided balloon dilation for pyloric stricture associated with Crohn disease (CD) while monitoring the outcome.

MATERIALS AND METHODS

Five patients (age range 15-34 y) were diagnosed with symptomatic pyloric stricture associated with CD between November 2006 and August 2009. All five patients underwent fluoroscopically guided balloon dilation one or more times.

RESULTS

The initial balloon dilations were technically successful in all patients. Two patients showed improvement of symptoms without further need of dilation, two patients had one more session of dilation, and one patient underwent two more sessions of repeated dilation. There were no procedure-related complications. Overall technical and clinical success rates were 100%. After the last dilation, all patients remained healthy, with no case of relapse of obstructive symptoms during the median follow-up of 16 months (range 6-22 mo).

CONCLUSIONS

Fluoroscopically guided balloon dilation seems to be a useful tool for management of symptomatic pyloric stricture in CD and may be a viable alternative to open surgery.

Benign strictures of the esophagus and gastric outlet: interventional management

Benign strictures of the esophagus and gastric outlet are difficult to manage conservatively and they usually require intervention to relieve dysphagia or to treat the stricture-related complications. In this article, authors review the non-surgical options that are used to treat benign strictures of the esophagus and gastric outlet, including balloon dilation, temporary stent placement, intralesional steroid injection and incisional therapy.

Benign duodenal strictures: treatment by means of fluoroscopically guided balloon dilation

Fluoroscopically guided balloon (15 or 20 mm in diameter) dilation was performed on eight patients with benign duodenal strictures caused by peptic ulcers (n = 6), Crohn's disease (n = 1), and postoperative adhesion (n = 1). The procedure was technically and clinically successful without complications in seven of the eight patients (88%). Duodenal perforation occurred immediately after 20-mm-diameter balloon dilation in one patient who underwent emergency surgery. During the mean follow-up of 30 months (range, 2-103 months), there was recurrence in two of the seven patients (29%) who then underwent surgery. The other five patients (71%) showed good results with no recurrence.

Long-term results of duodenectomy with highly selective vagotomy in the treatment of complicated duodenal ulcers

BACKGROUND

Highly selective vagotomy and complete circular or partial duodenectomy have been applied to complicated duodenal ulcer for many years. These procedures seem to provide better clinical results than truncal vagotomy and antrectomy.

METHODS

A retrospective analysis was conducted of 120 patients with complicated duodenal ulcer who underwent surgical treatment between 1986 and 1999. Patients with obstruction were treated with either circular complete (17) or partial duodenectomy (3) combined with highly selective vagotomy or truncal vagotomy and antrectomy (37). Those with perforation were treated primarily with highly selective vagotomy and partial duodenectomy, highly selective vagotomy alone, or truncal vagotomy and pyloroplasty. Every patient was followed up either by a clinic visit (75%) or questionnaire to determine the presence of ulcer pain, dumping, diarrhea, vomiting, weight loss, and Visick grade.

RESULTS

Long-term follow-up of patients treated with duodenectomy and highly selective vagotomy for obstruction showed that 94% had sustained weight gain whereas more than half of those treated with truncal vagotomy and antrectomy had weight loss. In patients with perforation, duodenectomy and highly selective vagotomy offered no advantage over highly selective vagotomy alone.

CONCLUSIONS

Highly selective vagotomy and complete circular or partial duodenectomy provide fewer sequelae and better weight gain long term than truncal vagotomy and antrectomy for patients with obstructing duodenal ulcers.

ODC, Módena JLP, Mente ED, Sankarankutty AK. DUODENOPLASTIA ASSOCIADA À VAGOTOMIA GÁSTRICA PROXIMAL NO TRATAMENTO DAS ÚLCERAS DUODENAIS ESTENOSANTES

A vagotomia gástrica proximal firmou-se como o procedimento de escolha no tratamento cirúrgico eletivo das úlceras duodenais crônicas, por ser a operação mais segura quanto à morbidade e mortalidade. Sua aplicação tem sido estendida às complicações da úlcera duodenal, mediante operação complementar que visa solucionar a complicação. Com o objetivo de avaliar a vagotomia gástrica proximal no tratamento das úlceras duodenais estenosantes os resultados clínicos de uma série consecutiva de 80 pacientes submetidos à vagotomia gástrica proximal e duodenoplastia (VGP + Dp) foram comparativos aos de uma série de 106 pacientes submetidos à vagotomia gástrica seletiva e antrectomia (VGS + A); os pacientes foram avaliados 2 a 16 anos após a cirurgia. As séries foram homogêneas quanto ao sexo e à idade. Cinco diferentes tipos de duodenoplastia foram realizados, de acordo com as características anatômicas do duodeno estenosado No grupo da VGS + A a reconstrução do trânsito alimentar foi gastroduodenal em 46 pacientes e gastrojejunal nos 60 pacientes restantes. O índice de mortalidade operatória foi de 1,2% com VGP + Dp e de 1,9% com VGS + A. Controle endoscópico pós-operatório demonstrou patência da luz duodenal e piloro conservado nos pacientes submetidos à duodenoplastia. A recorrência ulcerosa ocorreu em 5% após VGP + Dp e em 1,9% após VGS + A. Conclui-se que: 1. a duodenoplastia resolve a estenose duodenal sem dano do esfíncter pilórico, mantendo as vantagens da vagotomia gástrica proximal sem operação complementar de drenagem do estômago. 2 Na avaliação clínica global os melhores resultados foram obtidos com a vagotomia gástrica proximal. 3. A vagotomia gástrica proximal associada à duodenoplastia é uma boa opção de tratamento da úlcera duodenal estenosante.

Gastric outlet obstruction

Acquired gastric outlet obstruction is more commonly owing to malignancy than ulcer disease. Endoscopy is the preferred method for diagnosis. Surgical palliation for malignant disease has poor results and high rates of morbidity and mortality. Initial experiences with endoscopic palliation with expandable metallic endoprostheses appear promising. Peptic ulcer-induced gastric outlet obstruction can be treated safely with endoscopic balloon dilation. About 65% of patients have sustained symptom relief, but many require more than one dilation session. Outcomes may be improved with effective ulcer therapy with acid reduction and eradication of H. pylori. Surgery is associated with significant morbidity and mortality and should be reserved for endoscopic treatment failures.

Emptying of the intrathoracic stomach using three different pylorus drainage procedures--results of a comparative study

Patterns of gastric emptying in the vagotomized intrathoracic stomach (used for esophageal replacement) were studied using radioisotope techniques. Following esophagectomy and gastric mobilization, the patients were randomized into three groups: group 1, pyloroplasty; group 2, pyloromyotomy; and group 3, pylorus stretching. A total of 30 patients surviving the operation and who were still alive at least 3 months afterwards were included in this study. Gastric emptying (GE) was evaluated 6-8 weeks after the operation. The mean GE time for liquids was 3.3 +/- 2.7, 4.1 +/- 3.1, and 5.5 +/- 4.3 min in the three groups, respectively. The corresponding GE time for solids in the three groups was 9.9 +/- 5.1, 10.31 +/- 6.6, and 7.7 +/- 3.4 min. No statistical difference was observed in the GE in the three groups even though liquids tend to empty faster than solids. Clinically there was also no significant difference in their ability to tolerate normal meals. When evaluated for clinical evidence of altered GE (effect of vagotomy) there did not appear to be any significant differences between the three groups. It is therefore concluded that all pylorus drainage procedures behave in much the same way. Patients may develop some problems, but these disappear in due course after proper adjustments have been made in both posture and diet.

Prospective randomized study comparing three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer

A prospective randomized clinical trial was performed in order to evaluate the results of three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer. Ninety patients with clinical and laboratory evidence of gastric retention were enrolled. After laparotomy, patients underwent either highly selective vagotomy (HSV) + gastrojejunostomy, HSV + Jaboulay gastroduodenostomy, or selective vagotomy (SV) + antrectomy. One patient died after HSV + Jaboulay gastroduodenostomy due to postoperative acute pancreatitis. There were no differences in the postoperative course of the three groups. Patients were followed for a mean of 98 months (range: 30 to 156 months). There was a significantly better result after HSV + gastrojejunostomy than after Jaboulay anastomosis (p < 0.01), but not after SV + antrectomy. Gastric acid reduction was similar in the small group of patients studied. We propose HSV + gastrojejunostomy as the treatment of choice in patients with duodenal ulcer and gastric outlet obstruction.

Parietal cell vagotomy and dilatation for peptic duodenal stricture

Gastric outlet obstruction due to peptic duodenal stricture (pyloric stenosis) was treated with parietal cell vagotomy and dilatation of the stricture in 32 patients. Follow-up is in the range of 5 years in 37.4% of the patients, while 6 to 10 years follow-up is available in 62.4% of the patients. At their last follow-up, 74.9% of the patients were in either Visick 1 or 2 clinical status. Recurrence rates have been 3.1% at 1 year, 9.3% at 5 years, and 21.8% after 6 to 10 years follow-up. There has been only one instance (3.1%) of restenosis. Two patients required reoperation because of recurrence and one of them died.

Highly selective vagotomy in the treatment of complicated duodenal ulcer

Highly selective vagotomy has been utilized urgently in 33 patients with bleeding duodenal ulcer, 16 patients with pyloric stenosis and six patients presenting with perforated ulcer. Five patients died after surgery for bleeding duodenal ulcer, and two patients rebled after surgery. Forty-eight patients were reviewed at a mean of 28 months with an excellent outcome being obtained in 45 patients. Two of the three patients with poor results had proven ulcer recurrence while the third patient required reoperation for recurrent pyloric stenosis. No patient has suffered diarrhoea after vagotomy. Highly selective vagotomy is an effective treatment for urgent management of complicated duodenal ulceration and is without troublesome post-vagotomy symptoms.

Role of highly selective vagotomy and duodenoplasty in the treatment of postbulbar duodenal obstruction

The indications for highly selective vagotomy have expanded in recent years, with the technique being applied to selected cases of perforation and bleeding. Its use in obstruction is controversial, but two options are available for managing the stenotic pylorus or duodenum: dilatation or duodenoplasty. The latter choice requires that the stenosis be located in the postbulbar area. Since 1981, we have managed 15 patients with postbulbar stenosis by means of highly selective vagotomy and duodenoplasty. All patients had a previous history of ulcer disease, and vomiting was a consistent symptom. All patients were referred for surgery, 10 by a gastroenterologist. There was no operative mortality or procedure-related morbidity. Two patients have been lost to follow-up. Both were classified as Visick I and had normal endoscopic results at their last visit. The remaining 13 patients have all been followed very recently. Twelve patients (92%) are currently classified as Visick I or II. One patient (Visick IV), who was essentially asymptomatic, was found to have a recurrent ulcer on endoscopy. Endoscopic (11 patients) or radiographic (1 patient) patency of the duodenoplasty has been demonstrated in 12 patients. Highly selective vagotomy and duodenoplasty should be a surgical consideration when the pathologic anatomy of the duodenum lends itself to that choice.

Postoperative gastric atony after vagotomy for obstructing peptic ulcer

From 1979 through 1984, truncal vagotomy and drainage were performed in 71 patients with symptomatic obstructing peptic ulcers, whereas proximal gastric vagotomy with or without drainage was performed in 30 patients. Seven patients (7 percent) developed prolonged early postoperative gastric atony. Six of the 71 patients (8 percent) who had truncal vagotomy had atony, whereas only 1 of the 30 patients (3 percent) with proximal gastric vagotomy had atony (p = 0.08). The atony resolved with medical management in all patients after a median of 23 days. At follow-up (median 3 years), 74 percent of patients with truncal vagotomy had an excellent or good result compared with 86 percent of those with proximal gastric vagotomy (p greater than 0.1). The conclusion was that prolonged early postoperative gastric atony occurs uncommonly after vagotomy for obstructing peptic ulcer. Preservation of antropyloric innervation by using proximal gastric vagotomy instead of truncal vagotomy may be helpful, but does not completely prevent the atony.

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.

Highly selective vagotomy with dilatation or duodenoplasty. A surgical alternative for obstructing duodenal ulcer

Highly selective vagotomy (HSV) is an accepted choice for the treatment of uncomplicated duodenal ulcer. Its use in patients with gastric outlet obstruction, however, remains quite controversial. Since 1980, 69 patients have undergone HSV at the Medical College of Georgia Hospitals. Of these, 20 (29%) underwent either dilatation (14) or duodenoplasty (6) for accompanying outlet obstruction. The obstruction was graded as severe in 17 (85%) and moderate in three (15%). Follow-up evaluation has included Visick grading and endoscopy. There have been two deaths (38 and 54 months following surgery). Both patients were Visick I. Of the 18 patients available for review to date, 12 (67%) are Visick I and four (22%) are Visick II. There have been two failures (11%), discovered only by endoscopic follow-up in asymptomatic patients. No patients have required reoperation. HSV with dilatation or duodenoplasty is a reasonable surgical alternative for the treatment of obstructing duodenal ulcer disease.

Preliminary experience with hydrostatic balloon dilation of gastric outlet obstruction

In treating a group of 15 patients with gastric outlet obstruction, 12 (80%) had good to excellent relief of symptoms. Two patients required surgical intervention. One patient has symptoms that were persistent but mild enough to forego surgery. Balloon dilation offers an alternative to the surgical management of gastric outlet obstruction.

[Gastric outlet stenosis (benign): definition, incidence, therapy?]

According to a strict definition of a benign gastric outlet obstruction i.e. delayed vomiting, changing of symptoms, weight loss and intraoperative test by Hegardilators (less than 14), 2.2% real stenoses among 619 operative treated duodenal ulcer patients were found. All patients were treated by SPV and digital dilatation of the stenosis through a gastrotomy. During up to a 10 year follow-up no reoperation was necessary. All patients showed Visick-classification of I and II. In conclusion SPV with digital dilatation showed good clinical results for patients with benign gastric outlet obstruction in long-term follow up.

Duodenal ulcer perforation whilst on cimetidine therapy

Nine cases of perforation whilst patients received cimetidine therapy were identified and followed prospectively. There was a high correlation with the other major complications of duodenal ulceration: pyloric stenosis and haemorrhage. Initially, three of the nine patients had simple suture of the perforation, but eventually all required truncal vagotomy and a drainage procedure. The follow-up ranges from 6 months to 2.5 years and the results in the surviving patients are good. The preoperative identification of this group, being established medical failures with the high probability of requiring necessary definitive surgery, will aid the surgical management of this condition.

Highly selective vagotomy in duodenal ulceration and its complications. A 12-year review

Highly selective vagotomy (HSV) was performed in 509 patients over 12 years for the surgical management of duodenal ulceration; 103 HSVs were carried out during the treatment of complications. The overall rate of ulcer recurrence was 7%, ranging from 10% in the first 4 years to 4% in the 6 years between 1975 and 1980. Highly selective vagotomy was performed in addition to closure of a perforated ulcer in 16 patients, with no recurrent ulcers or re-perforations. After the control of their bleeding duodenal ulcers, 25 patients had HSV with no rebleeding, although two patients had recurrent ulceration. Highly selective vagotomy was performed in 62 patients with stenosis in addition to dilatation (44) or duodenoplasty (18). There was a high incidence of recurrent ulceration (7) and stenosis (9) with digital dilatation while duodenoplasty gave better results with one recurrent stenosis and no recurrent ulceration. The authors conclude that HSV is justified by its late results as a definitive operation in chronic duodenal ulceration that allows preservation of the pylorus during surgery for complications.

Pros and cons of parietal cell versus truncal vagotomy

The reliability of parietal cell vagotomy as a primary procedure for duodenal ulcer is still questioned by many, and several surgeons advocate pyloroplasty in certain subgroups. Since the opening of our hospital in 1972, a randomized, prospective study has been under way. Sixty-seven patients were randomized into three groups: truncal vagotomy and Jaboulay pyloroplasty (Group 1), parietal cell vagotomy and Jaboulay pyloroplasty (Group 2), and parietal cell vagotomy without drainage (Group 3). The overall operative mortality was zero, with an 18 percent morbidity. Postoperative Congo red testing revealed truncal vagotomy to be a more reliable vagotomy, with 25 percent of Group 1 patients noted to have some degree of incomplete vagotomy compared with 36 percent of patients in Group 3 (p less than 0.05). The ulcer recurrence in Group 1 was 4 percent, in Group 2 18 percent, and in Group 3 10 percent. No dumping or diarrhea was noted in Group 3 compared with Group 1 in which 4 percent of patients had dumping and 17 percent had diarrhea and Group 2 in which 14 percent of patients had dumping and 23 percent had diarrhea (p less than 0.05). The higher incidences of recurrence and postoperative side effects obviously related to the pyloroplasty made parietal cell vagotomy with pyloroplasty the least desirable operative procedure. Parietal cell vagotomy is technically a more difficult procedure, but if performed satisfactorily, results in greater patient satisfaction, with 81 percent of the patients symptom-free compared with 63 percent of those who had truncal vagotomy and pyloroplasty.

Proximal gastric vagotomy, truncal vagotomy with drainage, and truncal vagotomy with antrectomy for chronic duodenal ulcer. A prospective, randomized controlled trial

The relative merits of proximal gastric vagotomy (PGV), truncal vagotomy with drainage (TV + D), and truncal vagotomy with antrectomy (TV + A) in the treatment of chronic duodenal ulcer were evaluated and compared in 152 patients in a prospective, randomized and controlled clinical trial. One death occurred after TV + A, resulting in an operative mortality of 2% after gastrectomy and 0.7% for the entire series. After one to six years, stomal and duodenal ulcers proven by endoscopy occurred in eight patients after PGV (16%) and in six patients after TV + D (11.8%); the difference was not statistically significant (p greater than 0.5). One additional patient developed a gastric ulcer nine months after PGV. There was so far no ulcer recurrence after TV + A. Majority (13 patients) of the recurrent ulcers were discovered within three years after surgery. Patients after PGV experienced significantly less unwanted side effects than those after either TV + D or TV + A; particularly, dumping, epigastric fullness, and diarrhea. When the functional status was graded according to a modified Visick system that excluded ulcer recurrence, significantly more PGV patients were placed in the near-perfect grade (82.1%) than TV + A patients (58%). Patients after TV + D fared better than patients after TV + A; but the differences were not significant. However, when ulcer recurrence was included in the functional assessment, the advantage of PGV was lost.

Proximal gastric vagotomy: update

Experience with proximal gastric vagotomy at the Mayo Clinic from 1973 to Mayo 1980 is reported. Among 298 patients who had proximal gastric vagotomy for chronic duodenal, pyloric channel, or prepyloric ulcers, a recurrent ulcer rate of 7% was present, with a mean follow-up of 49 months. Three recurrences developed in six patients who had proximal gastric vagotomy for gastric ulceration. In 40 patients, proximal gastric vagotomy was combined with gastrojejunostomy, pyloroplasty, or pyloric dilatation for obstructing ulcers. There was a 15% incidence of reoperation in the gastrojejunostomy group. All nine patients who had proximal gastric vagotomy for active or recent bleeding ulcers were dismissed from the hospital without further hemorrhage, and only one developed a recurrent ulcer. It is concluded that proximal gastric vagotomy remains an acceptable operation for chronic duodenal and pyloric ulcers, but its efficacy in gastric ulcers is unproved.

Gastric outlet obstruction in peptic ulcer disease: an indication for surgery

Eighty-seven patients with duodenal peptic ulcer disease and gastric outlet obstruction were reviewed retrospectively. All patients were initially treated with standard medical regimens. Gastric outlet obstruction persisted in 49 patients (56 percent) for more than 5 days, necessitating operative intervention. Obstruction relented in the other 38 patients (44 percent), and they were discharged from the hospital. However, late follow-up on the entire cohort revealed that 98 percent of patients with chronic ulcer disease and 64 percent of patients with acute disease ultimately required an operation.

Highly selective vagotomy and pyloric dilatation for duodenal ulcer with stenosis

This paper presents the results obtained in 15 patients with duodenal ulcer and stenosis who were treated more than 3 years ago by highly selective vagotomy (HSV) and dilatation of the stenosis without a gastric drainage procedure. Patients were taking solid food 3--6 days postoperatively and were discharged after 7--14 days. There have been no recurrent stenoses. Fourteen of the 15 patients were Visick grade 1 or 2 at their last visit. One patient has a recurrent ulcer, but no restenosis. Barium meals performed on 6 patients with severe stenosis preoperatively showed satisfactory gastric emptying 1--3 years postoperatively. HSV and pyloric dilatation seems to be a safe and effective procedure for the treatment of pyloric stenosis due to chronic duodenal ulceration.

[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.

The combination of proximal gastric vagotomy with a rotational posterior gastropexy for duodenal ulcer

Preoperative oesophageal reflux symptoms have been controlled and the emergence of such symptoms de novo prevented in duodenal ulcer patients by combining proximal gastric vagotomy with a rotational posterior gastropexy. Fifty-two patients having such operations are compared with 46 patients treated by proximal gastric vagotomy (PGV) alone. The two groups match for age, sex and weight but there were more grade 3 refluxers in the group having rotational posterior gastropexy (28) than among those having proximal gastric vagotomy alone (5).

Six out of 28 patients in the PGV group who did not have preoperative regurgitation symptoms developed acid brash postoperatively on a 1–6½-year follow-up as against none of 17 patients in the other group. One year follow-up was complete in 94 cases and 57 had a 3·–6½-year follow-up. The 95 per cent confidence limits for cure of grade 3 reflux symptoms by the combined PGV and gastropexy operation were 44·7–88·7 for heartburn and 57·8–97·5 for regurgitation. Postoperative dysphagia can be minimized by attention to a few details during performance of the simple gastropexy procedure.

A pentagastrin-glucose pH monitoring test has been devised for this study. When the mean duration of reflux episodes during the 1 h after pentagastrin and the 1 h after 200 ml of 20 per cent glucose is plotted against the number of such episodes, the differences indicate that PGV impairs whilst PGV and gastropexy improves function at the gastro-oesophageal junction. Faber's peak acid output (PAO1) discriminant (Faber et al., 1975) was first used to define positive insulin tests in males. Such positive cases have been reported as having a 50 per cent chance of developing recurrent ulceration. We found that 9 out of 31 patients in the PGV group were positive at 1 year as against 2 out of 28 patients having the combined operation (P&lt;0·05). We have now applied Maybury's criterion (Maybury et al., 1977) of PAO1 adjusted for height to our results. Significant differences between the two operations were only evident after a curve derived from Maybury's data was increased by 50 per cent and then applied to our results. Nine out of 36 of the PGV group as against 1 out of 36 of the PGV and gastropexy group were positive by this test (P&lt;0·01). Addition of such a procedure to PGV may reduce the ulcer recurrence rate after PGV alone.

Gastric emptying after treatment of stenosis secondary to duodenal ulceration by proximal gastric vagotomy and duodenoplasty or pyloric dilatation

A consecutive series of 12 patients with stenosis secondary to duodenal ulceration were treated by proximal gastric vagotomy (PGV) and duodenoplasty or PGV and dilatation of the stenosis. Three months after operation the rate and pattern of gastric emptying of a solid meal was measured in each patient and compared with 18 patients with uncomplicated duodenal ulcer treated by PGV alone. Two patients developed gastric stasis in the early postoperative period which resolved with medical treatment. All patients were asymptomatic and were eating normally three months after operation. There was no significant difference in the rate of gastric emptying postoperatively between the patients who had stenosis and those who had uncomplicated duodenal ulcers. These results indicate that despite early postoperative difficulties in some patients pyloric dilatation or duodenoplasty with PGV are both effective treatments for stenosis due to duodenal ulceration.

Peroperative grading of pyloric stenosis: a long term clinical and radiological follow-up of patients with severe pyloric stenosis treated by highly selective vagotomy and dilatation of the stricture

Highly selective vagotomy (HSV) is now an accepted form of surgery for uncomplicated duodenal ulcer. Highly selective vagotomy and dilatation has been successfully used in some cases of pyloric stenosis, but many would regard severe pyloric stenosis as a contraindication to this procedure. Eleven patients with severe pyloric stenosis, measured objectively at operation, have been treated by HSV and dilatation of the stenosis and reviewed for periods of up to 3 years. The clinical results, immediate and long term, were good in all cases. Barium studies and histopathological findings were slower to return to normal. With intensive preoperative preparation to restore the tone of the dilated gastric muscle and gentle, controlled dilatation of the stricture, HSV in these patients should be as satisfactory as in those patients with uncomplicated duodenal ulcer.

Recurrence after proximal gastric vagotomy without drainage for duodenal ulcer: a 3-6-year follow-up

During the period December 1970 to August 1973, 99 patients with duodenal ulcer underwent proximal gastric vagotomy without drainage, and 93 per cent of the patients were followed up for 3-6 years after the operation. A proved recurrent duodenal ulcer was noted in 4.3 per cent and a strongly suspected recurrent duodenal ulcer in 2 per cent. It is suggested that this rate of recurrence on medium term follow-up is compatible with the continued use of proximal gastric vagotomy in the surgical treatment of duodenal ulcer.

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

Parietal cell vagotomy has been in clinical use for 7 years in elective treatment of nonobstructive duodenal ulcer, and for even a shorter period for complicated cases and for gastric ulcer The evolution of the surgical technique has not yet come to an end and the ability to perform the procedure is still improving. It can therefore be questioned, if this operation is yet ripe for a realistic clinical trial, and the great variation in recurrence rate reported in pilot series as well as in prospective randomized clinical trials points to the possibility that we will have to wait several years before the anticipated mean recurrence rate is known. At present it can be stated that even if gastric emptying is not quite undisturbed, the addition of a drainage procedure in nonobstructive cases is unnecessary. The same may be true in some patients with pyloric obstruction. Furthermore, the mortality rate is very low and the incidence of moderate-to-severe dumping and diarrhea is virtually nil.