Recurrent ulcer 5 1/2--8 years after highly selective vagotomy without drainage and selective vagotomy with pyloroplasty

Role of acid secretory response to sham feeding in predicting recurrent ulceration after proximal gastric vagotomy

The completeness of vagal denervation in determining the long-term outcome of patients with duodenal ulcer disease after proximal gastric vagotomy (PGV) was studied by examining the relationship between the postoperative acid secretory response to sham feeding ('chew and spit' technique) and the subsequent ulcer recurrence rate during a mean follow-up of 7.5 (range 5-15) years. The cumulative recurrence rate of 98 patients analysed prospectively was 11 per cent. Of 22 patients who had incomplete vagotomy as suggested by the sham feeding response, five had a later relapse. This compares with only an 8 per cent relapse rate among those with a secretory response suggesting complete vagotomy. Four patients suffered from a relapse more than 5 years after operation but none had undergone incomplete vagotomy. However, in seven patients with an early postoperative relapse (within 5 years) five had had incomplete vagal denervation (P < 0.05). In this latter group the median time elapsed from surgery until the first recurrence was only 1 year. It is concluded that the early postoperative acid secretory response to a sham feeding stimulus is clinically useful as it allows prediction of the risk of early relapse after PGV. This test may be helpful for the validation of new techniques of vagotomy.

Proximal gastric vagotomy and anterior seromyotomy with posterior truncal vagotomy assessed by the endoscopic congo red test

The completeness of vagotomy following proximal gastric vagotomy or anterior seromyotomy with posterior truncal vagotomy was assessed prospectively in 48 patients using the intraoperative congo red test. Pentagastrin (6 micrograms/kg) was given subcutaneously before the assessment. An endoscope was passed into the stomach and 180 ml congo red solution washed over the gastric mucosa. Continuing acid production was indicated by the appearance of a black colour (pH < 3) 2 min after introduction of the dye. A grading system was adopted where grades I and II showed little black discoloration and grades III and IV showed increasing areas of discoloration indicating that further denervation was required. All 20 patients undergoing anterior seromyotomy with posterior vagotomy were classified as grade I. Fifteen of an initial 23 patients receiving proximal gastric vagotomy were grade III or IV. Following division of either the right gastroepiploic nerve or the posterior vagal trunk, 22 patients improved to grade I (16) or II (six). In the subsequent five proximal vagotomies, modification of the dissection produced grade I results. Anterior seromyotomy with posterior truncal vagotomy gave consistently complete vagotomy. The congo red test highlighted major differences in the adequacy of vagotomy achieved using various dissection techniques during proximal gastric vagotomy. The test is a useful, reproducible and simple intraoperative method for assessing the completeness of denervation.

Twelve-year follow-up of a prospective, randomized trial of selective vagotomy with pyloroplasty and selective proximal vagotomy with and without pyloroplasty for the treatment of duodenal, pyloric, and prepyloric ulcers

Between 1973 and 1981, 161 patients with prepyloric, pyloric, or duodenal ulcers were randomly allocated to selective vagotomy with pyloroplasty, selective proximal vagotomy with pyloroplasty, or selective proximal vagotomy alone. No significant differences in clinical results were found 3 years after surgery by Emås and Fernström (Am J Surg 1985; 149: 236-42). There was one postoperative death, and one patient lost to follow-up. Of 159 patients, 52 underwent selective vagotomy with pyloroplasty, 55 selective proximal vagotomy with pyloroplasty, and 52 selective proximal vagotomy alone. Fifteen patients did not undergo endoscopy, but they had no epigastric complaints. From 1 to 16 years after surgery, recurrent ulcer was detected in 13%, 18%, and 23%, respectively, after selective vagotomy with pyloroplasty, selective proximal vagotomy with pyloroplasty, or selective proximal vagotomy without pyloroplasty. Twenty-eight percent of the patients with recurrent ulcer had no symptoms and received no treatment. Sixteen patients died within 8 years after surgery of causes unrelated to the ulcer disease. At their final examination, 14 of the 16 patients had Visick I or II (modified Visick scale) results, and the disease that caused their deaths obscured evaluation in 2 patients. The remaining 143 patients were followed up for 8 to 16 years (average: 12 years). Epigastric pain with or without ulcer was recorded more often (significant) after selective proximal vagotomy alone (40%) than after selective vagotomy with pyloroplasty (17%) or selective proximal vagotomy with pyloroplasty (14%). Bowel habits were unchanged in 96% of patients who underwent selective vagotomy with pyloroplasty or selective proximal vagotomy with pyloroplasty and 100% of patients who had selective proximal vagotomy alone. Mild dumping tended to be more common after vagotomy with pyloroplasty but was a minor nuisance in only a few patients. Very good or good results (Visick I or II) were recorded in 75% of the patients after selective vagotomy with pyloroplasty or selective proximal vagotomy with pyloroplasty or selective proximal vagotomy with pyloroplasty and in 54% after selective proximal vagotomy alone (significant difference). Seventeen patients underwent reoperation with antrectomy and gastrojejunostomy Roux-en-Y (13 patients) or gastroduodenostomy (4 patients) with no mortality. The results of the reoperations were graded as Visick I or II results in all but one patient. The final grading, including the reoperations, were Visick I or II in 85% of patients after selective vagotomy with pyloroplasty and selective proximal vagotomy with pyloroplasty and in 55% after selective proximal vagotomy alone (significant difference).(ABSTRACT TRUNCATED AT 400 WORDS)

Complications associated with ulcer recurrence following gastric surgery for ulcer disease

The present study is an attempt to assess the risks of the complications associated with recurrent ulcers in patients who have undergone gastric surgery and to determine whether these risks differ from those observed in patients receiving long term maintenance treatment with H2-receptor antagonists for ulcer disease. One hundred and thirty studies reported in the literature during the past three decades have been analysed to determine both the approximate rate of ulcer recurrence and the proportion of patients with recurrent ulcers who have presented with either haemorrhage or perforation following the various types of gastric surgery for ulcer disease. From these data, estimates of the risks of haemorrhage and of perforation during the years following gastric surgery have been calculated. Vagotomy and antrectomy is associated with a low risk of ulcer recurrence (less than 1%) and the risk of complications in later years is accordingly very small (less than 0.5%). Partial gastrectomy, although associated with low recurrence rates, has a higher risk of complications (1.3% for haemorrhage, 0.3% for perforation) because the proportion of recurrent ulcers that present with haemorrhage or perforation is high (33% and 8%, respectively). Truncal vagotomy plus drainage (TV + D) and highly selective vagotomy (HSV) are associated with recurrence rates of 9% and 12%, respectively, but ulcer recurrences following these operations are less frequently accompanied by complications then recurrences after gastric resection and, as a result, the risks of haemorrhage (1.7% for TV + D; 1.3% for HSV) are similar to the risks after gastric resection. During long term (five years or more) maintenance treatment with H2-receptor antagonists, the risks of haemorrhage and perforation are less than 2% and less than 0.5%, respectively. It appears, therefore, that the likelihood of developing haemorrhage or perforation following gastric surgery is of the same order as that during maintenance treatment with H2-receptor antagonists, at least during the first decade of follow-up.

Anterior lesser curve seromyotomy and posterior truncal vagotomy versus truncal vagotomy and pyloroplasty in the treatment of chronic duodenal ulcer

In a prospective randomized controlled clinical trial, anterior lesser curve seromyotomy with posterior truncal vagotomy (AMPT, n = 77) has been compared with truncal vagotomy and pyloroplasty (TVP, n = 69) in 146 patients with chronic duodenal ulcer with a mean duration of symptoms of 7 years. The mean follow-up time was 4.5 years with a range of 2-7 years. One elderly patient died from a myocardial infarction in the TVP group. Acid secretory inhibition in response to insulin and pentagastrin stimuli was equal in both groups, indicating a similar degree of vagal denervation. Recurrent ulcers were more common after AMPT (five) than TVP (two) (P = 0.29, n.s.). Dumping and diarrhoea were significantly commoner (P less than 0.001) after TVP, with 31 instances as opposed to eight with AMPT. The mean operating time was increased by 6 min when AMPT was performed rather than TVP. The results of this study have shown that AMPT is associated with a lower incidence of dumping and diarrhoea and achieves better overall Visick grading. However, continued monitoring is required to assess the long-term incidence of recurrent ulceration after this procedure.

Comparison of highly selective vagotomy with truncal vagotomy and pyloroplasty: results at 8-15 years

In 1983 we reported the early results (mean 5 years) of a prospective randomized comparison of highly selective vagotomy (HSV) with truncal vagotomy and pyloroplasty (TVP) where all 137 operations were performed by the same surgeon. HSV was significantly better than TVP in terms of Visick grading and side-effects. The same patients were assessed at a mean of 12 years (range 8-15 years) after operation. There was no difference on assessment using Visick grading between TVP (59 patients) and HSV (57 patients) (grades I and II, 75 per cent in each case). However, 20 per cent of TVP patients (but none of the HSV patients) had undergone reoperation in the intervening period. The endoscopically proven recurrence rate was 7 per cent after TVP and 5 per cent after HSV. This long-term follow-up supports the optimism that HSV is a better operation than TVP in the elective treatment of duodenal ulcer.

Highly selective vagotomy 5-15 years on

Highly selective vagotomy for duodenal ulcer was performed on 307 patients between 1973 and 1983 without operative mortality. Of these, 283 (92.2 per cent) were followed up prospectively for a minimum of 5 years. Recurrent ulcer was diagnosed in 49 (17.3 per cent). The recurrent ulcer rate increased from 13.2 per cent at 5 years to 19.4 per cent at 12 years. Age, length of history, previous haemorrhage or perforation and preoperative acid output were not associated with increased risk of recurrent ulceration. The risk in men and smokers was higher but not significantly so. The recurrence rate for individual surgeons varied from 5.3 to 25.6 per cent. Failure of healing with H2-receptor antagonists was not associated with a higher recurrent ulcer rate. Patients with a strong family history (more than one first degree relative affected) had a significantly higher recurrence rate (33.2 per cent at 10 years) than those without (13.5 per cent at 10 years). Of the 49 recurrent ulcer patients, 30 (61.2 per cent) required either an operation or regular H2-receptor antagonists. Of the 250 patients (81.4 per cent) available in 1988 for review of symptoms 5-15 years after operation, 5.4 per cent had dumping, 8.9 per cent epigastric pain, and 11.8 per cent heartburn every day or most days. H2-receptor antagonists were required by 10.7 per cent of patients on a frequent or regular basis. Of 239 patients who answered the question, 218 (91.2 per cent) felt that their symptoms had been cured or greatly improved and 203 (84.9) considered the operation a success. Despite the high recurrence rate, the operation was successful in controlling ulcer symptoms in around 90 per cent of patients and produced postvagotomy symptoms--none severe--in around 5 per cent of patients.

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.

Parietal cell vagotomy and truncal vagotomy in elective duodenal ulcer surgery--results after six to twelve years

In a randomized trial between 1974 and 1980, parietal cell vagotomy (PCV) was compared with truncal vagotomy (TV) in the treatment of duodenal ulcer in 106 patients. After a mean period of 3.9 years no significant differences were found between PCV and TV patients with respect to Visick grading and recurrence rates. Nor did the preoperative location of the ulcer-prepyloric or duodenal-significantly influence the recurrences. The latter follow-up reported in 1981, showed that PCV was not superior to TV. The present paper describes a re-analysis of the same material in 1985. After a mean observation time of 8.7 years no significant differences in the ulcer recurrence rate were found between PCV and TV. Equal patient satisfaction with the two procedures was found. In patients with prepyloric ulcers, preoperatively, there was a higher recurrence rate among those who had undergone PCV than TV.

Highly selective vagotomy: a 14-year experience

Since August 1971, 244 highly selective vagotomies were performed for pyloric and duodenal ulceration by one surgeon (W.A.F.M.). There was one postoperative death. Twenty (8 per cent) patients were lost to follow-up. The remaining 223 patients were followed up for 1 to 14 years (mean 4.2 years). On the modified Visick grading system 83.4 per cent were Visick I or II and 16.6 per cent were Visick III or IV. The failures were mainly recurrences. The recurrence rate was 11.2 per cent. Certain factors were examined to try to elucidate those influencing recurrence rate but no significant prognostic indicator was found. Acid studies were analysed and no significant relationship between these and the development of a recurrence could be found. The second 100 vagotomies were better than the first as judged by the results of studies of insulin-stimulated acid. Finally, we question whether all recurrences should automatically be regarded as treatment failures and the patients classified as Visick IV.

Highly selective vagotomy and duodenal ulcers that fail to respond to H2 receptor antagonists

A study was conducted to see whether patients with duodenal ulcers that failed to heal in response to H2 receptor antagonists had a higher incidence of recurrent ulceration after highly selective vagotomy than patients whose ulcers healed with these drugs. Between 1977 and 1983, 157 patients had a highly selective vagotomy for uncomplicated duodenal ulcer; in 57 patients the ulcer had failed to heal despite treatment with H2 receptor antagonists (refractory group), 19 patients had developed recurrent ulceration while receiving maintenance treatment, 67 patients had remained healed while taking H2 receptor antagonists but suffered frequent relapses when treatment was stopped, and 14 patients had not been given these drugs before operation. The overall incidence of recurrent ulceration was 6% after two years and 11% after five years of follow up. In the refractory group, however, the incidence of recurrent ulceration was 18% at two years and 34% after five years, whereas the incidence of recurrence was only 1.5% at two years and 3% after five years in patients whose ulcers had healed with H2 receptor antagonists. Resistance to H2 receptor antagonists was not related to preoperative basal or peak acid output but was related to cigarette smoking. Factors associated with recurrent ulceration after highly selective vagotomy were basal acid outputs before and after operation, cigarette smoking, and the surgeon who performed the operation. Duodenal ulcers that fail to respond to H2 receptor antagonists represent a more severe ulcer diathesis, for which highly selective vagotomy is less effective.

Anterior lesser curve seromyotomy with posterior truncal vagotomy versus proximal gastric vagotomy

In a prospective randomized trial anterior lesser curve seromyotomy with posterior truncal vagotomy (ASPTV, n = 48) has been compared with proximal gastric vagotomy (PGV, n = 43). Eighty-eight and eighty-three patients were available for follow-up studies at 1 year and 2 years, respectively. Six months postoperatively the mean reduction in pentagastrin-stimulated peak acid output (PAO) was 48.5 per cent (s.d. 26.3) after PGV and 50.5 per cent (s.d. 23.3) after ASPTV. Two years after the operation satisfactory clinical results (Visick I + II) were found in 84.2 per cent of the patients after PGV and in 88.9 per cent after ASPTV. There was a significant difference in the duration of surgery. No serious postoperative gastric sequelae were encountered after either operation. Up till January 1987, eight endoscopically proven, symptomatic recurrent ulcers have been diagnosed: four in the PGV group (9.3 per cent) and four in the ASPTV group (8.7 per cent). The results of this randomized study suggest that ASPTV is as good as PGV in the surgical treatment of chronic duodenal ulcers.

Diagnostic evaluation: gastric acid secretion and pH

The diagnostic value of gastric secretion tests has been found to be lower than what was previously believed. Thus basal and stimulated acid output is normal in most ulcer patients, and this is also so for gastric and duodenal pH. Gastric acid secretion does not separate patients with rapid recurrence after medical treatment from those with a long period of remission, and acid secretion is usually not higher in patients with recurrence after vagotomy than in patients without relapse. Today a gastric acid secretion test is used in patients suspected of the Zollinger-Ellison syndrome and it seems also to be valuable in ulcer patients who do not respond clinically satisfactory to medical treatment.

Should it be parietal cell vagotomy or selective vagotomy-antrectomy for treatment of duodenal ulcer? A progress report

This is a progress report of a prospective, randomized study involving 200 consecutive patients treated electively with either parietal cell vagotomy (PCV) or selective vagotomy and antrectomy (SV-A). Both groups comprised patients with pyloric, prepyloric, or duodenal ulcers. There was no operative mortality in either group. Patients were examined at 2, 6, 12 months, and every 12 months thereafter for 8-10 years. The two operations produced no statistical difference in the frequency of diarrhea. Dumping (p less than 0.0005) and weight loss (p less than 0.0005-p less than 0.05) were statistically less after PCV than after SV-A. There were two recurrent ulcers (2.2%) after SV-A. One was treated successfully by medical therapy and one patient suspected of having gastrinoma had total vagotomy. Nine patients had recurrent ulcers in the PCV group for an accumulated recurrence rate of 10.1% at 10 years by life-table analysis. There was a significant difference (p less than 0.033) between the curves for recurrent ulcers in the two groups of patients. The recurrent ulcer rate after PCV was 21% for patients with pyloric and prepyloric ulcers and 6% for patients with duodenal ulcer. There was no significant difference between the recurrent ulcer rate for PCV and SV-A if the patients with pyloric and prepyloric ulcers were withdrawn from the study. Of the nine patients with recurrent ulcers in the PCV group, three had an inadequate vagotomy and four had a pyloric or prepyloric ulcer before operation. Three patients were successfully treated with antrectomy. Five patients were treated successfully by medical therapy and remained healed for long periods without recurrence. One patient had five recurrences. He declined operation and remained free of symptoms for 3 years after his last recurrence. Poor gastric emptying necessitated gastroenterostomy in five patients in the SV-A group and in one patient in the PCV group. Patients' clinical results were evaluated according to a simple Visick grading scale. A significantly (p less than 0.0005) greater number of patients were in Visick I category after PCV than after SV-A. The clinical results obtained with PCV make this the operation of choice for the elective surgical treatment of duodenal ulcers even though the results obtained with SV-A were good.

One hundred patients ten years after parietal cell vagotomy

One hundred patients with duodenal or pyloric/prepyloric ulcer disease were operated with parietal cell vagotomy (PCV) and followed for a minimum of 10 years. At 6 weeks, 1,5 and 10 years postoperatively gastric secretory tests, haematological work-up and clinical examination or telephone interview were performed. There was no operative mortality and the frequency of postoperative sequelae was minimal. The cumulative ulcer recurrence rate was 18 per cent and another 14 per cent had slight to moderate symptoms of epigastric pain without any signs of ulcer. Upper gastrointestinal endoscopy was used to reveal recurrences but was performed only if the patient had symptoms of recurrence. A rise in basal acid secretion and in pentagastrin-stimulated secretion was observed the first year postoperatively, whereas insulin-stimulated peak acid output increased during the first 5 years. We conclude that PCV has a low rate of per- and postoperative complications and an acceptable recurrence rate. Therefore, it seems that PCV is the method of choice in chronic duodenal ulcer disease.

[Vagotomy and vagotomy follow-up--results of a survey]

A survey of 1006 surgical clinics in the Federal Republic of Germany in 1984 showed that the general surgical procedure for duodenal ulcers was vagotomy in 65.9%. 21.9% of the clinics checked the effectiveness of vagotomy intraoperatively by either performing electrostimulation (69.6%), leucomethylene-blue staining (20.9%), monitoring of the intragastric pH-value (7.3%), or Congo-red test (1.4%). Postoperative vagotomy controls were performed in 51% of the hospitals. Judging by the present results, application of intraoperative effectiveness control is not necessarily advisable. Evaluating the pre- and postoperative acid production allows the establishment of a quality control, however without any prognostic relevance.

Clinical results 1-10 years after highly selective vagotomy in 306 patients with prepyloric and duodenal ulcer disease

Overall clinical results were assessed 1-10 years after routinely performed highly selective vagotomy (HSV) in 326 consecutive patients suffering duodenal and prepyloric ulcer disease, operated on by 37 surgeons of varying seniority at a district general hospital. Three hundred and six (94 per cent) patients were followed up. No mortality was recorded after 326 primary and 50 reoperative procedures. Postoperative complications were few and diminished during the study period. Persistent moderate to severe dumping was found in 2.3 per cent of the patients; slight and periodic, but in no case disabling, diarrhoea in 11 per cent and gastric retention in 2.1 per cent. The overall clinical ulcer recurrence rate was 13.8 per cent, with a tendency towards better results during the second 5 year period. Significant differences were found between individual surgeons and groups of surgeons. Recurrences tended to be located more proximally than the primary ulcer. Fifty reoperations were performed in forty patients for ulcer recurrence (twenty-five), persistent ulcer-like symptoms (twelve) and gastric retention (three). When all recurrences and reoperations were classified as failures the symptomatic assessment according to Visick showed 67 per cent of the patients in grades I-II and 26 per cent in grade IV but the corresponding figures from the patients' own classification including the results of reoperations were 79 per cent and 7 per cent. It is concluded that for the time being HSV is the method of choice for the elective surgical treatment of duodenal and prepyloric ulcer disease.

Proximal gastric vagotomy or truncal vagotomy and drainage for chronic duodenal ulcer?

A comparison has been made between truncal vagotomy and drainage (TVD) and proximal gastric vagotomy (PGV) performed electively for chronic duodenal ulceration from 1968 to 1981 in 209 and 272 patients respectively. The morbidity was 23 per cent after TVD and 19.8 per cent after PGV, with a mortality of 0.5 per cent and 0.4 per cent respectively. Of 163 patients in the former group and 253 patients in the latter group the follow-up was an average of 5.7 and 6.2 years respectively; 128 patients (78.5 per cent) and 198 (78.3 per cent) respectively had a good functional result, graded as Visick I and II, but 35 (21.7 per cent) and 55 (21.7 per cent), respectively, had a poor result owing to recurrent ulceration in 23 (14.1 per cent) after TVD and 44 (17.4 per cent) after PGV. These results were not statistically different. The frequency of diarrhoea was 23 per cent and dumping 6.8 per cent after TVD which was significantly reduced to 2.0 per cent (P less than 0.005) and 1.2 per cent (P less than 0.025), respectively, after PGV. However, only five patients (3.0 per cent) had severe symptoms from diarrhoea and two (1.2 per cent) from dumping after TVD. Both operations seem to carry an equal incidence of unsatisfactory results, though for slightly different reasons it might be concluded that both procedures have an equal degree of acceptability.

Acid secretory tests in peptic ulcer disease before and after parietal cell vagotomy

The aim of the present study was to evaluate the role of gastric acid secretory tests in predicting ulcer recurrence in a consecutive series of patients before and up to 5 years after parietal cell vagotomy (PCV). Included in the study are 405 patients with prepyloric or duodenal ulcer disease (57 recurrences). There were no differences in acid secretion in the group of patients with pyloric or prepyloric ulcer disease, with or without recurrences. Thus pre- and post-operative acid secretory tests are of no value in predicting the outcome of PCV in this group of patients. In the duodenal ulcer group both postoperative basal acid output and peak acid output after pentagastrin and after insulin were higher in patients with recurrences. The two best discriminatory values were the ratio between the preoperative and the 6-week value of basal acid output and the 6-week value of peak acid output after insulin. The results of the study suggests that the ratio of the basal output before surgery and 6 weeks after surgery is enough for judging the acid reduction after PCV and that only in the case of a recurrence should an acid stimulation test be used.

The four to eight year results of the Sheffield trial of elective duodenal ulcer surgery--highly selective or truncal vagotomy?

In a prospective randomized trial between June 1973 and July 1978 highly selective vagotomy (HSV) was compared with truncal vagotomy and pyloroplasty (TVP) in 137 male patients undergoing elective surgery for chronic duodenal ulceration. Ninety per cent of patients were followed up for between 49 and 102 months (mean 77). A good result was obtained in 49 of 59 patients (83 per cent) after HSV compared with 41 of 64 (64 per cent) after TVP (P less than 0.02). The recurrent ulcer rate was 8.8 per cent after HSV and 9.4 per cent after TVP. Dumping and diarrhoea were significantly commoner after TVP (P less than 0.05). We believe that HSV is a better operation than TVP for the treatment of uncomplicated duodenal ulcer.

Prospective controlled vagotomy trial for duodenal ulcer: results after five years

A prospective, randomized, controlled trial was performed to study truncal vagotomy and drainage (TV), selective vagotomy and drainage (SV) and parietal cell vagotomy (PCV) as elective treatment for duodenal ulcer. Five years postoperatively, 233 patients were available for study: 73 TV, 81 SV and 79 PCV. The ulcer recurrence rates were 13.6, 19.8 and 30.4 per cent respectively. The incidence of severe dumping was 4.9, 10.9 and 1.9 per cent; of severe diarrhoea 4.9, 6.3 and 1.9 per cent; of severe pain/dyspepsia 3.3, 6.3 and 3.8 per cent and of severe nausea/vomiting 0, 1.6 and 0 per cent respectively. Women suffered more postvagotomy symptoms than men. After treatment of recurrences and postvagotomy symptoms, more patients after PCV achieved excellent results than after TV and SV, as recurrences were easier to treat than severe postvagotomy symptoms. The only factor found contributing to the high ulcer recurrence following PCV was the large number of surgical trainees operating in the trial.

In vitro and in vivo technique for assessing vagus nerve regeneration after parietal cell vagotomy in the rat

This study determined if the vagus nerve can regenerate and/or reinnervate the gastric parietal cell mass after parietal cell vagotomy (PCV) and examines tests for assessing vagus nerve regeneration in rats. Microscopic dissection of the neurovascular bundle allowed the vagus nerve to be divided at the gastric body with preservation of the antropyloric nerve and gastric vasculature. Gastric secretory tests were performed under basal and stimulated conditions using secretagogues and insulin hypoglycemia. The candidate hormone, pancreatic polypeptide, was measured in plasma following a mixed meal, insulin hypoglycemia and i.v. secretin. Rats were killed weekly for 9 weeks and the vagal nerve distribution examined by both light and electron microscopy. Stimulated gastric acid output fell from 164 to 26 mumol/h immediately after operation (P less than 0.001). One week following PCV, the nerves were swollen with fibroblast infiltration and collagen around axon groups showed degeneration. By the third week after PCV, the axons were more densely packed with neurofilaments and acid output had increased to 183 mumol/h. In the fourth and fifth weeks, the enlarged Schwann cell processes had more axons and acid output rose to 262 mumol/h. By the seventh week, both large and small axons were identified and the acid output was 93% higher than the preoperative level (P less than 0.001). PCV and antrectomy also was followed by reinnervation of the gastric mucosa. Pancreatic polypeptide concentration in plasma was virtually unchanged following ingestion of food, insulin hypoglycemia or secretin. In rats, following PCV, gastric secretory tests and electron microscopy seem to be the most reliable methods of assessing vagus nerve regeneration.

Proximal gastric vagotomy interferes with a fundic inhibitory mechanism. A hypothesis for the high recurrence rate of peptic ulceration

The mucosa of the proximal stomach contains a powerful inhibitor of acid secretion and gastrin release. The release of this inhibitor is dependent on intact vagal innervation of the proximal stomach. Thus, proximal gastric vagotomy interferes with the release of the inhibitor. After proximal gastric vagotomy for peptic ulcer, recurrence rates increase over time. In addition, there is some recovery of acid secretion. Although nerve regeneration or sprouting has been suggested as the possible explanation for these events, we propose that interference with the inhibitory mechanism of the proximal stomach may be another possible explanation for the increasing ulcer recurrence rates after proximal gastric vagotomy. At present, this is only a hypothesis and is suggested only by indirect evidence. Direct testing of the hypothesis will require complete purification of the inhibitor and the development of a specific radioimmunoassay.

A prospective randomized trial of vagotomy in chronic duodenal ulceration: 4-year follow-up

A total of 153 patients (124 male and 29 female) with uncomplicated chronic duodenal ulceration were studied in a prospective, randomized trial of proximal gastric vagotomy (PGV) and truncal vagotomy and pyloroplasty (TVP), conducted in four Manchester hospitals. Of these, 137 patients have now been followed up for 2.5 to 5.5 (mean 4.1) yr. There have been 15 (21 per cent) recurrent ulcers following PGV compared with 5 (7.5 per cent) after TVP (P less than 0.05). A satisfactory functional result was obtained in 82 per cent of patients after TVP compared with 73 per cent following PGV and there was little difference between the groups with regard to the incidence of dumping, heartburn and vomiting. There was significantly more diarrhoea following TVP (13 per cent) compared to PGV (1.4 per cent) but this represented only a minor clinical problem.

Arhus County Vagotomy Trial: ulcer recurrence rate related to alterations in gastric acid secretion after selective gastric and parietal cell vagotomy

Clinical and secretory data were analysed with respect to the recurrence rate for 685 patients treated with either selective gastric vagotomy (SGV) or parietal cell vagotomy (PCV) for duodenal ulcer disease. The duration of ulcer history before surgery was of no importance for the recurrence risk. Men with recurrence after SGV were significantly younger than men without recurrence, but no difference was found for women with SGV or for men and women with PCV. The recurrence rate was not higher for hypersecretors (pentagastrin-stimulated peak acid output (PAOpg) greater than 45 mmol/h) than for patients with lower PAOpg. Resting, basal, and stimulated secretion 3 months after surgery were higher for the patients with recurrence than for the patients without, but only a few of the secretion values were significantly different. A higher recurrence rate was found for the patients with the lowest initial acid reduction, and this trend was more pronounced in the PCV group. With regard to the change in gastric secretion during the first year after vagotomy a significant rise was seen for the PCV patients who developed recurrence in spite of initial reduction of more than 60%. For all SGV patients and the PCV patients with an initial reduction on the average or less, the change in secretion capacity had no influence on the recurrence rate. The findings are in accordance with reports about anatomical limitations for a sufficient PCV in about 20% of the patients.

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.

Morphologic and functional evidence of reinnervation of the gastric parietal cell mass after parietal cell vagotomy

The incidence of recurrent ulceration after parietal cell vagotomy varies greatly and the cause is largely unknown. Whether the vagus nerve can regenerate or reinnervate the gastric parietal cell mass after parietal cell vagotomy was investigated. Careful microscopic dissection of the neurovascular bundle in 130 rats allowed the vagus nerve to be divided to the gastric body with preservation of the antropyloric nerve and gastric vasculature. Gastric secretory tests were performed under basal and stimulated conditions after secretagogue and insulin hypoglycemia stimulation. Rats were killed weekly and the vagal nerve distribution examined by electron microscopy. Stimulated gastric acid output decreased from 164 to 26 mumol/hour immediately after operation (p less than 0.001). One week after parietal cell vagotomy the nerves were swollen with fibroblast infiltration and collagen around axon groups showed degeneration. By the third week after parietal cell vagotomy, the axons were more densely packed with neurofilaments and acid output had increased to 183 mumol/hour. In the fourth and fifth weeks, the enlarged Schwann cell processes had more axons and acid output increased to 262 mumol/hour. By the seventh week, both large and small axons were identified and the acid output was 93 percent higher than the preoperative level (p less than 0.001). The sequential neuropathologic changes of vagus nerve degeneration, regeneration and functional reinnervation of the gastric parietal cell mass after parietal cell vagotomy are shown by this study. If this occurs in man, it may be an important cause of recurrent peptic ulceration after parietal cell vagotomy.