The First 15 Years' Experience with Vagotomy and Drainage for Duodenal Ulcer at the Royal Prince Alfred Hospital,Sydney1

The first 15 years' experience with vagotomy and drainage for duodenal ulcer at the Royal Prince Alfred Hospital, Sydney, is summarized in a retrospective study. Proved ulcer recurrence in 16% of patients, a mortality rate of 2–6%, and a postoperative complication rate of 32% suggest that vagotomy and drainage as the procedure of choice in all patients with chronic and complicated duodenal ulcer sjiould be reconsidered. The delay in recognition of ulcer recurrence and the increase in the number of patients with longer follow-up show disturbing similarities to the recurrence of ulcer after gastroenterostomy alone.     

Gastroduodenal ulcer. Overview of 150 papers presented before the Southern Surgical Association 1888-1986.

By the early part of this century, members of the Southern Surgical Association as well as others began to realize that gastroenterostomy alone was unacceptable for the treatment of gastric ulcer. Ulcer excision and some type of limited resection was advised. At a later date, gastric resection of varying extent, depending on ulcer size and location, became the appropriate treatment for complications of this disease. For treatment of complications of duodenal ulcer, gastroenterostomy was widely used from the latter part of the 19th century until the late 1930s. Adequate gastric resection slowly but cautiously replaced gastroenterostomy during the 1940s. Vagotomy with drainage and vagotomy with antrectomy slowly developed and replaced adequate resection by the early 1970s. Beginning in the 1970s and extending into the 1980s, fewer duodenal ulcers were seen, and many of those encountered were being adequately managed using the H2 receptor blockers. For the intractable duodenal ulcer there is currently an increasing trend to use the less invasive operation of parietal cell vagotomy. Vagotomy with antrectomy for such cases is being used less frequently. Vagotomy and drainage has lost much of its appeal. Lesser procedures have been advocated recently for treatment of marginal ulcer after incomplete vagotomy irrespective of the original operation for ulcer. Massive bleeding and acute perforation are still frequently encountered as complications but are being seen more frequently in elderly high-risk patients, some of whom will tolerate only a lesser procedure as suture ligation, vagotomy with drainage, or simple ulcer closure. It appears that we are now seeing a different duodenal ulcer pattern in the good-risk patient. The ulcers are usually small, less virulent, and less likely to be found penetrating into the pancreas and adjacent organ structures. As Claude Welch so aptly stated recently before the Association, "We are seeing a trend in ulcer surgery that is currently being seen in other areas of surgical endeavors as well." He emphasized that we must be alert to changing disease patterns and adapt our procedures to new requirements.     

Giant marginal ulcer

Marginal ulcer is a well-known complication of gastroenterostomy. It occurs in 3% of patients post-Billroth II subtotal gastrectomy; it occurs in less than 1% if truncal vagotomy is included but in up to 30% of patients with gastroenterostomy without vagotomy [10, 11, 14, 16]. These ulcers occur at the anastomosis, but always on the jejunal side, and are known to develop complications of their own — e.g., intractable pain, hemorrhage, obstruction, perforation, and fistula formation [6, 8, 17]. Prior to the advent of upper-GI endoscopy the main method of diagnosis was by history and upper GI series but the accuracy of the upper-GI series was about 50% or less. Now that upper-GI endoscopy is available, the accuracy of diagnosis is 95% or better. Since truncal vagotomy has been widely adopted as an integral part of gastric surgery — e.g., antrectomy, hemigastrectomy, subtotal gastrectomy, and gastroenterostomy — the incidence of marginal ulcer has declined. The use of cimetidine, ranitidine, famotidine, omeprazole, sucralfate, and antacids has improved the medical management of duodenal ulcer to such a degree that in recent years there is much less need for surgical intervention and thus the incidence of marginal ulcer has declined even more. In addition, the H-2 blockers and omeprazole can be used in patients with marginal ulcer and achieve healing; therefore complications that so frequently required surgical intervention are much less frequent [3, 12]. This report describes the clinical course of a patient with a virulent form of marginal ulcer and recurrent gastric bezoars, who was 5 years post truncal vagotomy and hemigastrectomy, with no evidence of a Zollinger-Ellison syndrome and low gastric acid as determined by two studies.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Antonio, Texas, USA, 1988     

Acute perforated duodenal ulcer

This report is based on a personal experience with nineteen patients who were operated upon for acute perforation of a duodenal ulcer. Closure of the perforation and posterior gastroenterostomy was done in all and in twelve the appendix was removed. Drainage was used in only two cases. There was one death. This patient who was admitted in a state of shock five hours after perforation and operated upon at once died twenty-four hours later. The youngest, and only female in the group, was a girl of eighteen years. This is not a selected group but one which contains all cases of acute perforated duodenal ulcer which have come under my care in the past fifteen years.Many perforated duodenal ulcers become sealed temporarily to the undersurface of the liver, thereby preventing for a time widespread contamination of the peritoneum.Acute perforation is the result of an acute ulcerative process in either a recent or an old ulcer. The perforation is caused by erosion (acid) and not by rupture from increased pressure.The operation of choice should be closure of the perforation and posterior gastroenterostomy. The closure is made by three or four through-and-through cotton sutures re-enforced by several nearby fat tabs. Do not infold; do not use a purse-string suture.Except in the presence of advanced peritonitis, gastroenterostomy is advisable because (1) perforation does not cure the ulcer. Simple closure is followed by recurrence of ulcer in 40 to 60 per cent of the patients and in others the stomach may have motor difficulty from fixation of the pylorus to the undersurface of the liver. Gastroenterostomy is the best safeguard against recurrence and motor dysfunction of the stomach. (2) It protects the sutured area of perforation against tension and leakage. (3) It does not increase the operative risk.When the appendix is readily accessible, it should be removed. Spinal anesthesia is recommended except in the presence of shock. Drainage is rarely indicated.     

Surgical therapy of ulcer disease. Early and late results of elective and emergency interventions]

Between 6/1974 and 12/1988 910 patients with peptic ulcer disease have been treated operatively. In 523 cases a resection, gastroenterostomy resp. ligation of a bleeding ulcer, in 160 cases with duodenal ulcers a vagotomy, and in 227 cases with perforated ulcers simple closure or primary resection have been performed. During this study the percentage of female patients rose from 32.0 to 39.7. There was also an increase of the mean age of the patients. Operative mortality rate was 7.3% for resection, GE resp. ligation of a bleeding vessel, 0.6% for vagotomies, and 16.3% for perforated ulcers. The fate of all patients was followed regularly. In patients operated before 1985--with a follow-up of 5-16 years--reoperations were necessary in 6.0% following resection, gastroenterostomy resp. ligation, in 7.7% following vagotomy, and in 21.3% following simple closure or primary resection of a perforated ulcer.     

Bulbantrectomy with truncal vagotomy in the surgical treatment of duodenal ulcer

Duodenal ulcer benefits of very efficient medical treatment. In currently medical practice exist many cases with complicated duodenal ulcer (by stenosis or penetration in neighbor organs like pancreas or biliary tract or painful forms etc.) to which surgical treatment is necessary. Based on the retrospective study of 116 patients operated between 1991-2002 years for gastric or duodenal ulcer, this paper demonstrates that bulbantrectomy associated with bilateral truncal vagotomy (63.7% of cases) is the best surgery in the treatment of duodenal complicated ulcer or resistant to the medical procedures. Provided by correct indication, the intervention is the most pathogenic, offering the best immediate and long term postoperative results. If the bulbantrectomy is contraindicated (critical general status, etc.), the alternative is a bilateral truncal vagotomy associated with a drainage procedure: pyloroplasty (6.9% of cases) or gastroenterostomy. When the vagotomy are contraindicated or cannot be correctly performed, a large gastrectomy (29.3% of cases) followed by gastroduodenal (preferable) or gastrojejunal anastomosis are practiced.     

Duodenostomy revisited

Four patients were admitted to the Surgical Ward because of massive bleeding from a duodenal ulcer. In three the ulcer was induced by non-steroid anti-inflammatory drugs. On operation, following pylorotomy and suture of the bleeding artery, neither drainage nor stump closure could be affected safely. Partial gastrectomy with vagotomy, or high subtotal gastrectomy with gastroenterostomy were performed. The duodenum was dealt with by means of a tube duodenostomy. There was no mortality among these patients. Morbidity was related mainly to the extent of preoperative bleeding and associated pathology (e.g. perforation). Patient data is presented in Table I.     

Choice of the method of stomach resection

The authors studied the causes of the recurrence of peptic ulcer in 142 patients after various types of operations on the stomach for peptic ulcer. They came to the conclusion that operations which are characterized by alkalization of the gastrointestinal anastomosis, on condition that free hydrochloric acid is maintained in the gastric juice after the operation, may be a factor predisposing the development of peptic ulcer of the anastomosis and jejunum. Hofmeister-Finsterer gastroenterostomy must be performed in resection of the stomach for duodenal ulcers which are characterized by high acidity. Balfour's anastomosis is preferable in achlorhydria or marked hypoacidity of the gastric juice before the operation.     

腹腔镜辅助的胃大部切除术(附4例报告)

目的 :探讨腹腔镜辅助的胃大部切除的手术方法。方法 :选择胃平滑肌瘤、胃癌各 1例 ,十二指肠球部溃疡 2例 ,在腹腔镜下用超声刀离断胃周韧带与血管 ,辅以约 6cm的小切口进行胃大部切除胃肠吻合术 ,合并胆囊结石的 2例同期完成腹腔镜胆囊切除术。结果 :4例手术均获成功。结论 :腹腔镜辅助的胃大部切除术难度较大 ,用超声刀完成手术具有止血可靠 ,切割精确的优点 ,若掌握得当 ,手术是安全可行的。辅以小切口完成胃肠的离断与吻合 ,可减少手术难度 ,节约医疗费用     

Vagotomy and gastroenterostomy for stenosing duodenal ulcer

Vagotomy and gastroenterostomy (V-GE) was performed in 41 patients with chronic stenosing duodenal ulcer and gastric retention in the years 1965-84. There was no mortality and no severe complication occurred. One patient was reoperated for dysfunction of an antecolic stoma. After a follow-up of 1-16 (mean 8) years 30 patients were interviewed and gastroscopy was performed in 21. One recurrence of ulcer was found at endoscopy. Visick classification gave the following overall results: grade I 40%, grade II 13%, grade III 30% and grade IV 17%. One case of gastric carcinoma was found five years after operation. It was concluded that V-GE is a simple and safe method and will give satisfactory early and long-term results.     

Proximal gastric vagotomy with drainage for obstructing duodenal ulcer

The optimal treatment for obstructing duodenal ulcer is controversial because of questions about the efficacy of proximal gastric vagotomy (PGV) in controlling the primary ulcer diathesis. Impressed with the theoretic advantages of PGV with drainage as a primary treatment for this problem, we have treated 37 suitable patients by this approach. All patients underwent endoscopic examination and barium meal study that proved the diagnosis. PGV, including division of the gastroepiploic nerves as indicated by intraoperative testing, was followed by Jaboulay gastroduodenostomy (18), Finney pyloroplasty (12), Heineke-Mikulicz pyloroplasty (3), anterior hemipylorectomy (2), duodenoplasty (1), and gastroenterostomy (1). No recurrent ulcers were seen during a mean follow-up of 4.6 years. Three patients had mild early dumping at infrequent intervals. Bilious vomiting, alkaline gastritis, and other postgastrectomy complaints were recorded infrequently. PGV with drainage is a good treatment for the obstructing ulcer and does not have as many morbid risks as alternative operative procedures.     

Truncal vagotomy and pyloroplasty. Critical evaluation of one hundred cases

One hundred patients having truncal vagotomy and Heineke-Mikulicz pyloroplasty on the surgical service of a Veterans Administration hospital performing mainly vagotomy and distal antrectomy were carefully analyzed.In a follow-up study ranging from two to thirteen years, an operative mortality rate of 1 per cent and a proved recurrence rate of 2 per cent were found. The factors involved in the choice of operation for duodenal ulcer were reviewed, and in our hospital the following rates were developed: vagotomy and distal antrectomy, 73 per cent; vagotomy and pyloroplasty, 16.4 per cent; vagotomy and gastroenterostomy, 8.5 per cent; partial gastrectomy, 1.6 per cent; and miscellaneous operations, 0.5 per cent.     

Palliative biliodigestive anastomosis in non-resectable cancer of the head of the pancreas--with or without preventive gastroenterostomy?

In 226 patients with malignant obstructive jaundice over a 10-year period (1975-1984) 92 presented with an unresectable carcinoma of the head of the pancreas and were treated with a palliative bilioenteric diversion: in 52 cases alone, in 20 cases with a therapeutic gastroenterostomy because of early duodenal obstruction, and in 20 cases with a simultaneous prophylactic gastroenterostomy. The latter did not increase perioperative morbidity (25% vs. 50% in bilioenteric diversion alone), mortality (5% vs. 19%) nor length of hospital stay (19.9 vs. 20.6 days). Later on patients with a prophylactic gastroenterostomy showed a decreased incidence of chronic vomiting (15% vs. 42%). No secondary gastroenterostomy was performed in this group, vs. 14% (6 patients) in cases with bilioenteric diversion alone (mortality 33%). We recommend the simultaneous prophylactic gastroenterostomy which does not increase morbidity, mortality and length of hospital stay and helps avoiding a risky secondary gastroenterostomy.     

Surgical treatment of recurrent peptic ulcer disease.

One hundred twenty patients in whom recurrent peptic ulcer developed after various surgical procedures for primary duodenal ulcer were operated on at the Mayo Clinic between 1970 and 1975. The postoperative mortality rate was 3.3% for all cases, 0.9% for elective cases, and 23% for the 13 patients who required emergency surgical care. The mean hospital stay was 13 days, and postoperative complications developed in 25 patients (20%). Approximately 70% of the patients had excellent or good results, whereas the rest had significant postoperative sequelae, including 8.4% (9 patients) in whom rerecurrent ulceration developed. When remedial surgery for recurrent ulcer consisted of vagotomy and distal subtotal gastrectomy (35 patients) after previous vagotomy and drainage procedure (21 patients), subtotal gastrectomy (three patients), vagotomy and hemigastrectomy (eight patients), or gastroenterostomy alone (three patients), there were no operative deaths, 74% of 27 patients available for at least a 5-year follow-up had excellent or good results, and rerecurrent ulceration developed in only one patient. These results indicate that vagotomy and resection is a satisfactory operation for recurrent peptic ulcer and that the long-term results after this operation compare favorably with those reported for cimetidine therapy.     

原发性十二指肠恶性肿瘤的外科治疗

目的探讨原发性十二指肠恶性肿瘤的外科治疗策略。方法回顾性分析1997~2004年我院收治的72例原发性十二指肠恶性肿瘤病人的临床资料。52例行胰十二指肠切除术,8例行肿瘤局部切除术,5例行胆肠和/或胃肠吻合术解除梗阻,4例行肿瘤活检术以明确诊断,3例确诊后拒绝手术治疗。结果随访62例。46例行胰十二指肠切除术病人术后1年、3年和5年的生存率分别为76.1%,54.3%和28.3%。3例放弃手术治疗者及3例行肿瘤活检术者均于1年内死亡。4例仅行胆肠和/或胃肠吻合术者术后1年生存率为25%。6例行肿瘤局部切除术者均于术后短期内复发,仅2例存活1年。52例行胰十二指肠切除术病例中出现并发症的有8例。应用单层褥式交锁缝合进行胰肠重建的20例及保留幽门的8例术后经过均良好,无1例出现严重并发症。结论胰十二指肠切除术系原发性十二指肠恶性肿瘤的首选治疗方法,应严格掌握肿瘤局部切除术的适应证。     

Carcinoma of the head of the pancreas: bypass surgery in unresectable disease

One hundred patients who underwent bypass surgery for unresectable, histologically proven carcinoma of the head of the pancreas were studied to determine: the incidence of a second operation for duodenal obstruction in survivors who had a biliary diversion only; whether the addition of a prophylactic gastroenterostomy is associated with increased mortality. Eighty-six patients (Group A) had a biliary diversion alone while fourteen (Group B) had a biliary diversion and a prophylactic gastroenterostomy. Both groups were comparable regarding sex, age, symptomatology and clinical findings. The postoperative mortality was similar for both groups (Group A, 27.9 per cent; Group B, 14.3 per cent). The mean surgically related hospital stay was 22 +/- 6.5 days (Group A) and 20 +/- 7 days (Group B). Of the 62 patients in Group A who left hospital, 8 (13 per cent) required a second operation for duodenal obstruction (mean interval 5.4 +/- 2.7 months). The in-hospital stay for the second operation was 14.4 +/- 7.7 days. The overall survival for both groups was identical at 6 months (35.5 versus 33.3 per cent) and 12 months (19.3 versus 16.7 per cent). This study suggests that prophylactic gastroenterostomy adds no risk to patients requiring biliary diversion for carcinoma of the head of the pancreas. Its routine use is therefore justified since 13 per cent of the patients who survived the biliary diversion required further surgery for duodenal obstruction before death.     

Gastric emptying after anterior lesser curve seromyotomy and posterior truncal vagotomy

Anterior lesser curve seromyotomy with posterior truncal vagotomy (ASPTV) provides a simple, safe and expeditiously performed method of denervating the parietal cell mass, whilst preserving the pylorus. Dumping and diarrhoea are uncommon after this procedure. Gastric emptying has been assessed after ASPTV and other elective operations for duodenal ulcer. Liquid and solid phase gastric emptying studies were performed in control subjects (17), patients before and at least six months after ASPTV (14), vagotomy and pyloroplasty both without (8) and with (6) diarrhoea, vagotomy and gastroenterostomy (11), and Polya gastrectomy (7). There was no delay in emptying time for liquids or solids between ASPTV patients and controls. With the exception of an increase in the early emptying of liquids (P = 0.02) after ASPTV, gastric emptying was not different from normal. After truncal vagotomy and pyloroplasty in patients without diarrhoea the gastric emptying of solids, but not of liquids, was markedly increased (P = 0.00001), whereas in those with diarrhoea both liquid and solid phase emptying were markedly increased (P less than 0.001). When gastroenterostomy was used as the drainage procedure both phases of emptying were increased. After Polya gastrectomy, both early and late emptying of liquids and solids were increased (early phase P less than 0.05, overall emptying P less than 0.001).     

Several standard elective operations for duodenal ulcer: ten to 16 year clinical results.

A survey was undertaken of 558 men with duodenal ulcer who had been treated ten to 16 years previously by truncal vagotomy and drainage, truncal vagotomy and antrectomy and subtotal gastrectomy. Of the 558, 65 had died and 111, presumed living, could not be traced, leaving 382 available for assessment. Between 75 and 85% of the traced patients were considered to have an excellent or very good result, which is a slight improvement on the previously published results in this same group of patients at five to eight years follow-up. Some of the side effects of operation had diminished slightly in frequency and there had been no significant increase in the incidence of recurrent ulceration since the previous survey. Anemia was an uncommon finding. As between the various forms of operation, truncal vagotomy and antrectomy and subtotal gastrectomy demonstrated significantly better protection against proven recurrent ulcer than did truncal vagotomy and pyloroplasty (p less than 0.05). Compared with truncal vagotomy and gastroenterostomy, however, the results of both resection operations, though better, did not achieve statistical significance at p - 0.5 level (p less than 0.1). In regard to Visick gradings the resection procedures had better scores, but the differences were not significant at the p - 0.05 level, except for vagotomy and antractomy as compared with vagotomy and pyloroplasty. But it is stressed that in formulating a policy of surgical therapy for duodenal ulcer the greater inherent immediate risks of resection operations need to be borne in mind.     

Vertical Isolated Gastroplasty with Gastro-enteral Bypass: Preliminary Results

Background: The authors present a new restrictive and malabsorptive operation for treatment of morbid obesity, called vertical isolated gastroplasty (VIG). Methods: From Feb 2004 to May 2005, 30 patients with BMI ≥40 kg/m² or >35 kg/m² with co-morbidities underwent VIG via laparoscopy or laparotomy. The technique consisted in creation of a gastric tube preserving pylorus, and a Roux-limb of 300 cm to the bypassed stomach with the division 30 cm distal to the ligament of Treitz. Excess weight loss (EWL), BMI, complications and co-morbidities were assessed. Results: BMI and average preoperative weight were 41.2 kg/m² and 110.7 kg, respectively. At 12 months postoperatively, BMI and average weight were 23.4 kg/m² and 65.1 kg, respectively, with EWL 90.2%. None of the patients presented dumping. Improvement in co-morbidities was >90%. Complications consisted of: 1 dehiscence of gastric sutureline, 1 hemoperitoneum, 1 gastroenterostomy ulcer, 1 anemia of undetermined cause, and 3 cholelithiasis. There was no mortality. Conclusion: VIG has thus far been safe and effective, with the same results as other bariatric operations. VIG has certain advantages, such as lack of dumping and lack of clinically significant stenosis of the gastroenterostomy, which can occur with other techniques. Because a duodenal bypass is not performed, it allows physiologic absorption of iron and diagnostic and/or therapeutic access to the ampulla of Vater.     

Recurrent peptic ulceration after highly selective vagotomy: long-term outcome

A prospective assessment was made of the outcome 4 years after diagnosis of recurrence in a group of 27 patients with documented ulceration after highly selective vagotomy (16 symptomatic recurrence and 11 asymptomatic). In the 16 patients with a previous symptomatic recurrence, eight of the 11 patients with duodenal ulcer underwent a further endoscopy at 4 years and one active ulcer was found. Five patients with previous symptomatic gastric ulcer recurrence have all undergone further surgery. In the 11 patients who originally had an asymptomatic ulcer recurrence (five gastric, six duodenal) no patient has undergone further surgery, although two patients with a recurrent gastric ulcer and two with a recurrent duodenal ulcer subsequently developed symptoms from their ulcer and required H2 receptor blocker therapy. Eight of the 11 originally asymptomatic patients underwent further endoscopy at 4 years and two further duodenal ulcers were found. After highly selective vagotomy, asymptomatic ulcer recurrence occurs frequently and 40 per cent of these patients may develop symptoms.