Modified segmental gastrectomy combined with vagotomy for a gastric ulcer near the gastro-esophageal junction

To avoid proximal gastrectomy which destroys the gastroesophageal closing mechanism, modified segmental gastrectomy with vagotomy was performed on 3 patients with gastric ulcers located in the stomach near the gastro-esophageal junction. These were all patients in whom a proximal gastrectomy would usually have been performed. The proximal line of resection did not encroach upon the mucosal rosette being within 1 cm of it following the margin of the ulcer. In each patient, the modified segmental resection of the upper stomach consisted of the surgical removal of a continuous strip of tissue including the ulcer and ulcer-bearing area along the wall followed by an end to end gastro-gastrostomy. In the 10 years following surgery, there have been no signs of reflux esophagitis, stricture, or recurrent ulcers in any of the 3 patients. This modified segmental gastrectomy with vagotomy is therefore recommended for gastric ulcers located near the gastro-esophageal junction.     

腹腔镜下早期胃癌节段切除术

目的探讨胃节段切除在分化型早期胃癌手术中的可行性。方法严格挑选2013年8月至2015年6月间4例中段早期胃癌病人,实施腹腔镜下胃节段切除并D1+或D2淋巴结清扫。观察淋巴结清扫数目、术后并发症等情况。结果在清扫小弯侧淋巴结过程中没有保留迷走神经。远端切缘距离幽门4 cm以上,平均淋巴结获取数目为18.5枚。在术后1年内均存在胃排空缓慢的症状和影像学征像,1年后得到缓解。结论经腹腔镜行早期胃癌节段切除在技术上安全可行,是否保留迷走神经有待于进一步的观察。     

The preventive and therapeutic effects of vagotomy for stress ulcer —Experimental studies on the aspects of gastric submucosal blood flow and ulcer index—

The purpose of this study was to examine the preventive and therapeutic effects of vagotomy on the stress-induced ulcer in terms of gastric submucosal blood flow and ulcer index. Stress was induced in male Wistar rats by forced immersion in water, and the gastric submucosal blood flow (hydrogen clearance method) and ulcer index were determined in animals that underwent truncal vagotomy alone or truncal vagotomy+pyloroplasty as well as in untreated controls. Both truncal vagotomy alone and truncal vagotomy+pyloroplasty were effective in maintaining the blood flow during stress and preventing the development of ulcers, however, these effects were more notable in the truncal vagotomy+pyloroplasty animals. Truncal vagotomy alone or truncal vagotomy+pyloroplasty performed after the development of stress-induced ulcers had no therapeutic effects.     

十二指肠溃疡高选择性迷走神经切断术后胃粘液分泌的研究

通过对20例十二脂肠溃疡病人实施高选择性迷走神经切断术(HSV)前后,可视粘液排泌量术后稍降低,与术前比较差异不显著(P>0.05):溶解性粘蛋白排泌量术后降低,与术前比,有显著性差异(P<0.05);溶解性粘 排泌量术后升高.尤其刺激后胃液中升高明显,与术前比差异显著(P<0.05).说明HSV术不明显损害胃粘液屏障.     

Postoperative results of distal partial gastrectomy,selective vagotomy plus antrectomy,and selective proximal vagotomy for duodenal ulcers

We investigated the postperative results of distal partial gastrectomy, selective vagotomy plus antrectomy, and selective proximal vagotomy, to evaluate their effectiveness in the treatment of duodenal ulcers. The operative mortality of selective vagotomy plus antrectomy and selective proximal vagotomy seemed to be lower when compared to distal partial gastrectomy, although each procedure showed a sufficiently low mortality. The acid reduction rate was significantly lower after selective proximal vagotomy than after the other procedures (p<0.01). However, the rate of ulcer recurrence following selective proximal vagotomy tended to be higher compared with the other procedures. All three procedures showed good results according to Visick’s grading and postoperative symptoms occurred in about 50 per cent of all patients, no matter what the procedure. The regaining of physical ability was significantly greater following selective proximal vagotomy than following distal partial gastrectomy (p<0.05) and the capacity to work was also better after vagotomy, particularly selective vagotomy plus antrectomy (p<0.05). Thus, although distal partial gastrectomy and selective vagotomy plus antrectomy proved superior regarding the low ulcer recurrence rate and acid reduction, while selective proximal vagotomy proved superior for improving the quality of life, on the whole the three operations promise almost equivalent results.     

The role of vagotomy in healing of gastric ulcers induced in rats

The role of vagotomy for healing of gastric ulcer is obscure. To investigate the effect of vagotomy on healing of experimentally-induced gastric ulcer, a mucosal defect of a constant size was made in the gastric fundus of control rats and other rats subjected to abdominal bilateral vagotomy. Gastric acid secretory response to electrical stimulation of the cervical vagus nerve and changes in body weight and in ulcer index (mm²) were estimated postoperatively, in these groups. Significant acid secretory responses to the vagal stimulation and constant weight gain were observed in the control rats while there was no acid secretory response and a lesser weight gain in the vagotomized rats than in the controls. There were no significant differences of postoperative ulcer indices between the two groups. These results suggest that the procedure does not alter gastric mucosal circumstances related to the healing of the gastric ulcers, although vagotomy abolishes the cephalic phase of gastric acid secretion.     

改良高选择性迷走神经切断术治疗十二指肠溃疡急性穿孔

目的观察改良高选择性迷走神经切断术治疗十二指肠溃疡急性穿孔的远期临床效果。方法应用改良高选择性迷走神经切断术治疗十二指肠溃疡急性穿孔148例。随访观察术后并发症、胃酸下降情况及胃排空和溃疡复发情况,并按Visick标准进行分级。结果全组病例无围手术期死亡。126例获随访,随访时间6个月～9年,术后3年基础酸排出量(BAO)、最高酸排出量(MAO)、高峰酸排出量(PAO)仍保持术后低水平。Visick分级,Ⅰ级102例(81.0%),Ⅱ级15例(11.9%),Ⅲ级5例(4.0%),Ⅳ级4例(3.2%)。有2例患者溃疡复发(1.6%)。结论改良高选择性迷走神经切断术治疗十二指肠溃疡急性穿孔,设计合理、操作简单、效果确切,值得在基层医院推广应用。     

腹腔镜下迷走神经切断加溃疡穿孔粘堵治疗十二指肠溃疡穿孔38例报告

目的:探讨腹腔镜在溃疡穿孔治疗中的应用价值。方法:将明胶海绵卷成锥体栓,尖端塞入穿孔,基底部稍高于浆膜面,均匀滴入生物蛋白胶1.0~1.5m l在明胶海绵栓及其周围,采用H ill术式,切断迷走神经后干和高选择性切断前干。结果:全部病例术后8~9d痊愈出院。全部随访复查胃镜检查溃疡面愈合情况,38例中36例溃疡面愈合,另2例给予内科药物治疗痊愈。结论:腹腔镜下行迷走神经切断术加溃疡穿孔粘堵术治疗十二指肠溃疡穿孔疗效可靠,创伤小,值得推广。     

Differences in gastric emptying between highly selective vagotomy and posterior truncal vagotomy combined with anterior seromyotomy

Gastric emptying has been reported to be both delayed and unchanged following posterior truncal vagotomy combined with anterior seromyotomy (PTV + AS). When compared to highly selective vagotomy (HSV), our clinical experience was that PTV + AS not uncommonly produced postprandial distress. We studied gastric emptying of both liquids and solids 3 and 12 months following HSV and PTV + AS to determine what if any differences there were in gastric emptying between the two procedures. We compared these results with those from studies done in both normal subjects and unoperated duodenal ulcer patients. In 26 duodenal ulcer patients with perforation (n = 18) or bleeding (n = 8), who were treated with HSV (n = 10) or PTV + AS (n = 16), gastric emptying of liquids and solids was evaluated at 3 months and 12 months postoperatively. At 3 months, gastric emptying of liquids was delayed in both the HSV and PTV + AS groups as compared to values in both normal subjects and unoperated duodenal ulcer patients. The emptying of solids was markedly delayed by PTV + AS in contrast to HSV at 3 months (167.1 ±28.4 minutes vs. 79.9 ±16.7 minutes; P <0.05). The lag duration was not affected. A limited number of patients studied at 12 months showed similar and near-normal emptying of solids in both the HSV and PTV + AS groups (67.5 ±7.0 minutes vs. 70 ±6.6 minutes). PTV + AS in contrast to HSV produces more marked delayed emptying of liquids and solids at 3 months; with time (1 year) these values return to near normal. Supported by a grant from the National Science Council (NSC 85-2331-B016-035), Taipei, Taiwan, China.     

保留交感神经的壁细胞迷走神经切断术治疗十二指肠溃疡

目的 探讨保留交感神经的壁细胞迷走神经切断术治疗十二指肠溃疡的疗效。方法 36例病人行保留交感神经的壁细胞迷走神经切断术，其中27例为十二指肠溃疡并穿孔，5例为合并出血，2例为合并狭窄，2例为单纯十二指肠溃疡；评价病人术后死亡率、并发症的发生率及溃疡再发率。结果 全组均获随访24个月，无手术死亡率，无术后再出血，1例溃疡再发，Visick指数Ⅰ级为69．4％，Ⅱ级为19．4％。结论 保留交感神经的壁细胞迷走神经切断术为治疗十二指肠溃疡及其并发症的简单易行、有效的手术方式。     

Use of endoscopic Congo red test in the evaluation of ulcer recurrence risks after proximal gastric vagotomy

Summary The endoscopic Congo red test (ECRT) was performed in 43 patients who underwent proximal gastric vagotomy (PGV) for duodenal ulcer (DU). The aim of the study was to develop a standard and reliable way to interpret the results obtained in this test. Thus, the results of ECRT were related to post-operative clinical evaluation and to pre- and post-operative basal and pentagastrin-stimulated gastric acidity. Whenever ECRT was considered positive, we called it in large extension if a red-to-black colour change occurred in three or more of the areas studied. Positive ECRT was observed in 39 patients (90.7%). There was a statistically significant (P<0.01) correlation between poor clinical results and positive ECRT in large extension. We concluded that: (1) a positive ECRT result has no clinical or prognostic significance in DU patients after PGV; (2) ECRT, analysed according to the extension of the areas turning black, is a practical and reliable method to establish clinical results and prognosis in these patients.     

Modified Heineke-Mikulicz pyloroplasty as an effective gastric drainage procedure

Rats were prepared with modified Heineke-Mikulicz pyloroplasty with longitudinal seromuscular incision, centering at pyloric ring, separation of submucosal layer around the pylorus and addition of transverse closure. This procedure combined with vagotomy was applied to the rats with cortisone administration and obstructive jaundice or exposure to the restraint plus cold water stress. Pyloroplasty and vagotomy seemed to prevent the occurrence of the severe damage on gastric mucosa without any suture line leakage whereas. Control rats had often erosive gastritis or hemorrhage.     

Proximal gastric vagotomy by minimally invasive methods in an acute rat model

Summary In this prospective study, minimally invasive methods of proximal gastric vagotomy (PGV) were investigated in male Sprague-Dawley rats. Completeness of vagotomy by traditional operative therapy, by laser denervation of the gastric serosa, and by subserosal or transmucosal injections of chemoneurolytic agents was evaluated with postoperative Congo red testing, ulcerogenic stimulation of the gastric mucosa, and histochemical labeling of whatever vagal fibers remained in the gastric wall. Short-term results demonstrate that successful PGV can be performed with minimally invasive methods.     

Surgical management of acute hemorrhagic postbulbar duodenal ulcer after a previous major surgical procedure

The choice of operation for acute hemorrhagic postbulbar duodenal ulcer after an operation is discussed. Distal partial gastrectomy was performed in six patients. The ulcer was treated by resection, suture, or removal by mucoclasis. Hemostasis was attained in five patients. In another, multiple ulcers were observed in the descending portion of the duodenum and gastrectomy failed to control hemorrhage, resulting in death. Rebleeding was observed in two, one from a newly formed ulcer in the upper part of the papilla of Vater after gastrectomy with truncal vagotomy and which was halted by suture of the ulcer and another was from a newly formed ulcer in the remnant stomach after gastrectomy and which was halted by selective vagotomy and ligation of the left gastric artery. It is recommendable to perform a subtotal gastrectomy and vagotomy combined with removal of the ulcer by mucoclasis or ulcer suture. In some cases, pancreatoduodenectomy may have to be done.     

Laparoscopic-assisted distal gastrectomy versus open distal gastrectomy for advanced gastric cancer

Background  Laparoscopic-assisted gastric surgery has become an option for the treatment of early gastric cancer. However, there are few reports of laparoscopic surgery in the management of advanced gastric cancer. In this study we describe our experience with laparoscopic-assisted distal gastrectomy (LADG) for advanced gastric cancer (AGC). Methods  Between November 2004 and June 2007, 47 patients with AGC underwent LADG at our hospital, and 45 of those patients were enrolled in this study. These patients were compared with 83 patients who had AGC and underwent conventional open distal gastrectomy (ODG) during the same period. Results  Operation time was significantly longer in the LADG group than in the ODG group. Estimated blood loss in the LADG group was significantly less than in the ODG group. Time to ambulation and first flatus and duration of analgesic medication were significantly shorter in the LADG group. The morbidity and mortality rate were also lower than in the ODG group, with no statistically significant difference. The distance of the proximal resection margin showed no significant difference compared with ODG (6.3 ± 0.9 versus 6.5 ± 0.9 cm; p = 0.228). The mean number of nodes resected with LADG was 35.6 ± 14.2, and that with ODG was 38.3 ± 11.4 (p = 0.269). The mean follow-up for the LADG group was 23.6 months (range 9–40 months). In the LADG group, recurrence was observed in six patients (13.3%). Three patients had recurrence and died after 10 (IIIB), 11 (IIIA), and 13 (IIIB) months. Conclusions  LADG with extended lymphadenectomy for AGC is a feasible and safe procedure and has several advantages. Moreover, this method can achieve a radical oncologic equivalent resection. Indications for LADG with extended lymphadenectomy could be expanded in the treatment of locally advanced gastric cancer.     

Non-Hodgkin's lymphoma of the gastric stump developing 9 years after a distal gastrectomy for a peptic ulcer: A case report and review of the literature

We report herein the case of a 65-year-old man who developed non-Hodgkin's lymphoma of the gastric stump 9 years after undergoing a distal gastrectomy for a gastric ulcer. The patient presented with epigastric discomfort, and an upper gastrointestinal series and gastroscopy revealed a lymphoma lesion located close to the site of his gastroduodenal anastomosis. A total gastrectomy was performed, followed by combination chemotherapy, comprised of vincristine, Endoxan, prednisone and Adriamycin (VEPA). Histologically, the resected specimen was diagnosed as non-Hodgkin's lymphoma. The patient has :remained well without any signs of recurrence for 18 months since his operation. Although there have been a number of reports of adenocarcinoma devoloping in the gastric stump following surgery for peptic ulcers, the development of malignant lymphoma under such conditions is rare. Following the presentation of this case, we review the available literature and discuss the possibility of malignant lymphoma developing in the gastric stump.     

Anterior lesser curve seromyotomy using a stapling device and posterior truncal vagotomy for the treatment of chronic duodenal ulcer: longterm results

Background: Recently, gastric stapling with posterior truncal vagotomy has been performed, either by conventional or laparoscopic surgery, as an alternative to highly selective vagotomy and the Taylor procedure for the treatment of chronic duodenal ulcer. Our aim was to investigate the longterm effects after a stapling-modified Taylor procedure, conventional and laparoscopic, on gastric secretion and emptying and on clinical indices and recurrence rates in patients treated for duodenal ulcer before 1994.

Study Design: Thirty-one patients, aged 40 to 76 years (mean 53 years), were treated between 1986 and 1993, 21 by conventional and 10 by a laparoscopic stapling-modified Taylor procedure. Outcomes were studied for gastric acid secretion, solid and liquid gastric emptying, euterogastric reflux, endoscopic findings, and clinical indices using the Visick grading.

Results: Endoscopy revealed a healing ulcer in 29 patients. Two patients showed signs of chronic ulcerative disease with mild symptoms, without gastritis or pyloric stenosis indicative of progressive ulcerative diathesis, and were classified as Visick III. Twenty-four patients were classified as Visick I and 5 as Visick II. The enterogastric reflux index ranged from 0% to 27%, and basal and peak acid output were 1.5 ± 0.6 mmol H⁺/h and 12.2 ± 6.4 mmol H⁺/h, respectively. The half-emptying time of solid and liquid meals was 78 ± 9 minutes and 18 ± 6 minutes, respectively. These results are likely to be similar to those obtained from the series of patients who underwent highly selective vagotomy or Taylor procedure and are close to those achieved in healthy controls.

Conclusions: This modification of the original Taylor operation (conventional and laparoscopic) allows a more rapid, technically easier, and radical performance of the operation with excellent longterm results and should be considered an effective alternative for the treatment of duodenal ulcer.     

扩大壁细胞迷走神经切断术治疗十二指肠溃疡并发症10年随访报告

自１９７９年始采用自行设计的扩大壁细胞迷走神经切断术（ＥＰＣＶ）共治疗十二指肠溃疡并发症１３３例，其中穿孔９３例，出血１１例，狭窄２９例，经１０年随访结果显示，溃疡复发率２．６％，再狭窄率３．４％，无再出血率，ＶｉｓｉｃⅠ级和Ⅱ级为９２．８％，ＥＰＣＶ术后远期病人消化吸收功能，营养状态，以及恢复劳动能力和生存质量都较高，进一步证实该手术设计的合理性和可行性。     

A relic or still relevant: the narrowing role for vagotomy in the treatment of peptic ulcer disease

BackgroundGiven the rise of medical treatment for peptic ulcer disease (PUD), surgical treatment is necessary only in select cases and emergencies. The authors assess the current relevance of surgical vagotomy to treat PUD and its complications.Data SourcesAlthough historically significant, selective and highly selective vagotomy is very technically challenging, and highly selective vagotomy has a relatively narrow indication and high recurrence rates. Vagotomy and gastrectomy is associated with significant side effects. Two types of vagotomy remain relevant, within a narrow scope. Truncal vagotomy and pyloroplasty is safe and efficacious through a laparoscopic approach in certain emergent cases. Vagotomy and Roux-en-Y gastrojejunostomy can be used to treat severe PUD refractory to medical management.ConclusionsThe role of vagotomy in the management of PUD has a rich history but predated pharmacologic control of acid and understanding of the role of Helicobacter pylori in the disease. Thus, the current role of vagotomy is significantly limited. Specifically, the emergent use of truncal vagotomy is warranted for patients who are either resistant or allergic to proton pump inhibitors.     

Laparoscopic subtotal gastric resection for chronic gastric ulcers.

OBJECTIVES: We analyzed our experience with the laparoscopic approach for treating benign gastric lesions. METHODS: Between June 1998 and June 2002, we performed 18 gastric resections with the laparoscopic approach for 7 pyloric stenoses, 8 recurrent duodenal ulcers, and 3 chronic gastric ulcers. RESULTS: In our series, we performed Billroth II laparoscopic distal gastrectomy with no morbidity and mortality. CONCLUSIONS: Billroth II laparoscopic distal gastrectomy is safe in cases of benign gastric or duodenal lesions.