Prospective, randomized trial of selective vagotomy with pyloroplasty and selective proximal vagotomy with and without pyloroplasty in the treatment of duodenal, pyloric, and prepyloric ulcers

In a prospective, randomized trial, 161 patients with duodenal, pyloric, or prepyloric ulcer underwent selective proximal vagotomy. Randomization was then performed to determine if the operation was finished (52 patients), if a pyloroplasty should be added (56 patients), or in addition, if the nerves of Latarjet should be divided (53 patients). Prepyloric and secondary gastric ulcers were excised for microscopy; all were benign. Sex, age, site of ulcer, and duration and incidence of complications of the ulcer disease were similar for the three groups. There was one operative death. The postoperative complications did not differ for the three groups. Four patients were lost to follow-up. The average follow-up for the 156 patients was 3 years (range 1 to 8 years). Recurrent ulcer was detected up to 5 years after surgery in 4 of 53 patients who had selective vagotomy with pyloroplasty, in 4 of 53 who had selective proximal vagotomy with pyloroplasty, and in 5 of 50 who had selective proximal vagotomy. Diarrhea was rare and mild or absent. Dumping was twice as common after selective vagotomy or selective proximal vagotomy with pyloroplasty than after selective proximal vagotomy only, but dumping resistant to treatment was recorded in only two or three patients in each group. The overall results (modified Visick scale) were unsatisfactory in 7 patients after selective vagotomy with pyloroplasty, in 4 after selective proximal vagotomy with pyloroplasty, and in 10 after selective proximal vagotomy, mainly because of epigastric pain with or without recurrent ulcer. We conclude that pyloroplasty may cause mild dumping without nuisance to the patient. The rates of recurrent ulcer in long-term follow-up trials are essential for final evaluation of the operations.     

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 Em?s and Fernstr?m (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)     

Late results od selective proximal vagotomy with or without pyloroplasty in uncomplicated chronic duodenal ulcer

The authors analysed the late-term results of treatment 5 and 8 years after selective proximal vagotomy (SPV) and after SPV with pyloroplasty. Each group contained 39 patients. It is shown that pyloroplasty had no significant effect on the frequency of post-vagotomy complications, though the lactase deficiency syndrome developed more frequently. The authors believe that SPV without pyloroplasty is the operation of choice in uncomplicated duodenal ulcer.     

Five to nine years' results of selective proximal vagotomy with and without pyloroplasty for duodenal ulcer.

In a retrospective study the clinical and secretory results of 118 patients operated upon with selective proximal vagotomy (SPV) with or without pyloroplasty for duodenal ulcer were examined. The results of surgery in the two groups, with pyloroplasty or without pyloroplasty, were compared. The recurrence rate was higher, although statistically not significant, for patients operated upon without pyloroplasty (19.2%) than for patients operated upon with pyloroplasty (10.6%). Dumping was significantly more common and more severe after SPV with pyloroplasty than after SPV without pyloroplasty. The acid response to histalog stimulation at follow-up was significantly higher for patients operated upon without pyloroplasty. This study indicates that SPV without pyloroplasty results in less dumping but gives a poorer protection against recurrent ulceration than does SPV with pyloroplasty. Further long-term studies appear to be necessary, however.     

Results of a controlled randomized trial of proximal gastric vagotomy with and without pyloroplasty.

The 1--5 year results of a prospective randomized trial of proximal gastric vagotomy (PGV) with and without pyloroplasty in 64 men operated upon electively for chronic duodenal ulcer are reported. The effects of the operation on gastric secretion, as tested at 6 months with pentagastrin and isulin, were the same in both groups. There was no statistically significant difference in the clinical results between the two groups. The authors conclude that the addition of pyloroplasty makes little, if any, difference to the results of PGV. Pyloroplasty is thus better omitted as it adds nothing of value and may increase the risk of the procedure.     

Recurrence after proximal gastric vagotomy for gastric,pyloric, and prepyloric ulcers

Results after proximal gastric vagotomy (PGV) with ulcer excision for gastric ulcer type I (according to Johnson) show recurrence rates similar to those for duodenal ulcer. In the European Multicenter Trial with 71 patients, symptomatic recurrence was 7.9% at 5 years and the total recurrence (including asymptomatic recurrences) was 17.5%. Recurrent ulcers are mainly gastric ulcers. Treatment of recurrence is, initially, always conservative with antacids or H ₂-receptor blockers. From 19 patients with recurrent ulcer after PGV with ulcer excision for gastric ulcer type I reported from 3 prospective trials, 12 were managed conservatively. The operative procedure of choice for recurrence was partial gastric resection with a Billroth I or Billroth II reconstruction. Favorable results for this type of gastric ulcer after PGV may be explained by maintenance of gastric continence for solids, reduction of duodenogastric reflux and of postoperative gastritis. Preoperatively and intraoperatively, malignancy has to be excluded by multiple biopsies and frozen sections. Combined gastric and duodenal ulcers (gastric ulcer type II) may also be treated by PGV in controlled trials so that more data will be available for that rare type of ulcer. Recurrence rates after PGV for pyloric and prepyloric ulcers (gastric ulcer type III) are significantly higher than those for gastric ulcer type I or duodenal ulcers. After 5 years, recurrence rates of 16.4–35% are reported. This may be due to gastric retention, which is a common feature in patients with prepyloric ulcers. In fact, selective gastric vagotomy and drainage or vagotomy and antrectomy give significantly better results. The operation rate for recurrent ulcers after pyloric and prepyloric ulcers following PGV is about 25% because of pyloric stenosis. It is concluded that PGV and ulcer excision seem to be suitable for gastric ulcer type I and probably for type II. Pyloric and prepyloric ulcers should no longer be treated by PGV alone because of high recurrence rates. A drainage procedure should be added. In general, the operation should be performed by experienced surgeons since recurrence rates depend on the number of surgeons involved in clinical trials.

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Resumen Los resultados con la vagotomía gástrica proximal (VGP) con resección para la Úlcera gástrica tipo I (segÚn Johnson) demuestran tasas de recurrencia similares a las de la Úlcera duodenal. En el Ensayo Clínico Interinstitucional Europeo con 71 pacientes, la recurrencia sintomática fue de 7.9% a los 5 años y la recurrencia total (incluyendo recurrencias asintomáticas) fue de 17.5%. Las Úlceras recurrentes principalmente son Úlceras gástricas. Inicialmente el tratamiento de la recurrencia es siempre conservador, con antiácidos y bloqueadores de receptores H₂. De 19 pacientes con Úlcera recurrente después de VGP con resección para Úlcera gástrica tipo I informados en 3 estudios prospectivos, 12 fueron manejados en forma conservadora. La operación preferida para la recurrencia fue la resección gástrica parcial con reconstrucción Billroth I o Billroth II. Los resultados favorables en este tipo de Úlcera gástrica con la VGP pueden ser explicados por el mantenimiento de la continencia gástrica para sólidos y la reducción del reflujo o duodenogástrico y de la gastritis postoperatoria. Tanto preoperatoriamente como intraoperatoriamente debe descartarse la presencia de malignidad mediante la toma de biopsias mÚltiples y de cortes por congelación. La combinación de Úlceras gástrica y duodenal (Úlcera gástrica tipo II) también puede ser tratada con VGP en ensayos clínicos controlados, en tal forma que puedan aportarse más datos sobre este raro tipo de ulceración. Las tasas de recurrencia con VGP en Úlceras pilóricas y prepilóricas (Úlcera gástrica tipo III) son significativamente mayores que en la Úlcera gástrica tipo I o en las Úlceras duodenales. A los 5 años, se informaron tasas de recurrencia de 16.4% a 35%. Esto puede ser causado por retención gástrica, que es una manifestación frecuente en pacientes con Úlceras prepilóricas. Realmente, la vagotomía gástrica selectiva y drenaje, o la vagotomía y antrectomía, proveen resultados significativamente mejores. La tasa de reoperación para ulceración recurrente con VGP en Úlceras pilóricas y prepilóricas es de alrededor de 25%, debido a estenosis pilórica. La conclusión es que la VGP con resección de la Úlcera parece ser una operación adecuada para Úlcera gástrica tipo I y probablemente para el tipo II. Las Úlceras pilóricas y prepilóricas no deben ser tratadas con VGP sola debido a elevadas tasas de recurrencia; debe añadirse un procedimiento de drenaje. En general la operación debe ser practicada por cirujanos expertos, mesto que las tasas de recurrencia dependen del nÚmero de cirujanos involucrados en los ensayos clinicos.

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Résumé Les résultats après vagotomie gastrique proximale (VGP) et excision de l'ulcère gastrique type I (selon la classification de Johnson) démontrent que les taux de récidive sont semblables à ceux de l'ulcère du duodénum. Au cours d'un essai multicentrique européen comportant 71 malades, le taux de récidive symptomatique à 5 ans a été de 7.9% et le taux total de récidive (récidive asymptomatique incluse) a été de 17.5%. La récidive ulcéreuse est essentiellment gastrique. Au début le traitement de la récidive est conservateur consistant en l'emploi d'antiacides et d'inhibiteurs H₂. Parmi 19 malades ainsi traités et provenant de 3 groupes différents 12 ont été traités médicalement. En cas de récidive l'opération de choix est la gastrectomie partielle Billroth I ou Billroth II. Les résultats favorables obtenus par la vagotomie gastrique proximale pour traiter l'ulcère de type I peuvent s'expliquer par le maintien de la continence pour les aliments solides, la réduction du reflux duodénogastrique, et de la gastrite post-opératoire. Avant l'intervention et au cours de l'intervention, il est essentiel d'éliminer le diagnostic d'ulcération maligne en procédant à de multiples biopsies et à l'examen histologique extemporané. L'association ulcère gastrique-ulcère duodénal (ulcère gastrique de type II) peut Être traitée par vagotomie gastrique proximale en ayant recours à des essais contrôlés de manière à accumuler plus de données propres à ce type d'ulcère rare. Les taux de récidive après vagotomie gastrique proximale pour ulcère pylorique ou ulcère pré-pylorique (ulcère gastrique type III) sont plus élevés que pour l'ulcère gastrique de type I ou l'ulcère duodénal. Le taux de récidive après 5 ans peut aller de 16.4 à 35%. Ceci peut s'expliquer par la rétention gastrique qui est un fait courant chez les malades atteints d'ulcère prépylorique. En fait la vagotomie gastrique proximale avec drainage ou la vagotomie avec antrectomie donne de meilleurs résultats. Le taux d'intervention pour ulcère récidivant après vagotomie gastrique proximale pratiquée pour traiter une lésion ulcéreuse pré-pylorique ou pylorique est de 25% en raison de la sténose pylorique. En conclusion, la vagotomie gastrique proximale et l'éxérèse de l'ulcère paraissent logiques pour traiter l'ulcère de type I et probablement l'ulcère de type II. En revanche l'ulcère pré-pylorique et l'ulcère pylorique ne doivent plus Être traités par une vagotomie gastrique proximale en raison du taux élevé de récidive.

     

Highly selective vagotomy or truncal vagotomy and pyloroplasty for chronic duodenal ulceration: a randomized, prospective clinical study.

The results of a randomized, prospective clinical trial of highly selective vagotomy (HSV) versus truncal vagotomy and pyloroplasty (TVP) in 126 male patients undergoing elective surgery for chronic duodenal ulceration are presented. The operations were performed by surgeons of all grades of experience. At a mean follow-up time of just over 3 years a satisfactory result was obtained in 93 per cent of patients following HSV and 78 per cent of patients following TVP, the difference being probably statistically significant (P less than 0.05). The incidence of early and late dumping, bile vomiting, flatulence, post-prandial epigastric discomfort and wound infection was statistically significantly less after HSV than after TVP. Three patients have developed a recurrent duodenal ulcer after each type of operation (5.4 per cent). At this early stage HSV has advantages over TVP; it will be interesting to see if these are maintained with the passage of time.     

Long-term results of truncal and selective proximal vagotomy with pyloroplasty

The work is based on the results of analysis of clinical material concerning patients who were treated by operation for duodenal ulcer 3-5 years earlier. Truncal vagotomy and pyloroplasty (TV + P) was performed in 166 and selective proximal vagotomy with pyloroplasty (SPV + P) in 195 patients. The authors found the long-term results to be similar in both groups and did not reveal any advantages of SPV + P over TV + P, in view of which they do not find it necessary in principle to decline from conducting TV + P at the present time.     

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.     

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

We investigated the postoperative 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 less than 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 less than 0.05) and the capacity to work was also better after vagotomy, particularly selective vagotomy plus antrectomy (p less than 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.     

Proximal selective vagotomy without pyloroplasty. A randomized clinical study.

50 consecutive male patients with a proven duodenal ulcer disease without pyloric stenosis were electively treated with a proximal selective vagotomy. They were randomized in a group with and a group without pyloroplast. Up to now (1-3 years follow-up) no recurrences were found, and only two patients have major complaints (Visich grading 3). There are no differences between the two groups, as judged by the clinical result, the pentagastrin test, the Hollander test (2-DODG stimulation), and the gastrin analysis. Pyloroplasty therefore is not needed. Although the vagotomy which completely preserves antral motility is mostly incomplete in the Hollander test, it is sufficient as judged by the clinical results and the acid response.     

Is selective proximal vagotomy expedient in the treatment of bleeding duodenal ulcers?

The article analyses the results of truncal and selective proximal vagotomy with gastric draining operations in 101 patients with bleeding duodenal ulcer. The patients' condition, the results of special methods of examination, and the morphological changes in the gastric mucosa were studied. It was found that selective proximal vagotomy with drainage of the stomach had no advantages over truncal vagotomy. Besides, being a technically more difficult operation than truncal vagotomy, it fails to meet the requirements of emergency surgery and its application in patients with a bleeding duodenal ulcer isnot expedient.     

Parietal cell vagotomy in the surgical treatment of chronic duodenal, pyloric and prepyloric ulcer disease

During the 1970s, parietal cell vagotomy (PCV) gradually became accepted as a suitable method in the surgical treatment of prepyloric, pyloric and duodenal ulcer disease. This study reports the data from a study of 405 consecutive patients with chronic ulcer disease treated with PCV. Mortality was low (0.5%) and there were few postoperative sequelae (periodic loose stools in 2% and mild dumping in 2%). Reduction in basal acid output was 75% and in pentagastrin stimulated acid secretion 50%. The ulcer recurrence rate was initially higher in pyloric-prepyloric (PU/PPU) than in duodenal ulcer disease but after the seventh postoperative year this difference was no longer statistically significant. The accumulated recurrence rate was 17.5%. Few side effects and a comparatively low recurrence rate makes PCV the method of choice in the surgical treatment of peptic ulcer disease.     

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.     

Late results of selective proximal vagotomy with transverse gastroduodenal anastomosis in pyloric stenosis caused by duodenal ulcer

The late-term results of treatment of pyloroduodenal ulcerous stenosis by means of selective proximal vagotomy (SPV) in combination with transverse gastroduodenoanastomosis (GDA) were studied in 110 patients. The results are compared with those of SPV combined with longitudinal GDA after Jaboulay. Clinical, radiological, endoscopic, biochemical, and morphological examination showed the advantages of transverse GDA over longitudinal GDA. It is concluded that combination of SPV with transverse GDA is the operation of choice.     

10 years' results following proximal selective vagotomy in duodenal ulcer disease. A prospective study

The results 10 years after proximal gastric vagotomy for chronic duodenal ulcer disease in a prospective trial are presented. Among 76 patients 5 were lost to follow-up, 3 had died from causes unrelated of ulcer disease. 80.3% of the patients remained clinically free from recurrence. 92.2% had a Visick grade I or II. The symptomatic recurrence rate was 19.7%, total recurrence rate including asymptomatic recurrences having been 25.3%. 6 patients (8.4%) had to be reoperated, 12 (16.9%) were treated medically. 3/4 of the medically treated patients only had 1 recurrence throughout 10 years. The rate of mild dumping and diarrhea was 2% each. Patients with recurrence showed no more significant reduction of BAO or pentagastrin stimulated maximal acid output (MAO) 10 years postoperatively. Patients without recurrence had a significant reduction of BAO and MAO of 42%. Based upon the results presented, the indication for proximal gastric vagotomy for chronic duodenal ulcer is still justified.