Proximal gastric vagotomy and mucosal antrectomy: effect on gastric acid secretion, plasma gastrin, and experimental ulcerogenesis in the dog

The aim of this study was to determine whether mucosal antrectomy, which preserves antropyloric motility, would enhance the antiulcer properties of proximal gastric vagotomy (PGV). Hydrochloric acid and gastrin secretion were studied in five dogs before and after PGV and mucosal antrectomy, while the response to the Mann-Williamson operation (an ulcer-producing operation) was evaluated in four control dogs with intact stomachs, five dogs with PGV alone, and six dogs with PGV plus mucosal antrectomy. Proximal gastric vagotomy and mucosal antrectomy decreased mean +/- SEM basal and pentagastrin-stimulated acid secretion from 4.3 +/- 1.3 to 0.4 +/- 0.3 mEq/hr and from 21 +/- 0.7 to 7.4 +/- 1.8 mEq/hr, respectively (p less than 0.05). Basal plasma gastrin was altered little by the operation (68 +/- 9.7 pg/ml before, 58 +/- 11 pg/ml after; p greater than 0.05) but the 4-hour integrated plasma gastrin response to a 200 gm meat meal decreased from 13 +/- 1.8 to 3.3 +/- 0.7 ng X min/ml (p less than 0.05). Only one of six dogs with mucosal antrectomy and PGV developed peptic ulcer after the Mann-Williamson operation, whereas four of five with PGV alone and three of four controls developed ulcers (p less than 0.05, PGV alone versus PGV and mucosal antrectomy). In conclusion, PGV and mucosal antrectomy decreased acid secretion and postcibal gastrin response and provided greater protection against peptic ulcer than PGV alone.     

Serum pepsinogen before and after proximal gastric vagotomy in duodenal ulcer treatment

Serum pepsinogen (SP) behavior was evaluated under basal conditions and under betazole stimulation in 59 patients: 14 controls, nine unoperated duodenal ulcers (DU) and 36 DU after proximal gastric vagotomy (PGV), 14 with and 22 without recurrent ulcer. The mean follow-up of the 36 patients who underwent PGV was 38.7 months. SP was higher in unoperated DU than in the control group (p less than 0.05). After PGV in DU, there is a significant decrease of SP for both the patients with and without recurrent ulcer (p less than 0.05), being statistically similar to the control group. No difference of SP was observed between DU with and without recurrent ulcer after PGV. We concluded that SP can differentiate normal subjects from DU patients, although it is not a sensitive indicator of recurrent ulcer after PGV.     

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.     

Proximal gastric vagotomy. A prospective study of 829 patients with four-year follow-up

A prospective controlled trial of proximal gastric vagotomy (PGV) in 829 patients at three surgical services is presented. Peroperative tests of vagotomy completeness were made in two of the three groups of patients. The follow-up period was four to six years. The hospital stay after PGV averaged 9.2 days. The postoperative mortality rate was 0.2%. The reduction of gastric acidity was maintained four years after PGV. Postoperatively no patient had severe diarrhoea. The incidence of dumping after PGV was 1.5% and of gastric stasis 7.3%. Though 7% of the patients reported pyrosis after PGV, only a few required treatment. Transient dysphagia was reported by 2.5% of the patients. In about 4% of the series there were relatively mild ulcer-like symptoms postoperatively, without confirmation of ulcer. Duodenal ulcer recurred in 2% of cases during the observation period and gastric ulcer appeared in 1.5%. According to the Visick classification, 74% of the series showed grade I clinical result, 18% grade II, 4% grade III and 4% grade IV. There were no intergroup differences in Visick grades.     

Prospective trial of proximal gastric vagotomy

Forty men who were to have elective operation for nonobstructive duodenal or pyloric channel ulcer were randomized prospectively to undergo either proximal gastric vagotomy without drainage (PGV, n = 18) or selective vagotomy, antrectomy, and gastroduodenostomy (SVA, n = 22). Gastric acid analyses were accomplished before and 3 and 12 months after operation. Clinical interviews were conducted yearly. Thirty-nine patients were evaluable at 2 years, 25 at 4 years, and 15 at 5 years. No operative deaths occurred. Recovery was more rapid and the incidence of serious operative morbidity was lower after PGV than after SVA. Reduction of basal and stimulated gastric secretion was greater after SVA than PGV. Significant long-term sequelae other than recurrent ulcer were less frequent after PGV compared to SVA. Recurrent ulcer may occur more often after PGV; 3-month gastric secretory studies may be helpful in anticipating recurrence. Patients who undergo PGV have a particularly increased risk of developing pyloric channel ulcer disease, and low secretory values indicating an adequate vagotomy do not assure future protection from pyloric channel ulcer recurrence. Long-term sequelae after SVA, particularly dumping, do not have dependable reoperative options, whereas antrectomy should be a reliable reoperative solution to ulcer recurrence after PGV. PGV, performed correctly with a 5 to 7 cm vagal-esophageal separation, is preferable to vagotomy and resection for elective treatment of nonobstructing duodenal ulcer disease.     

The temporary effect of proximal gastric vagotomy on experimental duodenal ulcers and gastric secretion.

A proximal gastric vagotomy (PGV) prevented experimental duodenal ulcers in rats for only 5 days and thereafter all rats developed duodenal ulceration. In sham-operated rats the mean stimulated gastric acid output was 186 mumol/60 min. Immediately following a PGV there was a significant decrease in gastric juice volume and acidity (P less than 0.001) with a fall in the mean stimulated acid output to 12 mumol/60 min. On the seventh day after vagotomy the stimulated acid output (volume and concentration) significantly increased to 88 mumol/60 min (P less than 0.001). When the dose of gastric secretagogues was reduced by 50 per cent, a PGV on day 0 prevented any changes occurring in the duodenal mucosa, but when repeated at 4 weeks after a PGV the severity of duodenal ulcers in vagotomized rats was greater than in those having had a sham operation (P less than 0.05). This transient effect of a PGV on duodenal ulcerogenesis and gastric secretion may be due to recovery of the parietal cell mass.     

Reperitonealization and invagination of the lesser curvature of the stomach following proximal gastric vagotomy.

Lesser curve necrosis usually presents as free perforation. A case of large gastric ulcer occurring very shortly after proximal gastric vagotomy (PGV) for a duodenal ulcer that was almost certainly due to ischemic necrosis of the lesser curve is presented here. Reperitonealization and invagination of the lesser curve is recommended following PGV so that, if necrosis occurs, it will take place within the stomach and not into the free peritoneal cavity. This maneuver may also avoid possible vagal reinnervation and the formation of dense adhesions between the stomach and liver.     

Proximal gastric vagotomy and mucosal antrectomy: a comparative physiologic examination

Proximal gastric vagotomy-mucosal antrectomy (PGV-MA) was devised in an attempt to reduce the cephalic and hormonal phases of acid secretion without disturbing gastric emptying. The current study determines the effects of proximal gastric vagotomy (PGV), or PGV-MA on acid secretion, gastrin, and gastric emptying. Twelve dogs underwent measurement of gastric emptying, fasting and postcibal acid production, and fasting and postprandial gastrin levels. The animals then underwent either PGV or PGV-MA and the studies were repeated. PGV markedly decreased basal acid (P less than 0.001); however, there was still a large postprandial acid increase. In contrast, PGV-MA nearly abolished both fasting and postprandial acid secretion (difference from control and PGV significant at P less than 0.001). Gastric emptying was not significantly altered by either procedure. PGV was associated with increased fasting and postprandial gastrin levels, while PGV-MA produced lower gastrin levels at all intervals than either controls or PGV-MA. PGV-MA emulates the effects of truncal vagotomy and antrectomy on acid secretion, without affecting gastric emptying and deserves further investigation as a possible surgical alternative in the treatment of duodenal ulcer disease.     

Prospective randomized multicentre trial of proximal gastric vagotomy or truncal vagotomy and antrectomy for chronic duodenal ulcer: results after 5-7 years

In a prospective, randomized study 145 patients with duodenal ulcer have been followed 5-7 years after proximal gastric vagotomy (PGV) or truncal vagotomy with antrectomy (TVA). Postoperative complications were significantly higher after TVA (P less than 0.0005). There was one death due to anastomotic leakage after TVA. The recurrence rate was significantly higher after PGV (9.9 per cent). Postoperative symptoms were less after PGV (P less than 0.01). Due to the recurrence rate after PGV there was no overall significant difference in the Visick grading, although perfect results (Visick I) were seen significantly more often (P less than 0.01). It is concluded that better results follow PGV.     

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.     

The effect of proximal gastric vagotomy plus duodenoplasty on duodenogastric reflux.

Alkaline reflux gastritis is a clinical syndrome that results from a mucosal injury by duodenal contents. In this study, the amount of duodenogastric reflux was assessed in patients who previously underwent proximal gastric vagotomy (PGV group; n = 11) and PGV plus duodenoplasty (PGV+D group; n = 10) as a treatment for duodenal ulcer. The control group (A) consisted of 11 healthy volunteers without endoscopic abnormalities. A quantitative index of duodenogastric reflux was obtained in each case by determining the percentage of the injected dose of 99mTechnetium-DISIDA that was recovered by continuous aspiration of gastric juice in fasting subjects. In the PGV group, the percentage of administered 99mTechnetium-DISIDA recovered from the stomach (median: 0.69%; range: 0.09%-3.61%) did not differ significantly (P > 0.05) from that of the PGV+D group (median: 0.49%; range: 0.09%-3.91%) and from that of the A group (median: 1.47%; range: 0.22%-3.01%). The results show that proximal gastric vagotomy plus duodenoplasty did not increase duodenogastric reflux.     

Results of elective duodenal ulcer surgery in women: comparison of truncal vagotomy and antrectomy, gastric selective vagotomy and pyloroplasty, proximal gastric vagotomy.

This study provides a retrospective comparative analysis of results in 90 women patients who underwent three different elective operations for intractable duodenal ulcer disease. Group I (30 patients) underwent truncal vagotomy/antrectomy (TV + A); group II (30 patients) gastric selective vagotomy/pyloroplasty (GSV + P); and Group III proximal gastric vagotomy (PGV). There were no operative deaths among the 90 patients. No patient after TV + A has developed a recurrent ulcer. Two recurrent ulcers developed after GSV + P, and one gastric ulcer occurred after PGV. Dumping, diarrhea, and reflux gastritis were lower after PGV than with TV + A and GSV + P. Follow-up studies have been from six months to ten years. The clinical results among the three groups of women patients compare favorably with results obtained in a recent prospective randomized study using the identical operative procedures in three groups of men patients operated upon for intractability. There was no statistically significant difference between women and men after similar operative procedures, but the postgastrectomy sequelae were less after PGV in both women and men patients.     

Proximal gastric vagotomy compared with vagotomy and antrectomy and selective gastric vagotomy and pyloroplasty.

A prospective, randomized study of proximal gastric vagotomy without drainage (PGV) was done in 174 adult men with chronic duodenal ulcer intractable to medical therapy. PGV was randomized against truncal vagotomy with antrectomy (TV + A) and against selective gastric vagotomy with Finney pyloroplasty (SGV + P). Postgastrectomy sequelae (dumping, diarrhea and reflux gastritis) were less after PGV. One patient after PGV developed a recurrent ulcer as did one patient after SGV + P. Two patients developed gastric ulcers after PGV. Good to excellent results (Visick I and II) were obtained in 96% of patients with PGV, 94% with TV + A and 86% with SGV + P. Follow-up studies were from six months to four years.     

Post-vagotomy disorders in patients with duodenal ulcer in relation to the method of proximal gastric vagotomy

The article deals with the results of study of the effect of the degree of inhibited gastric acid-producing activity on the frequency of the development of postvagotomy disorders (PVD) in 158 patients with duodenal ulcer after treatment by various methods of proximal gastric vagotomy (PGV) and PGV with a stomach-draining operation. The frequency and severity of PVD were found to correlate intimately with the degree of inhibition of the gastric acid-producing activity by the PGV and the character of the draining operation. PVD were more severe and encountered more frequently in patients in whom HCl secretion was inhibited by 80% and 100% as compared to the initial value, especially in patients who underwent a stomach-draining operation. Organic PVD (stenosis, an indolent or a recurrent ulcer adhesions) are mostly encountered in the late-term postoperative period.     

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.     

Sham feeding for testing gastric secretory capacities before and after parietal cell vagotomy

The usefulness of acid secretory data collected during a modified sham-feeding (MSF) test was examined in 50 patients suffering from duodenal ulcer before and after parietal cell vagotomy. In these patients basal acid output pentagastrin-stimulated acid output and MSF-stimulated acid output were measured. Preoperative MSF-stimulated acid output was found to be correlated with preoperative basal acid output, and postoperative MSF-stimulated acid output was correlated with both preoperative basal acid output and postoperative basal and pentagastrin-stimulated acid outputs. The addition of preoperative MSF-stimulated acid output to preoperative pentagastrin-stimulated acid output did not noticeably increase the close relationship between the latter and postoperative pentagastrin-stimulated acid output. It is concluded that basal and MSF-stimulated secretory rates overlap. Therefore, it is suggested that in both preoperative and postoperative conditions the addition of the sham-feeding test to the more simple basal and pentagastrin-stimulated studies could be discarded.     

The importance of an innervated and intact antrum and pylorus in preventing postoperative duodenogastric reflux and gastritis.

This study has investigated the relationship between duodenogastric reflux, gastritis and certain symptoms 6-12 months after three operations for uncomplicated duodenal ulcer. The operations studied were proximal gastric vagotomy (PGV, 20 cases), truncal vagotomy and pyloroplasty (TV+P, 22 cases) and truncal vagotomy and antrectomy (TV+A, 21 cases). Duodenogastric reflux was assessed both by a radiological technique and by measuring the concentration of bilirubin in the gastric aspirate before and after operation. Incidence and severity of postoperative gastritis were determined by endoscopic biopsy. Symptoms were assessed by symptomatic score and Visick grading. There was a significant correlation between duodenal reflux and histological evidence of both severe superficial gastritis and glandular atrophy (P less than 0-01). There was also a close association between the degree of reflux and the presence of severe heartburn, epigastric pain and bile vomiting after operation. The amount of reflux did not differ before operation. There was significantly less reflux following PGV than after either TV+P (P less than 0-025) or TV+A (P less than 0-001). The results indicate that an operation which preserves an innervated and intact antrum and pylorus will protect against postoperative duodenogastric reflux, gastritis and symptoms.     

20 years of vagotomy: indications and choice of procedure--duodenal ulcer

At present proximal gastric vagotomy is the best long-term therapy for duodenal ulcer. It is indicated in cases in which conservative treatment has failed. Controlled studies in the context of this surgical approach have shown the average rate of recurrence to be about 17 per cent. Inadequate acid reduction due to incomplete proximal gastric vagotomy (PGV) has proved to be the most common cause of postoperative recurrence of ulcer. The extent of distal skeletisation is considered to be a weak point of PGV and is discussed with reference to technical modifications, in particular pyloroplasty. Postoperative quality checks were found to be useful in providing information on whether the therapeutic purpose of PGV has been accomplished or if the patient should be associated with a high-risk group of ulcer recurrence. Preliminary results obtained from intragastric long-term pH-metry appear to support hopes for better postoperative differentiation.     

Characteristics of adrenocortical function, gastrin release and gastric secretion in duodenal ulcer etiology.

Measurements of serum cortisol and gastrin along with gastric acid-pepsin secretion in the resting state were carried out in gastric and duodenal ulcer patients. Increased basal corticosteroid concentrations were observed in patients with duodenal ulcer and gastric ulcer. Higher concentrations of the hormone were observed in the former group (P less than 0.05 for the latter). Fasting gastrin levels were significantly higher in gastric ulcer patients where gastric secretion is low than those in duodenal ulcer patients (P less than 0.001). These results suggest that the effect of adrenal cortical hormone on lowering the threshold of oxyntic gland cell reactivity against gastrin is an important factor in duodenal ulcer etiology. Extra-antral control mechanism(s) of gastric acid-pepsin secretion should not be overlooked.     

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.