Proximal selective vagotomy with or without pyloroplasty?]

Proximal gastric vagotomy without drainage is the operation of choice for uncomplicated duodenal ulcer. There are few contraindications for PGV as uremia, diabetes, hypertension, age over 65 years and a history of splenectomy. Only in cases of severe pyloric stenosis or bleeding ulcer or perforation in the pyloric area, a pyloroplasty should be added. The Wangensteen pyloroplasty is a safe drainage procedure and especially recommended in case of extensive scarring of the pylorus.     

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 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.     

Proximal gastric vagotomy and suprapyloric antrectomy. Experimental evaluation in dogs.

In five dogs with Heidenhain pouches, proximal gastric vagotomy and suprapyloric antrectomy did not alter the rate of gastric emptying of 300 mL of 1% dextrose or of 40 plastic spheres, or disrupt the barricade preventing duodenogastric reflux. However, the operation did slow gastric emptying of 50 g of cubed liver and increase the postprandial secretion of hydrochloric acid from the pouch. We concluded that suprapyloric antrectomy can be combined with proximal gastric vagotomy without disturbing the gastric emptying of liquids and indigestible solids or resulting in increased duodenogastric reflux. However, the operation does slow gastric emptying of digestible solids.     

Age and morbidity of vagotomy with antrectomy or pyloroplasty

When carcinoma of the lung invades the carina, it is by definition a stage III lesion and frequently incurable. However, when lymph node invasion does not preclude resection for cure and when there are no other contraindications to such resection, techniques are now available for resection of the carina and primary reconstruction. While tracheal sleeve pneumonectomy is the operation most frequently employed for invasion of the carina by bronchogenic carcinoma that is otherwise operable, occasionally the lower lobe may also be saved. When the carina is involved by a primary neoplasm of the airways, primary resection with carinal reconstruction with or without various amounts of pulmonary resection is clearly indicated when possible.     

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.     

Proximal gastric vagotomy versus selective vagotomy with antrectomy: results of a prospective, randomized clinical trial after four to twelve years

This prospective, randomized study of selective vagotomy with antrectomy (SVA) versus proximal gastric vagotomy (PGV) for patients with duodenal ulcer compares the incidence of recurrent duodenal ulcer and postoperative morbidity during a 4- to 12-year follow-up period. In 46 patients with SVA there were no recurrent ulcers, but 26% of these individuals had serious digestive problems that were not amenable to medical treatment. The 40 patients with PGV had eight recurrent ulcers (20%), but five of these were found in the first 15 patients (33%) compared with three in the 25 patients (12%) who had operations after the need for extensive periesophageal denervation was discovered in the mid-1970s. Most recurrent ulcers were amenable to medical treatment, but 5% of the patients who had PGV had postoperative dysphagia that required periodic bougienage. The data are consistent with several interpretations, depending on the bias of the individual. However, based upon the fact that recurrent ulcers could be managed nonoperatively after PGV versus the lack of effective treatments for postgastrectomy complaints after SVA, it is reasonable to consider wider use of PGV. There are reasons to believe that the variable ulcer recurrence rates after PGV can be explained by subtle differences in operative technique, including those based upon use of the Congo red test for completeness of vagotomy. Unlike SVA, PGV remains an operative procedure in evolution that requires further clinical investigation. At this time either operation can be applied if both the surgeon and the patient have a clear understanding of the possible effects.     

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.     

New additional operation in the prevention of gastric stasis after selective gastric vagotomy with antrectomy

The new additional operation for the prevention of the gastric stasis after the selective gastric vagotomy with antrectomy (SV + A) was performed. Our additional operative procedure was followed: After selective gastric vagotomy and antrectomy, gastroduodenostomy was anastomosed at acute angle with the longitudinalis of the stomach. Then, both lesser and greater omentum were incised outside of the gastric vessels. After these procedure, posterior wall sided to lesser curvature was fixed with the edge of the hepatogastric ligament and posterior wall sided to greater curvature was fixed with the retroperitoneum inferior to the pancreas by several sutures. The outcome of these treatments of the additional operation on SV + A enabled to shorten the duration of drainage of gastric juice, as well as smooth intake. By fluoroscopic examination one month after operation, gastric stasis was observed on SV + A due to the contrast medium stored in the ptotic corpus, whereas, in the case of SV + A with our additional operation, smooth gastric emptying was observed without any stasis of the contrast medium, because the corpus was placed upper from the anastomosis portion. In conclusion, our additional operation to SV + A was able to perform easy and safely, and was observed the effective prevention of gastric stasis.     

Proximal gastric vagotomy and pyloroplasty for duodenal ulcer with pyloric stenosis: A thirteen-year experience

Between 1970 and 1983, seventy-eight patients with duodenal ulcer and pyloric stenosis causing gastric outlet obstruction have been operated on with a proximal gastric vagotomy (PGV) and a Heineke-Mikulicz pyloroplasty. The mean observation time was 90 months. There was no operative mortality or major complications. The reduction in mean acid output was greater after PGV and pyloroplasty than after PGV without drainage in patients with duodenal ulcer without stenosis. The clinical results were excellent or good in 93% of the patients (Visick I and II). Only 1 patient (1.3%) developed a recurrent ulcer, while 5 patients (6.4%) had symptoms of slight or moderate dumping. It is concluded that PGV and pyloroplasty is a good operation in patients with duodenal ulcer and pyloric stenosis. There is a low incidence of ulcer recurrence, a low risk of serious complications, and good long-term symptom control.

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Resumen Setenta y ocho pacientes con úlcera duodenal y estenosis pilórica causante de obstrucción de la desembocadura del estómago fueron sometidos a vagotomía gástrica proximal (VGP) y piloroplastia de Heineke-Mikulicz entre 1970 y 1983. No se presentó mortalidad operatoria y tampoco se registraron complicaciones mayores. La reducción en la secreción gástrica media fué superior después de VGP y piloroplastia que después de VGP sin drenaje en pacientes con úlcera duodenal sin estenosis. Los resultados clínicos fueron excelentes o buenos en 93% de los pacientes (Visick I y II). Sólo un paciente (1.3%) desarrolló úlcera recurrente, mientras 5 pacientes (6.4%) eshibieron síntomas de dumping leve o moderado.Se llega a la conclusión de que la VGP y piloroplastia es una buena operación en pacientes con úlcera duodenal y estenosis pilórica. Se observa una baja incidencia de úlcera recurrente, un bajo riesgo de complicaciones y un buen control sintomático a largo plazo.

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Résumé De 1970 à 1983, 78 malades porteurs d'un ulcère duodénal compliqué de sténose pylorique ont subi une vagotomie hypersélective combinée à une pyloroplastie de type Heineke-Mikulicz. La durée moyenne du suivi postopératoire a été de 90 mois alors qu'aucun décès opératoire, qu'aucune complication ne fut notée. La réduction du débit acide moyen fut plus importante après vagotomie hypersélective et pyloroplastie qu'après vagotomie hypersélective sans drainage complémentaire chez les sujets qui présentaient un ulcère duodénal sans sténose pylorique associée. Les résultats cliniques ont été excellents ou bons dans 93% des cas (Visick I et II). Un seul opéré (1,3%) a présenté une récidive ulcéreuse cependant que cinq sujets (6,4%) ont accusé un dumping syndrome léger ou modéré.On peut conclure de ces faits que la vagotomie hypersélective avec pyloroplastie est une bonne opération chez les malades qui présentent un ulcère du duodénum compliqué de sténose pylorique. Le risque de récidive est faible ainsi que celui de complications postopératoires alors que le contrôle à long terme de l'aifection est bon.

     

Fasting and postprandial serum gastrin levels before and after highly selective gastric vagotomy, truncal vagotomy with pyloroplasty and truncal vagotomy with antrectomy: is there a cholinergic antral gastrin inhibitory and releasing mechanism?

Fasting serum gastrin levels and postprandial gastrin response were measured before and 1 month after highly selective vagotomy, truncal vagotomy with pyloroplasty and truncal vagotomy with antrectomy. The three groups of patients, 12 in each group, were closely matched for age, sex, maximum acid output and completeness of vagotomy. After highly selective and truncal vagotomy an identical and significant increase in fasting gastrin was observed, whereas after truncal vagotomy with antrectomy the pre- and postoperative fasting gastrin levels were not different. The net postprandial gastrin output over basal value was significantly increased after highly selective vagotomy, unchanged after truncal vagotomy and significantly lowered after truncal vagotomy with antrectomy. These results suggest the presence in the intact subject of a cholinergic inhibitory mechanism in the gastric body and fundus for the release of antral gastrin in the fasting and postprandial states and a possible cholinergic facilitatory mechanism for the release of antral gastrin after meals.     

Proximal gastric vagotomy: update.

Experience with proximal gastric vagotomy at the Mayo Clinic from 1973 to Mayo 1980 is reported. Among 298 patients who had proximal gastric vagotomy for chronic duodenal, pyloric channel, or prepyloric ulcers, a recurrent ulcer rate of 7% was present, with a mean follow-up of 49 months. Three recurrences developed in six patients who had proximal gastric vagotomy for gastric ulceration. In 40 patients, proximal gastric vagotomy was combined with gastrojejunostomy, pyloroplasty, or pyloric dilatation for obstructing ulcers. There was a 15% incidence of reoperation in the gastrojejunostomy group. All nine patients who had proximal gastric vagotomy for active or recent bleeding ulcers were dismissed from the hospital without further hemorrhage, and only one developed a recurrent ulcer. It is concluded that proximal gastric vagotomy remains an acceptable operation for chronic duodenal and pyloric ulcers, but its efficacy in gastric ulcers is unproved.