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.     

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.     

Prospective, randomized trial of selective proximal vagotomy with ulcer excision and partial gastrectomy with gastroduodenostomy in the treatment of corporeal gastric ulcer

In a prospective, randomized trial, selective proximal vagotomy with complete ulcer excision was compared with partial gastrectomy with gastroduodenostomy for the treatment of primary corporeal gastric ulcer in 30 patients. The results were evaluated by clinical follow-up examinations at regular intervals, endoscopy, and blood tests. The mean follow-up period was 3 years for both operations. There was no mortality. Postoperative complications, ulcer recurrence rates, the overall clinical results (Visick classification), and blood test results were similar in the two groups. Three of 15 selective proximal vagotomy patients were classified grade IV due to recurrent ulcer (two patients) or dumping (1 patient), and 2 of 14 partial gastrectomy patients as were classified grades III (epigastric pain) and IV (recurrent ulcer). Considering the risk for late symptoms of impaired resorption and gastric cancer after partial gastrectomy, the similar results with selective proximal vagotomy and partial gastrectomy justify further trials of selective proximal vagotomy with ulcer excision for treatment of corporeal gastric ulcer.     

Recurrent peptic ulcer after surgery in Japan--a nationwide questionnaire survey of 57 institutions]

Patients with recurrent peptic ulcer undergoing surgery were reviewed at 57 institutions by the 18th meeting of the Japanese Research Society of Gastric Surgery. The factors involved in recurrence was analyzed in patients fulfilling the following criteria: the minimum follow-up period was over 5 years, the age was over 15 years, tetragastrin-stimulated acid secretion was measured before surgery, and the recurrence was confirmed by endoscopy or upper gastrointestinal radiography. In 632 patients, the recurrence rate of duodenal ulcer was significantly higher than that of gastric ulcer. However, the duodenal ulcer patients undergoing selective vagotomy and antrectomy did not develop recurrence. A significant difference in the recurrence rate was observed between selective vagotomy and antrectomy and the wide gastrectomy or selective proximal vagotomy. By analysis using the Cox proportional hazard model, the risk factors for recurrence of duodenal ulcer were the ulcer stage, the operative procedure, the location of the ulcer, and the age of the patient. Especially, recurrences in patients receiving selective proximal vagotomy depended on the location of the ulcer and the age, but the risk factors for patients undergoing wide gastrectomy were uncertain.     

选择性迷走神经切断术加胃窦切除术治疗十二指肠溃疡远期疗效观察

目的：研究选择性迷走神经切断加胃窦切除术（SV＋A）治疗十二指肠溃疡远期疗效。方法：1977年11月－2001年11月采用SV＋A治疗193例十二指肠溃疡患者,其中顽固性溃疡28例,溃疡伴出血112例,溃疡伴幽门梗阻41例,胃十二指肠复合性溃疡12例。结果：SV＋A术后及术后随访基础胃酸分泌（BAO）、胰岛素刺激后胃酸分泌（IMAO）、五肽胃泌素刺激后胃酸分泌（PMAO）和血清胃泌素显著下降,壁细胞呈现分泌抑制的特征;术后1－10年和11－24年的随访,患者属于Visick I、Ⅱ级分别占95．60％和96．61％,Ⅲ级分别占（4．40％）和（3．39％）,无溃疡复发。结论：SV＋A降酸显著而持久,无溃疡复发。该术式是手术治疗十二指肠溃疡特别是溃疡并发症的有效方法。     

Effects of selective vagotomy with or without drainage on glucose tolerance test

Effects of selective proximal vagotomy (SPV) with pyloroplasty, SPV without a drainage, selective gastric vagotomy with antrectomy and distal gastrectomy with gastro-duodenostomy on the oral glucose tolerance test (OGTT) were studied in 25 patients with duodenal ulcer. Hyperglycemia occurred at 30 and 60 min after glucose loading and hypoglycemia occurred at 120 min in all three types of selective vagotomy. The pattern of the OGTT, however, was not remarkably changed after gastrectomy. These findings suggested that an altered pattern in the OGTT might relate to vagotomy, but not to gastrectomy or pyloroplasty. Hormonal factors, such as immunoreactive insulin (IRI), pancreatic glucagon (PG) and gut glucagon-like immunoreactivity (GLI) were measured to elucidate the mechanism of the altered patterns of OGTT after selective vagotomy. The enhanced response of IRI was found in selective vagotomy groups, in comparison with the preoperative study or gastrectomy group. The exaggerated response of IRI might the responsible for hypoglycemia. GLI and PG had little or no effect on blood glucose level on the OGTT.     

Effects of selective vagotomy with or without drainage on glucose tolerance test

Effects of selective proximal vagotomy (SPV) with pyloroplasty, SPV without a drainage, selective gastric vagotomy with antrectomy and distal gastrectomy with gastro-duodenostomy on the oral glucose tolerance test (OGTT) were studied in 25 patients with duodenal ulcer. Hyperglycemia occurred at 30 and 60 min after glucose loading and hypoglycemia occurred at 120 min in all three types of selective vagotomy. The pattern of the OGTT, however, was not remarkably changed after gastrectomy. These findings suggested that an altered pattern in the OGTT might relate to vagotomy, but not to gastrectomy or pyloroplasty. Hormonal factors, such as immunoreactive insulin (IRI), pancreatic glucagon (PG) and gut glucagon-like immunoreactivity (GLI) were measured to elucidate the mechanism of the altered patterns of OGTT after selective vagotomy. The enhanced response of IRI was found in selective vagotomy groups, in comparison with the preoperative study or gastrectomy group. The exaggerated response of IRI might be responsible for hypoglycemia. GLI and PG had little or no effect on blood glucose level on the OGTT.     

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.     

five years' experience with proximal gastric (highly selective) vagotomy.

In the five-year period 1972 to 1976 the author's preferred treatment for patients with chronic duodenal or prepyloric peptic ulcer requiring surgery was proximal gastric vagotomy. In spite of this preference, only two-thirds of such patients were so treated. Most patients with bleeding and stenosis were treated by bilateral truncal vagotomy and drainage, and a few by Pólya gastrectomy. Proximal gastric vagotomy proved to be a safe elective operation without mortality and with a proven ulcer recurrence rate so far of 6%. Compared with those who had bilateral truncal vagotomy and drainage, the proximal gastric vagotomy patients complained less often of diarrhoea but more often of weight loss and reflux. Two patients have had persistent postprandial non-peptic pain, thought possibly due to upper gastric ischaemia.     

Selective vagotomy plus antrectomy and Roux-en-Y gastrojejunostomy in the treatment of duodenal ulcer]

From 1982 to October 1990, 284 patients with duodenal ulcer were surgically treated. Partial gastrectomy and Billroth anastomosis (PGB) were performed in 92 patients, selective vagotomy plus antrectomy and Billroth anastomosis (VAB) in 92, and selective vagotomy plus antrectomy and Roux-en-Y gastrojejunostomy (VARY) in 98. Follow-up showed that VARY was superior in many respects to PGB and VAB such as in decreasing gastric acidity, long-term complications and Visick grading of I and II (P < 0.05). We conclude that VARY can be used in the treatment of duodenal ulcer.     

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.     

Ulcer recurrence,morbidity, and mortality after operations for duodenal ulcer

Due to fear of duodenal ulcer recurrence, PGV is not yet accepted by most surgeons in the United States as a satisfactory operation for treatment of intractable duodenal ulcer. Currently PGV has a 30 day operative mortality of 0.3 percent, a severe morbidity of 1 percent, and a long-term ulcer recurrence rate of about 11 percent. Truncal vagotomy and pyloroplasty has a mortality of 0.7 percent, a morbidity of 5 percent, and a recurrence rate of about 10 percent. Truncal vagotomy and antrectomy has a mortality of 1 percent, a morbidity of 5 percent, and a recurrence rate of about 2 percent. Thus, PGV is preferable to vagotomy and pyloroplasty since vagotomy and pyloroplasty has higher mortality and morbidity rates. The recurrence rate is similar. Furthermore, since postoperative morbidity is more difficult to manage than ulcer recurrence, a cogent argument can be made that PGV is superior to vagotomy and antrectomy as an operation for intractable duodenal ulcer.     

Truncal vagotomy and pyloroplasty for duodenal ulcer.

Two hundred sixty-five patients who underwent vagotomy and pyloroplasty for duodenal ulcer disease were observed postoperatively, 220 for two to ten years, with an average follow-up of five years. Vagotomy and pyloroplasty carried a higher overall recurrence rate (3.6%) than did subtotal gastrectomy and vagotomy (1%), largely because of the high ulcer recurrence rate more than two years after operation for massive bleeding (9.2%) rather than that following elective operation (1.8%). Thirty-five percent of these patients with recurrent ulcers did well with medical management and did not require a second operation. The mortality of vagotomy and pyloroplasty for a massively bleeding ulcer (11%) was less than that following subtotal gastrectomy (21%). The mortality of elective vagotomy and pyloroplasty was 1%.     

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)     

Antrectomy for recurrent ulcer after parietal cell vagotomy

The results of antrectomy for recurrent ulcer after parietal cell vagotomy are reviewed. Eighteen patients underwent precise antrectomy between 6 months and 7 years after their primary operation. Fourteen patients were reconstructed with a gastroduodenostomy and 4 with a gastrojejunostomy. Eighteen patients were available for follow-up of between 18 months and 10 years. One patient (6.25 per cent) developed a recurrent ulcer 1 year after antrectomy. There was no operative mortality. Six patients (33 per cent) had minor complications in the immediate postoperative period, and one (5.5 per cent) had a major complication. According to Visick grading, 75 per cent had good or excellent results and 25 per cent poor results. Antrectomy following parietal cell vagotomy can be achieved with a low operative mortality, a low ulcer recurrence rate and a satisfactorily low incidence of post-gastrectomy problems.     

保留幽门的胃窦黏膜切除加高选择性迷走神经切断术后临床疗效观察

目的观察保留幽门的胃窦黏膜切除加高选择性迷走神经切断术(高选迷切术)治疗十二指肠溃疡的疗效。方法对实施该术式的48例患者术后3～6个月及8～12年临床随访结果进行分析总结。结果全组无死亡病例。术后3～6个月及8～12年VisickⅠ～Ⅱ级分别为93.8％和95.3％。术后胃酸及胃窦黏膜幽门螺杆菌感染率与术前比较明显降低(P＜0.05),术后胃液胆酸及血清胃泌素无明显改变,X线钡餐及胃镜检查未发现溃疡复发。结论保留幽门的胃窦黏膜切除加高选迷切术不仅能保留胃窦、幽门功能,使胃内环境保护相对稳定,而且能有效、持久地降低胃酸分泌,减少溃疡复发和术后并发症的发生,是治疗十二指肠溃疡较理想的术式。     

Clinical results of reoperation after failed highly selective vagotomy

The results after reoperation after failed highly selective vagotomy during a 10 year period have been reviewed retrospectively. Forty of 306 patients (13 percent) underwent reoperation due to recurrent ulcer (25 patients), severe dyspepsia without proved recurrence (12 patients), and gastric stasis without recurrence (3 patients). In the first two groups, 16 patients had a second vagotomy and 17 underwent partial gastrectomy, 10 with gastroduodenostomy and 7 with gastrojejunostomy. The need for a second reoperation was disquietingly high after both revagotomy (5 of 16 patients) and partial gastrectomy with gastroduodenostomy (4 of 10 patients). These results contrasted with a successful outcome in all seven patients who underwent reoperation with partial gastrectomy and gastrojejunostomy. At the time of follow-up, 85 percent of the reoperated patients (34 of 40 patients) were in Visick grade 1 or 2 as determined by their own judgement.     

Reoperation for postsurgical peptic ulcer recurrence: appraisal of ten years' experience.

Between January 1, 1965 and December 31, 1974, 47 patients were treated at the University of Florida Affiliated Hospitals for peptic ulcer after a generally acceptable ulcer operation. Twenty-seven patients had had vagotomy and drainage, four patients had had vagotomy and antrectomy and 16 patients had had partial gastric resection. Forty-nine definitive operations were performed with a 4% operative mortality. Three patients (7%) had another ulcer recurrence following surgery. Left transthoracic vagotomy is the treatment of choice when recurrent ulceration follows subtotal gastrectomy or vagotomy and antrectomy. For ulceration following vagotomy and drainage, antrectomy, antrectomy is preferred. Synergism between hormonal and neural gastric stimulants causes a decreased parietal cell responsiveness to vagal stimulation after antrectomy. Exploration of the hiatus at the time of antrectomy increases the morbidity of the procedure. Should ulcers recur after antrectomy, vagotomy may be performed with a low morbidity through the transthoracic approach.     

Should it be parietal cell vagotomy or selective vagotomy-antrectomy for treatment of duodenal ulcer? A progress report.

This is a progress report of a prospective, randomized study involving 200 consecutive patients treated electively with either parietal cell vagotomy (PCV) or selective vagotomy and antrectomy (SV-A). Both groups comprised patients with pyloric, prepyloric, or duodenal ulcers. There was no operative mortality in either group. Patients were examined at 2, 6, 12 months, and every 12 months thereafter for 8-10 years. The two operations produced no statistical difference in the frequency of diarrhea. Dumping (p less than 0.0005) and weight loss (p less than 0.0005-p less than 0.05) were statistically less after PCV than after SV-A. There were two recurrent ulcers (2.2%) after SV-A. One was treated successfully by medical therapy and one patient suspected of having gastrinoma had total vagotomy. Nine patients had recurrent ulcers in the PCV group for an accumulated recurrence rate of 10.1% at 10 years by life-table analysis. There was a significant difference (p less than 0.033) between the curves for recurrent ulcers in the two groups of patients. The recurrent ulcer rate after PCV was 21% for patients with pyloric and prepyloric ulcers and 6% for patients with duodenal ulcer. There was no significant difference between the recurrent ulcer rate for PCV and SV-A if the patients with pyloric and prepyloric ulcers were withdrawn from the study. Of the nine patients with recurrent ulcers in the PCV group, three had an inadequate vagotomy and four had a pyloric or prepyloric ulcer before operation. Three patients were successfully treated with antrectomy. Five patients were treated successfully by medical therapy and remained healed for long periods without recurrence. One patient had five recurrences. He declined operation and remained free of symptoms for 3 years after his last recurrence. Poor gastric emptying necessitated gastroenterostomy in five patients in the SV-A group and in one patient in the PCV group. Patients' clinical results were evaluated according to a simple Visick grading scale. A significantly (p less than 0.0005) greater number of patients were in Visick I category after PCV than after SV-A. The clinical results obtained with PCV make this the operation of choice for the elective surgical treatment of duodenal ulcers even though the results obtained with SV-A were good.     

A prospective, randomized study comparing highly selective vagotomy and extended highly selective vagotomy in patients with duodenal ulcer

The recurrence rate of duodenal ulcer after highly selective vagotomy is nearly 10 percent. To diminish this percentage, extended highly selective vagotomy with sectioning the gastroepiploic nerves has been proposed in order to reduce postoperative gastric acid secretion. We have prospectively compared the decrease in gastric acid secretion through measurement of basal acid output, maximal acid output, and peak acid output in patients who underwent highly selective vagotomy or extended highly selective vagotomy. No significant differences in postoperative gastric acid secretion were found and, therefore, no changes in the probability of postoperative recurrence of duodenal ulcer were seen.