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.     

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.     

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.     

Dumping syndrome after selective proximal vagotomy

An analysis of causes of the development of dumping-syndrome after selective proximal vagotomy (SPV) has been made. Dumping-syndrome most frequently developed after SPV with draining operation (12.9%). The dumping-syndrome was rare and of light degree after SPV without drainage. The authors consider that disturbed motor-evacuatory function of the stomach and small intestine is responsible for the development of dumping-syndrome after SPV as well as the width of gastroduodenal anastomosis in draining operation which must be not more than 2-2.5 cm.     

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.     

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.     

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)     

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.