Videothoracoscopic vagotomy in surgical treatment of patients with peptic ulcer of the gastroenteroanastomosis after resection of the stomach

Treatment of 130 patients with peptic ulcer of the gastroenteroanastomosis after resection of the stomach included operation by the method of videothoracoscopic truncal vagotomy (22 patients), left-side videothoracoscopic truncal vagotomy (19 patients), and operation from the right-side access (3 patients). Cicatrization of the ulcer in the postoperative period was obtained in 16 patients. Recurrent peptic ulcer was revealed in 2 patients. There were no lethal outcomes.     

Laparoscopic management of acid peptic disease

BACKGROUND: Despite successful medical treatment to reduce acid hypersecretion and eradicate Helicobacter pylori, surgery still plays an important role in the management of complicated peptic ulcer disease. Almost all types of conventional operations available for ulcer disease have been successfully performed by the laparoscopic approach and this has become the preferred approach in tertiary centers for operative management of acid peptic disease. METHOD: Between 1995 and 2004, laparoscopic management was offered to refractory or obstructive acid peptic disease patients. For intractable disease, we performed either posterior truncal vagotomy with anterior fundal seromyotomy or posterior truncal vagotomy with anterior proximal gastric vagotomy. For peptic ulcer disease complicated with gastric outlet obstruction, we carried out bilateral truncal vagotomy with gastrojejunostomy. RESULTS: Two hundred sixty three patients were operated of whom 236 (89.7%) were men and the average age of the patients was 48.4 years. Thirty-two (12.2%) patients underwent posterior truncal vagotomy with anterior seromyotomy, 89 (33.8%) underwent posterior truncal vagotomy with anterior proximal gastric vagotomy, 120 (45.6%) underwent bilateral truncal vagotomy with stapled gastrojejunostomy whereas 22 (8.4%) underwent bilateral truncal vagotomy with hand-sewn gastrojejunostomy. The average operating times were 142, 110, 98, and 72 minutes, respectively. The average postoperative stay was 5.4 days. CONCLUSIONS: Laparoscopic posterior truncal vagotomy with anterior proximal gastric vagotomy for refractory disease and laparoscopic bilateral truncal vagotomy with stapled gastrojejunotstomy for obstructive disease have become the standard at our institution. Regardless of the preference of individual surgeon, our results have shown that laparoscopic surgery may become the gold standard for surgical management of peptic ulcer disease.     

Quantification of duodenogastric reflux in gastroduodenal peptic ulcer and in gastric operation patients, using a 24-h gastric pH measurement as a quantification technique

Twenty-four-hour gastric pH measurement was used to study duodenogastric reflux. To differentiate between gastric hyposecretion and duodenogastric reflux, we also measured bile acid concentrations in the gastric juice, and regarded pH increases to above 4 as possible episodes of reflux. The procedure was used in 60 patients, divided into the following groups: (1) control group (ten patients); (2) duodenal ulcer (ten patients); (3) type 1 gastric ulcer (five patients); (4) type 3 gastric ulcer (five patients); (5) bilateral truncal vagotomy plus pyloroplasty (ten patients); (6) truncal vagotomy plus Billroth I partial gastrectomy (ten patients); and (7) truncal vagotomy plus Billroth II partial gastrectomy (ten patients). The amount of reflux (areas of pH greater than 4) in the type 1 gastric ulcer and Billroth I and Billroth II groups was significantly greater than that found in the control, duodenal ulcer, type 3 gastric ulcer and truncal vagotomy plus pyloroplasty groups. The mean concentration of total bile acids was also greater in the gastrectomized patients than in the rest of the groups studied. In the type 1 gastric ulcer group the mean bile acid concentration was similar to that of the control group.     

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.     

The long-term outcome of Billroth I partial gastrectomy for benign gastric ulcer.

A study was done of 144 patients undergoing Billroth I partial gastrectomy for benign gastric ulcer. At a mean follow-up of 9.4 years, 95 patients were alive. Of 79 patients reviewed, 84% had an excellent or good result on clinical (Visick) grading. Five cases of proven recurrent ulceration were found; two of these patients required subsequent truncal vagotomy. There was one early death after operation, and 48 late deaths, including one from carcinoma of the gastric remnant (at two years), one from a reticulum cell sarcoma of the stomach (at three years), and one from reactivation of pulmonary tuberculosis. The operation was not attended by appreciable nutritional sequelae, although there was a tendency towards iron deficiency anemia.     

FIVE YEARS‘ EXPERIENCE WITH PROXIMAL GASTRIC (HIGHLY SELECTIVE) VAGOTOMY

In the five-year period 1972 to 1976 the authors' 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 Polya 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.     

Truncal vagotomy using videothoracoscopy without gastric drainage. A prospective study of 250 cases surgically treated in Senegal]

AIM OF THE STUDY: The aim of this prospective study was to report early results of videothoracoscopic truncal vagotomy in non-complicated chronic duodenal ulcers. PATIENTS AND METHODS: From 1995 to 1998, 250 patients suffering from chronic duodenal ulcer without pyloric stenosis were operated on in the main hospital of Dakar. They underwent videothoracoscopic truncal vagotomy without gastric drainage. The quality of gastric emptying and the incidence of secondary side-effects were assessed in the postoperative course and after one and three months. RESULTS: There were two intraoperative deaths, one due to aortic wound and the other one due to a poor surveillance after premature extubation. Postoperative complications included bronchopulmonary infection (n = 9), one septic pleural effusion and one chylothorax. A postoperative gastroplegia occurred in 12 patients, which was always spontaneously regressive without endoscopic pyloric dilatation. After one month, 204 patients (82%) were classified Visik 1, and 44 (18%) classified Visik 2. An endoscopic control examination showed a healed peptic ulcer and open pylorus in all patients, and a gastric stasis present in 40 cases (16%). After three months and a new evaluation, 234 were classified Visik 1 (94%) and 14 Visik 2 (6%). Dumping syndrome was not observed in this series and the incidence of diarrhea, which was 40% after one month, decreased to 3% after three months. CONCLUSION: The functional results of truncular vagotomy without gastric drainage were good or very good and improved with time. The quality of digestive comfort and the low frequency of side-effects are good arguments in favor of this procedure as an elective treatment of duodenal ulcers in developing countries.     

Selective proximal vagotomy with ulcer excision or Billroth I resection in chronic stomach ulcer. A prospective randomized multicenter study

In a prospective randomised multicenter study in 41 patients with chronic gastric ulcer type I according to Johnston we compared selective proximal vagotomy (SPV) plus ulcerectomy (21 patients) with a standardised Billroth I gastrectomy (20 patients). The follow-up period was at least 2 years. Preoperative characteristics of both groups did not differ. Intraoperatively, in 5 patients of the SPV group technical problems during dissection of the lesser curvature occurred. The main postoperative complaints were pain and epigastric fullness after SPV and bile vomiting, early dumping or diarrhea after Billroth I gastrectomy. 3 of 21 patients after SPV developed recurrent ulceration, whereas after BI resection no recurrence was observed. This study indicates a higher recurrence rate in gastric ulcer patients after SPV compared to Billroth I gastrectomy.     

Peptic ulcer disease and thoracoscopic left truncal vagotomy.

BACKGROUND: This study illustrates our experience in treating duodenal ulcer by means of thoracoscopy and laparoscopy over a period of six years. MATERIALS AND METHODS: From October 1991 to October 1998, we submitted 38 patients (31 males and 7 females), average age 51 years (range 22-78 years), with duodenal ulcer to vagotomy with minimally invasive access: 23 Hill-Barkers, 2 Taylors, 9 thoracoscopic truncal vagotomies and 4 laparoscopic truncal vagotomies. The patients submitted to thoracoscopic truncal vagotomy had previous gastric surgery (5 ulcers of the neostoma in patients who had undergone gastric resection, 3 hemorrhagic gastritis of the gastric neostoma and 1 incomplete abdominal vagotomy). RESULTS: The average time required for the thorascopic approach was 30 minutes (range 20-40 minutes) with return to normal feeding in 1 day, without any difficulty, and discharge on day 3 (range 2-5 days). The patients were followed for 3-54 months. Twenty-two patients (91.3%) out of 23 submitted to anterior superselective and posterior truncal vagotomy, and the patients submitted to thoracoscopic vagotomy, were pain free without medical therapy. One patient (4.3%) was lost to the follow-up. There was only one relapse (4.3%) after seven months where the patient underwent left thorascopic truncal vagotomy. We had no mortality and no intraoperative or postoperative complications. CONCLUSIONS: In our opinion, minimally invasive treatment of peptic ulcer disease may represent the "gold standard." It is simple, quick, effective and delivers the same excellent results of open surgery but with minimum trauma.     

Phytobezoar: an uncommon cause of small bowel obstruction.

Phytobezoars are an unusual cause of small bowel obstruction. We report 13 patients presenting with 16 episodes of small bowel obstruction from phytobezoars. Eleven patients had previously undergone surgery for peptic ulceration (eight truncal vagotomy and pyloroplasty). A history of ingestion of persimmon fruit was common and the majority of cases presented in the autumn when this fruit is in season. One phytobezoar causing obstruction at the third part of the duodenum was removed by endoscopic fragmentation, while an episode of jejunal obstruction was precipitated by endoscopic fragmentation of a gastric bezoar. Twelve patients underwent surgery for obstruction on 15 occasions, with milking of the phytobezoar to the caecum performed in ten, enterotomy and removal in four and resection in one patient. Associated gastric phytobezoars were found in two cases and multiple small bowel bezoars in two other cases. These were removed to prevent recurrent obstruction. Phytobezoar should be considered preoperatively as a cause of obstruction in patients with previous ulcer surgery. Wherever possible milking of a phytobezoar to the caecum should be performed. Careful assessment for other phytobezoars should be made. Prevention of phytobezoars is dependent upon dietary counselling of patients by surgeons after gastric resection or vagotomy and drainage for peptic ulcer.     

Transthoracic vagotomy for postoperative peptic ulcer. Effects on basal, sham feeding- and pentagastrin-stimulated acid secretion, and on clinical outcome.

Transthoracic vagotomy was performed in 16 patients with postoperative peptic ulcer diagnosed by endoscopy. Transabdominal vagotomy had been attempted at a previous operation in 10 patients. Five patients had been treated previously by subtotal gastrectomy without vagotomy and one had had gastrojejunostomy without vagotomy. Three of the 16 patients had had no previous gastric resection. Before transthoracic vagotomy, the ratio of sham feeding-stimulated acid output (SAO) to peak pentagastrin-stimulated acid output (PAO) was greater than 0.10 in each patient, suggesting intact vagal innervation of the stomach (mean ratio: 0.44; range: 0.17-0.79). After transthoracic vagotomy, SAO and PAO decreased by 98 +/- 1% and 73 +/- 8%, respectively. There was no operative mortality, and a clinically important postoperative complication developed in only one patient. Two patients had delayed gastric emptying transiently, and three have developed diarrhea. No patient has developed recurrent peptic ulceration or ulcer complications during a mean follow-up period of 3.9 years (range: 1.0-7.5 years). This study indicates that: (1) sham feeding is useful for identifying patients to undergo transthoracic vagotomy, and (2) transthoracic vagotomy is a safe and effective means of reducing acid secretion and preventing peptic ulcer recurrence, regardless of previous operation.     

Surgical treatment of recurrent peptic ulcer disease.

One hundred twenty patients in whom recurrent peptic ulcer developed after various surgical procedures for primary duodenal ulcer were operated on at the Mayo Clinic between 1970 and 1975. The postoperative mortality rate was 3.3% for all cases, 0.9% for elective cases, and 23% for the 13 patients who required emergency surgical care. The mean hospital stay was 13 days, and postoperative complications developed in 25 patients (20%). Approximately 70% of the patients had excellent or good results, whereas the rest had significant postoperative sequelae, including 8.4% (9 patients) in whom rerecurrent ulceration developed. When remedial surgery for recurrent ulcer consisted of vagotomy and distal subtotal gastrectomy (35 patients) after previous vagotomy and drainage procedure (21 patients), subtotal gastrectomy (three patients), vagotomy and hemigastrectomy (eight patients), or gastroenterostomy alone (three patients), there were no operative deaths, 74% of 27 patients available for at least a 5-year follow-up had excellent or good results, and rerecurrent ulceration developed in only one patient. These results indicate that vagotomy and resection is a satisfactory operation for recurrent peptic ulcer and that the long-term results after this operation compare favorably with those reported for cimetidine therapy.     

Endoscopic management of peptic ulcer disease.

OBJECTIVE: This article reviews the authors' experience with endoscopic management of duodenal ulcer and ulcers occurring after a previous drainage procedure. SUMMARY BACKGROUND DATA: Patients with complications of duodenal ulcer and ulcers occurring after a previous drainage procedure still require surgical management. Virtually all operations for duodenal ulcer include some form of vagotomy. American surgeons in academic centers prefer highly selective vagotomy in suitable candidates. Video-directed laparoscopic and thoracoscopic operations have been done for all complications of duodenal ulcer except for acute hemorrhage. METHODS: The authors have performed laparoscopic operation on eight patients with intractable chronic duodenal ulcer, seven patients with gastroesophageal reflux disease combined with duodenal ulcer, one patient with chronic duodenal ulcer and gastric outlet obstruction, and one patient with acute perforation. Operations performed included omentopexy, anterior seromyotomy plus post truncal vagotomy, and highly selective vagotomy. Seven patients had a simultaneous Nissen fundoplication; and the patient with obstruction underwent concomitant pyloroplasty and vagotomy. Six patients with intestinal ulcers occurring after a previous drainage procedure were treated with thoracoscopic vagotomy. Techniques used are shown. RESULTS: There has been one recurrent ulcer in the laparoscopic group after anterior seromyotomy plus posterior truncal vagotomy. The patient treated by omentopexy for duodenal perforation recovered gastrointestinal function promptly with no further difficulty, but eventually died of primary medical disease. Patients undergoing thoracoscopic vagotomy have all become asymptomatic. Postoperative hospital stay after highly selective vagotomy, anterior seromyotomy plus posterior truncal vagotomy, or thoracoscopic vagotomy was 1-5 days. CONCLUSIONS: Laparoscopic management of duodenal ulcers is feasible. Larger numbers of patients with longer follow-up are essential. Ulcers occurring after a drainage procedure deserve thoracoscopic vagotomy.     

Parietal cell vagotomy as an emergency procedure for bleeding peptic ulcer.

Twenty-three selected patients presenting with massive bleeding from peptic ulcers underwent emergency parietal cell vagotomy (PCV). Nineteen patients had a duodenal ulcer, two a prepyloric ulcer, and one a gastric ulcer. The patients were studied retrospectively with regard to postoperative mortality and morbidity, early rebleeding, and recurrent ulceration. Two patients (9%) died after operation, one of rebleeding. No others suffered rebleeding. One further patient had major respiratory complications and 14 others developed minor complications. The remaining 21 patients were followed for between 2 and 72 months. Two patients (10%) developed recurrent ulcers. The authors conclude that parietal cell vagotomy may be used as an emergency operation for bleeding peptic ulcer in selected cases with an acceptably low mortality, rebleeding rate, and incidence of recurrent ulceration.     

Surgical treatment of complicated ulcer disease of the stomach and duodenum at the health department of a metallurgical factory]

The case records of 419 patients with complicated gastric and duodenal ulcer disease were analysed. Frequent asymptomatic course of the ulcer disease was noted in workers of the metallurgical and engineering industry. Different modifications of Billroth resection of the 2/3 of the stomach were used in 240 patients, selective proximal vagotomy (SPV) with ulcer excision--in 87, transverse gastric resection with preservation of the pyloric sphincter--in 30, closure of a perforative hole--in 60, closure of a perforative hole with excision of the ulcer margins and bilateral truncal vagotomy--in 2. The most favourable long-term result was noted in patients after SPV with ulcer excision and transverse gastric resection with preservation of the pyloric sphincter.     

Recurrence after parietal cell vagotomy for peptic ulcer disease

The value of parietal cell vagotomy as a safe surgical procedure in the treatment of chronic peptic ulcer disease has been seemingly limited by the high recurrence rate usually reported. In this 10 year experience of 405 consecutive parietal cell vagotomy operations, 57 patients with recurrent ulceration were evaluated to try to answer the questions of where and why recurrent ulceration appears and how to treat it. Patients with pyloric or prepyloric ulcer disease had recurrence of disease earlier than did patients with chronic duodenal ulcer disease. Consequently, pyloric or prepyloric ulcer patients had a higher recurrence rate in the early postoperative period than chronic duodenal ulcer patients, but this difference disappeared after the seventh postoperative year. Patients with recurrent chronic duodenal ulcer disease have high postoperative acid secretion levels, indicating incomplete vagotomy as a causative factor. Patients with recurrent pyloric or prepyloric ulcer disease have postoperative acid secretion similar to that of patients without recurrence, suggesting another etiologic factor. Thirty of 57 patients with recurrent ulcer had successful medical treatment. A conservative attitude towards recurrences is justified, particularly when symptoms are few and the postoperative acid secretion tests indicate complete or partial vagotomy. Surgical therapy consisting of truncal vagotomy and pyloroplasty in cases of incomplete vagotomy and antrectomy in cases of complete vagotomy should be reserved for patients with symptoms and a disease course that cannot be controlled by conservative treatment.     

Bile reflux and degree of gastritis in patients with gastric ulcer: before and after operation

The incidence and degree of bile reflux and gastritis has been measured in normal subjects and in patients with gastric ulcer before operation and after treatment by highly selective vagotomy with ulcer excision, Billroth 1 partial gastrectomy, and truncal vagotomy and drainage. Before operation patients had significantly higher (P less than 0.001) bile acid concentrations in the stomach than normal subjects. Treatment by highly selective vagotomy resulted in significantly lower bile acid concentrations than those before operation and those found after Billroth 1 partial gastrectomy. Antral and body gastritis was significantly less in normal subjects than in the preoperative and all postoperative groups. There was no significant difference in antral or body gastritis between the preoperative gastric ulcer patients and the patients after any of the surgical procedures despite the significant differences in bile acids. Though highly selective vagotomy in the treatment of gastric ulcer results in a reduction in duodenogastric reflux of bile there is no improvement in the gastritis that is present.     

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.     

Anterior lesser curve seromyotomy and posterior truncal vagotomy for chronic duodenal ulcer: the results at five years

In one surgical unit, 241 patients have undergone anterior gastric seromyotomy and posterior truncal vagotomy for chronic duodenal ulcer. The postoperative mortality rate was 0.4 per cent. Four patients (1.6 per cent) required a drainage procedure for gastric stasis. The first 66 patients (Group A) were followed prospectively and 58 were available for assessment at 5 years. Eight patients (14 per cent) had developed a recurrent ulcer. In seven of these patients this responded to conservative treatment with H2 receptor antagonists. One patient has required Polya partial gastrectomy for recurrent ulceration. At 5 years 47 patients (81 per cent) were placed in the Visick I or II categories. In the next 175 patients (Group B), the ulcer recurrence rate was 3 per cent, suggesting a learning curve in mastering the procedure. We conclude that the immediate and 5-year results of the first 66 patients are at least comparable with those of highly selective vagotomy. Anterior gastric seromyotomy with posterior truncal vagotomy is an easy and rapid procedure and may be more widely applicable than highly selective vagotomy.     

Laparoscopic gastric surgery. Early experiences

In the Department of General Surgery the authors performed 12 elective laparoscopic gastric operations for gastric pathologies. The indications for the procedures were recurrent or therapy resistant and complicated peptic ulcer in 9 cases, benign gastric tumors in 2 cases and early gastric cancer in 1 case. Operative procedures were the next: posterior truncal vagotomy with anterior lesser curve seromyotomy (5 patients), total truncal vagotomy with gastrojejunostomy (2 patients), total truncal vagotomy with pyloroplasty (1 patient), total truncal vagotomy with antrectomy and Billroth-II reconstruction (1 patient), resection of benign gastric tumor by the transgastric approach (1 patient), Billroth-II resection for benign gastric tumor (1 patient), wedge resection of gastric wall for early gastric cancer (1 patient). Intraoperative gastroscopy was used for location of the lesion in 4 of 12 cases. Apart from delayed gastric emptying (2 cases), patients recovered without any problem. The mean hospital stay was 5.7 days. Early experiences with laparoscopic gastric surgery has shown that there are certain important advantages to the approaches. They hold the promise of less pain, less immobility, quicker alimentation, shorter hospitalization, less wound and respiratory complications and an earlier return to normal activities.