腹腔镜下高选择性迷走神经切断术(Hill术式)治疗急性十二指肠溃疡穿孔

目的探讨腹腔镜下高选择性胃迷走神经切断术(Hill术式)治疗急性穿孔性十二指肠溃疡及其效果。方法腹腔镜下行溃疡穿孔修补,游离胃迷走神经并行迷走神经后干切断和前干高选择性切断术治疗十二指肠溃疡急性穿孔患者19例。结果 19例患者均获得手术成功,无中转开腹手术者。术后17例溃疡症状消失,6个月后复查胃镜示溃疡已经愈合;2例患者术后溃疡症状明显减轻,药物治疗可控制。结论腹腔镜下高选择性胃迷走神经切断术治疗穿孔性十二指肠溃疡,具有创伤小、恢复快、效果好等优点,是治疗十二指肠溃疡穿孔的一种好方法。     

改良高选择性迷走神经切断术治疗十二指肠溃疡急性穿孔

目的观察改良高选择性迷走神经切断术治疗十二指肠溃疡急性穿孔的远期临床效果。方法应用改良高选择性迷走神经切断术治疗十二指肠溃疡急性穿孔148例。随访观察术后并发症、胃酸下降情况及胃排空和溃疡复发情况,并按Visick标准进行分级。结果全组病例无围手术期死亡。126例获随访,随访时间6个月～9年,术后3年基础酸排出量(BAO)、最高酸排出量(MAO)、高峰酸排出量(PAO)仍保持术后低水平。Visick分级,Ⅰ级102例(81.0%),Ⅱ级15例(11.9%),Ⅲ级5例(4.0%),Ⅳ级4例(3.2%)。有2例患者溃疡复发(1.6%)。结论改良高选择性迷走神经切断术治疗十二指肠溃疡急性穿孔,设计合理、操作简单、效果确切,值得在基层医院推广应用。     

腹腔镜下高选择性迷走神经切断术治疗穿孔性十二指肠溃疡

目的　探讨腹腔镜下高选择性胃迷走神经切断术 (LHSV )治疗穿孔性十二指肠溃疡的操作要点和有效性。方法　应用腹腔镜下修补溃疡穿孔 ,超声刀游离胃迷走神经并进行高选择性切断治疗十二指肠溃疡穿孔患者 2 0例。结果　 2 0例患者均获得手术成功 ,无中转开腹手术者。术后 15例溃疡症状消失 ,半年复查胃镜示溃疡已经愈合 ;5例病人术后溃疡症状明显减轻 ,易为药物治疗控制。结论　LHSV治疗穿孔性十二指肠溃疡 ,具有创伤小 ,恢复快 ,效果好等优点 ,是治疗十二指肠溃疡穿孔的一种良好方法     

扩大壁细胞迷走神经切断术治疗十二指肠溃疡急性穿孔体会

目的探讨扩大壁细胞迷走神经切断术（EPCV）治疗十二指肠溃疡急性穿孔的效果。方法回顾性分析2002年1月至2006年10月29例十二指肠溃疡急性穿孔患者行扩大壁细胞迷走神经切断术治疗的临床资料。结果本组病例均临床治愈出院,其中21例获随访。Visick分级,Ⅰ级24例（82.9%）;Ⅱ级3例（10.3%）;Ⅲ级1例（3.4%）;Ⅳ级1例（3.4%）;Ⅰ级和Ⅱ级共占27例（93.2%）。十二指肠溃疡复发1例（3.4%）。结论规范化EPCV手术治疗十二指肠溃疡急性穿孔的术后复发率低,临床效果满意。因此,EPCV术是目前治疗十二指肠溃疡急性穿孔首选的术式。     

腹腔镜高选择性迷走神经离断术治疗上消化道溃疡穿孔的临床研究

目的:评价腹腔镜穿孔修补术联合高选择性迷走神经离断术治疗胃十二指肠溃疡穿孔的疗效.方法:回顾分析2003年1月至2007年1月273例胃十二指肠溃疡穿孔患者的临床资料,其中胃穿孔149例,十二指肠穿孔124例.134例行腹腔镜穿孔修补加高选择性迷走神经切断术(研究组),139例行剖腹穿孔修补加高选择性迷走神经切断术(对...     

保留交感神经的壁细胞迷走神经切断术治疗十二指肠溃疡

目的 探讨保留交感神经的壁细胞迷走神经切断术治疗十二指肠溃疡的疗效。方法 36例病人行保留交感神经的壁细胞迷走神经切断术，其中27例为十二指肠溃疡并穿孔，5例为合并出血，2例为合并狭窄，2例为单纯十二指肠溃疡；评价病人术后死亡率、并发症的发生率及溃疡再发率。结果 全组均获随访24个月，无手术死亡率，无术后再出血，1例溃疡再发，Visick指数Ⅰ级为69．4％，Ⅱ级为19．4％。结论 保留交感神经的壁细胞迷走神经切断术为治疗十二指肠溃疡及其并发症的简单易行、有效的手术方式。     

扩大壁细胞迷走神经切断术治疗十二指肠溃疡并发症150例的远期效果

目的探讨扩大壁细胞迷走神经切断术（ＥＰＣＶ）的远期临床效果。方法自１９７９年始应用ＥＰＣＶ治疗十二指肠溃疡并发穿孔、出血和狭窄１５０例,其中穿孔１０３例,出血１２例,狭窄３５例。结果全组１３１例获得随访,总的溃疡复发率为２．３％,复发狭窄率为２．９％,再出血率为０。ＶｉｓｉｃｋⅠ级为８３．２％,Ⅱ级为１０．６％,Ⅲ级为３．１％,Ⅳ级为３．１％;Ⅰ级和Ⅱ级共占９３．８％。结论作者认为ＥＰＣＶ术后远期患者无论是消化吸收功能和营养状态,还是恢复劳动能力和生活质量都较高,进一步证实该手术设计的合理性和可行性     

扩大壁细胞迷走神经切断术治疗十二指肠溃疡及其并发症

目的：评价扩大壁细胞迷走神经切断术（EPCV）治疗十二指肠溃疡及其并发症的远期临床疗效。方法：采用EPCV共治疗十二指肠溃疡及其并发症321例。其中慢性溃疡56例,并发急性穿孔204例,出血21例,狭窄40例。评价内容包括：术后并发症发生率、胃酸分泌功能、胃排空功能、胃镜和上消化道钡餐检查、营养状态、Visick分级。结果：全组321例患者中289例获得随访,随访率为90%,随访期为0.5-22.0年,平均为11.3年。全组无手术死亡,无纵隔炎和倾倒综合征发生。发生粘连性肠梗阻4例（1.4%）,进食后上腹胀19例（6.5%）,返酸17例（5.8%）,总的溃疡复发16例（5.5%）,其中慢性十二指肠溃疡为19.5%,出血为0,狭窄为5.3%,穿孔为3.1%。16例复发溃疡经内科药物治疗后溃疡愈合10例,其余6例经胃部分切除或胃窦切除痊愈。EPCV总的优良率（VisickⅠ和Ⅱ级）为91.7%,其中穿孔为95.3%,效果最佳。结论：EPCV具有手术操作简便、术后并发症较少、溃疡复发率低、术后远期患者营养状况良好、生活质量较高的特点,疗效优良。EPCV术是治疗十二指肠溃疡及其并发急性穿孔、出血和狭窄首选的安全有效术式。     

改良壁细胞迷走神经切断术治疗十二指肠溃疡穿孔45例体会

目的　探索治疗十二指肠溃疡穿孔简捷、有效的手术方法。方法　自 1993～ 1996年对壁细胞迷走神经切断术进行改良 ,手术不游离食道下段、不显露迷走神经、不分离切断胃大弯近侧网膜及胃底血管 ,对胃底浆肌层仅作部分切开 ,以此法治疗十二指肠溃疡穿孔 45例。结果　应用此法 (改良壁细胞迷走神经切断术 )使手术难度降低 ,手术时间缩短 ,适应范围扩大。 45例平均随访34 6个月 ,VisickⅠ、Ⅱ 41例 (41/ 45 ,91% )。基础胃酸排量 (basalacidoutput,BAO) (4 1± 2 1)mmol/h ,最高胃酸分泌量 (maximalacidoutput,MAO) (16± 6 )mmol/h ,溃疡复发 3例 (3/ 35 ,9% )。结论　改良壁细胞迷走神经切断术是治疗十二指肠溃疡穿孔的合理方法 ,对穿孔时间较长及老龄病人尤为适宜。     

老年人胃十二指肠溃疡穿孔的特征和治疗

目的：探讨老年人胃十二指肠溃疡穿孔的特征和治疗手段。方法：回顾性总结近20年来收治的58例60岁以上胃十二指肠溃疡穿孔患者的临床资料。结果：58例中56例行手术治疗，治愈46例，死亡12例。死于心肺功能衰竭5例，感染性休克4例，肾衰竭3例。结论：老年人胃十二指肠溃疡穿孔，宜争取早期手术；治疗方法以穿孔修补加高选迷走神经切断术，或修补加简化迷走神经切断术为较好选择。     

Six-year results of a prospective, randomized trial of selective proximal vagotomy with and without pyloroplasty in the treatment of duodenal, pyloric, and prepyloric ulcers.

In a consecutive series of patients with uncomplicated prepyloric, pyloric, or duodenal ulcer, 39 patients were randomly allocated to selective proximal vagotomy with pyloroplasty, and 40 patients to selective proximal vagotomy alone with no operative mortality. Before surgery, all patients had undergone H2-receptor antagonist treatment. No patient was lost for follow-up. At an average follow-up of 6 years, recurrent ulcer was recorded in 15% and 20%, respectively, after selective proximal vagotomy with and without pyloroplasty. Three of 14 recurrent ulcers were asymptomatic. Epigastric pain with or without ulcer was significantly less common after selective proximal vagotomy with (13%) than without pyloroplasty (40%). Mild diarrhea or mild dumping was recorded in a few patients. The overall results were very good or good (Visick I or II) in 77% and 55% (significant difference) after vagotomy with and without pyloroplasty, respectively, and in 82% and 58%, if asymptomatic ulcers were graded as Visick I or II results. Of the 27 patients with Visick III or IV results, three patients needed no treatment (asymptomatic ulcers), and 10 patients had no symptoms during medical treatment. Two patients with vagotomy and pyloroplasty and nine with vagotomy alone were reoperated. There were no deaths, and the results were graded as Visick I or II in 10 patients and as Visick III in one patient. The authors conclude that selective proximal vagotomy with pyloroplasty is superior to vagotomy alone for the treatment of prepyloric-pyloric and duodenal ulcer. Recurrent ulcer after vagotomy has a benign course and responds well to ranitidine treatment.     

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。     

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)     

Combined vagotomy in the surgical treatment of patients with duodenal ulcer]

Short-term and long-term results of surgical treatment of 487 patients with duodenal ulcer were studied. In 337 patients (69.2%) truncal vagotomy was performed; in 94 patients (19.3%)--combined vagotomy; in 56 patients (11.5%)--selective vagotomy. With no lethal outcomes, the frequency of general surgical complications was 5.6% which did not depend on the type of vagotomy. According to the Visick criteria long-term excellent and good results were noted after truncal vagotomy in 90.4% of the patients, after combined vagotomy--in 88% and after selective proximal vagotomy--in 70% of the patients. With the same frequency of recurrent ulcers, diarrhea and dumping-syndrome combined vagotomy has some advantages in recovery of the motor evacuating function as compared with truncal vagotomy; yielding in frequency of diarrhea it has better long-term results by the Visick criteria as compared with selective proximal vagotomy and less frequency of recurrent ulcers.     

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.     

Role of highly selective vagotomy and duodenoplasty in the treatment of postbulbar duodenal obstruction

The indications for highly selective vagotomy have expanded in recent years, with the technique being applied to selected cases of perforation and bleeding. Its use in obstruction is controversial, but two options are available for managing the stenotic pylorus or duodenum: dilatation or duodenoplasty. The latter choice requires that the stenosis be located in the postbulbar area. Since 1981, we have managed 15 patients with postbulbar stenosis by means of highly selective vagotomy and duodenoplasty. All patients had a previous history of ulcer disease, and vomiting was a consistent symptom. All patients were referred for surgery, 10 by a gastroenterologist. There was no operative mortality or procedure-related morbidity. Two patients have been lost to follow-up. Both were classified as Visick I and had normal endoscopic results at their last visit. The remaining 13 patients have all been followed very recently. Twelve patients (92%) are currently classified as Visick I or II. One patient (Visick IV), who was essentially asymptomatic, was found to have a recurrent ulcer on endoscopy. Endoscopic (11 patients) or radiographic (1 patient) patency of the duodenoplasty has been demonstrated in 12 patients. Highly selective vagotomy and duodenoplasty should be a surgical consideration when the pathologic anatomy of the duodenum lends itself to that choice.     

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.     

Twenty years after parietal cell vagotomy or selective vagotomy antrectomy for treatment of duodenal ulcer. Final report.

OBJECTIVE: This study was a prospective, randomized evaluation of parietal cell vagotomy (PCV) and selective vagotomy-antrectomy (SV-A) in the treatment of duodenal ulcer. BACKGROUND DATA: Operative treatment of duodenal ulcer is associated with mortality and mechanical and metabolic morbidity. At the time that surgeons appear to have succeeded in developing operations with low morbidity and mortality, the number of patients requiring elective operation has decreased partly because of the simultaneous, dramatic improvement in medical therapy. Nevertheless, surgical therapy still is important, especially in certain socioeconomic environments. METHODS: After a pilot study of PCV, 200 patients with duodenal ulcers were randomized to PCV or SV-A. One surgeon was responsible for the operations and follow-up studies. An attempt was made to evaluate all patients annually in the hospital. Gastric analyses were performed on each visit, for which the patient gave his/her consent. RESULTS: There was no operative mortality. The recurrence rate-by-life table analysis was less (p < 0.003) after SV-A than PCV. Dumping was greater (p < 0.001), and there was no difference in the frequency of diarrhea after SV-A compared with PCV. The percentage of patients with grades Visick I or Visick II was not different for the two operations, but more patients were graded Visick I after PCV than after SV-A. CONCLUSIONS: Selective vagotomy-antrectomy and parietal cell vagotomy are effective and safe operations, when used appropriately. Selective vagotomy-antrectomy is preferable for patients with pyloric and prepyloric ulcers and pyloric obstruction. Parietal cell vagotomy is the authors' choice for duodenal ulcer patients because of the occasional patient who becomes disabled by SV-A.     

Anterior lesser curve seromyotomy using a stapling device and posterior truncal vagotomy for the treatment of chronic duodenal ulcer: longterm results

Background: Recently, gastric stapling with posterior truncal vagotomy has been performed, either by conventional or laparoscopic surgery, as an alternative to highly selective vagotomy and the Taylor procedure for the treatment of chronic duodenal ulcer. Our aim was to investigate the longterm effects after a stapling-modified Taylor procedure, conventional and laparoscopic, on gastric secretion and emptying and on clinical indices and recurrence rates in patients treated for duodenal ulcer before 1994.

Study Design: Thirty-one patients, aged 40 to 76 years (mean 53 years), were treated between 1986 and 1993, 21 by conventional and 10 by a laparoscopic stapling-modified Taylor procedure. Outcomes were studied for gastric acid secretion, solid and liquid gastric emptying, euterogastric reflux, endoscopic findings, and clinical indices using the Visick grading.

Results: Endoscopy revealed a healing ulcer in 29 patients. Two patients showed signs of chronic ulcerative disease with mild symptoms, without gastritis or pyloric stenosis indicative of progressive ulcerative diathesis, and were classified as Visick III. Twenty-four patients were classified as Visick I and 5 as Visick II. The enterogastric reflux index ranged from 0% to 27%, and basal and peak acid output were 1.5 ± 0.6 mmol H⁺/h and 12.2 ± 6.4 mmol H⁺/h, respectively. The half-emptying time of solid and liquid meals was 78 ± 9 minutes and 18 ± 6 minutes, respectively. These results are likely to be similar to those obtained from the series of patients who underwent highly selective vagotomy or Taylor procedure and are close to those achieved in healthy controls.

Conclusions: This modification of the original Taylor operation (conventional and laparoscopic) allows a more rapid, technically easier, and radical performance of the operation with excellent longterm results and should be considered an effective alternative for the treatment of duodenal ulcer.     

Laparoscopic modified taylor procedure in the treatment of duodenal ulcer: technique and outcome after 5-year follow-up

BACKGROUND: Recently, gastric stapling with posterior truncal vagotomy has been performed by laparoscopic surgery, as an alternative to highly selective vagotomy (HSV) and the Taylor procedure for the treatment of chronic duodenal ulcer. AIM: To investigate, after a mean 5-year follow-up, the effect of the stapling-modified laparoscopic Taylor procedure, on gastric secretion, emptying and reflux as well as clinical parameters and recurrence rates in patients treated for duodenal ulcer. METHODS: 16 patients, aged 38-66 years, were treated from January 1993 to January 1996 (median 60.5 months), by the laparoscopic stapling-modified Taylor procedure, using the Endo-GIA stapler device. Assessment of the results of gastric acid secretion, solid and liquid gastric emptying, enterogastric reflux, endoscopic findings and clinical parameters, using the Visick grading, was performed. RESULTS: Endoscopy found healing ulcer in 15 patients. One patient showed signs of chronic ulcerative disease without gastritis or pyloric stenosis indicative of progressive ulcerative diathesis and was classified as Visick III. 14 patients were classified as Visick I and 1 as II. The enterogastric reflux index ranged from 0 to 26%, basal and peak acid output were 1.4 +/- 0.6 and 11.7 +/- 6.1 mmol H(+)/h, respectively. The half-emptying times of the solid and liquid meal were 82 +/- 7 and 16 +/- 6 min, respectively. These results are likely to be similar to those obtained from series of patients who underwent HSV or Taylor procedure and are closed to those from healthy controls. CONCLUSIONS: The laparoscopic modified Taylor procedure, using the Endo-GIA stapler device allows a more rapid, technically easier and radical performance of the operation with excellent long- term results and should be included in the armamentarium of the treatment of chronic duodenal ulcer.