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.     

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.     

Development of laparoscopic anterior seromyotomy and right posterior truncal vagotomy for ulcer prophylaxis.

This study investigated the feasibility of a laparoscopic antiulcer procedure. The following antiulcer operations were performed laparoscopically in 20 pigs: truncal vagotomy and pyloroplasty (n = 5), highly selective vagotomy (n = 5), right truncal vagotomy and left highly selective vagotomy (n = 5), and anterior seromyotomy and posterior truncal vagotomy (n = 5). Each procedure was videotaped and assessed in terms of ease of access, need for additional trocars, requirements for suturing, and complexity of the procedure. The anterior seromyotomy and posterior truncal vagotomy provided the optimal combination of antiulcer prophylaxis and adaptivity to the laparoscopic approach. We employed a Nd:YAG laser operating at 20 W delivered via a 600 micron sculpted tip which simplified the anterior seromyotomy. Anterior seromyotomy-posterior truncal vagotomy was then performed in three cadavers without evidence of perforation of the stomach. Our initial experience in a 46-year-old male demonstrates that the procedure can be performed with relative ease in humans. Thus, an effective antiulcer operation, anterior seromyotomy-posterior truncal vagotomy can be performed laparoscopically and may be a reasonable alternative for treating those patients who had a poor response to medical therapy.     

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.     

Surgeons'' attitudes to the operative management of duodenal ulcer perforation and haemorrhage.

The currently preferred operative management of duodenal ulcer haemorrhage and perforation was assessed by means of a questionnaire sent to 274 consultant general surgeons in England. A 70% response rate was achieved. Simple closure, with or without H2 antagonist treatment, was the most popular management of a perforated acute duodenal ulcer. For perforation of a chronic duodenal ulcer occurring during H2 antagonist therapy, truncal vagotomy and drainage was the definitive procedure of choice. There was no consensus about the operative management of perforation complicating non-steroidal anti-inflammatory drug treatment in the elderly patient. Proximal gastric vagotomy appears to have few advocates in the definitive management of either duodenal ulcer perforation or haemorrhage. Of our sample 70% selected truncal vagotomy and drainage with underrunning of the ulcer as the operative treatment of choice for bleeding. Endoscopic coagulation appears to be used only rarely.     

Pancreatic function after seromyotomy of the canine stomach

Anterior gastric seromyotomy combined with posterior truncal vagotomy has been proposed as an acid-reducing operation for patients with duodenal ulcer. Section of the posterior vagal trunk could, however, be held responsible for reduced pancreatic function, seen in patients after bilateral truncal vagotomy. In this study the pancreatic function after anterior gastric seromyotomy and posterior truncal vagotomy has been evaluated in a series of canine experiments by means of a direct hormone stimulation test. No reduction of the basal or stimulated exocrine pancreatic secretion was noted after this type of vagotomy.     

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     

Anterior lesser curvature laser seromyotomy with posterior truncal vagotomy: a potential treatment of peptic ulcer disease

Anterior lesser curvature seromyotomy combined with posterior truncal vagotomy has been suggested as an alternative to proximal gastric vagotomy in the treatment of peptic ulcer. The argon laser may be an ideal instrument for performing seromyotomy. This study compares anterior lesser curvature argon laser seromyotomy/posterior or truncal vagotomy with anterior proximal gastric vagotomy/posterior truncal vagotomy in a canine preparation. Six dogs underwent anterior lesser curvature argon laser seromyotomy/posterior truncal vagotomy and six others underwent anterior proximal gastric vagotomy/posterior truncal vagotomy. Gastric emptying and acid secretion studies were performed preoperatively and at 1 and 6 months postoperatively. Operating time and blood loss were determined. Anterior lesser curvature argon laser seromyotomy was performed with the argon laser at 10 W, continuous, delivered through a 600 micron unsheathed quartz fibre. Anterior proximal gastric vagotomy and posterior truncal vagotomy were performed in the standard fashion. Solid phase gastric emptying was slowed with both operations (P less than 0.05) but this was not manifest clinically. Blood loss (millilitres) was less following anterior lesser curvature argon laser seromyotomy/posterior truncal vagotomy than following anterior proximal gastric vagotomy/posterior truncal vagotomy (21(6.8) versus 95(28.1), mean (s.e.m.), P less than 0.05) but operating time was not significantly different between the groups. Mean basal acid secretion was reduced by 64 per cent 6 months after anterior lesser, curvature argon laser seromyotomy/posterior truncal vagotomy (P less than 0.05) and by 53 per cent after anterior proximal gastric vagotomy/posterior truncal vagotomy (not significant). Mean stimulated acid secretion was reduced by 41 per cent 6 months after anterior lesser curvature argon laser seromyotomy/posterior truncal vagotomy (P less than 0.05) and by 24 per cent after anterior proximal gastric vagotomy/posterior truncal vagotomy (not significant). We conclude that anterior lesser curvature argon laser seromyotomy/posterior truncal vagotomy is an acceptable alternative to anterior proximal gastric vagotomy/posterior truncal vagotomy and may provide superior parietal cell denervation with less operative blood loss.     

腹腔镜下迷走神经切断加溃疡穿孔粘堵治疗十二指肠溃疡穿孔38例报告

目的:探讨腹腔镜在溃疡穿孔治疗中的应用价值。方法:将明胶海绵卷成锥体栓,尖端塞入穿孔,基底部稍高于浆膜面,均匀滴入生物蛋白胶1.0~1.5m l在明胶海绵栓及其周围,采用H ill术式,切断迷走神经后干和高选择性切断前干。结果:全部病例术后8~9d痊愈出院。全部随访复查胃镜检查溃疡面愈合情况,38例中36例溃疡面愈合,另2例给予内科药物治疗痊愈。结论:腹腔镜下行迷走神经切断术加溃疡穿孔粘堵术治疗十二指肠溃疡穿孔疗效可靠,创伤小,值得推广。     

Remaining indications for vagotomy with drainage or antrectomy in duodenal ulcer.

Proximal gastric vagotomy (PGV) consists of denervation of the body and fundus of the stomach, the antral nerve supply being left intact. It has a low operative morbidity and mortality and there are few postvagotomy side effects. However, the recurrent ulcer rate may be higher than with other operations for duodenal ulcer. Nevertheless it is usually easier to treat post-PGV recurrence than the complications of other gastric acid lowering operations. This study defines those patients in whom we have not performed a PGV. Of 110 operations for duodenal ulcer since 1980, 70 were PGVs while 40 consisted of truncal or selective vagotomy combined either with a drainage procedure or antrectomy. It is our practice not to perform a PGV in those patients with prepyloric ulcers, pyloric stenosis, bleeding or perforated ulcers and recurrent ulcers.     

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.     

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.     

Anterior seromyotomy of the body and the functional part of the stomach combined with posterior truncal vagotomy and ulcer excision in the surgical treatment of complicated stomach ulcer

Anterior seromyotomy of the body and fundus of the stomach was combined with posterior truncal vagotomy and excision of the ulcer in 23 patients with gastric ulcer complicated by bleeding or perforation. Seventeen patients had chronic ulcers of the body of the stomach (type I), 3 patients had concurrent ulcers (type II), and 3 more patients had acute ulcers of the body of the stomach. Operation was undertaken for active bleeding from the ulcer in 20 patients and for perforating ulcer in 3 patients. One patient died. Mild disorders of evacuation of an aqueous barium sulfate suspension from the stomach were noted in 4 patients.     

A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocoelioscopy.

We performed truncal posterior right vagotomy with lesser curve anterior gastric myotomy by videocoelioscopy on 10 patients (5 men and 5 women, ranging in age from 19 and 54 years, with a mean age of 32 years). All had a long history of chronic duodenal ulcer with a mean duration of symptoms of 3.8 years. The mean length of the operation was 60 minutes (range: 55 to 110 minutes). There was no morbidity, and all patients were discharged after 5 days. The acid secretion tests under basal conditions and under insulin stimulation preoperatively and 1 month postoperatively showed a mean decrease in the basal output of 79.3% and a mean decrease of 83.04% in the maximal output. The fibroscopic control at the second postoperative month showed a complete healing of the ulcer in nine patients and a residual ulcer scar in one. No patients had any abdominal complaints. Right truncal vagotomy and anterior lesser curve seromyotomy by videocoelioscopy is an efficient and elegant method of treating chronic duodenal ulcer, but it needs thorough experimental practice.     

Fundic vagotomy by waveguide CO2 laser: experimental study of a new technique in dogs

Anterior lesser curve seromyotomy with posterior truncal vagotomy is an alternative operation to the highly selective vagotomy. After preoperative gastric function testing, four dogs underwent an anterior lesser curve seromyotomy with posterior truncal vagotomy. However, a new prototype hand-held laser was used to perform the seromyotomy. This laser delivers 20 W and is small, light, and highly maneuverable. Results of the operation indicate that this laser was easy to use and yielded a very effective seromyotomy without complications. Peroperatively, the laser performed simultaneous section and hemostasis. Postoperatively, no significant acid production could be stimulated with either histamine, pentagastrin, or insulin. This operation yields good control of acid production and is faster and easier than the highly selective vagotomy. The hand-held waveguide CO2 laser may further facilitate the ease of this procedure.     

Anterior lesser curve seromyotomy and posterior truncal vagotomy versus truncal vagotomy and pyloroplasty in the treatment of chronic duodenal ulcer

In a prospective randomized controlled clinical trial, anterior lesser curve seromyotomy with posterior truncal vagotomy (AMPT, n = 77) has been compared with truncal vagotomy and pyloroplasty (TVP, n = 69) in 146 patients with chronic duodenal ulcer with a mean duration of symptoms of 7 years. The mean follow-up time was 4.5 years with a range of 2-7 years. One elderly patient died from a myocardial infarction in the TVP group. Acid secretory inhibition in response to insulin and pentagastrin stimuli was equal in both groups, indicating a similar degree of vagal denervation. Recurrent ulcers were more common after AMPT (five) than TVP (two) (P = 0.29, n.s.). Dumping and diarrhoea were significantly commoner (P less than 0.001) after TVP, with 31 instances as opposed to eight with AMPT. The mean operating time was increased by 6 min when AMPT was performed rather than TVP. The results of this study have shown that AMPT is associated with a lower incidence of dumping and diarrhoea and achieves better overall Visick grading. However, continued monitoring is required to assess the long-term incidence of recurrent ulceration after this procedure.     

Do perforated duodenal ulcers need an acid-decreasing surgical procedure now that omeprazole is available?

If a chronic duodenal ulcer perforates, the choice of operation will depend on the patient's condition. Preoperative shock, concurrent medical diseases, severe generalized peritonitis, or the presence of an intra-abdominal abscess are contraindications to a definitive ulcer operation; hence, simple closure or omental patch closure is performed. Omeprazole can then be used to heal the ulcer in the early postoperative period, with long-term H2-blocker therapy to follow. The patient without a contraindication to a definitive operation should have a proximal gastric vagotomy in addition to an omental patch closure of the perforation. The addition of this procedure does not change the operative mortality rate in properly selected patients, does not cause the gastrointestinal sequelae associated with truncal vagotomy and pyloroplasty or resection, and has a low rate of recurrent ulcer in experienced hands. The presence of a synchronous posterior "kissing" duodenal ulcer would prompt some to choose a vagotomy and pyloroplasty in preference to a proximal gastric vagotomy. The appropriate operation to perform after perforation of an acute duodenal ulcer in a patient with any of the contraindications listed above is simple closure or omental patch closure. In the stable nonseptic patient, the choice is not as clear. Boey and associates noted cumulative recurrent ulcer rates of 37% and 31% at 3 years in separate studies in which omental patch closure was used for perforated acute duodenal ulcers. This may reflect the asymptomatic nature of chronic duodenal ulcers in some patients prior to perforation, the failure of the surgeon to recognize the extent of periduodenal scarring at operation, or differences in the length of postperforation follow-up in series reporting perforations of acute or chronic ulcers. Jordan has suggested that all stable patients with perforated duodenal ulcers should undergo a proximal gastric vagotomy in addition to omental patch closure. In his hands, the addition of proximal gastric vagotomy has an operative mortality rate of 0 to 1%, a recurrent ulcer rate of 3% to 5%, and no adverse postoperative sequelae. He has noted that "this operation gives protection from further ulcer disease to those who need it and will produce no harm to the unidentifiable patients that might not have benefited from definitive surgery." Boey and Wong suggested that omental patch closure is indicated for "acute ulcers associated with drug ingestion or acute stress" in addition to those that occur in patients who are considered to be poor risk, while proximal gastric vagotomy should be added in the remaining patients with perforations of acute ulcers.(ABSTRACT TRUNCATED AT 400 WORDS)     

逆行游离高选择性胃迷走神经切断术治疗十二指肠溃疡

目的：探讨逆行游离高选择性胃迷走神经切断术治疗十二指肠溃疡的可行性和有效性,评估该术式的远期效果,为临床治疗提出新思路。方法：应用逆行游离高选择性胃迷走神经切断术治疗十二指肠溃疡主其工发穿孔、出血和狭窄患者70例,其溃疡穿孔61例,出血6例,狭窄3。结果：65例患者获得访,总的溃复发率为7.69%,再出血率为0。随访30-120个月,属改良VisickⅠ级56例占86.2%,Ⅱ级4例占6.1%,Ⅲ级2例占3.0%,Ⅳ级3例占4.6%,Ⅰ、Ⅱ级共占92.3%。结论：逆行游离高选择性胃迷走神经切断术治疗十二指肠溃疡及其并发症,具有缩短手术时间、简化手术操作、患者远期预后好等优点,可作为治疗十二指肠溃疡合并症的一种有效的方法。     

Parietal cell vagotomy for duodenal and pyloric ulcers: I. Clinical factors leading to failure of the operation

In a prospective study, 170 consecutive unselected patients with duodenal (n = 115) or pyloric (n = 55) ulcers underwent elective parietal cell vagotomy, with an additional drainage procedure in patients with stenosis. The patients were classified in two consecutive groups and were followed up for 3 to 7 years after operation, in 132 cases for more than 5 years. The follow-up was complete. Patients with symptoms suggestive of ulcer for more than 3 days, independent of roentgenographic or endoscopic findings, were classified as having symptoms of recurrent ulcer and were specially analyzed.There was no mortality; splenic injuries occurred in 5 cases (3 percent), dumping symptoms in 4 percent after parietal cell vagotomy but in 34 percent after vagotomy plus drainage. Diarrhea occurred in 3 percent of the patients after parietal cell vagotomy and in 20 percent after vagotomy plus drainage.Fifty-five patients had clinical recurrences, significantly more patients with pyloric ulcer (46 percent) than with duodenal ulcer (28 percent). In 27 patients, the symptoms responded well to conservative therapy. In the other 28 patients the symptoms were severe, and 14 underwent reoperation for proven recurrent ulcers. The difference in the recurrence rates for duodenal and pyloric ulcer was found only in patients who did not undergo a drainage procedure, while pyloric ulcer patients with stenosis and a drainage operation were comparable in this respect to duodenal ulcer patients with and without drainage.A decrease in the rate of recurrence was achieved between the earlier and later parts of the series, even considering the difference in length of follow-up. The decrease is considered to reflect mainly our increased experience with the method. The results in patients in the later part of the series, followed up for more than 5 years, were a 22 percent incidence of recurrent ulcer symptoms and an 8 percent incidence of proven recurrent ulcers in those with duodenal ulcer, and a 28 percent incidence of recurrent ulcer symptoms and a 22 percent incidence of proven recurrent ulcers in those with pyloric ulcer.The overall results in patients followed up to more than 5 years, according to a modified Visick scale which incorporates differences in the severity of recurrent ulcer symptoms and the results after reoperation, were satisfactory in 89 percent of the patients with duodenal ulcer and in 73 percent of those with pyloric ulcer.     

Is selective proximal vagotomy expedient in the treatment of bleeding duodenal ulcers?

The article analyses the results of truncal and selective proximal vagotomy with gastric draining operations in 101 patients with bleeding duodenal ulcer. The patients' condition, the results of special methods of examination, and the morphological changes in the gastric mucosa were studied. It was found that selective proximal vagotomy with drainage of the stomach had no advantages over truncal vagotomy. Besides, being a technically more difficult operation than truncal vagotomy, it fails to meet the requirements of emergency surgery and its application in patients with a bleeding duodenal ulcer isnot expedient.