Proximal gastric vagotomy with drainage for obstructing duodenal ulcer

The optimal treatment for obstructing duodenal ulcer is controversial because of questions about the efficacy of proximal gastric vagotomy (PGV) in controlling the primary ulcer diathesis. Impressed with the theoretic advantages of PGV with drainage as a primary treatment for this problem, we have treated 37 suitable patients by this approach. All patients underwent endoscopic examination and barium meal study that proved the diagnosis. PGV, including division of the gastroepiploic nerves as indicated by intraoperative testing, was followed by Jaboulay gastroduodenostomy (18), Finney pyloroplasty (12), Heineke-Mikulicz pyloroplasty (3), anterior hemipylorectomy (2), duodenoplasty (1), and gastroenterostomy (1). No recurrent ulcers were seen during a mean follow-up of 4.6 years. Three patients had mild early dumping at infrequent intervals. Bilious vomiting, alkaline gastritis, and other postgastrectomy complaints were recorded infrequently. PGV with drainage is a good treatment for the obstructing ulcer and does not have as many morbid risks as alternative operative procedures.     

Proximal gastric vagotomy or truncal vagotomy and drainage for chronic duodenal ulcer?

A comparison has been made between truncal vagotomy and drainage (TVD) and proximal gastric vagotomy (PGV) performed electively for chronic duodenal ulceration from 1968 to 1981 in 209 and 272 patients respectively. The morbidity was 23 per cent after TVD and 19.8 per cent after PGV, with a mortality of 0.5 per cent and 0.4 per cent respectively. Of 163 patients in the former group and 253 patients in the latter group the follow-up was an average of 5.7 and 6.2 years respectively; 128 patients (78.5 per cent) and 198 (78.3 per cent) respectively had a good functional result, graded as Visick I and II, but 35 (21.7 per cent) and 55 (21.7 per cent), respectively, had a poor result owing to recurrent ulceration in 23 (14.1 per cent) after TVD and 44 (17.4 per cent) after PGV. These results were not statistically different. The frequency of diarrhoea was 23 per cent and dumping 6.8 per cent after TVD which was significantly reduced to 2.0 per cent (P less than 0.005) and 1.2 per cent (P less than 0.025), respectively, after PGV. However, only five patients (3.0 per cent) had severe symptoms from diarrhoea and two (1.2 per cent) from dumping after TVD. Both operations seem to carry an equal incidence of unsatisfactory results, though for slightly different reasons it might be concluded that both procedures have an equal degree of acceptability.     

Proximal gastric vagotomy in the emergency treatment of bleeding duodenal ulcer

Proximal gastric vagotomy for bleeding duodenal ulcer was performed in 52 low-risk patients between 1973 and 1986. Duodenotomy without violation of the pylorus was done in all patients to allow inspection and control of the bleeding site. The median duration of operation was 3 hours and 20 minutes, although 25% of the procedures required 4 or more hours. There was no postoperative mortality and no early reoperations. Among the six patients with postoperative complications, one rebled from the ulcer and two developed prolonged gastric atony. At the time of follow-up (median, 2.9 years), 48 of the patients were alive and 4 had died of non-ulcer causes. No patient had significant postvagotomy sequelae. Ulcer recurrence was documented in six patients, and three required reoperation. Proximal gastric vagotomy is a safe, effective therapy for bleeding duodenal ulcer. Because of the length of the operation, it should be restricted to low-risk patients who are hemodynamically stable at the time of operation.     

Proximal gastric vagotomy and pyloroplasty for duodenal ulcer with pyloric stenosis: A thirteen-year experience

Between 1970 and 1983, seventy-eight patients with duodenal ulcer and pyloric stenosis causing gastric outlet obstruction have been operated on with a proximal gastric vagotomy (PGV) and a Heineke-Mikulicz pyloroplasty. The mean observation time was 90 months. There was no operative mortality or major complications. The reduction in mean acid output was greater after PGV and pyloroplasty than after PGV without drainage in patients with duodenal ulcer without stenosis. The clinical results were excellent or good in 93% of the patients (Visick I and II). Only 1 patient (1.3%) developed a recurrent ulcer, while 5 patients (6.4%) had symptoms of slight or moderate dumping. It is concluded that PGV and pyloroplasty is a good operation in patients with duodenal ulcer and pyloric stenosis. There is a low incidence of ulcer recurrence, a low risk of serious complications, and good long-term symptom control.

---

Resumen Setenta y ocho pacientes con úlcera duodenal y estenosis pilórica causante de obstrucción de la desembocadura del estómago fueron sometidos a vagotomía gástrica proximal (VGP) y piloroplastia de Heineke-Mikulicz entre 1970 y 1983. No se presentó mortalidad operatoria y tampoco se registraron complicaciones mayores. La reducción en la secreción gástrica media fué superior después de VGP y piloroplastia que después de VGP sin drenaje en pacientes con úlcera duodenal sin estenosis. Los resultados clínicos fueron excelentes o buenos en 93% de los pacientes (Visick I y II). Sólo un paciente (1.3%) desarrolló úlcera recurrente, mientras 5 pacientes (6.4%) eshibieron síntomas de dumping leve o moderado.Se llega a la conclusión de que la VGP y piloroplastia es una buena operación en pacientes con úlcera duodenal y estenosis pilórica. Se observa una baja incidencia de úlcera recurrente, un bajo riesgo de complicaciones y un buen control sintomático a largo plazo.

---

Résumé De 1970 à 1983, 78 malades porteurs d'un ulcère duodénal compliqué de sténose pylorique ont subi une vagotomie hypersélective combinée à une pyloroplastie de type Heineke-Mikulicz. La durée moyenne du suivi postopératoire a été de 90 mois alors qu'aucun décès opératoire, qu'aucune complication ne fut notée. La réduction du débit acide moyen fut plus importante après vagotomie hypersélective et pyloroplastie qu'après vagotomie hypersélective sans drainage complémentaire chez les sujets qui présentaient un ulcère duodénal sans sténose pylorique associée. Les résultats cliniques ont été excellents ou bons dans 93% des cas (Visick I et II). Un seul opéré (1,3%) a présenté une récidive ulcéreuse cependant que cinq sujets (6,4%) ont accusé un dumping syndrome léger ou modéré.On peut conclure de ces faits que la vagotomie hypersélective avec pyloroplastie est une bonne opération chez les malades qui présentent un ulcère du duodénum compliqué de sténose pylorique. Le risque de récidive est faible ainsi que celui de complications postopératoires alors que le contrôle à long terme de l'aifection est bon.

     

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.     

Recurrent ulceration after proximal gastric vagotomy for duodenal ulcer

Proximal gastric vagotomy has been performed in 605 patients. Ulcer recurrence occurred in 59 (9.8%) and the relationship of recurrent ulceration to age, sex, gastric emptying time, and gastric acid secretion has been examined. The recurrence rate in 428 of the patients followed for more than 5 years was 11.4%. There was no significant difference in recurrence rates between men and women. Less than half of the recurrences were located in the duodenal bulb (40%). No significant difference in gastric emptying time was found between patients with and without recurrence. The results of the 3 gastric secretion tests—basal acid output (BAO), maximal acid output (MAO), and the insulin test—showed that patients with ulcer recurrence in the duodenal bulb, both pre- and postoperatively, had significantly higher mean values of acid secretion than the other patients with recurrence and the control group without recurrence. At the time of recurrence, the mean values of acid secretion in patients with duodenal recurrence were significantly higher than in the control group, and the insulin test was Hollander positive in 87% of the patients. The acid secretion in patients with pyloric, prepyloric, and gastric recurrence was not significantly different from the control group. The results suggest that an incomplete vagotomy is an important factor in the development of ulcer recurrence in the duodenal bulb. Recurrences confined to the stomach, however, seem to develop in spite of an adequate vagotomy and no causal factor could be discovered in these patients.     

Proximal gastric vagotomy in dyspeptic patients without an ulcer

Proximal gastric vagotomy (PGV) was performed in 40 patients who had suffered from dyspepsia for several years, but who did not have any demonstrable ulcer. Great care was taken to obtain a thorough history of the disease. Patients with symptoms not likely to be caused by gastric hypersecretion were not treated surgically. There was a distinctive reduction of both basal and pentagastrin-stimulated acid secretion after the operation. The decrease in acid output was accompanied by a marked relief of symptoms. Most patients noted the improvement within 3 months after surgery. Thirty patients were interviewed after 5 years. Of these, 23 were either completely cured of dyspepsia or were at least much better than before the operation. Only 1 person reported no relief 5 years after PGV. It is concluded that surgical treatment may be of value in patients with chronic dyspepsia even in the absence of a peptic ulcer.

---

Resumen La vagotomía gástrica proximal fué realizada en 40 pacientes que sufrían de dispepsia por varios años, pero quienes no poseían úlcera gástrica demostrable. Se prestó especial cuidado a la obtención de una meticulosa historia de la enfermedad. Aquellos pacientes con síntomas que posiblemente no eran causados por hipersecreción gástrica no fueron sometidos a tratamiento quirúrgico. La operación produjo una clara reductión tanto de la secreción ácida basai como de la secreción en respuesta a la estimulación con pentagastrina, y la disminución de la secreción ácida se acompa¯nó de marcada mejoría de los síntomas. La mayoría de los pacientes notó mejoría dentro de los primeros tres meses después de la cirugía. Treinta pacientes fueron entrevistados después de cinco años de la operación, y de éstos, 23 se hallaron completamente curados de la dispepsia, o por lo menos mucho mejor que antes de la cirugía; sólo una persona informó que no había mejoría 5 años después de la vagotomía gástrica proximal. Se concluye que el tratamiento quirúrgico puede tener valor en pacientes con dispepsia crónica aún en ausencia de úlcera péptica.

---

Résumé Une vagotomie hypersélective a été practiquée chez 40 malades qui présentaient un état dyspeptique depuis plusieurs années mais qui n'étaient pas atteints d'ulcère duodénal. Leur histoire pathologique fut étudiée avec grand soin et les sujets qui n'accusaient pas de troubles identiques à ceux provoqués par l'hypersécrétion gastrique ne furent pas traités chirurgicalement.Apres l'intervention il fut possible de constater une réduction de la secrétion basale et de la secrétion stimulée par la Pentagastrine. La diminution de la secrétion acide s'accompagna d'une amélioration marquée des symptômes accusés antérieurement par les patients, 3 mois après l'intervention.Trente malades ont été revus 5 ans après avoir été opérés. Parmi eux 23 se considéraient comme guéris ou très améliorés. Un seul accusait le même état dyspeptique qu'avant l'opération.On peut conclure de ces faits que la vagotomie hypersélective est susceptible de contrôler les troubles dyspeptiques qui existent en l'absence d'ulcère.

     

Rate of gastric emptying after vagotomy in duodenal ulcer

An analysis of results of studying the rate of emptying the stomach in 103 patients with duodenal ulcer has shown that evacuation was considerably quicker in patients in the vertical position than in those in horizontal position. It was slower in patients with subcompensated or decompensated stenosis. After vagotomy the emptying of the stomach took less time. In patients with a recurrent ulcer slower evacuation was noted but with the narrowing of the pyloroduodenal canal.     

Effect of a drainage operation on gastric secretion in patients with duodenal ulcer after vagotomy

The work analyzes alterations of gastric secretion in 687 patients subjected to various kinds of vagotomy in combination with or without draining operations on the stomach for ulcer of the duodenum. Draining operations were established to decrease activity of gastric secretion. The Jaboulay gastroduodenal anastomosis proved to be less beneficial since 50% of the patients had the positive insulin test and ulcer recurred almost in 11% of the cases. Results were most favorable after vagotomy in combination with pyloroplasty after Finney and Heineke-Mikulicz. The disease recurred after these interventions in 7 and 8% correspondingly.     

胃小弯前壁浆膜肌层切开加后迷走神经干切断术在十二指肠溃疡急性穿孔应用

目的 探讨胃小弯前壁浆膜肌层切开加后迷走神经干切断（ASPTV）在十二指肠溃疡急性穿孔治疗中的作用。方法 回顾性分析47例十二指溃疡急性穿孔采用穿孔修补加ASPTV治疗的患者的临床资料。结果 47例手术时间平均70min，术中出血250ml左右。术后切破胃粘膜4例，均经修补愈合。未发生胃排空障碍等重大并发症，无手术死亡病例。术后6－12个月胃镜复查44例，溃疡病灶均愈合，无胃潴留。47例随访3－7年（平均5年），术后溃疡复发2例（4．3％），均经药物治疗控制。结论 ASPTV术式简捷、安全有效，手术创伤小，适合十二指肠溃疡急性穿孔的治疗。     

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%.     

Proximal gastric vagotomy: update.

Experience with proximal gastric vagotomy at the Mayo Clinic from 1973 to Mayo 1980 is reported. Among 298 patients who had proximal gastric vagotomy for chronic duodenal, pyloric channel, or prepyloric ulcers, a recurrent ulcer rate of 7% was present, with a mean follow-up of 49 months. Three recurrences developed in six patients who had proximal gastric vagotomy for gastric ulceration. In 40 patients, proximal gastric vagotomy was combined with gastrojejunostomy, pyloroplasty, or pyloric dilatation for obstructing ulcers. There was a 15% incidence of reoperation in the gastrojejunostomy group. All nine patients who had proximal gastric vagotomy for active or recent bleeding ulcers were dismissed from the hospital without further hemorrhage, and only one developed a recurrent ulcer. It is concluded that proximal gastric vagotomy remains an acceptable operation for chronic duodenal and pyloric ulcers, but its efficacy in gastric ulcers is unproved.     

The effect of the size of the gastric outlet on gastric emptying after vagotomy for duodenal ulcer.

Gastric emptying of isotopically labelled solid meals was studied in normal human subjects and in 30 patients who had had an operation for chronic duodenal ulcer. Each patient had a vagotomy of the whole stomach combined with either a Finney pyloroplasty to produce a large gastric outlet or a Heineke-Mikulicz pyloroplasty to produce a relatively small outlet. At 10-22 days after operation gastric emptying was equally and significantly slowed in both groups when compared with the normal controls. This delay occurred regardless of whether the vagotomy was complete or incomplete. At 4-6 months after operation emptying had returned to normal in the patients who had had a Finney pyloroplasty but remained significantly slowed after Heineke-Mikulicz pyloroplasty. Mild symptoms of gastric stasis frequently occurred in both groups in the early postoperative period, but were rare 4-6 months after operation. There was no correlation between the incidence of these early symptoms of stasis and the size of the gastric outlet constructed.     

Perforated duodenal ulcer managed by proximal gastric vagotomy and suture plication.

Twenty-one patients with acute perforated duodenal ulcer were managed by proximal gastric vagotomy without drainage and simple closure of the perforation reinforced with an omental patch. There was no operative mortality. No recurrent duodenal ulcers have developed. All patients have achieved a good to excellent clinical result from their operation. Dumping, diarrhea, and reflux gastritis have not developed. Follow-up studies extend to three and one-half years. Proximal gastric vagotomy with simple closure is safe, effective management for the patient with an acute perforated duodenal ulcer. This operation is a satisfactory compromise between simple closure alone which does not protect against recurrent ulcer and definitive ulcer operations which may subject patients who would not have further ulcer symptoms to the unnecessary risk of increased mortality, morbidity, and postgastrectomy disorders.