Canine gallbladder bile. Effects of proximal gastric vagotomy, truncal vagotomy, and truncal vagotomy with pyloroplasty on volume and composition.

Three groups of four dogs each underwent proximal gastric vagotomy, truncal vagotomy, or truncal vagotomy with pyloroplasty. Two dogs had sham operations. Gallbladder bile was aspirated and measured. Aliquots were cultured and assayed for cholesterol, phospholipid, and bile salts initially and at subsequent laparotomies. Both truncal vagotomy groups showed marked increases in aspirate volume at subsequent laparotomies. The sham and proximal gastric vagotomy groups showed a small initial decrease in mean aspirate volume without further significant changes. When the bile assay data were plotted on triangular coordinates, all point for all groups remained well within the area of cholesterol solubility. Nevertheless, two dogs in each truncal vagotomy group were found to have gallstones. No stones were found in the sham and proximal gastric vagotomy groups. Proximal gastric vagotomy appears to preserve fasting gallbladder bile volume and does not alter bile composition in the dog.     

Preference for proximal gastric vagotomy combined with cholecystectomy

The incidence and severity of postvagotomy diarrhoea has been studied in 32 patients who had undergone both vagotomy and cholecystectomy. Sixteen of these patients had had a proximal gastric vagotomy and 16 a truncal vagotomy and pyloroplasty. Diarrhoea was present in 68 per cent of patients in whom the vagotomy was truncal and in 31 per cent of those in whom it was proximal gastric. Matched groups of patients with truncal vagotomy with pyloroplasty and proximal gastric vagotomy without cholecystectomy were also compared. The possible mechanisms of this diarrhoea following combined vagotomy and cholecystectomy have been discussed.     

Interrelations between serum gastrin levels, gastric emptying and acid output before and after proximal gastric vagotomy and truncal vagotomy and antrectomy.

In a prospective study of proximal gastric vagotomy and truncal vagotomy and antrectomy measurements were made, before and after operation, of acid output, gastrin output and gastric emptying of a solid and a liquid meat extract meal. No relationships were demonstrable between acid output and gastrin output. Truncal vagotomy and antrectomy (TVA) produced rapid early emptying of both meals combined with gross prolongation of the overall emptying of the solid meal. Truncal vagotomy and antrectomy reduced the intergrated gastrin output after either meal. Proximal gastric vagotomy (PGV) produced rapid early emptying of the liquid meal with no alteration in the early emptying of the solid meal; however, overall solid meal emptying was delayed. Proximal gastric vagotomy increased basal, peak and integrated gastrin output. In preoperative patients slow solid meal emptying was associated with higher gastrin output but after PGV the reverse was found, the slowest emptiers having the lowest gastrin output. These findings do not support the contention that a pyloroplasty should be added to PGV to reduce the hypergastrinaemia produced by the operation.     

The preventive and therapeutic effects of vagotomy for stress ulcer —Experimental studies on the aspects of gastric submucosal blood flow and ulcer index—

The purpose of this study was to examine the preventive and therapeutic effects of vagotomy on the stress-induced ulcer in terms of gastric submucosal blood flow and ulcer index. Stress was induced in male Wistar rats by forced immersion in water, and the gastric submucosal blood flow (hydrogen clearance method) and ulcer index were determined in animals that underwent truncal vagotomy alone or truncal vagotomy+pyloroplasty as well as in untreated controls. Both truncal vagotomy alone and truncal vagotomy+pyloroplasty were effective in maintaining the blood flow during stress and preventing the development of ulcers, however, these effects were more notable in the truncal vagotomy+pyloroplasty animals. Truncal vagotomy alone or truncal vagotomy+pyloroplasty performed after the development of stress-induced ulcers had no therapeutic effects.     

Truncal vagotomy as a possible potentiator of gastric atony

To stimulate ulcer patients undergoing operation for gastric outlet stenosis, pyloric obstruction was created in dogs and repaired with pyloroplasty to which was added truncal vagotomy, proximal gastric vagotomy, or no vagotomy. Gastric antral contractile activity after feeding a solid meal was studied before and after repair (2 week period of study). This activity was correlated with the initial lag and regulated phases of solid meal emptying. Five quantified indices of contractile activity measured during the first postprandial hour indicated variable and inconclusive results in the antrum during the lag phase (first 20 minutes). Consistent percentage changes in these indices after obstruction repair were seen during the subsequent regulated phase. Gastric work was reduced 28 to 35 percent, but not work capability (mean area), by pyloric obstruction in the no vagotomy dogs. Reductions seen in proximal gastric vagotomy dogs were not different from those in the no vagotomy dogs. Higher percentages of reduction in amplitude (70 percent) and mean area of contractions (53 percent) occurred after truncal vagotomy compared with what occurred in the no vagotomy dogs. Mean area was also reduced more compared with what occurred in the proximal gastric vagotomy dogs. These data indicate that the reduced gastric work after feeding and impaired work capability caused by truncal vagotomy when superimposed on that produced by pyloric obstruction may exaggerate gastric atony and contribute to the delayed recovery of gastric emptying seen in the clinical setting.     

Effect of truncal vagotomy and pyloroplasty on rat gastric mucosal H,K-ATPase and HCO3-ATPase activities.

The effect of truncal vagotomy and pyloroplasty on rat gastric mucosal H,K-ATPase and HCO3-ATPase activities was studied 15 and 30 days past the operation. A significant decrease in gastric body mucosal H,K-ATPase activity occurred 15 days after vagotomy, compared with pyloroplasty (p < 0.05) and non-operated control rats (p < 0.01). A recovery in the enzyme activity on the 30th postoperative day occurred. Gastric body and antral mucosal HCO3-ATPase activity was significantly (p < 0.01) decreased 15 and 30 days after vagotomy and pyloroplasty, compared with pyloroplasty controls. The observed changes in gastric mucosal H,K-ATPase and HCO3-ATPase activities after vagotomy reflect the decrease in gastric acid secretion, as well as the possible changes in mucosal bicarbonate secretion and acid-base status. A gradual recovery in mucosal H,K-ATPase activity after vagotomy may occur.     

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.     

Electrical,contractile, and radiographic studies of the stomach after proximal gastric vagotomy

The effects of proximal gastric vagotomy on the gastric electrical and contractile activities and on gastric emptying of solid food were studied in dogs. Proximal gastric vagotomy produced only minimal alteration of the electrical activity and did not significantly alter the response of the electrical and contractile activities to vagal stimulation (insulin) and local stimulation (food). Barium meal studies showed no delay in gastric emptying time after proximal gastric vagotomy but significant delay after truncal vagotomy. The findings support the clinical impression that gastric motility and empyting (solid) remain relatively normal after proximal gastric vagotomy.     

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.     

犬双侧迷走神经干切断术对Oddi括约肌肌电的影响

目的研究双侧迷走神经干切断术对Oddi括约肌(SO)肌电的影响。方法禁食16~18h(可自由饮水),成年杂种犬麻醉后,实验组行膈肌水平双侧迷走神经干切断术加幽门成形术,对照组仅行幽门成形术。手术后8周行SO肌电记录(SOE)。结果实验组慢波幅度明显升高,快波未观察到显著性变化。结论双侧迷走神经干切断术对SO肌电产生明显影响。     

The preventive and therapeutic effects of vagotomy for stress ulcer--experimental studies on the aspects of gastric submucosal blood flow and ulcer index

The purpose of this study was to examine the preventive and therapeutic effects of vagotomy on the stress-induced ulcer in terms of gastric submucosal blood flow and ulcer index. Stress was induced in male Wistar rats by forced immersion in water, and the gastric submucosal blood flow (hydrogen clearance method) and ulcer index were determined in animals that underwent truncal vagotomy alone or truncal vagotomy + pyloroplasty as well as in untreated controls. Both truncal vagotomy alone and truncal vagotomy + pyloroplasty were effective in maintaining the blood flow during stress and preventing the development of ulcers, however, these effects were more notable in the truncal vagotomy + pyloroplasty animals. Truncal vagotomy alone or truncal vagotomy + pyloroplasty performed after the development of stress-induced ulcers had no therapeutic effects.     

Fasting and postprandial serum gastrin levels before and after highly selective gastric vagotomy, truncal vagotomy with pyloroplasty and truncal vagotomy with antrectomy: is there a cholinergic antral gastrin inhibitory and releasing mechanism?

Fasting serum gastrin levels and postprandial gastrin response were measured before and 1 month after highly selective vagotomy, truncal vagotomy with pyloroplasty and truncal vagotomy with antrectomy. The three groups of patients, 12 in each group, were closely matched for age, sex, maximum acid output and completeness of vagotomy. After highly selective and truncal vagotomy an identical and significant increase in fasting gastrin was observed, whereas after truncal vagotomy with antrectomy the pre- and postoperative fasting gastrin levels were not different. The net postprandial gastrin output over basal value was significantly increased after highly selective vagotomy, unchanged after truncal vagotomy and significantly lowered after truncal vagotomy with antrectomy. These results suggest the presence in the intact subject of a cholinergic inhibitory mechanism in the gastric body and fundus for the release of antral gastrin in the fasting and postprandial states and a possible cholinergic facilitatory mechanism for the release of antral gastrin after meals.     

Antral proliferation of G cells after truncal,parietal cell,and antral vagotomy

Antral gastrin cell numbers and serum gastrin levels were studied in five groups of rats: (1) control, (2) truncal vagotomy, (3) truncal vagotomy with pyloroplasty, (4) parietal cell vagotomy, and (5) antral vagotomy. Female Sprague-Dawley rats weighing approximately 225 g were used. Eighteen days after operation radiographic study was performed to assess gastric size and emptying rate. At sacrifice serum was obtained for gastrin assay, gastric pH measured, and the antrum removed for G-cell quantitation. Gastric pH was elevated in all groups except antral vagotomy. Variable degrees of gastric distention and delayed gastric emptying were observed in the rats with truncal vagotomy alone, truncal vagotomy plus pyloroplasty, and antral vagotomy. Parietal cell vagotomy rats had no change in gastric size or emptying rate. Rats with truncal vagotomy, truncal vagotomy plus pyloroplasty, and parietal cell vagotomy had significant increases in serum gastrin levels and in G-cell density. Antral vagotomy resulted in no significant differences from controls. A gastrin inhibitory mechanism residing in the corpus may become inoperative after vagal denervation. Alternatively, proliferation of G cells and increased serum gastrin levels may be a consequence of decreased luminal acid after vagotomy. Vagal innervation of the corpus is a critical variable in control of the antral G-cell mass, but antral innervation is not. Distention by itself does not seem to produce G-cell hyperplasia.     

Experimental study on canine gastric motility following selective proximal vagotomy (author's transl)]

Electromyographical studies were made on the gastric motility of dogs following selective vagotomy (SV) and selective proximal vagotomy (SPV) as the subsequent studies on the changes after truncal vagotomy (TV) after which gastric motility is fairly disturbed, and the influence of pyloroplasty additionally performed to SPV. Gastric discharge frequency was suppressed by SV similar to that by TV. Dysrhythmia of motility occurred after gastric vogotomy. Restoration to the normal was the fastest after SPV. Changes in the discharge frequency after SPV did not differ much from those in the normal stomach and other types of vagotomy. With SPV, the decrease in the propagation velocity of basic electrical rhythms (BER) was mild, and a pattern similar to the control was shown compared with TV and SV. The antiperistaltic discharge was observed even with SPV, but the frequency was low compared with TV and SV. The frequency of peristaltic discharge was the highest when pyloroplasty was performed in addition to SPV. The responses to vagostigmine, insulin tetragastrin in SPV were similar to those in the normal stomach. During the gastric emptying time, there was neither difference before and after SPV, nor any significant difference due to the presence or absence of pyloroplasty. The above data show that SPV is advantageous for retaining the function of gastric peristalsis, also for gastric secretion, but the addition of pyloroplasty will not be advantageous for the elimination of gastric content.     

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.     

Antral compensation after proximal gastric vagotomy

Proximal gastric vagotomy (PGV) has little impact on the normal pattern of solid gastric emptying, despite denervation of the proximal two thirds of the stomach and loss of the proximal gastric pump. In four healthy volunteers and four patients with PGV, we investigated the possible compensatory mechanisms that may come into play after proximal denervation of the stomach. We measured antropyloroduodenal motility with a 10-lumen sleeve/side-hole catheter for 180 minutes after ingestion of a dual-isotope radiolabeled mixed liquid/solid meal. Patients with PGV exhibited faster liquid emptying, but the rate of solid emptying was similar to that in healthy volunteers. The frequency of propagated antropyloric pressure waves was similar between the two groups, but patients with PGV exhibited less isolated pressure waves in the proximal antrum. The amplitude and duration of pressure waves recorded in the distal antrum were significantly increased in the PGV patients as compared to healthy volunteers. Although the pattern of propagated antral contractions and solid gastric emptying remains unchanged after PGV, there is an increase in the amplitude and duration of distal antral contractions, which may compensate for loss of proximal gastric pumping mechanisms.     

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.     

Proximal gastric vagotomy and mucosal antrectomy: a comparative physiologic examination

Proximal gastric vagotomy-mucosal antrectomy (PGV-MA) was devised in an attempt to reduce the cephalic and hormonal phases of acid secretion without disturbing gastric emptying. The current study determines the effects of proximal gastric vagotomy (PGV), or PGV-MA on acid secretion, gastrin, and gastric emptying. Twelve dogs underwent measurement of gastric emptying, fasting and postcibal acid production, and fasting and postprandial gastrin levels. The animals then underwent either PGV or PGV-MA and the studies were repeated. PGV markedly decreased basal acid (P less than 0.001); however, there was still a large postprandial acid increase. In contrast, PGV-MA nearly abolished both fasting and postprandial acid secretion (difference from control and PGV significant at P less than 0.001). Gastric emptying was not significantly altered by either procedure. PGV was associated with increased fasting and postprandial gastrin levels, while PGV-MA produced lower gastrin levels at all intervals than either controls or PGV-MA. PGV-MA emulates the effects of truncal vagotomy and antrectomy on acid secretion, without affecting gastric emptying and deserves further investigation as a possible surgical alternative in the treatment of duodenal ulcer disease.     

Surgical treatment of high bleeding gastric ulcer

In the surgical treatment of 68 consecutive patients with benign, high, bleeding gastric ulcer between 1966 and 1981, the following operative procedures were used; high gastric resection in 31 (45.5%) cases, local ulcer excision with truncal vagotomy and pyloroplasty in 23 (33.8%), local ulcer excision with low gastric resection in 11 (16.2%) and a local procedure alone in three (4.5%) cases. Of these 68 operations, 40 (59%) were early elective operations and 28 (31%) acute or emergency operations. Altogether, six (8.9%) patients died postoperatively, all but one after acute or emergency operation. High gastric resection was the most risky operation and five of the six deaths were in this operative group. Nonfatal complications developed in 18 (26.4%) cases but without correlation to the timing or to the type of operation. Early rebleeding during the hospital stay necessitating reoperation occurred in three (4.4%) patients, two of these among the three cases operated on using a local procedure and without a definitive operation. During the follow-up five (7.3%) recurrent ulcers developed, four after local ulcer excision with truncal vagotomy and pyloroplasty and one after high gastric resection. It seems to us that in the treatment of patients with high gastric ulcer, local operation alone is never acceptable. High gastric resection is often technically hazardous with a high postoperative mortality rate. The best methods seemed to be local ulcer excision combinated with truncal vagotomy and pyloroplasty or, perhaps preferably, with low gastric resection.