Anterior Seromyotomy Research Articles

Hellers Oesophagocardiomyotomy and Anterior Watson Fundoplication for Achalasia

Aim: To present a video of laparoscopic oesophagocardiomyotomy in a 16-year-old achalasia patient with two failed attempts at balloon dilatation. Demonstrated is a technique of myotomy with anterior fundoplication performed in the context of a challenging operative environment consequent to previous attempts at oesophageal dilatation. Methods/Techniques: The operation was performed using a four-port approach, with an additional epigastric incision for a Nathanson liver retractor. Pneumoperitoneum is induced using Hasson technique and intra-abdominal pressure is maintained at 12 mmHg. There is minimal perioesophagitis and mobilization of the oesophagus goes without complication. However, anterior seromyotomy over the distal 7 cm of oesophagus and cardio-oesophageal junction proves difficult and bloody because of extensive fibrosis from the previous dilatations. Myotomy is achieved with hook diathermy and Marylands dissectors, and neither oesophageal calibration nor endoscopic guidance is necessary to assist myotomy. Saline infusion of the myotomy site with concomitant intraluminal gas insufflation excludes mucosal perforation. The operation is completed by approximating the posterior crura, recreating the angle of His and fashioning an anterior fundoplication by approximating the fundus to the oesophagus and crural repair posteriorly. Results: Patient was permitted oral fluids on the evening of operation with soft diet the next day. He was discharged within 24 hours of the procedure. Barium swallow at 8 weeks postsurgery showed evidence of fundoplication but resolution of achalasia. Conclusion: Fibrosis within the muscular layers from previous attempts at dilatation makes for a difficult myotomy. Laparoscopic oesophagocardiomyotomy with anterior Watson fundoplication for control of reflux works well for achalasia patients. Recovery from this approach is robust and relatively pain free, and the esthetic outcome is excellent. No competing financial interests exist. Runtime of video: 8 mins 50 secs

Laparoscopic Management of Acid Peptic Disease

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. 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. 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. 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 and anterior seromyotomy with posterior truncal vagotomy assessed by the endoscopic congo red test.

The completeness of vagotomy following proximal gastric vagotomy or anterior seromyotomy with posterior truncal vagotomy was assessed prospectively in 48 patients using the intraoperative congo red test. Pentagastrin (6 micrograms/kg) was given subcutaneously before the assessment. An endoscope was passed into the stomach and 180 ml congo red solution washed over the gastric mucosa. Continuing acid production was indicated by the appearance of a black colour (pH < 3) 2 min after introduction of the dye. A grading system was adopted where grades I and II showed little black discoloration and grades III and IV showed increasing areas of discoloration indicating that further denervation was required. All 20 patients undergoing anterior seromyotomy with posterior vagotomy were classified as grade I. Fifteen of an initial 23 patients receiving proximal gastric vagotomy were grade III or IV. Following division of either the right gastroepiploic nerve or the posterior vagal trunk, 22 patients improved to grade I (16) or II (six). In the subsequent five proximal vagotomies, modification of the dissection produced grade I results. Anterior seromyotomy with posterior truncal vagotomy gave consistently complete vagotomy. The congo red test highlighted major differences in the adequacy of vagotomy achieved using various dissection techniques during proximal gastric vagotomy. The test is a useful, reproducible and simple intraoperative method for assessing the completeness of denervation.

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.

Ulcère duodénal perforé : traitement cœlioscopique de la perforationet de la maladie ulcéreuse

Perforated duodenal peptic ulcer. Laparoscopic treatment of perforation and peptic ulcer disease. Study aim: The aim of this retrospective study was to report a continuous series of 44 perforated duodenal peptic ulcers operated on through laparoscopic approach with curative treatment of the peptic ulcer disease for socio-economic purpose. Patients and method: From February 1995 to May 1996, 44 patients were operated on laparoscopically. There werre 42 men and two women (mean age: 36 years). All patients had peritonitis with pneumoperitoneum in 68%. Duodenal peptic ulcer was known in 12 patients and antecedent of episodic epigastric pain were present in 27. Four trocads were used. The diagnosis was confirmed by abdominal exploration and peritoneal lavage was performed with physiological serum. Results: The procedures were: suture of perforated ulcer associated with posterior vagotomy and anterior seromyotomy ( n = 6), with troncular vagotomy and pyloroplasty ( n = 24) and single suture ( n = 1). A conversion into laparotomy was necessary in 13 patients (29.5%). There was no mediastinitis, no postoperative death. Peritonitis by leakage occured in two patients who were reoperated by laparotomy; mean duration of hospital stay was 5.5 days. With a one-year follow-up, all patients were in good condition, free of pain. Conclusion: With laparoscopic surgery, diagnosis of peptic ulcer perforation was confirmed, peritoneal lavage was perfectly done, duodenal perforation was sutured and surgical treatment of the peptic ulcer disease was performed, which is important in poor countries.

Proximal gastric vagotomy: does it have a place in the future management of peptic ulcer?

Proximal gastric vagotomy (PGV) is a modification of truncal vagotomy, which was introduced by Dragstedt for the treatment of duodenal ulcer (DU) in 1943. It is a technically demanding operation; but when performed by an experienced surgeon, it is safe and gives a cure rate for DU of more than 90%, with minimal side effects. The operation permanently alters the natural history of the disease and may be used for gastric ulcer (GU), with ulcer excision; but it is not as effective. Further adaptations, such as posterior truncal vagotomy with anterior seromyotomy, were introduced to simplify and shorten the operation, but they did not receive wide acceptance. Recently, with the identification of Helicobacter, it was found that DU can also be cured by eliminating the infection. PGV is therefore used electively in patients with persistent DU that is not Helicobacter-positive or in the few in whom Helicobacter cannot be eliminated. In patients with bleeding or perforated DUs, PGV may be used in conjunction with underrunning the vessel or patching the perforation. However, few surgeons doing emergency peptic ulcer surgery have experience with PGV, so simple suture followed by medical treatment is the safest option. Because elective PGV is now a rare procedure, patients should be referred to a center with special expertise. If Helicobacter becomes resistant to antibiotics in the future, surgery may be needed regularly again, but the technical nuances would have to be learned.

Differences in gastric emptying between highly selective vagotomy and posterior truncal vagotomy combined with anterior seromyotomy

Gastric emptying has been reported to be both delayed and unchanged following posterior truncal vagotomy combined with anterior seromyotomy (PTV + AS). When compared to highly selective vagotomy (HSV), our clinical experience was that PTV + AS not uncommonly produced postprandial distress. We studied gastric emptying of both liquids and solids 3 and 12 months following HSV and PTV + AS to determine what if any differences there were in gastric empyying between the two procedures. We compared these results with those from studies done in both normal subjects and unoperated duodenal ulcer patients. In 26 duodenal ulcer patients with perforation (n = 18) or bleeding (n = 8), who were treated with HSV (n = 10) or PTV + AS (n = 16), gastric emptying of liquids and solids was evaluated at 3 months and 12 months postoperatively. At 3 months, gastric emptying of liquids was delayed in both the HSV and PTV + AS groups as compared to values in both normal subjects and unoperated duodenal ulcer patients. The emptying of solids was markedly delayed by PTV + AS in contrast to HSV at 3 months (167.1 ± 28.4 minutes vs. 79.9 ± 16.7 minutes; P <0.05). The lag duration was not affected. A limited number of patients studied at 12 months showed similar and near-normal emptying of solids in both the HSV and PTV + AS groups (67.5 ± 7.0 minutes vs. 70 ± 6.6 minutes). PTV + AS in contrast to HSV produces more marked delayed emptying of liquids and solids at 3 months; with time (1 year) these values return to near normal.

Proximal Gastric Vagotomy

The authors compared open and laparoscopic proximal gastric vagotomies for efficacy of acid reduction and preservation of gastric emptying. Laparoscopic methods have been used to perform vagotomy in patients with duodenal ulcer; however, no direct comparisons are available of laparoscopic and open surgical procedures regarding acid reduction and gastric emptying. Thirty-one consecutive dogs were randomized to open proximal gastric vagotomy (OPGV; n = 11), laparoscopic anterior seromyotomy and posterior truncal vagotomy (ASPTV; n = 10), or laparoscopic proximal gastric vagotomy (LPGV; n = 10). Intraoperative endoscopic Congo red testing assured complete vagotomy. Basal acid output (BAO) and maximal acid output (MAO) during pentagastrin and insulin-induced hypoglycemia were measured with marker dilution techniques, and gastric emptying was assessed with radionuclide-labelled solid and liquid markers before and 5 weeks after operation. Operative time (mean +/- standard error of the mean) for OPGV was shorter compared with ASPTV and LPGV (86 +/- 7 minutes vs. 124 +/- 7 minutes and 115 +/- 7 minutes; p < 0.002). Postoperative BAO did not decrease in any group. Open proximal gastric vagotomy and LPGV, but not ASPTV, decreased MAO (p < 0.05); (after pentagastrin, OPGV from 26.4 +/- 1.7 mEq/hour to 11.3 +/- 0.1 mEq/hour, LPGV from 21.4 +/- 1.0 mEq/hour to 6.4 +/- 0.5 mEq/hour; after insulin-induced hypoglycemia, OPGV from 9.9 +/- 0.5 mEq/hour to 2.2 +/- 0.3 mEq/hour, LPGV from 7.9 +/- 0.5 mEq/hour to 1.9 +/- 0.4 mEq/hour). Gastric emptying of liquids and solids, as quantitated by the time for one half of the marker to empty (T 1/2) and the shape of the emptying curve, were similar before and after all three surgical procedures. Laparoscopic proximal gastric vagotomy was comparable to OPGV in decreasing stimulated gastric acid production without significantly altering gastric emptying. Anterior seromyotomy and posterior truncal vagotomy was less effective in decreasing MAO and required more operative time. Laparoscopic proximal gastric vagotomy has the potential to become accepted therapy for patients with duodenal ulcer managed presently with OPGV.

Laparoscopic Posterior Truncal Vagotomy and Anterior Seromyotomy.

For patients with peptic ulcer disease who only require acid reduction, laparoscopic procedures such as posterior truncal vagotomy and anterior seromyotomy can be offered. Elective surgery after a complete physiological workup can improve the results for a certain group of patients. The experiences with the Taylor procedure in open surgery promise the interest of gastroenterologists to include elective surgery among the therapeutic options. As experienced with other procedures, a minimally invasive approach will increase patients' acceptance of surgical treatment.

Carbon dioxide laser vagotomy: Early results

SummaryCarbon dioxide (CO2) laser may selectively destroy peripheral nerves and preserve the accompanying blood vessels within the same neurovascular bundle. In this study we examined the effects on acid secretion of CO2 laser irradiation on the vagal distribution of the anterior wall of the stomach with posterior truncal vagotomy. Posterior truncal vagotomy and CO2 laser anterior seromyotomy (LV) was carried out on 10 mongrel dogs. Furthermore, five dogs received posterior truncal vagotomy and anterior highly selective vagotomy as controls (HSV). Basal acid pH (BpH) and maximal acid pH (MpH) in response to pentagastrin (7.5μg/kg) were measured pre- and post-vagotomy. The mean BpH in the carbon dioxide laser vagotomy group pre-operatively was 4.01 ± 0.8 compared to 4.96 ± 1.3 post-operatively (ns). The mean MpH pre-operatively was 1.55 ± 0.6 compared to 4.17 ± 1.0 postoperatively (P < 0.05), showing a significant reduction in pentagastrinstimulated acid output following carbon dioxide laser vagotomy. In t...

Endoscopic management of peptic ulcer disease.

This article reviews the authors' experience with endoscopic management of duodenal ulcer and ulcers occurring after a previous drainage procedure. 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. 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. 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. 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.

Laparoscopic Vagotomy

The increasing applicability of advanced laparoscopic procedures has fueled the ongoing request for the perfect ulcer operation. Using the laparoscopic approach to selectively denervate the parietal cell mass has led investigators to evaluate laparoscopic right posterior truncal vagotomy with anterior seromyotomy. The history of this procedure and its appeal to the laparoscopist is discussed. The technical aspects of the operation are outlined. Laparoscopic vagotomy may play a central role in the surgical treatment of peptic ulcer disease.

Laparoscopic Posterior Truncal Vagotomy and Anterior Seromyotomy: A Porcine Model

A training technique for posterior truncal vagotomy and an anterior seromyotomy in the anesthetized pig is described. The first of five procedures was performed open in a conventional method. All succeeding procedures were performed after the establishment of a pneumoperitoneum with CO2 insufflation and the placement of two 10 mm trocars and three 5-mm trocars. A 45 degree camera and monopolar electrocautery were used during the video laparoscopic procedure. After completion of the procedure, the pigs were opened to closely inspect the surgery performed. Though there are some minor anatomic differences between porcine and human anatomy, the pig is an excellent model for gaining technical experience in the performance of a posterior truncal vagotomy and anterior seromyotomy.

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.

Arterial vascularization of the operated stomach: Highly selective vagotomy, anterior lesser curve seromyotomy, esophageal replacement by transposed stomach after esophagectomy or circular pharyngolaryngectomy

The rich vascularisation of the stomach is well known and the remarkable tolerance of the organ to vascular ligatures has been emphasised. However, some clinical observations as well as more and more detailed anatomical studies suggest some modification of this classical concept, especially when operating on the viscus. The aim of this work was to evaluate particularly the importance of parietal ischemia which follows hyperselective vagotomy and the more recent anterior seromyotomy, on the one hand, and the gastrolysis that precedes gastro-esophagoplasty after esophagectomy or circular pharyngolaryngectomy on the other hand. The stomachs of 40 unembalmed adult cadavers were studied by angiography in various ways, according to the operation which was being considered. The findings indicated that hyperselective vagotomy caused an avascular band 2 cm wide along that part of the lesser curve affected by the surgical intervention, and that anterior seromyotomy (allowing for some technical artifacts) caused almost no parietal ischemia, and lastly, that the ischemia from gastro-esophagoplasty varied according to the technique used. Useful conclusions, supported by numerous illustrations, will allow the surgeon to define better the vascular requirements when choosing the procedure to be used, taking account of the clinical situation.

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.